Emotional responses

Emotional
Responses
Vicarious Trauma,
Burnout and
Transformation
Presentation by
Chris Lobsinger
“That which is to give light
must endure burning”
Victor Frankel
Clinical Pastoral Education
2012 1

Emotional Responses
 This presentation concerns the emotional
responses of careers working with
traumatized people.
 The effects that these emotions have on
careers.
 And some ideas about managing the
negatives effects and enhancing the
positives effects.
Emotional Responces 2006 2

Overview
“Many mental health
professionals unconsciously
assume that their profession
‘magically’ shields them from
traumatic experience.”
 (Kreichman1984)

Definition of Trauma
 Dictionary definition
trauma, n., pl. -mata -mas 1. Pathol. A bodily injury. 2.
Psychol. A startling experience which has a lasting effect
on mental life; a shock. - traumatic, adj. The Macquarie
Dictionary New Budget Edition (1985).
 Working definition
trauma: an inescapably stressful event that overwhelms
people's existing coping mechanisms.

RAA :Basics of traumatic symptoms
 Re-experiencing
 Arousal
 Avoidance

Post Traumatic Stress Disorder
 The essential feature of Post Traumatic
Stress Disorder is the development of
characteristic symptoms following
exposure to an extreme traumatic stressor
involving direct personal experience of an
event that involves actual or threatened
death or serious injury,
American Psychiatric Association (1994) Diagnostic and statistical manual of mental
disorders (4th edition) (DSM-IV). Washington DC.

Acronyms
 VT (Vicarious Trauma)
 CT (Counter-transference)
 STS (Secondary Traumatic Stress)
 CF (Compassion Fatigue)
 Burnout
 Is the ‘devil in the detail’?

Terms
 Compassion Fatigue
A general term for any one who suffers as a
result or serving in a helping capacity.
(Figley 1995)
 Burnout
Describes anyone whose health is suffering
or whose outlook on life has turned
negative because of the impact of
overload of work.

Terms
 Primary Traumatization
The impact of traumatic incident on the
obvious victim of the incident.
 Secondary Traumatization
Includes the family members and close
associates of the victim.
Also refer to therapists, and helpers who
are eyewitness to incident they are try to
mediate.

Terms
 Vicarious Traumatization
Even when a therapist has not witnesses
trauma they can still vicariously
experience the client trauma in their
nervous system. Even though they are not
exposed to the event they can feel it.
Barbette Rothschild Help the helper 2006

 “These constructs have not proven
empirically separable, and the consensus
view now is that they share many features,
but primarily in their affective domains,
which are self in-efficacy in relation to
burnout, and fear in relation to vicarious
traumatisation”
(Linley and Joseph 2007)

Vicarious Traumatisation
 By witnessing or hearing about someone
else’s trauma, people can be vicariously
traumatized, hence the term vicarious
Traumatisation.
Pearlman, L. & Saakvitne, K. (1995) Treating
traumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disorders
in those who treat the traumatized. Brunner-Routledge: New York.

Secondary Traumatic Stress
 Secondary traumatic Stress is a natural
consequence of caring between two people, one
of whom has been initially traumatized and the
other of whom is affected by the first traumatic
experience. Risk factors for (STS) are empathy
and exposure. Additional risk factors are the
care giver’s Previous trauma experiences and
the extent to which these have been resolved
(Figley 1995)

Burnout
 Being involved in emotionally demanding
situations over a long period can cause physical.
emotional and mental exhaustion. This is know
as burnout and is a cumulative process rather
than a fixed condition. Burnout begins gradually
and become progressively worse. The most
salient factor associated with the symptoms of
burnout include client problems- chronicity,
acuity, complexity-that are perceived to be
beyond the capacity of the service provider.

What's most important to know?
 Vicarious Trauma= symptoms of PTSD
 Burnout = Depletion

Burn Out Process and Experience
 Process: A helper becomes overly
involved or overly extends him/herself in
their professional role.
 The helper experiences overload

 Emotional exhaustion
 Feelings of being drained and empty that
is caused by excessive psychological and
emotional demands.
 Depersonalization
 The feeling of callousness and cynicism
and a reduced sensitivity towards others.
 Reduced Personal accomplishment
 The feeling that one’s action and efforts
are wasted and worthless.
(Schulz and Schulz 2006)

The difference, Burnout and VT
 Burnout begins gradually
 Vicarious Trauma can happen quickly
 Burnouts main symptoms are around
exhaustion.
 Vicarious traumas main symptoms mirror
Post traumatic stress.

Stress Vs Burnout
Stress Burnout
Characterized by over-engagement Characterized by disengagement
Emotions are overactive Emotions are blunted
Produces urgency and hyperactivity Produces helplessness and hopelessness
Exhausts physical energy Exhausts motivation, drive, ideals and hope
Leads to anxiety disorders Leads to paranoia, detachment and
depression
Causes disintegration Causes demoralization
Primary damage is physical Primary damage is emotional
Stress may kill you prematurely, and you won't
have enough time to finish what you started
Burnout may never kill you, but your life may
not seem worth living

Stressors uniquely associated with
counseling and other similar roles
include
  Maintaining concentration, discipline
and skill. This intensity is rarely
understood by others not working in the
field.
  The high level of continuous output of
energy.
  Issues are often intense, painful and
sometimes irresolvable.

Role expectations of counselors are often
out of proportion to what is reasonably
achievable.
Limited organizational support for
counselors.
Feelings of isolation and having
expectations placed upon them.
Feeling inadequate and having self-doubt
when outcomes are not achieved.
(Potter, 1987)Counseling-orientated problems, with other factors previously mentioned, have the
potential to place counselors at a high risk of burnout.

Picture

Aspects of Alterations of Self:
Changes in…
 Perceptions of self and other
 Personal identity
 Worldview
 Spirituality
 Personal capacities
 Ego resources
 Psychological needs
 Sensory systems

Changed Worker Sense of:
 Safety
 Trust
 Esteem
 Intimacy
 Control

Post Traumatic Growth
Positive changes have been reported by
people who experience psychological
trauma
Enhanced relationship and increased
compassion and altruism.
( Tedeschi and Calhoun)

 Improved view of themselves as be more
resilient, or more accepting.
 Some report changes in life philosophy
and finding more appreciation in daily life.
( Tedeschi and Calhoun)

Other factors to consider
 As postgraduate training increases,
traumatic symptoms in workers decrease
 Greater involvement and greater caseload
elevate levels of trauma symptoms
 Women report more symptoms than men
 Workers with administrative
responsibilities (multiple roles) and longer
service have more severe symptoms

 Symptoms reduce with years of
experience
 Under 2 years experience increased
symptoms
 Personal history of sexual abuse /trauma
exhibit highest levels of symptoms (mixed
results)

Vicarious Traumatization
The transformation of the person’s inner
experience resulting from empathic exposure to
the client’s material (Pearlman, Saakvitne 1995)
 Occupational hazard
 Effects are cumulative and permanent
 Vicarious traumatisation is a response to the
effects of traumatic exposure on our clients.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),
Compassion fatigue: secondary traumatic stress disorders in those who treat the
traumatized. Brunner-Routledge: New York.

Impact -Vicarious trauma
Includes changes in the person’s:
 Sense of identity
 Relationships with self/others/world
 Beliefs about self/others/world
 Tolerance of feelings
 Psychological needs
 Memory and imagery changes (vulnerable to PTSD
symptomatology)
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),
Compassion fatigue: secondary traumatic stress disorders in those who treat the
traumatized. Brunner-Routledge: New York.

Impact of Vicarious traumatisation
 Depression
 Despair
 Cynicism
 Inability to find enjoyment
 Alienation from self/others
 Professional impairment
 Re-enactment

Organizational impact of Vicarious
Traumatisation
 Reduced team effectiveness
 High staff turnover
 Reduced morale
 Loss of hope/faith
Figley, C. (1995) Treating therapists with vicarious traumatisation and secondary traumatic stress disorders. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.
Pearlman, L. & Saakvitne, K. (1996). In van der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body and
society. The Guildford Press: New York.der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body and society.
The Guildford Press: New York.

VT’s impact on clinical work
“” In Clinical Work secondary trauma( VT)
involves a violation of the therapists sense
of basic trust, where the therapists
assumptions are undermined or shattered.
As the assumptions are undermined, the
behavior of the therapist is likely to be
affected as well””
Charles Figley’in compassion fatigue 1995 Brunner/Mazel inc New York, New York

Emotional Responses
 Helplessness
 Guilt
 Anger
 Hate
 Erotic transference
 Dread and horror
 Idealisation
 Personal vulnerability
 Avoidance reactions
 Fulfilment
Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered lives training guide. Victorian Foundation for Survivors of Torture Inc: Victoria. (p. 148-152)

Flow on of Strong Emotions
 Helplessness—loss of confidence—underestimation of
clients resources and increased advocacy,-- doing
everything leads to exhaustion.
 Guilt—viewing survivors as fragile --- taking excess
responsibility—avoidance of painful topics
 Anger—dismay at bystanders—identification with
destructive thoughts—perpetrator victim split—anger at
victim—for not being morally superior
 Dread and horror—feeling of being overwhelmed by

Flow on of Strong Emotions
 Idealization—view survivors as superhuman—
minimizing pain in self and others.
 Personal sense of vulnerability intolerance of
violence
 Avoidance reactions—denial detachment—
disassociation—self medication
 Fulfillment—growth , deeper awareness of
human condition

Patterns of Traumatic Engagement
 Splitting
 Re-enactments
 Parallel process
 Transference / Counter transference.

Dadi Janki of India Wisdom Keeper 1992
Dadi Janki- “ to take on the their suffering
would be to double the amount of pain in the
world”
Interviewer- “how do you help then”
Dadi Janki- “I try to wrap the others persons
suffering in love”
Toxic Emotions at work, Peter J Frost Harvard Business school 2003 p107-108

Dis-identification Exercise
 Find a quit space
 Take three deep breaths
 Acknowledge your care and responsibility
 Say tour full name and age
 3 things you like about yourself
 3 ways you are different from your client
 Repeat a few times.

Risk Factors
 Too high demands from others and the situation.
 Lack of resources, personnel and time.
 Lack of control over the situation.
 Lack of support from leaders, organisations,
colleagues.
 Unrealistic expectations.
 Lack of acceptance and acknowledgment.
Smith, B., Agger, I., Danieli, Y. & Weisaeth, L. (1996) Health activities across populations: emotional responses of
international humanitarian aid workers. In Danieli, Y. et al. (Eds.), International responses to traumatic stress:
humanitarian, human rights, justice, peace and development contributions, collaborative actions and future
initiatives. Baywood Publishing: New York.

Contributing factors
 Characteristics of work
- Clients with traumatic histories
- Clients who are continually exposed to danger
- Clients who are difficult to understand
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disorders in those
who treat the traumatized. Brunner-Routledge: New York.

 Characteristics of the worker
- Vulnerabilities
- Experience of personal trauma
- Ideas, values
- Ability to attend to their own care
needs
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:

 Characteristics of society
- Society’s tolerance of abuse
- Society’s attitude towards violence
and social justice e.g.. misogynist, racist and hetero-sexist
and victim-blaming contexts.

Reducing Risk
PERSONAL STRATEGIES
 Maintain a personal life
 Use personal life
 Identify healing activities
 Attend to your spiritual needs

Reducing Risk
PROFESSIONAL STRATEGIES
 Arrange supervision
 Develop professional connection
 Develop a balanced work life
 Remain aware of your goals
 Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York

Reducing Risk
ORGANISATIONAL STRATEGIES
 Attend to physical setting
 Arrange for adequate resources
 Create an atmosphere of respect
 Develop adjunctive service

Overinvolvement-Underinvolvement Continuum
Towards working with survivors Away from working with survivors
• wanting to know
more
• empathy
• responsibility for
one’s behaviour
and the reactions
of others
• developing
strategies
• advocacy for
intervention
• ‘crusader’
approach
• doing it all
oneself
• excessive
responsibility for
people’s feelings
• excessive
accommodation
of people’s
difficulties
• observing faculty
• professional
detachment
• maintaining
boundaries
•involvement in a
range of activities
• preoccupation with
efficiency
• cynicism
• minimising contact
• no responsibility
for people’s
reactions
• insufficient
allowance for
problems
• displacement onto
other issues
OVER-INVOLVEMENT IDEAL RANGE UNDER-INVOLVEMENT

Self care
 Physical
 Psychological
 Emotional
 Spiritual
 Workplace care
 Balance

Active Ingredients of self care
 Intentionality
 Connection
 Self soothing
 Self care
 Exercise, meditation, nutrition, spirituality
 Working harder creates an sense of entitlement and
can lead to a breach of professional boundaries.
Compassion fatigue: A crucible of Transformation Eric Gentry. PhD (Cand), Mt.Cac 2002 Haworth Press Journal of
trauma practice 1(3/4), 37-67.

Active Ingredients of self care
 Narrative timeline
 Desensitization and reprocessing.
 Nutrition
 Sleep
 Routine
 Entertainment
 Fun
 Activity/Exercise
 Talking about it
Compassion fatigue: A crucible of Transformation Eric Gentry. Phd (Cand), Mt.Cac 2002 Haworth Press Journal of
trauma practice 1(3/4), 37-67.

 “” when caregivers fail to maintain a life
that is rich with meaning and gratification
outside the professional arena then they
often look to work as the sole source of
these commodities.
In this scenario, caregivers interact with
their clients from a stance of depletion and
need, It is completely understandable that
this orientation would produce symptoms
in care givers””

Making Meaning
 “The making of meaning is the opposite of the erosion or
negation of meaning that results for VT.”’
 Meaning can be found in simple activities
 The pursuit of the aesthetic
 Existential awareness here and now
 Acceptance of change allowing for transformation

Healing compassion fatigue
and burnout
 Relaxation Perceived threat (when listening to clients or
when remembering experiences)
 Building and maintaining relationships( getting support
allowing other to confront when symptomatic; telling on
ourselves when we breach integrity; accountability)
 Sharing Narratives -Painful work experiences(with clients
and co-worker
Eric Gentry prevention and Resiliency for the Workforce

Implications and Directions
 Alterations of self may be inescapable if
not inevitable
 Self (both personal and professional) is a
relational and contextual process
 Worker ‘self-care’ is an ongoing collective
responsibility with implications for
organisations and systems
 Positive growth is a potential alteration of
self given the right conditions

 “… Yet when addressing the distress of
colleagues, we have focused on the use of
individual coping strategies, implying that
those who feel traumatised may not be
balancing work and life adequately and
may not be effectively making use of
leisure, self care, and supervision”
 (Bober and Regehr 2006)

Winnocott and supporting careers
 1. Helping the primary care giver feel well cared
for and providing a sense of social security and
hope for the future.
 2. Supporting the authority of the primary
caregiver while allowing for splits
 3. Enrich the life of the one receiving care
through the personal quality, ideals and
knowledge and liveliness of the other.
Winnicott, D. W.1964 The child the family and the outside Wourld Reading Mass Addison Wesley

Team care
 “” a community absorbs –the traumatic
experience of an individual by diffusing its
effects among many people and
demonstrating that the survivors feelings
are understood””
 Like direct trauma then secondary trauma
violates trust severs contact to community
and destroys meaning

Team approach to VT
 Team identifies trauma emergent patterns
 Therapist with trauma patterns like a client may have a
narrowed focus and be unaware.
 Team expects to see staff with traumatic behavior on a
regular basis and confront them as early as possible.
 Team maintains supportive trusting community
environment
 A community absorbs the traumatic experience of the
individual by diffusing its effects among many people.

Three tenants of team based care
 1. Acceptance of the reality of Secondary
trauma.
 2. Acceptance of secondary trauma as a
natural and valuable process, rather then
a defect.
 3.That others can accurately observe
workers responses to secondary trauma.
Munroe et al 1995

TRUST
 Validating affect
 Identifying patterns
 Proposed healthily alternatives
 Patterns that restore trust

Team Care
“a community absorbs –the traumatic
experience of an individual by diffusing its
effects among many people and
demonstrating that the survivors feelings are
understood”

Self-care vs. Transformation
 Self care approach address the stress and
applies self and soothing and stress reduction
methods.
 Transformation addresses the need to transform
the negative beliefs, despair and loss of
meaning.

Transformation
 Self Care
 Nurturing activities
 Escape
 Create meaning
 Infuse a current activity with meaning
 Challenge your negative beliefs and assumptions.
 Participate in community building activities
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion
fatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-
Routledge: New York

What have Workers found Useful?
 Based on a study by Harrison and Westwood
(2008):
 Countering isolation
 Supervision as relational healing
 Training, professional development, and organisational
support
 Diversity of professional roles
 Developing Mindful Awareness
 Embracing Complexity

What have Workers found Useful?
(cont.)
 Active Optimism
 Holistic Self-Care
 Clear Boundaries and Limits
 Exquisite Empathy
 Professional Satisfaction
 Creating Meaning
Harrison and Westwood (2008)

Ethical Considerations
 Educate workers of risks to alterations of
self
 Train how to cope with ‘exposure’
 Train in empathic disengagement
 Titrated exposure vs being thrown in ‘at
the deep end’
 Evaluation of capacity to cope

Organisational Responsibilities
 Organisational culture (sets expectations)
 Workload (diverse and manageable)
 Environment (safe, comfortable, private)
 Education (duty to warn of VT, ongoing education)
 Group support (informal peer debriefing)
 Supervision (regular, with focus on impact on self)
 Resources for self-care (stress-reduction, yoga etc)

“” For therapist, organizations, institutions,
the key to successfully working with
trauma victims is understanding
secondary trauma and the risks
associated with hearing traumatic material
and finding ways to process and cope with
it. “
.
Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSW
Clinical social work journal Vol 30, No3 Fall(2002)

 “It is not sufficient for employers…to
instruct their therapists to take care of
themselves off the job: active preventative
measures should be a regular part of the
work environment.”(Monroe 1999)
 agencies should structure schedules to
allow ample time for supervision and avoid
dual relationships in which the supervisor
is the agency director Sommer and Cox (2005)

“Addressing secondary or vicarious
trauma is without a doubt in the
best interest of the recipients of
out services our--- clients.”
Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSW
Clinical social work journal Vol 30, No3 Fall(2002)

“What is to give light must
endure burning”
Victor Frankel
“To keep a lamp burning we
have to keep putting oil in it”
Mother Teresa

References
American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th
edition) (DSM-IV). Washington DC.
Bustos, E. (1990) Dealing with the unbearable. Reactions of therapists and therapeutic institutions
working with survivors of torture. In Suedfeld, P. (Ed.), Psychology and torture. Hemisphere
Publications: New York.
Figley Charles R (1995) Compassion Fatigue, New York: Brunner/Mazel
Gentry Eric J. Phd cand Mt,Cac Compassion Fatigue: A crucible of Transformation, 2002 Haworth
Press incJournal Of Trauma Practice 1(3/4),37-67
Pearlman, L. & Saakvitne, K. (1996) in van der Kolk, B., et al. (Eds.), Traumatic stress: the effects of
overwhelming experience on mind, body and society. The Guildford Press: New York.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion
fatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-
Routledge: New York.
Winnicott, D. W.1964 The child the family and the outside World Reading Mass Addison Wesley
Wilson, J. & Lindy, J. (1994) Countertransference in the treatment of PTSD. Guildford Press: New
York. (p. 15)
Horowitz, M. (1976) Stress response syndromes. Jason Aronson Publishers: New York.

Resources
David Balwins Trauma Pages
www.trauma-pages.com

Emotional responses

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