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.1 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.2
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.3 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.4 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.5 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.
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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