Secondary and vicarious trauma: implications for faith and clinical practice.

Wang, David C. ; Strosky, Daniel ; Fletes, Alexis 等

The paradox of the wounded healer--the one called to look after their own wounds while at the same time remaining prepared to heal the wounds of others--is a metaphor rich in biblical allusion, providing a profound entry point for those interested in contemplating the person and work of Christ (Nouwen, 1979). It is also a metaphor that captures the experience of many mental health professionals as they journey empathically alongside their clients. Figley (1995) was among the first to highlight what he described as the cost to caring--how mental health professionals (especially those who work extensively with survivors of trauma) who empathically listen to their clients' stories of fear, pain, and suffering often find themselves feeling similar fear, pain, and suffering.

In the past two decades, a growing body of literature has formally investigated the effects of trauma work on those who are working with traumatized individuals. Trauma workers represent a population of special interest due to the frequency of exposure to traumatic material inherent in their work. This is the case in part because empirically supported treatments for Posttraumatic Stress Disorder (PTSD), such as Cognitive Processing Therapy (CPT; Resick & Schnicke, 1992) and Prolonged Exposure (PE; Foa, Rothbaum, Riggs, & Murdock, 1991) typically involve the telling and retelling of traumatic experiences in significant detail. This is done in the hope of breaking through clients' avoidance of traumatic memories and reminders (Elwood, Mott, Lohr, & Galovski, 2011), which is understood to be a key component to recovery from PTSD. As such, clinician exposure to distressing material accumulates significantly as treatment is provided to multiple clients concurrently over time. Research interest in this area has been further galvanized in recent history by a revision of the diagnostic criteria for PTSD in 1994 to account for the possibility that the witnessing or hearing of threatened death or serious injury occurring to another individual may in itself constitute a traumatic event (APA, 1994).

Secondary Traumatic Stress

Secondary Traumatic Stress (STS) is a term used to describe reactions and symptoms observed among trauma workers that run parallel to those observed in people directly exposed to trauma (Bride, Robinson, Yegidis, & Figley, 2004). Understandably, a therapist might run the risk of absorbing the sight, sound, touch, and feel of the stories told in detail by the trauma survivor (Richardson, 2001). These consequences are understood to be the result of secondary or indirect exposure to the traumatic material of clients who experienced the trauma first-hand (Cieslak et al, 2014). The symptoms of STS are nearly identical to those of PTSD and include all three symptom clusters of PTSD--intrusive re-experiencing of the primary survivor's traumatic event, persistent arousal, and the avoidance of reminders of the traumatic event. Furthermore, it is believed that STS can potentially develop immediately following just one exposure or incident (Figley, 1995). Because secondary exposure to trauma can occur among persons having close contact with a trauma survivor (regardless of whether or not they are mental health professionals), STS may also be present among members of the survivor's primary social support network, such as close family members (Jenkins & Baird, 2002).

STS can also be understood as the natural consequence of caring between two people--one who has been initially traumatized and the other who is affected by listening to the former's traumatic experiences (Figley & Kleber, 1995). As such, Figley (1995) at times expressed preference for the use of the broader term, compassion fatigue, over STS to decrease stigma and to normalize this reaction as a common occupational hazard for those who conduct work in trauma. Compassion fatigue is defined as a reduced capacity for empathy or client interest manifested through behavioral and emotional reactions from exposure to the traumatic experiences of others (Adams, Figley, & Boscarino, 2008). Though related to STS, compassion fatigue refers to a broader range of emotional or cognitive consequences to secondary exposure--including those that may not directly resemble PTSD-like symptoms (Cieslak et al., 2014). Unfortunately, the distinction between STS and compassion fatigue is not always clearly delineated and the two terms are frequently used interchangeably in the literature (Devilly, Wright, & Varker, 2009).

Vicarious Trauma

While secondary traumatic stress refers to the experiencing of PTSD-like symptoms among individuals exposed to the trauma narratives of others, vicarious trauma (VT) incorporates the pervasive and cumulative effects of indirect exposure to trauma over time, which often entails long-term modifications to an individual's way of experiencing themselves, others, and the world (Pearlman & Saakvitne, 1995; Trippany, White, & Wilcoxon, 2004). Vicarious trauma is further distinguished from secondary traumatic stress in that the former tends to be associated with trauma that is chronic, repetitive and pervasive while the latter may be associated with a single traumatic event (Jordan, 2010). Neumann and Gamble (1995) suggested that VT represents a form of counter-transference stemming from inadequate differentiation between the therapist and the traumatized client. Most research on vicarious trauma, however, draws from the Constructivist Self-Development Theory (CSDT; McCann & Pearlman, 1990) as its theoretical framework, which posits that individuals construct their own realities through the development of cognitive schemas--that is, cognitive structures that include a person's beliefs, assumptions, and expectations about themselves, others, and the world. These schemas evolve over time, as new information is assimilated from new life experiences. However, if this new information is incompatible with existing belief systems and cannot be readily assimilated into them, the original schemas can become invalidated or shattered--as is often the case when clinicians emotionally process and make sense of the horror of their clients' traumatic experiences (Janoff-Bulman, 1992). When an individual experiences vicarious traumatization, their schemas are being modified in a manner that heightens emotional distress and amplifies sensitivity to information that confirms negative beliefs regarding their safety, power, control, independence, esteem, and intimacy with others (Elwood et al., 2011).

Empirical evidence suggests that the deleterious effects of indirect trauma exposure on the therapist include: greater emotional distress, lower levels of self-trust, dissociative symptoms, and diminished quality of interpersonal relationships (Betts-Adams, Matto, & Harrington, 2001; Pearlman & Maclan, 1995). The findings of studies investigating the prevalence and specificity of secondary trauma symptoms in trauma clinicians are mixed, however, as they often report symptoms that do not reach clinically significant thresholds (Elwood et al., 2011). Of the studies that did report clinically-significant secondary traumatic stress, prevalence rates varied across samples, ranging from 8-10% in humanitarian aid workers (Shah, Garland, & Katz, 2007; Eriksson, Vande Kemp, Gorsuch, Hoke, & Foy, 2001), 15.2% in social workers (Bride, 2007), 16.3% to approximately 20% among clinicians treating patients affected by cancer (Kadambi & Truscott, 2004), 34% in child protective services workers (Bride, Jones, & MacMaster, 2007), to 4652% in clinicians treating sexual offenders and sexual abuse survivors (Steed and Bicknell, 2001; Way, VanDeusen, Martin, Applegate, & Jandle, 2004).

Several potential risk factors predicting greater negative effects of indirect trauma exposure have been identified, including: increased caseload and severity of client trauma symptoms (Bober, Regeher, & Zhou, 2006; Craig & Sprang, 2010), fewer years of clinical experience (Adams & Riggs, 2008), a self-sacrificing approach to psychological defensiveness (Adams & Riggs, 2008), a lack of available organizational support such as peer supervision and consultation (Jordan, 2010), and the use of clinical treatments that were not evidence-based (Craig & Sprang, 2010). Notably, studies investigating whether having a personal trauma history predicted secondary trauma have been inconclusive, with some reporting a significant relationship (Bride, Jones, & MacMaster, 2007; Jenkins & Baird, 2002) while others finding little or no relation (Bober & Regehr, 2006; Michalopoulos & Aparicio, 2012). Among the studies that did not find a relationship between the two, Michalopoulos and Aparicio (2012) suggested that part of the reason why may be because those with a personal trauma history typically received their own treatment, which buffered them from developing not only their own primary trauma symptoms, but also vicarious trauma symptoms as well. Last, the type of trauma being worked on also moderated the impact of trauma work on the therapist. For example, Bober and Regehr (2006) found that the types of trauma that correlated most strongly with secondary trauma symptoms included physical assault on the wife, child abuse, child sexual abuse, sexual violence, rape, and torture; however, work with workplace trauma, victims of violent crime, and unexpected death did not correlate strongly with STS.

As previously noted, vicarious trauma may entail negative long-term modifications to an individual's way of experiencing themselves, others, and the world. For example, Cunningham (2003) found that clinicians who regularly treated sexual abuse clients endorsed greater disruption in their own ability to perceive others as safe, trustworthy, and esteemed. Although spirituality has been suggested as a protective factor for vicarious trauma (Trippany et al., 2004), Dombo and Gray (2013) note that VT can also threaten a clinician's spirituality by compromising their ability to deriving meaning and purpose from their work, resulting in a greater sense of hopelessness and internalized suffering of their client's trauma.

Clinical Applications

Clinicians would benefit from identifying and applying protective practices that mitigate the risks of indirect traumatization. Harrison and Westwood (2009) underscore how the ethical responsibility to address the serious problem of vicarious trauma is shared not only by individual clinicians but also by employers, educators, and professional bodies; this can be done in part through the provision of consistent and supportive supervision as well as relevant education and training opportunities, organizational policies that promote work-life balance, opportunities for clinicians to take part in a diversity of professional roles (e.g., teaching, supervising, and/or administration in addition to direct practice), both professional and personal social support networks, coping and self-care practices (e.g., sleeping practices, exercise, eating habits, anxiety management), and referrals for clinicians to receive their own personal therapy if needed (Jordan, 2010; Trippany et al., 2004; Way et al., 2004). Concerning the protective role of supervision on vicarious traumatization, especially for new therapists, researchers highlight the importance of early detection, special supervisory attention on issues relating to counter-transference and potential boundary violations between therapist and client, and a safe, supportive environment where the therapist does not feel ashamed to be experiencing vicarious trauma but rather recognizes it as a normal response for those who work with trauma clients (Neumann & Gamble, 1995).

Six peer-nominated master therapists were interviewed in a qualitative study conducted by Harrison and Westwood (2009), where each therapist was asked the question, "How do you manage to sustain your personal and professional well-being, given the challenges of your work with seriously traumatized clients?" Notably, the authors found that most of the clinicians described how intimate and empathic engagement with clients sustained them even in their trauma work; this was a surprise given that empathic engagement was understood to be a risk factor for vicarious traumatization rather than a protective practice. This paradoxical finding is an important one to consider as it underscores the point that efforts to prevent vicarious traumatization should not preclude the empathic bond between therapist and client that is so fundamental to the therapeutic process. One research participant in the study explained, "I actually can find sustenance and nourishment in the work itself, by being present and connected with the client as possible. I move in as opposed to move away, and I feel that this is a way that I protect myself against secondary traumatization. The connection is the part that helps and that is an antidote to the horror of what I might be hearing." (Harrison and Westwood, 2009, p. 213)

Dombo & Gray (2013) also encourage the implementation of spiritually based interventions for vicarious trauma such as rest-taking, spiritual collaboration, pro-spiritual support and supervision, meditation, and the maintenance of individual spiritual practices that bear personal significance to the clinician--such as prayer, the reading of sacred texts, and spending time out in nature. Enhancement of therapist spirituality is thought to reinforce several positive dispositions and beliefs, including the conviction that people are resilient and can heal, that growth can still occur within the context of trauma, that there is more to life than suffering, that their professional efforts are indeed meaningful, and that they are not solely responsible in their efforts to heal their clients' trauma (Harrison & Westwood, 2009). Another approach to integrating the practice of spirituality into the daily life of the therapist is to cultivate greater mindfulness--and specifically, a more mindful awareness of the interrelatedness of one's mind, body, and spirit (for further guidance on the practice of mindfulness from a Christian perspective, see Tan, 2011).

Because indirect exposure to trauma may potentially lead to cognitive shifts that negatively influence therapists' basic assumptions about the self and the safety of the world (Janoff-Bulman, 1992), as well as their beliefs concerning matters relating to trust, intimacy, and control, supervision may also provide an ideal context for these cognitive shifts to be discussed openly (Trippany et al., 2004). Moreover, for the Christian therapist in particular, it may be especially important for supervision to address potential shifts in religious and spiritual cognitions. This is because religious beliefs comprise a substantial part of one's global meaning system (Park, 2005) and because they also address issues of existential meaning, which may be called into question through either direct or indirect exposure to trauma (Janoff-Bulman, 1992).

The relationship between trauma and the practice of one's Christian faith is complex, however, with some trauma survivors relying upon their faith as a significant resource for recovery, while others finding it as a source of distress, and still others abandoning their faith altogether (Harris et al., 2008). This multidimensional impact of trauma on faith can similarly be expected for Christian therapists indirectly exposed to trauma as well. For instance, exposure to trauma may give rise to different manifestations of spiritual discontent (Pargament, Koenig, & Perez, 2000), such as anger directed toward God, a sense of betrayal from God, a questioning of God's love, mistrust toward God, or the feeling that one has been abandoned by God. Just as such themes may naturally arise within the trauma client over the course of therapy, parallel themes may also emerge within therapists as they seek to make meaning of the traumatic experiences for themselves, often from within the context of their own Christian beliefs. Notably, spiritual discontent has been found to not only be related to PTSD symptoms (Exline, Yali, & Lobel, 1999), but also to partially mediate the relationship between trauma and PTSD symptomatology (Wortman, Park, & Edmondson, 2011). As such, it is possible that interventions targeting the specific impact of trauma on faith (within the context of training, education, and supervision, for example) can be understood as not only a preventative measure but also a possible treatment for vicarious traumatization or secondary traumatic stress.

When someone personally experiences a trauma or bears witness to another person's trauma, religious assumptions are likely to be disrupted as belief in a benevolent, omnipotent God may appear inconsistent with traumatization (Cadell, Regehr, & Hemsworth, 2003). Said differently, trauma may lead one to doubt whether God is loving, whether God is all-powerful, or perhaps both. To illustrate, a traumatic event may sensitize an individual to their lack of personal control over matters relating to their own safety or to the safety of those they love. They may then choose to compensate for their own perceived lack of control by attributing the traumatic event to God's control (Kay, Gaucher, Napier, Callan, & Lauin, 2008). However, doing so would not only call into question God's kindness, but would also likely not reduce trauma-related anxiety either--because the perceptions of threat have been merely redistributed from human forces to spiritual ones (Wortmann, Park, & Edmondson, 2011). As the conviction that God is both loving and all-powerful represent tenets that are fundamental to the Christian faith, it would be understandable for a Christian therapist--one who may be seen within their spiritual community as an exemplar of the faith and a spiritual guide to many--to experience marked ambivalence in disclosing these personal doubts. Supervision should therefore seek to be sensitive to and minimize the potential impact of religious guilt and shame inherent in expressing such uncertainties. In doing so, it is hoped that therapists may begin to more freely explore and discover how they might newly relate to God in light of these traumatic events.

A Christian approach to making sense of trauma must take seriously the mystery of the theodicy paradox--that is, how so much evil and suffering can exist in a world that was created and is sustained by a good and omnipotent God. An important starting point to this end would be to avoid trivializing this paradox by presuming that it can be rationally resolved or explained away (cf. Job 18:5, Job 24:31-37). Part of the reason why this is the case is because evil cannot be adequately conceptualized in the abstract--it can be experienced only in particular forms (Boyd, 1997). And the full horror of evil that is often experienced (whether directly or indirectly) within the context of trauma often shatters any previously held explanations of evil and suffering--theological or not. Therefore, phrases such as "God has His reasons" and "His ways are not our ways," regardless of their possible theological or philosophical merit, can be counterproductive because they may represent superficial and trite explanations that tend to disregard the profound gravity of the trauma survivor's lived experience.

Last, a Christian approach to trauma also makes space for the powerful negative emotions that arise at the hand of trauma-related injustice, grief, and loss. Indeed, Scripture is steeped in the language of lament (cf. Jeremiah 15:18, Psalm 10:1, Psalm 13:1), which was modeled by Christ Himself (cf. Mark 16:34). Biblical lament language is the language of the soul, of lived human experience, of uncensored feelings spoken freely and audaciously before the presence of God. It is spoken out of the conviction that God's will is not perfectly realized in this current age (Ladd, 1990), and as a response to this reality, petitions that God's Kingdom come and will be done on earth as it is in heaven (cf. Matthew 6:10). And in so doing, our work in trauma may take an eschatological turn--because things such as sickness, disease, war, death, sorrow and tears will all come to an end when God's Kingdom is consummated and every evil which causes such sorrow, vanquished (Boyd, 1997).

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David C. Wang, Daniel Strosky, & Alexis Fletes

Biola University

Correspondence concerning this paper should be addressed to David C. Wang, Th.M., Ph.D. at Rosemead School of Psychology, 13800 Biola Avenue, La Mirada, CA 90639; david.wang@biola.edu.

David C. Wang, Th.M. (Regent College), Ph.D. (University of Houston) is an Assistant Professor of Psychology at the Rosemead School of Psychology, Biola University in La Mirada, CA. He is also the Associate Editor of the Journal of Psychology and Theology. His research focuses on trauma/traumatic stress, spiritual theology (spiritual dryness and the Dark Night of the Soul), multicultural psychology, and mindfulness.

Daniel Strosky, M.A. (Talbot School of Theology), M.A. (Rosemead School of Psychology) is a student in the Psy.D. program at the Rosemead School of Psychology.

Alexis Fletes, M.A. (Pepperdine University), M.A. (Rosemead School of Psychology) is a student in the Psy.D. program at the Rosemead School of Psychology.