Working with trauma survivors has long been recognised as having a potentially profound impact on therapists (McCann and Perlman, 1990). This has been termed in the literature ‘vicarious trauma’ and defined as the changes in one’s view of self and the world as a result of indirectly being exposed to another’s traumatic event (Pearlman & Maclan, 1995).
Therapists are arguably at high risk of vicarious trauma as they are frequently exposed to the traumatic stories of their clients. A survey of 253 trauma therapists in the UK found that 70% of therapists were at high risk of secondary traumatic stress (Sodeke-Gregson, Holttum & Billings, 2013).
So, is trauma by default ‘contagious’ as originally argued by Herman (1992)? Is it an inevitable occupational hazard, or can it also confer potential for satisfaction and growth?
The aim of this meta-ethnographic review by Dr Natalie McNeillie and Prof John Rose was to explore and describe how specialists who provide therapy to trauma survivors experience their work. The objective of the study was to “normalize vicarious trauma for therapists and the organisations that support them, and to increase awareness and thus improve the quality of patient care”.
Meta-ethnography was chosen by the authors as it offers the opportunity to explore the similarities and differences between studies using different qualitative methodologies (Barnett-Page & Thomas, 2009). The original themes from the articles included in this study were extracted and re-analysed to enrich the literature and better understand the experiences of therapists working with trauma survivors.
The literature search was completed through 3 electronic databases: MEDLINE, PsychINFO, and Embase. The authors included articles that had fully or partly qualitative methodology, explored therapists’ experiences of working with trauma survivors, were peer-reviewed published articles, and at least 75% of the sample were therapists engaging in therapy with trauma survivors.
The authors found 261 articles from their initial database searches. However, some studies were excluded because they were not written in English, were thesis/conference abstracts or books, or were not related to the research question. Nineteen studies from the database searches and one paper from reviewing references lists of the included papers fully met the inclusion criteria. As a result of the quality appraisal conducted on these 20 studies, four articles that were thought to not meet the Critical Appraisal Skills Programme (CASP) criteria were left out of the review due to lower quality. In total, sixteen articles were included in the meta-ethnography.
In this study, the researchers identified five themes by re-analysing the original themes from the 16 included qualitative studies.
1. Altered outlook on life and perception of self and others
The authors noted therapists’ changing perspectives about self, others, and the world, based on their exposure to clients’ traumatic events. Although this change manifested itself as negative beliefs for some therapists, it could also bring growth and development for others.
1a. View of the self
Within this theme, the authors identified two sub-themes. The first, View of the self, described changes in therapists’ “self” perception as a result of working with trauma. On the one hand, the authors noted that therapists may experience “a real sense of inadequacy, low self-esteem and doubting of one’s professional abilities” in response to trauma work.
On the other hand, some therapists experienced growth and development. For example, therapists, who witnessed their patients’ resistance despite all the difficulties they experienced, could focus on their own skills, strengths, potential growth, and being resistant to the problems they encountered in their own lives. In addition, witnessing clients’ post-traumatic growth and progress increased therapists’ confidence and their belief that they are effective as clinicians.
1b. View of others and the world
The second sub-theme, View of others and the world, related changes in therapist’s view of others and the world as a result of working with trauma survivors. Some therapists who were exposed to traumatic stories experienced enhanced awareness of the “capability of mankind for cruelty”. Additionally, some of the therapists reported that they tended to overgeneralise the existence of abuse, express shock and disgust, and have a heightened sense of danger. Some mentioned that their core beliefs about the world as a safe, fair, and controllable place were shaken by their exposure to traumatic events.
Shaded my view of life…
(Arnold et. al., 2005; 254)
Hope and optimism could also develop in therapists who saw that trauma victims had overcome adversity and thrived.
2. Emotional experiences
Working with trauma could lead to different emotional experiences for therapists. The authors described how some experienced burnout, shock and disgust, guilt, frustration, irritability, hopelessness, and helplessness. Others reported increased compassion, empathy, sensitivity, and awareness of their own strength/resilience.
3. Physiological experiences
Working with trauma also had effects on therapists’ physiology. The authors describe how some therapists chose “weariness”, “fatigue”, “tiredness”, “exhaustion”, and “lack of energy” to describe their physiological experiences. They mentioned that therapists suffered from pain, nausea, dizziness/light-headedness, headaches/migraines, muscle tension/soreness, breathing difficulties (including asthma), and sleep disturbances.
4. Cognitive experiences
Working with trauma had both positive and negative effects on the cognitive experiences of therapists. The authors tell us that therapists’ views that “the self is vulnerable, others are dangerous, and the world is unsafe” could be reinforced by exposure to traumatic stories. The authors describe how many therapists shared that they had intrusive thoughts, images, and nightmares about their clients’ traumas. They noted how this in turn could affect intimacy in their own relationships. Some reported feeling more suspicious, paranoid, confused, forgetful, and scared. This manifested itself as hypervigilance and hyperarousal.
The authors also noted that therapists’ perspectives could be altered. They noted that while some therapists felt hopeless, helpless, and powerless, other therapists who witnessed the recovery process of their clients felt more hopeful and optimistic. Additionally, they may have felt more motivated to support trauma survivors during their recovery and felt more gratitude about their own personal lives.
5. Behavioural responses
Finally, the authors observed that one of the most common behavioural responses in therapists exposed to the traumatic stories of their clients was the intense desire to protect their own loved ones. Another common behaviour was to “pull away from others” via isolation and avoidance. For some therapists, however, this work led them to live their lives more fully and to appreciate people in their lives more.
- The authors of this review describe how working with trauma can have a profound impact on therapists and that traumatic material can infiltrate the therapist’s personal life.
- They describe how therapists present with cognitive, emotional, physiological and behavioural ‘symptoms’ of vicarious trauma, which seem to parallel their clients’ experiences of PTSD and post-traumatic growth.
- They conclude that armed with this new knowledge, therapists can act in ways to enhance the safety of self and others.
Strengths and limitations
This is an interesting paper on an important topic, which makes a valuable contribution to the literature. The article collates and synthesises findings from previous qualitative literature and offers new insight into the topic of vicarious trauma amongst therapists. There are some limitations to the paper.
- Firstly, only a few quotes from participants in the original studies were included in the analysis. We would be happy to see more quotes which would enrich the analysis and allow us to better understand therapists’ experiences from their perspectives.
- Secondly, reflexivity is one of the most important parts of the trustworthiness criteria of qualitative research (Teh & Lek, 2018), as acknowledged by the authors in their quality appraisal of the included studies. However, there is no information about the authors behind this analysis nor is a statement of reflexivity included in the paper. In qualitative research, it is recognised that researchers bring their own experience, knowledge, and subjectivity to their research (Dodgson, 2019). Therefore, to maintain the trustworthiness of qualitative research and to better understand the study findings it would have been helpful to know a bit more about the authors and their relationship with this topic.
- Thirdly, the authors did not mention the sample sizes or characteristics of the participants in the included studies, making it hard to draw any conclusions about the potential transferability of the findings.
- Finally, there was a lack of detail about the countries and contexts in which the research was carried out, further making the transferability of findings challenging.
Implications for practice
This review synthesises a body of qualitative research and lends further support to evidence that working with trauma survivors can have a profound impact on therapists. The authors achieve their stated objective of increasing awareness of vicarious trauma for therapists and the organisations that support them, and their findings strengthen the argument that staff wellbeing should be prioritised by the organisations in which they work.
The authors recommend that it would be helpful for therapists to talk about vicarious trauma in clinical supervision, training, and reflective practice. This requires therapists being willing to do this, and therefore, being supported and encouraged by their supervisors to do so.
Additionally, one of the most important findings of this review is that some therapists experience growth as they witnessed their clients’ recovery during therapy sessions. This can be especially protective against thoughts of self-doubt (Bartoskova, 2017). Therefore, integrating stories of strength and resilience into clinical supervision, training and reflective practice programmes could be a significant protective factor for the mental health of therapists.
Finally, the authors do note that the studies included in their review did not consider the impact of vicarious trauma on the therapeutic relationship nor on the quality of patient care. This is an important area that warrants further attention.
Statement of interests
ST is a first-year PhD student at UCL in the Division of Psychiatry, exploring the impact of trauma on high-risk occupational groups and their families.
JB is a Consultant Clinical Psychologist and Associate Clinical Professor in the Division of Psychiatry at UCL with over 20 years of experience working in the NHS and in specialist trauma services, with particular expertise in PTSD, mental health, and well-being in high-risk occupational groups.
McNeillie, N., & Rose, J. (2020). Vicarious trauma in therapists: a meta-ethnographic review. Behavioural And Cognitive Psychotherapy, 49(4), 426-440. doi: 10.1017/s1352465820000776.
Arnold, D., Calhoun, L. G., Tedeschi, R., & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of Humanistic Psychology, 45, 239-263.
Barnett-Page, E., & Thomas, J. (2009). Methods for the synthesis of qualitative research: a critical review. BMC Medical Research Methodology, 9, 59–70.
Bartoskova, L. (2017). How do trauma therapists experience the effects of their trauma work, and are there common factors leading to post-traumatic growth? Counselling Psychology Review, 32, 30–45.
Herman, J.L. (1992). Trauma and Recovery: The Aftermath of Violence. New York, USA: Basic Books.
Pearlman, L., & MacIan, P. (1995). Vicarious traumatisation: an empirical study of the effects of trauma work on trauma therapists. Professional Psychology—Research and Practice, 36, 558–565.
Sodeke-Gregson, E., Holttum, S., & Billings, J. (2013). Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients. European Journal Of Psychotraumatology, 4(1), 21869. doi: 10.3402/ejpt.v4i0.21869.
Stevenson, D., & Farmer, P. (2017). Thriving at work: the Stevenson/Farmer review of mental health and employees [online]. Department for Work & Pensions and Department of Health.
Teh, Y. Y., & Lek, E. (2018). Culture and reflexivity: Systemic journeys with a British Chinese family. Journal of Family Therapy, 40, 520–536. doi:10.1111/1467-6427.12205