Vicarious traumatization

Vicarious traumatization (VT) is a transformation in the self of a trauma worker or helper that results from empathic engagement with traumatized clients and their reports of traumatic experiences. Its hallmark is disrupted spirituality, or meaning and hope. McCann and Pearlman(1990a) coined this term specifically with reference to the experience of psychotherapists working with trauma survivor clients. Others, including Saakvitne, Gamble, Pearlman, and Lev (2000) have expanded its application to a wide range of persons who assist trauma survivors, including clergy (Day, Vermilyea, Wilkerson, & Giller, 2006),front line social service workers (Pryce, Shackelford, & Pryce, 2007), justice system professionals (Levin & Greisberg, 2003; Peters, 2007), health care providers (Madrid & Schacher, 2006; Shah, 2010a), humanitarian workers (Shah, 2007; Pearlman & McKay, 2009), journalists, and first responders (Shah, 2010a).

Contributing factors
Vicarious trauma, conceptually based in constructivist self-development theory (McCann & Pearlman, 1990b; Pearlman & Saakvitne, 1995; Saakvitne, et al., 2000), arises from an interaction between individuals and their situations. This means that the individual helper's personal history (including prior traumatic experiences), coping strategies, and support network, among other things, all interact with his or her situation (including work setting, the nature of the work s/he does, the specific clientele served, etc.), to give rise to individual expressions of vicarious trauma. This in turn implies the individual nature of responses or adaptations to VT as well as individual ways of coping with and transforming it.

Anything that interferes with the helper's ability to fulfill his/her responsibility to assist traumatized clients can contribute to vicarious trauma. Many social service workers report that they experience the demands of their agencies as the greatest impediment to their effectiveness and work satisfaction (Pryce et al., 2007).

Signs and symptoms
The signs and symptoms of vicarious trauma parallel those of direct trauma, although they tend to be less intense. Workers who have personal trauma histories may be more vulnerable to VT, although the research findings on this point are mixed (see Bride, 2004,for a review of this literature). Common signs and symptoms include, but are not limited to, social withdrawal; emotional lability; aggression; greater sensitivity to violence; somatic symptoms; sleep difficulties; intrusive imagery; cynicism; sexual difficulties; difficulty managing boundaries with clients; and core beliefs and resulting difficulty in relationships reflecting problems with security, trust, esteem, intimacy, and control (Arvay & Uhlemann, 1996; Bober, Regehr,& Zhou, 2006; Brady, Guy, Poelstra, & Brokaw, 1999; Cunningham, 1999; Ghahramanlou & Brodbeck, 2000; Pearlman, 2003; Schauben & Frazier, 1995).

Related concepts
While the term "vicarious trauma" has been used interchangeably with "compassion fatigue" [link] and "secondary traumatic stress disorder," "burnout," and "countertransference," [link] and "work-related stress," there are important differences. These include the following:


 * 1) Unlike compassion fatigue, VT is a theory-based construct. This means that observable symptoms can serve as the starting for a process of discovering contributing factors and related signs, symptoms, and adaptations. VT also specifies psychological domains that can be affected, rather than specific symptoms that may arise. This specificity may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices).
 * 2) Countertransference is the psychotherapist's response to a particular client. VT refers to responses across clients, across time.
 * 3) Unlike burnout, countertransference, and work-related stress, VT is specific to trauma workers. This means that the helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference (Pearlman & Saakvitne, 1995). The burnout and vicarious traumatization constructs overlap (specifically in the area of emotional exhaustion [Gamble, Pearlman, Lucca, & Allen, 1994]). A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other (Pearlman & Saakvitne, 1995).
 * 4) Unlike vicarious trauma, countertransference can be a very useful tool for psychotherapists, providing them with important information about their clients.
 * 5) Work-related stress is a generic term without a theoretical basis, specific signs and symptoms or contributing factors, or remedies. Burnout and vicarious trauma can co-exist. Countertransference responses may potentiate vicarious trauma (Pearlman & Saakvitne, 1995).

Mechanism
The posited mechanism for vicarious traumatization is empathy [link](Pearlman & Saakvitne, 1995; Rothschild, 2006; Wilson & Thomas, 2004). Different forms of empathy may result in different effects on helpers. Batson and colleagues have conducted research that might inform trauma helpers about ways to manage empathic connection constructively (Batson, Fultz, & Schoenrade, 1987; Lamm, Batson, & Decety, 2007). If helpers identify with their trauma survivor clients and immerse themselves in thinking about what it would be like if these events happened to them, they are likely to experience personal distress, feeling upset, worried, distressed. On the other hand, if helpers instead imagine what the client experienced, they may be more likely to feel compassion and moved to help.

Measurement of VT
Over the years, people have measured VT in a wide variety of ways. Vicarious trauma is a multifaceted construct requiring a multifaceted assessment. More specifically, the aspects of VT that would need to be measured for a complete assessment include self capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms (see McCann & Pearlman, 1990b, Pearlman, 2001, and Saakvitne et al., 2000 for discussions of these realms of the self). Measures of some of these elements of VT exist, including the following: Psychological needs: Trauma and Attachment Belief Scale (Pearlman, 2003). This scale is available through Western Psychological Services, Inc. at www.wpspublish.com. Self capacities: Inner Experience Questionnaire (Pearlman, 1995). Available from Laurie Anne Pearlman at lpearlmanphd@comcast.net Inventory of Altered Self-Capacities (IASC, Briere, 2002). Available from Psychological Corporation. Trauma symptoms:
 * PTSD Checklist (PCL, Weathers et al., 1993)
 * Impact of Events Scale (IES, Horowitz, 1979)
 * Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1996)
 * Trauma Symptom Inventory (Briere, 1996)
 * Detailed Assessment of Posttraumatic Stress (DAPS, Briere, 2001)

World view: World Assumptions Scale (Janoff-Bulman, 1989)

Addressing VT
Vicarious traumatization is not the responsibility of clients or systems, although institutions that provide trauma-related services bear a responsibility to create policies and work settings that facilitate staff (and therefore client) well-being (Shah, 2008; Shah, 2010b). Each trauma worker is responsible for self-care (Saakvitne, Pearlman, and the Staff of the Traumatic Stress Institute, 1996), working reflectively (Pearlman & Caringi, 2009), and engaging in regular, frequent, trauma-informed professional confidential consultation (Pearlman & Saakvitne, 1995).

There are many ways of addressing vicarious traumatization. All involve awareness, balance, and connection (Saakvitne et al., 1996). One set of approaches can be grouped together as coping strategies. These include, for example, self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies. Transforming strategies aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one's personal life (Saakvitne et al., 2000; Saakvitne et al., 1996) and professional life(Pearlman & Caringi, 2009). Organizations that provide trauma services can also play a role in mitigating vicarious trauma (Rosenbloom, Pratt, & Pearlman, 1995; Stamm, 1999).

Vicarious transformation
Beyond vicarious traumatization lies vicarious transformation (VTF). This is the process of transforming one's vicarious trauma, leading to spiritual growth. Vicarious transformation is a process of active engagement with the negative changes that come about through trauma work. It can be recognized by a deepened sense of connection with all living beings, a broader sense of moral inclusion, a greater appreciation of the gifts in one's life, and a greater sense of meaning and hope. Like VT, VTF is a process, not an endpoint or outcome. If we can embrace, rather than fending off, our clients’ extraordinary pain, our humanity is expanded. In this receptive mode, our caring is deepened. Our clients feel that we are allowing them to affect us. This reciprocal process conveys respect. We learn from our trauma survivor clients that people can endure horrible things and carry on. This knowledge is a gift we can pass along to others.

Related constructs
Vicarious post-traumatic growth. Arnold, Tedeschi, Calhoun, and Cann, 2005) reported this phenomenon after interviews with 21 psychotherapists who were asked about the effects their work had on them. Unlike VTF, VPG is not a theory-based construct, but based on self-reported signs.