Treating the Trauma of the Trauma Treaters

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.

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Treating the Trauma of the Trauma Treaters by Mackenzie Parks

Mental health professionals who treat those suffering from the effects of trauma are fully aware of the devastating impact that traumatic life experiences can have on individuals. Trauma therapy requires considerable training, empathic capacities, and compassion in order to effectively help those suffering. When those empathic capacities are taxed, therapists may be at risk for developing a phenomenon called compassion fatigue. Known by various names including vicarious trauma and secondary trauma, compassion fatigue manifests when the continuous exposure to traumatic material leads the clinician to experience too much empathy. As stated by Charles Figley (1995):

We have not been directly exposed to the trauma scene, but we hear the story told with such intensity, or we hear similar stories so often, or we have the gift and curse of extreme empathy and we suffer. We feel the feelings of our clients. We experience their fears. We dream their dreams. Eventually, we lose a certain spark of optimism, humor, and hope. We tire. We aren’t sick, but we aren’t ourselves.

Compassion fatigue has created a paradox of sorts for mental health clinicians. Their empathy is essential to effective therapeutic work, yet it is their empathy that may cause them distress. In trauma therapy, compassion fatigue is especially pertinent. Actively and empathetically listening to traumatic stories for 30 to 40 hours per week taxes a therapist’s ability to maintain healthy levels of compassion and empathy for his or her clients. If these levels are taxed enough, a clinician may face adverse effects.

The experience of compassion fatigue involves symptoms similar to PTSD or other trauma responses. These may include anxiety, nervous system arousal, sleep problems, difficulty concentrating, intrusive imagery, irritability, and difficulty controlling negative emotions. A clinician’s beliefs about their world and interpersonal relationships can profoundly shift. For example, a loss of perception of safety or trust in others may occur. It is important to remember that compassion fatigue, secondary traumatization, and vicarious traumatization are not diagnoses. Symptoms meeting DSM-5 criteria for any diagnosis may be distinct from compassion fatigue and secondary/vicarious traumatization, but they may also contribute. For example, someone with diagnostic depression levels may also experience compassion fatigue independently. Similarly, symptoms of diagnostic depression levels may likely contribute to the experience of compassion fatigue.

Another term used to describe the negative possibilities of trauma therapy is burnout. Clinician burnout is different than compassion fatigue. Whereas compassion fatigue involves a profound shift in worldview and the emotional capacities to continue feeling compassion for others, burnout is a physical and emotional exhaustion that can occur with low job satisfaction or feeling powerless or overwhelmed in the work environment. Low levels of self-efficacy, feeling as if your efforts make no difference, and having a high work load or a non-supportive work environment are contributing factors. Burnout usually has a gradual onset, whereas compassion fatigue has a more rapid onset. The good news is that burnout can usually be resolved by environmental changes such as changing jobs or locations. Burnout is observed in many other occupational realms, but it is especially important to identify and prevent in the field of mental health treatment.

These terms – compassion fatigue, vicarious traumatization, secondary traumatization, burnout – are often used interchangeably in clinician dialogue, but they have important distinctions. In addition to compassion satisfaction, components of compassion fatigue make up our professional quality of life. The components of compassion fatigue are burnout and secondary trauma. Vicarious trauma is included as a form of secondary trauma, which is defined as being exposed to others’ traumatic event in some way. Vicarious trauma is defined as repeatedly hearing traumatic stories from others (which is a form of exposure). Therefore, vicarious trauma is a form of secondary trauma. Burnout and secondary trauma comprise compassion fatigue. Compassion satisfaction and compassion fatigue comprise professional quality of life. This model of conceptualizing the effects of compassion fatigue is the basis for ProQOL – the most commonly used assessment measure of the effects of trauma therapy on the therapist.

Identifying and measuring levels of compassion fatigue is absolutely essential to providing quality treatment. If compassion fatigue goes unaddressed, it can produce occupational hazards and possibly harmful effects on clients seeking treatment. There are no specific psychological treatments for compassion fatigue but if the symptoms manifest into more severe forms (e.g., depression, PTSD, anxiety disorders, suicidal thoughts) treatments such as counseling or medications are recommended. Personal strategies are the most common method to address compassion fatigue. Reducing hours spent working directly with traumatized individuals is the single most effective way to reduce vicarious trauma. Working in a healthy, supportive, flexible environment that provides ongoing professional education and flexible scheduling contributes to compassion satisfaction. Maintaining a strong social support at home and work, self-narrative work like journaling, and meditation are all effective remedies. Finally, it is highly recommended among trauma therapy professionals to take breaks or vacations as needed to relieve the intensity of the work. There are also a number of resources for helping professionals to receive support, training, and counseling. The fundamental aspect of maintaining a delicate balance of appropriate empathy is key to avoiding compassion fatigue.

Perhaps the most important question, then, is how this phenomenon effects clients. Those people seeking treatment for their traumatic experiences certainly wouldn’t benefit from a fatigued therapist. There are no specifiers as to which therapists may be experiencing or are at risk of developing compassion fatigue. As with many helping professions, particularly medical, it is the responsibility of the recipient to decide which professional best suits his or her needs. Unfortunately, the effects of compassion fatigue may go unnoticed for some time. In regard to the mental health professional realm, there is a greater responsibility and accountability placed on the clinician to uphold standards of wellness in order to provide to their clients without causing harm or distress. The importance of keeping compassion fatigue at bay is monumentally important to the very crux of mental health services.