gusman_vicarious_a

Vicarious Traumatization:Towards Recognition & Resilience-Building : 

Vicarious Traumatization:Towards Recognition & Resilience-Building Fred D. Gusman, M.S.W. National Center for PTSD Director, Education Division; VISN 21 Co-Chair Mental Health Leadership Pamela J. Swales, Ph.D. National Center for PTSD Education Division

Overview : 

Overview Recognize Vicarious Traumatization (VT) and related concepts Describe how VT changes Basic Assumptions about self/others/world Recognize variables that increase risk of VT Recognize when VT is interfering with self or provision of care Identify methods to support/increase resilience and positive coping

Traumatic Stress: Recognition : 

Traumatic Stress: Recognition Major Terms: Primary Traumatic Stress Secondary Traumatic Stress Vicarious Traumatization Compassion Fatigue

1. Primary Traumatic Stress : 

1. Primary Traumatic Stress Direct exposure to, or witnessing of, extreme events and one is overwhelmed by the trauma (Figley, 1992 at Ist ISTSS Conference)

2. Secondary Traumatic Stress : 

2. Secondary Traumatic Stress Direct exposure to extreme events directly experienced by another and one is overwhelmed by the trauma (Figley & Kleber, 1995)

3. Vicarious Traumatization (VT)*** : 

3. Vicarious Traumatization (VT)*** The phenomena of transmission of traumatic stress by bearing witness to the stories of traumatic events (McCann & Pearlman, 1990) ***Vicarious traumatization can be experienced from once to numerous times

VT: Natural Process : 

VT: Natural Process VT is considered a NATURAL and inevitable response to spending significant time working with, or studying, trauma survivors (Pearlman & Saakvitne, 1995)

VT: Soul Weariness : 

VT: Soul Weariness There is a soul weariness that comes with caring. From doing business with the handiwork of fear. Sometimes it lives at the edges of one’s life….at other times, it comes crashing in, overtaking one with its vivid images of another’s terror with its profound demands for attention; nightmares, strange fears, and generalized hopelessness.” Beth Hudnall Stamm, Ph.D.

VT of the Provider: Definition : 

VT of the Provider: Definition Vicarious traumatization : the transformative effect upon the provider of working with survivors of traumatic events… A process through which the provider’s inner experience is negatively transformed through empathic engagement with the client’s trauma material (Pearlman & Saakvitne, 1995)

VT: What it Isn’t : 

VT: What it Isn’t Countertransference: Process of overidentifying with the client or of meeting one’s needs through the client (Corey, 1991) Burnout: A state of physical, emotional, mental exhaustion caused by long term involvement in emotionally demanding situations (Pines & Aronson, 1988)

4. Compassion Fatigue (CF): Cumulative Trauma : 

4. Compassion Fatigue (CF): Cumulative Trauma The CUMULATIVE (build up over time) of: Primary Traumatic Stress (direct trauma experience of provider) + Secondary Traumatic Stress (direct witnessing of others’ trauma) + Vicarious Traumatization (bearing witness to others’ trauma stories)

Traumatic Stress: Types : 

Traumatic Stress: Types Primary Secondary Vicarious Compassion Fatigue

Compassion Fatigue: Symptoms : 

Compassion Fatigue: Symptoms Preoccupation with clients’ traumatic events Avoidance and numbing of events Increased negative arousal Lowered frustration tolerance Intrusive thoughts of clients’ material Dread of working with certain clients Decrease in subjective sense of safety Feelings of therapeutic impotence Diminished sense of purpose Decreased functioning in a number of areas (Figley, 1996)

VT: Ecological Model of Trauma : 

VT: Ecological Model of Trauma Traumatic events- great impact on the immediate survivors as well as those around them (Harvey (1996) – Event acts like a “stone thrown into water”: Center = Immediate survivor/s Concentric rings (around the survivor/s) = Family members Caregiver Friends Community

VT: Like a Stone Thrown into Water : 

VT: Like a Stone Thrown into Water Trauma Victim Family members Caregivers Community Friends

VT: Like a Stone Thrown into Water : 

VT: Like a Stone Thrown into Water Vicarious Traumatization: Those in rings CLOSEST to survivor likely to have greatest risk for developing secondary traumatic stress disorder or vicarious traumatization (Yassen, 1995)

VT: “The Intruder” : 

VT: “The Intruder” VT “Intrudes” on and disrupts- Four main areas of functioning: Cognitive schemata Psychological needs Memory system World View/frame of reference (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995)

VT: “The Intruder”-1 : 

VT: “The Intruder”-1 Cognitive Schemata: Decreased: trust sense of safety self-esteem intimacy connectedness to others Shattered frame of reference, world view Power issues

Common Cognitive Distortions : 

Common Cognitive Distortions Catastrophizing (worst-case scenario) Minimizing (e.g. minimizing issues/situations) Discounting the Positive Dwelling on the negative All-or-Nothing thinking Mind reading (assuming you know) Self-blame

VT: “The Intruder” -2 : 

VT: “The Intruder” -2 Psychological needs: Decreased self-worth Self-depreciation Hopelessness Helplessness

VT: “The Intruder” -3 : 

VT: “The Intruder” -3 Memory system: Internalization of clients’ memories Therapist may experience flashbacks of client’s material Dreams (similar to client’s material) Intrusive thoughts (of client’s material) Powerful emotional states upon reminders of traumatic material (e.g. sadness, anger)

VT: “The Intruder” -4 : 

VT: “The Intruder” -4 Frame of reference disrupted: Basic identity challenged Spirituality questioned World view may be shattered

VT: Contributing Factors-1 : 

VT: Contributing Factors-1 Proximity to the situation Relationship with the person(s) involved Element of surprise or shock Presence of interpersonal violence Having witnessed or experienced traumas, particularly--similar traumas in the past Unresolved personal issues Rekindling-subtle issues seep into therapy

VT: Contributing Factors-2 : 

VT: Contributing Factors-2 Provider’s Lack of: Skills Knowledge base Affect tolerance (self/others) Understanding of ethical issues Awareness of trauma’s impact on self/others Self-awareness Professional identity Administrative support Competent supervision

VT: Effects on Provider : 

VT: Effects on Provider The greater the percentage of trauma survivors in the provider’s caseload, the greater the number VT symptoms reported (Adams et al., 2001)

VT: Reactions/Symptoms : 

VT: Reactions/Symptoms May appear soon after the event, or can be triggered at a later time by a reminder of the event (examples): Shock or disbelief Irrational guilt/self-blame Intrusive symptoms Numbing and Avoidance Increased hyperarousal Irrational fear for the safety of loved ones Feeling isolated and misunderstood Low energy Disrupted sleep/nightmares Anger Risk-taking/rule breaking

VT: Provider-Case Example #1 : 

VT: Provider-Case Example #1 Mental Health Intern Provider’s HX: Parents divorced Father : military; etoh Stoicism Setting: VA Medical Center Out-patient mental health services Supervisor’s observation: “You treat etoh clients differently”

VT: Providers-Case Example #2 : 

VT: Providers-Case Example #2 Workshop During Desert Storm Anger workshop for therapists (mandatory) Approx 30% of group were ANGRY Multiple issues: Felt they were abandoning patients Felt abandoned by leadership Underlying issues with authority figures Many had symptoms of stress reactions

Slide 32: 

Provider Self-Care

Slide 33: 

Perspectives/Reactions to Trauma are Unique

Risk/Resilience: Self-Assessment : 

Risk/Resilience: Self-Assessment How can I know if I am at risk for, or if I am experiencing VT or CF?

Risk/Resilience: Self-Assessment-1 : 

Risk/Resilience: Self-Assessment-1 Work: Am I enjoying my work? Are there certain clients that are too stressful for me? How do I feel when I arrive at work? How do I feel when I leave work? Do I dream about work-related things? Do I over-identify with, or distance myself from certain clients?

Risk/Resilience: Self-Assessment-2 : 

Risk/Resilience: Self-Assessment-2 Self-Care: Have I noticed changes in my health? Have there been any changes in how I spend my leisure time? Am I: drinking, smoking, overeating, not getting enough sleep, etc? Is my body showing signs of stress?

Risk/Resilience: Self-Assessment-3 : 

Risk/Resilience: Self-Assessment-3 Self-Capacities: Has my sense of my-self changed? Do I feel worthwhile? How am I managing stress? Am I under stress? Am I making good life decisions? Should I be making big decisions right now? Do I separate my work and personal lives?

Risk/Resilience: Self-Assessment-4 : 

Risk/Resilience: Self-Assessment-4 Interpersonal Relationships: Do I like/enjoy being with others? Do I spend meaningful time with my family? Do I feel close to others? Do I share myself more/less? Do I feel understood by others? Have I changed in the way I think/feel about others who are close to me?

Resilience: Red Flags : 

Resilience: Red Flags Overwhelmed Agitated/irritable/nervous/ “up tight” Isolated Depressed Lack of interest in things General negative attitude Problems falling/staying asleep Low energy Laying awake and worrying about things You’re not doing the things you like to do Work intrudes on home and personal life Feeling helpless/ like you can’t cope

Resilience-Personal : 

Resilience-Personal Awareness of one’s limits, emotions, resources Balance among personal and professional activities Connection to one’s inner self, to others, and to something “larger” (spiritual) to others-breaks the silence of unacknowledged pain offsets isolation increases validation and hope

Resilience: Helpful Hints-1 : 

Resilience: Helpful Hints-1 Acknowledge the trauma Maintain a normal schedule Create balance and separateness between work and personal lives Pay attention to basic/good self-care Do NOT “numb out” with “excesses”: alcohol/other substances gambling, eating, shopping, TV, exercising Minimize your exposure to traumatic stimuli This includes violent movies or TV news

Resilience: Helpful Hints-2 : 

Resilience: Helpful Hints-2 Engage in leisure activities Nurture aspects of yourself-health, creative, artistic, spiritual Know your own “red flags” “Debrief” about the event with colleagues If symptoms persist for more than a couple of weeks-seek further assistance Consider personal counseling

Resilience: Helpful Hints-3 : 

Resilience: Helpful Hints-3 Make connections/relationships Avoid seeing crises as insurmountable problems Accept that change is inevitable Set goals and actively move toward them Take decisive actions Look at problems as triggers for personal growth Nurture a positive self-view Don’t blow things out of proportion Remember and use past coping, success,strengths (APA Task Force on Resilience, 2002)

Resilience: Professional : 

Resilience: Professional Know type of client who you can/cannot work with Refer certain clients Manage Caseload Lessen overall trauma load Develop variety Limit # and type of trauma clients Continuing education Confide in a colleague Express emotions Seek support Obtain supervision Obtain consultation Take mental health break

Resilience: Organizational : 

Resilience: Organizational Reduce feelings of isolation Provide/offer Adequate funding, space, and supplies Access to mental health benefits Balanced/manageable caseloads Inservice training to address VT/other topics Acknowledgement/respect for clinician’s task An Atmosphere of encouragement and growth Adequate resources Safe physical space Offer Release time Peer groups Support Informal socializing (Pearlman & Saaktvine, 1995)

Slide 46: 

Common Obstacles to Building Resilience: Not recognizing problems and Not doing your own self-care

Vicarious Traumatization: Summary : 

Vicarious Traumatization: Summary VT can be insidious VT can be a natural consequence of empathic listening “You are your equipment—maintain it.” Developing resiliency can support you—both personally and professionally