Gertie Quitangon, MD

Psychiatrists and other mental health clinicians have a distinct susceptibility to vicarious trauma from repeated exposure to aversive details of patients’ traumatic experiences. Understanding trauma has evolved since combat stress was first observed in soldiers returning from war, and the advent of the #MeToo movement heightened awareness of the prevalence of trauma in the general population. The recognition of a wide range of traumatic experiences-physical or sexual assault, motor vehicular accidents, life threatening illness, unexpected death or serious injury to significant others, bearing witness to severe human suffering, natural disasters, war, terrorism-has implications for understanding the vulnerability to vicarious trauma inherent in a clinician’s practice.

Empathy in validating another’s suffering makes the clinician vulnerable. Vicarious trauma refers to negative changes in the clinician’s view of self, others, and the world resulting from repeated empathic engagement with patients’ trauma-related thoughts, memories, and emotions.

 This construct is based on the Constructivist Self-Development Theory (CSDT) of personality that conceptualizes trauma as a disruption of human development and adaptation, specifically disruption of the basic human needs for safety, esteem, trust, control, independence and intimacy. From the CSDT perspective, the clinician’s efforts to adapt to exposure to patients’ traumatic memories and emotional responses is disrupted. Empathic listening to story after story of human suffering challenges the clinician’s deeply held beliefs, assumptions, and expectations, which can manifest as intrusive thoughts and images as well as other emotional and behavioral manifestations.

Overlapping work-impact concepts: burnout, compassion fatigue, vicarious trauma

There is consensus in the professional community that secondary exposure to patients’ trauma has the potential to negatively affect quality of care and professional well-being. However, the overlapping theories and constructs are not commonly well understood by service providers. In reviewing the literature, the most frequent constructs used interchangeably with vicarious trauma are secondary traumatic stress, compassion fatigue, and burnout.

Compassion fatigue was originally referred to as secondary traumatic stress syndrome observed in caregivers and family members of trauma survivors who mirrored symptoms of PTSD but with lesser intensity.

 The term compassion fatigue, coined by Charles Figley, is thought to be a less stigmatizing characterization than secondary traumatic stress. Defined as empathic strain and general exhaustion resulting from caring for people in distress, compassion fatigue is most often associated with helping professions such as first responders, nurses, physicians, and disaster recovery workers.

 Similar to vicarious trauma, it involves empathic engagement and secondary trauma exposure, which could present as PTSD-like symptoms. Unlike vicarious trauma however, symptoms can manifest without cumulative secondary trauma exposure, and compassion fatigue is not associated with cognitive disruptions.

Unlike vicarious trauma, both compassion fatigue and burnout are not specific to clinicians who work with trauma survivors, but all three constructs describe manifestations of emotional and physical exhaustion. Burnout is defined as a persistent state of exhaustion, cynicism, and inefficacy as a result of work-related stress.

 The central domain of burnout is emotional exhaustion due to high work demands and often presents as frequent absenteeism, chronic tardiness, and underperformance on clinical and administrative responsibilities.

Is vicarious trauma a specific form of burnout?

Vicarious trauma is the only construct that specifically describes a cumulative, long-lasting impact on clinicians’ personal beliefs and world view. However, on closer examination, two of the three domains of burnout-cynicism or depersonalization and reduced sense of accomplishment or inefficacy-describe shifts in cognition, emotion, and behaviors. Vicarious trauma and burnout have been considered conceptually distinct from the assumption that cognitive disruptions associated with burnout are limited to work conditions while the effects of vicarious trauma are wider in scope. There are more polemical arguments about all the overlapping concepts than evidence in the literature to support this assumption. Conducting more research has been widely recommended and the accumulating literature on burnout in recent years could direct the path to conceptual clarity and significant implications for management.

Congress created the Occupational Safety and Health Administration (OSHA), under the auspices of the Department of Labor, to assure workplace safety by reducing hazardous conditions that could cause worker illness and injury. OSHA interventions modify the work environment to minimize job-related risks from exposures to physical, biological, chemical, ergonomic, and psychosocial hazards and stressful work situations.

Vicarious trauma is a psychological hazard for mental health clinicians and safe work conditions should demonstrate efforts at mitigating the effects of exposure to secondary trauma. In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria DSM-5 and they added “repeated or extreme indirect exposure to aversive details of a traumatic event” as a qualifying stressor to meet criteria for diagnosis of PTSD. This criterion supports the assertion that secondary exposure to trauma is a job-related risk and suggests that if left unaddressed, vicarious trauma and burnout could progress to PTSD.

Studies have shown that integrating work safety and wellness programs is more effective in reducing chronic conditions.

 Wellness and self-care practices reduce individual risk-related factors while work safety reduces work-related risk factors. Examples of wellness programs are smoking cessation, weight control, healthy nutrition, physical activity, flu vaccination, meditation, and mindfulness. Combining wellness practices and psychological safety at work for clinicians is a comprehensive risk management approach to prevent vicarious trauma and burnout and foster resilience.

Meaningful action to foster resilience and prevent vicarious trauma and burnout

Integrate vicarious trauma education and training in curriculum

Residency training programs, internships/externships can adopt a primary prevention approach by integrating vicarious trauma and burnout in the academic curriculum. A course on trauma and PTSD is not complete without teaching vicarious trauma and a forum on burnout without discussing vicarious trauma is an oversight. FEMA and SAMHSA have recognized the need to better understand the negative mental health outcomes of disaster work by mandating programs to include training events and support services on compassion fatigue, secondary traumatic stress and vicarious trauma prior to deployment.

Screening is a secondary prevention strategy and many employers screen for workplace stress and offer health coaching, stress management and related programs when appropriate.

 Forensic workers responding to massive disasters undergo screening for stress-related disorders to monitor emergence of negative mental health outcomes.10 Similarly, offering self-assessment and screening tools for vicarious trauma raises awareness of personal strengths and vulnerabilities and establishes a baseline of symptoms that could be monitored over time.

There are a number of standardized tools that can assess symptoms of vicarious trauma (

). Most of these standardized tools were developed to measure other work-impact concepts and has not been psychometrically validated to assess vicarious trauma. However, they have been adapted for research purposes and accepted as screening tools for vicarious trauma. They are not meant to be diagnostic tools. Rather these tools can used to monitor changes in symptomatology longitudinally. Self-administered tools available electronically increases access and privacy and encourages staff participation.

Enhance personal and professional supports

Social support, both personal and professional, is a protective factor and has been associated with a decreased risk of vicarious trauma. Consultation with colleagues and peers has been shown to reduce feelings of isolation and increase feelings of efficacy.

 The role of managers and supervisors is key in enhancing staff support. Managers can use one-on-one supervision to provide support for challenging cases and manage caseloads, ensuring a balance of volume and complexity of trauma patients for each clinician. Research has shown an association between a high caseload of trauma victims and an increased risk of symptoms of vicarious trauma.

 Supervisors can also assist staff in the development and implementation of self-care plans. A survey of therapists and hospital workers revealed that while the majority believed that self-care strategies can reduce the risk of vicarious trauma, very few actually reported using the strategies.

Research has shown an association between a high caseload of trauma victims and an increased risk of symptoms of vicarious trauma.

 Managers can use one-on-one supervision to provide support for challenging cases and manage caseload, ensuring a balance of volume and complexity of trauma patients for each clinician. Supervisors can also assist staff in the development and implementation of self-care plans. A survey for therapists and hospital workers revealed that while the majority believed that self-care strategies can reduce the risk of vicarious trauma, very few reported actually practicing the strategies.

Supportive organizational culture that build resilience

Primary prevention strategies that build resilience begin with the alignment of organizational values with an individual’s goals and values. These values solidify a culture of strong communication, ethical management practices, and visible leadership support.

 Incorporating professional well-being in the organization’s mission and vision and adopting the value of personal, family and work life balance is foundational in guiding behaviors that promote resilience in the workplace.

Dr Quitangon is Clinical Assistant Professor of Psychiatry, New York University School of Medicine and Medical Director, Community Healthcare Network, New York, NY. 

Dr Quitangon reports that she receives royalties from Routledge for her book, Vicarious Trauma and Disaster Mental Health: Understanding Risks and Promoting Resilience.

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Articles

The recognition of a wide range of traumatic experiences-physical or sexual assault, motor vehicular accidents, natural disasters, terrorism-has implications for understanding the vulnerability to vicarious trauma inherent in a clinician’s practice.

Author | Gertie Quitangon, MD

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