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This is to certify that the

dissertation entitled

THE IMPACT OF WORKING WITH TRAUMA SURVIVORS
ON TRAUMA THERAPISTS

presented by
Brooke VanBuren-Hay

has been accepted towards fulfillment
of the requirements for

Ph .D . degree in Counselinfi Psychology

 

 

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Date 6/45/01

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PLACE IN RETURN Box to remove this checkout from your record.

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6/01 chlRC/DataDuepSS-DJS

THE IMPACT OF WORKING WITH TRAUMA SURVIVORS ON THE TRAUMA
THERAPIST
By

Brooke VanBuren—Hay

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Counseling Psychology

2001

ABSTRACT
THE IMPACT OF WORKING WITH TRAUMA
SURVIVORS ON THE TRAUMA THERAPIST
By

Brooke VanBuren-Hay

This study explored the impact of working with trauma survivors on the
trauma therapist. Self-care skills of the therapist were also addressed. Six
trauma therapists were interviewed for ninety minutes. A follow up contact one
week later was used to further illicit information. The data was analyzed using a
modified analytic induction process. The data were reviewed for common and
divergent information. Main themes were created for each case, and then
compared with all of the cases in order to create consistency. The final results
were presented to illustrate the impact of work with trauma survivors, as well as
the self-care skills used by the therapists. A model of the results was created to
display a pictorial representation of the findings. Recommendations for training,

supervision, and support for the new trauma therapist are provided.

This is dedicated to Bill, VIctoria, and Quinton, without your love and support, this

would not have been possible.

iii

ACKNOWLEDGMENTS

Bill, thank you for all the love and support. I will always be appreciative and
moved by the way you used to stay up with me at night while I worked, just
because this is the type of person you are!

Victoria and Quinton, thank you for helping Mama remember what is truly
important.

Thank you to my Mom, who taught me that a woman can complete this project
with two children, and do it well. i admire you.

Thank you to my Dad, who always supported me, and knew that I knew
exactly what I was doing.

Thank you to Chris and Robin, for helping me to maintain my sense of humor.

Aunt Janice, thank you for all of the fun diversions; the puzzles, they do help
develop good cognitive skills.

Barbara and Jack, thank you for making the meaning of extended family so
supportive and warm.

John and Yvette, thanks!

Dave and Cora, thank you for all your support and love.

Judy, there are not enough words to tell you how important you have been to
me in this process, and in my life. Thank you for all the Friday nights of fun, food,

and good conversation!

Laura, without you I would not have made it through this program having had
as much fun. You are a great support, and a wonderful friend. Thank you!

To all of my women friends-Anna, Moira, Jacque, Barb-thanks for the support
andlove.

Dr. Rice, thank you for all of your guidance through this process.

Dr. Steward, your support through this program, and through this project has
been much needed and appreciated. l will always remember your kind and warm
nature.

Dr. Schuiteman, I was very lucky that our paths crossed. Your support and
advice have helped me through some difficult moments. Thank you.

Dr. Campbell, I appreciated all of your insight and guidance on this project.

Dr. Patterson and Carmen Gear, your support, good humor, and faith in me
helped me through. Thank you.

Thank you to the therapists that were interviewed for this project. Your

insight, knowledge, and willingness to share made this possible.

TABLE OF CONTENTS

CHAPTER 1
Introduction .................................................................................................. 1
Background ................................................................................................. 1
Purpose of the study .................................................................................... 7
Approach to inquiry ...................................................................................... 8
CHAPTER 2
Literature review ........................................................................................ 11
Secondary traumatic stress/compassion fatigue ................................... 11
Vicarious traumatization ........................................................................ 14
Countertransference .............................................................................. 26
Burnout ................................................................................................. 28
Self-care skills ....................................................................................... 32
CHAPTER 3
Design ....................................................................................................... 44
Data collection ........................................................................................... 45
Participants ................................................................................................ 46
Data analysis ............................................................................................. 47
Generalizability .......................................................................................... 48
Role of the researcher ............................................................................... 49
CHAPTER 4
The therapists .............................................................................. 52
Initial hypothesis ........................................................................................ 53
Main themes .............................................................................................. 53
Skills ..................................................................................................... 54
Emotional toll ........................................................................................ 57
Circumstances ...................................................................................... 68
Self care skills ....................................................................................... 76
Support ................................................................................................. 80
Opportunity ........................................................................................... 83
Altruism ................................................................................................. 84
Benefits ................................................................................................. 86
Growth .................................................................................................. 88
Coping with emotion-application ............................................................ 91
Core values ........................................................................................... 94
Personal history .................................................................................... 95
Hope ..................................................................................................... 96
CHAPTER 5
The model ................................................................................................ 112

vi

TABLE OF CONTENTS

Limitations ................................................................................................ 1 16
Implications .............................................................................................. 1 18
Conclusion ............................................................................................... 120
APPENDICES .................................................................................................. 121
REFERENCES ................................................................................................. 126

vii

Chapter One
Introduction

This study explores the impact of work with trauma survivors on the therapist.
Self-care skills of the trauma therapist are also addressed. A qualitative design
was used to illustrate a model of the impact of trauma work and the self-care
skills of the therapists who continue to do this work.
Backgroung

The incidences of trauma in this country continue to rise (FBI Statistics, 1998).
According to the Diagnostic and Statistical Manual 4th edition (DSM-IV), 58% of
the population has or will experience some form of trauma that may warrant a
diagnosis of Posttraumatic Stress Disorder (PTSD) (APA, 1994). Given the
number of people experiencing trauma, the number of these people seeking
mental health services is substantial. As a result, more knowledge and attention
needs to be given to the therapists working with trauma survivors. To date, the
majority of literature addressing trauma focuses on the primary trauma survivor.

INIIson and Lindy (1994) define traumas as being divided into human-made
and naturally occurring traumas. According to the DSM- IV, natural or human-
made traumas that could lead to a diagnosis of PTSD could include sexual
assault, natural disaster, domestic violence, or an act of terrorism. It is important
to note that although these events are distressing in and of themselves, it is the
individual’s response to the event that determines whether the event is traumatic.

An event is considered traumatic to the individual when he or she is unable to use

everyday coping skills to attend to the event. A trauma taxes a person’s coping
ability.

It has been documented that doing psychotherapy is difficult, and that it affects
the therapist (Figley, 1995). Trauma therapists face a unique set of difficulties
given that they are facing material that is often horrific, and that can illustrate the
cruelty of humans towards each other. Given the difficult nature of this work it is
important to understand how this work affects the therapist, not only in an effort to
support and protect the therapist, but also in an effort to assist in providing quality
services to clients. As Pearlman and Saakvitne (1995) note, “too often,
therapists, counselors, trauma workers, and researchers lack conceptual
frameworks, practical approaches, and supportive environments for either
examining their role in relationships with trauma survivors or for understanding
the impact their work has on them. Lack of information and training increases the
likelihood that therapists will impose their needs and conflicts on their clients and
psychotherapies" (p. 1). Therefore, it is important for therapists to understand the
impact on them that work with trauma survivors can have. It is not often that '
therapists find a forum in which to share their work; not having such a forum
keeps the impact of working with trauma a solitary act. The literature will show
that feelings of being alone are often quite disturbing to trauma therapists.

Several concepts address the potential impact trauma may have on support
people such as therapists. These concepts most commonly referred to include
secondary traumatic stress/compassion fatigue, vicarious traumatization,

countertransference, and burnout. Although the concepts may have overlapping

I‘J

components, each one provides a distinct and important description of the effects
of trauma work.

Secondary traumatic stress or compassion fatigue is a concept that was
created by Charles Figley (1991) that uses Posttraumatic Stress Disorder as a
foundation. This concept identifies the trauma symptoms that professionals may
develop as a result of working with the primary traumatized individual. According
to Figley (1995), unwanted memories of a traumatic event, a sudden re-
experiencing of a traumatic event, feelings of detachment, difficulty concentrating,
and sleep disturbances are all symptoms that can appear in therapists as a result
of work with trauma survivors. Whereas this construct is symptom based,
another similar construct, vicarious traumatization, focuses less on symptoms and
more on “...meanings and adaptations...” (Pearlman & Saakvitne, 1995, p. 281).

Vicarious traumatization is the damaging effects on therapists who work with
trauma survivors over a long period of time (Pearlman & Saakvitne, 1995). The
duration of the work is critical in vicarious traumatization. Saakvitne and
Pearlman (1996) define vicarious traumatization as ‘...the cumulative
transfom'tative effect upon the trauma therapist of working with survivors of
traumatic life events” (p. 31). Vicarious traumatization encompasses not only
behavioral or symptom responses but addresses cognitive schemes of the
therapist that can be affected by working with the survivor population. McCann
and Pearlman (1990) noted several specific schemes that can be affected when a
therapist begins to engage with his or her client. These schemes are identity,

worldview, psychological needs, beliefs, and memory system of the therapist

(McCann & Pearlman, 1990). Each of these schemes can be affected either in a
positive or negative manner. It is believed that “vicarious traumatization is the
transformation in the inner experience of the therapist that comes about as a
result of empathic engagement with clients’ trauma material” (Saakvitne &
Pearlman, 1996, p. 31). Being able to engage with clients is the basis for good
clinical work, yet as noted above, it is also what may be the catalyst for vican'ous
traumatization. The concept of vicarious traumatization speaks to the idea that
trauma work changes a person forever, and is not situationally or momentarily
based.

Countertransference is a psychological concept that originated with Sigmund
Freud in the early 19005 (Wilson & Lindy, 1994). Countertransference is the
reaction of the therapist to the client's responses to the material discussed in
therapy and to the therapist. Wilson and Lindy ( 1994) describe
countertransference responses as being expected aspects of work with trauma
survivors. Two very important reasons for beginning to understand the
countertransference reactions of therapists are the potential harm to self and to
the clients that unresolved countertransference issues could cause. These
authors identify how countertransference can have both positive and negative
effects on the therapist and the survivors (Wilson & Lindy, 1994).
“Countertransference positions (role enactments) range from positive (the
therapist becomes a fellow survivor or a helpful supporter, rescuer, or comforter
near the trauma) to negative (the therapist becomes a ‘tumcoat' collaborator or

hostile judge)” (Wilson & Lindy, 1994, p. 9). A therapist’s reaction to the trauma

story of his or her client may be the result of the therapist’s own personal history
or it may be only related to the horrific nature of trauma. Either way it is important
for each therapist to attend to countertransference issues with each client.

Wilson and Lindy ( 1994) note that “...countertransference can lead to empathic
strain which, if unmanaged, will cause a rupture of empathy and a loss of
therapeutic role” (p. 13).

According to Wilson and Lindy (1994) empathic strain can manifest in
several different reaction styles of the therapist. There are four types of reactive
styles: empathic withdrawal, empathic disequilibrium, empathic enmeshment,
and empathic repression. These reactive styles can be divided into two
categories: objective and subjective. Empathic disequilibrium and empathic
withdrawal are considered objective reactions. These reactions are characterized
by “...expectable affective and cognitive reactions experienced by the therapist in
response to the personality, behavior, and trauma story of the client...” (p. 16).
Alternatively empathic enmeshment and empathic repression are thought of as
subjective reactions. These reactions “...originate from the therapist’s personal
conflicts, idiosyncrasies, or unresolved issues from life course development”
(Wilson & Lindy, 1994, p.16). Wilson and Lindy have created a model that helps
a therapist to begin to understand his or her reaction style as it relates to
countertransference issues. Wilson and Lindy (1994) found that,

elaborating a two-dimensional model for a topology of countertransference
has its limitations as well as its value, and we do not mean to say that all

relevant complex countertransference reactions to PTSD fit neatly into one

of the four quadrants...Nevertheless, this model provides an important
starting point, one that includes rather than excludes other descriptive
dimensions and, for purposes of clinical use, establishes an important point
of orientation. (p. 18)
Although the countertransference reactions of therapists are often difficult to
identify, the research supports active awareness of these reactions in order to
decrease the harm that can occur to therapists and to their clients.

Burnout is another concept used to identify the effects of working with a
difficult population. Burnout is defined as “emotional exhaustion resulting from
the stress of interpersonal contact” (Maslach, 1978, p. 56). One major
distinguishing factor between burnout and the previously mentioned concepts is
that burnout can occur with any client population whereas the other concepts are
trauma population specific. lliffe and Steed (2000) note that some relevant
symptoms of burnout a therapist might experience are “...diminished self-concept,
irritability, loss of compassion, and feelings of discouragement” (p. 395). In
addition to these emotional symptoms, burnout can include physical components
as well. Ailments such as headaches, recurrent colds and other stress related
illnesses have been noted (lliffe 8: Steed, 2000).

Each of these concepts provides a good basis for beginning to understand the
impact of trauma work. However another component needs to be added that
describes how a therapist copes with these effects. After exploring how trauma

work affects therapists, a natural second inquiry concerns self-cane skills, and the

ways in which therapists take care of themselves given the difficult nature of
trauma work.

Self-care is a topic that has received very little attention in the literature. Many
of the studies or writings that address self-care do so by focusing on the client as
opposed to the therapist. “So much has been written about treating survivors of
sexual abuse, but not until recently have sexual abuse therapists acknowledged
the need to develop a certain set of practices to assist them in dealing
emotionally and mentally with the traumatic stories imparted to them on an
ongoing basis” (Bell-Gadsby & Siegenberg, 1996, p. 213). Of considerable
interest is the minimal attention directed towards the self-care literature for both
general psychotherapists and trauma therapists.

Purpose of the Study

The main purpose of this study is to provide a model of how trauma work
impacts therapists based on interviews with six trauma therapists. This model will
also address the self-care skills used by trauma therapists. I will identify how
trauma impacts not only the professional life of the therapist but the personal life
as well. I would hope that this small-scale model would be used to provide
support for future research in the area of trauma therapists, which in turn could
aid teaching, training, and supervision. I also hope this model and the process of
participating in the study will be beneficial to the trauma therapists. Hopefully, by
being able to discuss his or her work, each therapist will gain a better

understanding of how this work has impacted him or her. Also by giving each

therapist an opportunity to discuss his or her self-care skills, perhaps this will

assist in identifying strengths or weakness in the area of self-care.

Aggroach tg lnguijy

The interest in interviewing, and using the data to begin to create a model of
the impact of trauma work on therapists, is based in narrative theory. Narrative
theory is based in constructivism, which has many different models. In general,
constructivists believe that the individual creates meaning and reality. “It is our
own personal truth, with its inner coherence and internal logic, that we construct”
(Rosen & Kuehlwein, 1996, p. 5). The form of constructivism that was used in
this project was more closely related to social constructivism, in that I the
researcher was not merely a silent observer, but influenced either directly or
indirectly, the responses of the therapist. The therapist’s responses in turn
influenced my behavior as well. Thus, what was constructed was not solely from
the individual but from the interaction of the environment as well. Use of
narrative theory in psychotherapy allows the client to tell and retell his or her
story, and begin to construct new meanings and possibly new outcomes to his or
her life. I believe that narrative theory provides a good foundation for listening to
therapists’ discussion of their work with trauma survivors. Perhaps through the
telling of their story as a trauma therapist, he or she can make sense, draw
conclusions, and affect change in his or her life as needed. Also because many
therapists have limited opportunity to discuss with anyone the impact of providing

therapy, allowing each therapist to talk about him or herself may be healing. And

by sharing their stories through this project, other therapists may also be able to
gain new meaning and perspective about their work with trauma survivors.

A qualitative design is the most appropriate design given this theoretical
approach. Narrative theory relies on the individual being able to talk about his or
her experiences in an open format, which a qualitative design more clearly allows
than a quantitative design. Qualitative designs can have many different forms but
all are created from a similar foundation. This foundation is comprised of several
assumptions that form the basis for qualitative study. First, the qualitative
researcher is interested primarily in process, and secondarily with outcomes or
products. Another assumption is that the researcher is concerned with meaning
or how the individual makes sense of his or her experience or situation. A third
assumption is that the researcher is the primary instrument in data collection and
analysis. Fourth, qualitative research involves fieldwork; the researcher has to go
out into the field to discover the events and the people. The fifth assumption is
that qualitative research is descriptive; the researcher will describe processes,
events, and experiences. Lastly qualitative research is inductive rather than
deductive. The researcher is attempting to build hypotheses or theories from
small pieces of information (Bogdan & Biklen, 1982).

The rationale for conducting a qualitative study on the impact of work with
trauma on therapists can be found in Morse’s (1991) descriptions of the
appropriate use of qualitative designs. “Characteristics of a qualitative research
problem are: (a) the concept is ‘immature’ due to a conspicuous lack of theory

and previous research; (b) a notion that the available theory may be inaccurate,

inappropriate, incorrect, or biased; (c) a need exists to explore and describe the
phenomena and to develop theory; or (d) the nature of the phenomenon may not
be suited to quantitative meesures.”(p. 120). The rationale for this study is
encompassed by all of the criteria. This study will attempt to create a model of
the impact of working with trauma survivors on trauma therapists, as well as how

the therapists respond to these effects.

IO

Chapter Two

Literature Review

d re m i st slcom assion feti u

The empirical literature on secondary traumatic stress/compassion fatigue is
scent. The majority of the literature is theoretical. Originally, secondary traumatic
stress (STS; Figley, 1991) was created to describe the effects of trauma work on
first responders such as police, fire, or emergency medical personnel. As the
field of traumatology grew, the need to understand the effects of trauma work on
other professionals became apparent. Dutton and Rubinstein (1995) have used
Figley’s concept of STS to identify the possible effects of trauma work on mental
health professionals. According to their model, there are three primary areas that
an be affected by work with trauma survivors. These areas are psychological
distress or dysfunction, changes in cognitive schema, and relational disturbances
(Dutton 8 Rubinstein, 1995). From these anticipated areas of disturbance,
Dutton and Rubinstein (1995) have created a theoretical model that explains STS
reactions. The authors note four main domains of their model as being the
traumatic event, the trauma worker's reaction to the event, the coping strategy of
the trauma worker, and the personal and environmental aspects of the trauma
workers life. According to these authors, a mental health person who works with

trauma survivors will note disturbances in either one or more of these domains.

ll

The first domain identified by Dutton and Rubinstein (1995) is the traumatic
event itself. The authors believe that the number of traumatic incidences a
person encounters does not matter but that it is the simple fact of facing a trauma
that can lead to STS. This point becomes very important when considering that
trauma therapists at times solely encounter trauma day in and day out. The very
focus of the trauma therapists’ work is trauma.

The second domain is the reactions of the mental health worker to the
traumatic event. Given that mental health workers often work with survivors of
trauma over an extended period of time, the response of the mental health worker
can be quite varied. The work over an extended period of time often focuses not
only on the traumatic event itself but also on the psychological response of the
survivors. It can be these responses that affect the functioning of the mental
health worker. Dutton and Rubinstein (1995) note that being faced with the fear,
guilt, shame, rage, and hopelessness of a survivor can be overwhelming. “The
complex assignment to integrate knowledge of the client’s life history, premorbid
(i.e., prior to the onset of current or prior traumatic event) level of functioning,
tangible and social support resources, other stressors in the client’s life, and
personal strengths with information about the traumatic event and the client’s
response to it places considerable demands on the trauma worker” (Dutton &
Rubinstein, 1995, p. 93). The trauma therapist not only has to be skilled in how
to help clients manage strong emotions, but must also be skilled in managing his

or her own emotional responses.

l2

The third domain identified by Dutton and Rubinstein ( 1995) is the coping
strategies of the mental health professional. The coping strategies of the mental
health professional will help to determine the level of distress he or she
experiences as a result of working with trauma survivors. Dutton and Rubinstein
(1995) believe that the mental health worker will have coping strategies to use in
private life and also ones to use in the professional arena. It is hypothesized that
the more a mental health therapist uses both personal and professional types of
coping the less traumatized he or she may become.

The final domain is the personal and environmental characteristics that may
influence the level of traumatization of the mental health worker. Dutton and
Rubinstein (1995) identify four personal factors that may impact how working with
trauma survivors affects the mental health worker. Inner strength, personal or
professional vulnerability, countertransference issues, and general satisfaction
with personal and professional life are identified as important factors that should
be addressed when conceptualizing the impact of trauma work on mental health
professionals. Some environmental factors that may impact a mental health
worker are personal and professional support, other personal stressors,
institutional responses to trauma, and the social and political context of the
mental health worker (Dutton & Rubinstein, 1995). Each of these areas can
potentially inform the STS reactions of the mental health worker in either a
positive or a negative direction.

Although this concept of secondary traumatic stress reaction for mental health

professionals is discussed in the field of trauma, few studies have been

conducted to verify or document its prevalence or intensity. To date, there are no
empirical studies that have specifically researched secondary traumatic stress.
The studies that mention STS are generally measuring vicarious traumatization
as the primary line of inquiry. These two concepts appear to be considered
interchangeable in the current literature even though their definitions encompass
different aspects of the impact of trauma work on therapists. Given the
overlapping nature of these concepts, the few empirical studies available will be
discussed under the concept of vicarious traumatization in keeping with the
primary line of inquiry of the study, and in many cases keeping with the
terminology used by the authors. A study that addresses the criteria for STS and
the coping skills of the individual would be beneficial given that the model of STS
encompasses not only aspects of the trauma but aspects of the therapist as well.
Vicariogs traumatization

Because vicarious traumatization is a relatively new concept, the few studies
that address the concept were conducted to operationalize and measure
vicarious traumatization. The majority of the writing on this subject has been
conceptual or theoretical in nature, and headed by the team of researchers that
coined the term.

Researchers from the Traumatic Stress Institute coined the term vicarious
traumatization in the eaiiy 19905. Several studies have emerged from these
researchers verifying and further defining the term, as well as providing guidance
for the future on this topic. Pearlman and Saakvitne (1995) authored a book that

addresses specifically the theoretical and conceptual aspects of vicarious

traumatization. The empirical studies that have been conducted support the
existence of vicarious traumatization, and reveal that its effects can have a great
impact on the therapist.

Working with sexual violence survivors

In a study by Schauben and Frazier (1995), 148 counselors were surveyed
regarding their work with sexual violence survivors. The researchers surveyed a
group of female psychologists from an organization of women psychologists, as
well as sexual violence counselors from the Midwest. The participants in this
study were primarily from the organization of women psychologists, White,
heterosexual, in a relationship, and held Master’s degrees. The two groups of
participants differed in that the sexual violence counselors were younger, had
lower incomes, and less education. The two groups were given several different
instruments to identify how the work affected them. F irst, the counselors were
asked about their work with sexual violence survivors. Counselors were also
asked about their personal experiences with trauma. Five subscales of The
Traumatic Stress Institute(TSl) Belief Scale (Pearlman & Maclan, 1993) were
administered in order to measure beliefs and schemes about self and others.
This scale measures the psychological needs described earlier of safety, self-
trust, other-trust, other-esteem and other-intimacy.

Posttraumatic Stress Disorder was assessed using a symptom checklist from
the DSM Ill-R. As noted earlier, F igley’s Secondary Traumatic Stress
disorder(STS) uses the criteria for PTSD. Therefore, this study not only

addresses vicarious traumatization it also was used as a measure of STS.

l5

Vicarious trauma was assessed by using several different scenarios and having
the therapist rate the event or feeling on a five point Likert scale. Negative effect
was also measured in this study by using four subscales of the Brief Symptom
Inventory (BSI). The subscales measured anxiety, depression, hostility, and
obsessive-compulsive symptoms, which can be common among survivors of
sexual violence. Lastly, the Maslach Burnout Inventory (MBI, 1986) was given to
assess levels of burnout.

Schauben and Frazier ( 1995) also asked two open-ended questions in their
study. The first question asked about the five most difficult aspects of this work
and the second question asked about the five most rewarding aspects of working
with survivors. The researchers also assessed coping strategies by having the
therapists endorse the coping strategies they utilized most frequently.

Schauben and Frazier found that counselors that had a high percentage of
survivors on their caseload reported more disruptions in their view of themselves
and others, as well as more PTSD symptoms, and more vicarious traumatization.
Vicarious traumatization was not correlated with negative affect or burnout.
Another finding was that there were no differences in symptoms between
clinicians with or without a prior trauma history.

The final area of the study addressed coping strategies. The most commonly
identified strategies were active coping (defined as doing something about the
problem), seeking emotional support, planning, seeking instrumental support
(defined as getting advice from someone about what to do), and humor.

Schauben end Frazier (1995) found that these five most common coping

strategies were related to lower PTSD symptoms, disrupted beliefs, and vicarious
traumatization. The subjects were asked to write other coping strategies that
were important to them. A common theme in the strategies was performing some
physical activity like exercise. The second most commonly written in response
was engaging in spiritual activities such as meditating and enjoying nature.
Schauben and Frazier ( 1995) found that the third most frequently endorsed
coping strategy was to participate in leisure activities.

. The importance of this study in the literature on vicarious traumatization is that
clinicians’ prior trauma history does not make performing trauma therapy more
difficult; it is equally difficult for clinicians without a prior trauma history.

Schauben and Frazier (1995) conclude based on their findings that hearing the
abuse stories are what makes this work most difficult for clinicians.

This study also found that the clinician’s c0ping strategies are very important.
Clinicians with active coping styles had lower levels of PTSD symptoms,
disrupted beliefs, vicarious traumatization, and negative effect (Schauben &
Frazier, 1995). Although this study does provide information regarding what
helps alleviate some of the difficulties in working with this population, this study
could be strengthened. A more in depth qualitative inquiry would provide the
reader with more information as to how the clinicians developed these active
coping styles. It seems that although active coping is correlated with more
positive functioning for the clinician, no information was gleaned regarding how or
when the clinicians adopted these coping styles. Also it would be important to

find out if the clinicians always had used active coping styles or if they developed

17

as a result of doing trauma work. It would also be beneficial to address how the
clinician’s coping styles at work were similar to or dissimilar from caping styles
used outside of work in order to identify if working with trauma necessitates a
certain type of coping style for longevity in this field. Another issue that could
strengthen the utility of this study to the field of traumatology is further delineating
the differences and/or similarities between STS and vicarious traumatization.
Criteria for STS were gathered, but the syndrome itself was not discussed.
Similar to other studies and articles, these two concepts were used
interchangeably.

There are a few additional limitations to this study. One is that the clinicians
assessed were all White and female. This study also only had clinicians that
worked with survivors of sexual abuse. Other types of trauma would be important
to include in future studies to help identify if there is a difference in how the
clinician is impacted. Each of these limits generalizability to other trauma
clinicians.

Therapist trauma history Contrary results to the Schauben and Frazier ( 1995)
study was found in another study that attempted to operationalize and measure
vicarious traumatization. Pearlman and Maclan (1995) surveyed 188 self-
identified trauma therapists on several measures. The independent measure was
a demographic sheet that tapped prior trauma history of the therapist, hours
spent doing trauma work, and general background questions. The dependent
measures used were the Traumatic Stress Institute(TSl) Belief scale, Impact of

Event Scale, Symptom Checklist-90—R, and the Marlowe-Crowne Social

l8

Desirability Scale. The TSI Belief scale was used to measure disrupted cognitive
schemes. The Impact of Event Scale measures PTSD symptoms, whereas the
Symptom Checklist-90-R measures general distress (Pearlman & Maclan, 1995).
The Marlowe-Crowne Scale was used to assess the participants‘ need for
approval.

Pearlman and Maclan (1995) found that on the TSI Belief scales this sample
showed the least disruption of all samples studied by these researchers over
several years. Therapists with a trauma history showed greater disruption than
did therapists without a trauma history. They found that therapists with a
personal trauma history showed more disruption in cognitive schemes such as
beliefs about self and others, worldview, and esteem than those without personal
trauma histories. Each of these findings was different from the findings of the
Schauben and Frazier (1995) study that showed no significant differences of
functioning between therapists with and without a prior trauma history.

These researchers note that more studies are needed to clarify the
relationship between prior trauma history of the therapist and doing trauma work
(Pearlman & Maclan, 1995); as well as questions about what specifically the
therapists find traumatic about doing this work. Pearlman and Maclan (1995)
also make recommendations for new therapists entering this specific field such as
more training on trauma, more supervision by experienced trauma therapists, and
more support.

The Pearlman and Maclan (1995) study could also be strengthened by adding

a section where the clinician is allowed to further describe his or her experiences

in working with trauma survivors. This study also did not account for therapist
self care. The ability to utilize self-care techniques may contribute to how a
therapist is or is not affected by working with trauma survivors. This study also
measured PTSD symptoms of the clinicians but did not discuss how endorsement
of these items is related to STS, and how this is similar or dissimilar to vicarious
traumatization.

Another limitation of this study is the low return rate for the surveys. Only 32%
overall returned the packets, and only 24% were completed (Pearlman 8 Maclan,
1995). This low response rate reduces the generalizability of the study. The
Schauben and F rezier (1995) study had a 28% response rate, which also limits its
generalizability to therapists.

Another study that addressed the effects of working with trauma survivors on
the therapist was conducted by Elliott and Guy (1993). Two thousand nine
hundred and sixty-three professional women were asked to complete a packet of
surveys. A general demographic sheet along with the Family Environment Scale,
the Trauma Symptom Checklist-40, and the Object Relations Scale of the Ego
Functioning Assessment Questionnaire were used. Similar to the Peariman and
Maclan (1995) study, the majority of women sampled reported some form of a
trauma history. However, this study supported the Schauben and Frazier (1995)
study in that the therapists with a trauma history showed no more disruption than
therapists without a trauma history. Although these results sound promising for
the mental health field, the discrepancy of findings between studies is disturbing.

Again, this study does not allow the clinician to explore or explain why a prior

trauma history had no effect on his or her performance as a clinician. One key to
beginning to understand and put in place training programs or support systems
for trauma therapists would seem to rest with understanding the impact of a
trauma history or some other characteristic on the therapist. As mentioned
previously, an analysis of self care techniques may also provide much needed
information regarding how personal characteristics have an effect on vicarious
traumatization.

Additional limitations of this study include low generalizability given that many
women chose not to participate for various reasons. Generalizability was not only
limited to professional women but to mental health workers as well. The majority
of mental health workers in the study held master’s degrees in social work.
Therefore, it may be unreasonable to generalize these findings to all disciplines.

Emgtional exhaustion and coping Follette, Polusny, and Milbeck (1994) also
have contributed to the literature on vicarious traumatization. They surveyed 225
mental health professionals and 46 law enforcement professionals on three
measures: Therapist Response Questionnaire(TRQ), Law Enforcement
Response Questionnaire(LERQ), and the Trauma Symptom Checklist—40. This
study found that about 20 percent of both mental health and law professionals
reported some type of physical or sexual abuse as children. Mental health
professionals displayed a lower level of traumatic symptoms than law
enforcement professionals. Both groups were found to use more positive coping
strategies than the groups without a trauma history. This study is consistent with

the Elliot and Guy (1993) and Schauben and Frazier ( 1995) that therapists with a

trauma history showed no more disturbances than those without a trauma history.
It is noteworthy that law enforcement professionals with a trauma history did show
more symptoms of distress than mental health professionals.

This study asked its respondents to identify the c0ping strategies used to do
their work. The most commonly endorsed positive coping techniques were
consulting with colleagues, educating self and others about abuse, getting
assistance and support from others, and the using humor.

The group of workers that reported less disruption also reported using more
active caping styles. The researchers did not provide information regarding
whether these workers developed active coping styles as a result of this work, or
if these individuals would be considered to have more of a hardy or resilient
personality type. In addition, it would be beneficial to identify if the therapists
used similar caping styles both a work and at home to help alleviate stress to
determine if trauma therapists who remain in this field for many years use a
coping style that is specific to their work environment or to the individual
therapist.

Follette et al. (1994) addressed several limitations to their study. First, the
study relies on all self-report measures, and there are no measures that would
triangulete or provide support for the therapist’s responses. There also may be
some gender discrepancies in that the majority of therapists were women,
whereas the majority of law enforcement professionals were men. The study
does not analyze the gender differences beyond suggesting that the helping field

in general attracts more women than men. This can limit the extent that the

t»)
[J

findings can be generalized to a more diverse group in the future because not all
therapists are women nor are all law enforcement professionals men. Another
issue of concern for this study is the cross-sectional design, which does not
enable a causal inference to be made. Despite these limitations, this study
provides interesting and helpful information to this line of inquiry.

In a study by Johnson and Hunter (1997), 41 sexual assault and 32 general
counselors were surveyed. They completed the Maslach Burnout Inventory, The
Ways of Coping Scale, and the Beliefs and Values Questionnaire. The research
found no significant differences between the sexual assault counselors and the
comparison group of counselors on demographic variables, such as age, years of
education, years at this job, or gender. One significant difference between the
two groups was that the sexual assault counselors had a more diverse
background of education than the comparison group. These sexual assault
counselors could have a degree in disciplines other than psychology or social
work.

The findings on the Maslach Burnout Inventory showed that sexual assault
counselors endorsed more emotional exhaustion than the general counselors.
On the Ways of Coping Scale, the sexual assault counselors as a group more
frequently endorsed escape-avoidance as a primary coping mechanism. After
completing an exploratory factor analysis on the Beliefs and Values
questionnaire, the authors were able to determine that the each of the items were
measuring different constructs. A multiple regression was used to look for

relationships between the Beliefs and Values questionnaire and the burnout

inventory. The results for the sexual assault counselors showed that intimacy,
power and safety/trust issues had a significant relationship with burnout. Since
emotional exhaustion was the most commonly endorsed item experienced by the
sexual assault counselors, this was used to conduct another multiple regression.
Intimacy and power were found to be related to the emotional burnout scores.
According to these authors, intimacy reflected difficulties in interpersonal
relationships, while power reflected the difficulty counselors may experience in
the advocacy role with outside agencies.

According to these authors, the results support their hypothesis that doing
trauma work affects therapists greater than doing general therapy. Although this
study provides a good picture of many ways that trauma therapists and general
therapists differ, a next step would seem to be to begin to identify factors that play
a significant role in these differences. such as past trauma history and level of
support. Another area that could help to improve and provide rigor to this study
would be to either use a psychometrically validated measure similar to the Beliefs
and Values Inventory, or to enhance this inventory to a level that is
psychometrically acceptable. In addition, because this study used surveys as
the sole method, response bias is a possibility. These researchers did not
provide evidence to the contrary which makes it difficult to ascertain how the
results on each of the measures is deviant from or in keeping with responses
from other similar studies.

Wgrking with dgmestic violgngg survivors The one solely qualitative study

that addresses the impact of trauma work on therapists was conducted by lliffe

24

and Steed (2000). These researchers interviewed 18 domestic violence
counselors on the ways in which each was impacted by working with trauma
survivors. The study identified several areas that were affected by working with
trauma survivors. According to lliffe and Steed (2000), most of the participants
identified feeling a loss of confidence in the beginning stages of work with trauma
survivors. Most participants also endorsed feeling as if they were taking too
much responsibility in the counseling relationship, and that each needed to learn
to pull back. lliffe and Steed (2000) also found that most of the participants felt
horrified at one time or another by what they heard, and that oftentimes what they
heard came back to them not only in words but also as visual representations of
the trauma. These participants also endorsed common responses to hearing
trauma material such as anger and physical illness (lllife & Steed, 2000).
Participants in this study noted several disruptions of certain cognitive schemes
consistent with vicarious traumatization. For instance, lllife and Steed (2000)
found that the majority of participants felt less secure and more aware of issues
of power and control. Some of the participants found they were less trusting of
others as a result of working with this population. Although this study provides a
good example of the rich data that qualitative studies can bring to the discussion,
its main limit would be in only interviewing domestic violence counselors.
Although many aspects of trauma are similar, each specific type of trauma
provides a different perspective that may be important to illuminate by
interviewing therapists who work with a wide range of trauma survivors. The

empirical literature on vicarious traumatization is limited yet provides a good

25

beginning to understanding some of the results of working with trauma survivors.
Countertransference is another area that may shed additional light on the impact
of working with trauma survivors.
Countertransference

Countertransference has a long history in psychoanalytic and dynamic
literature, and to a lesser extent in the trauma literature. One well-known
researcher in the area of Holocaust survivors and their families is Danieli. In
1988, Danieli wrote about the effects of working with Holocaust survivors on
therapists. This work leads the field in addressing how countertransference to
the trauma material, as opposed to countertransference to the survivor, impacts
the therapist. Danieli (1988) was able to identify several themes that he
determined to be countertransference. These themes were defense, guilt, rage,
shame, dread and horror, grief and mourning, references to death and dying, and
an inability to contain intense emotions. Danieli (1988) also identified the theme
of therapists struggling with being both victim and liberator. This may be a
common theme for many therapists working with trauma survivors in that the
therapist may feel victimized on one hand but, on the other hand, may perceive
her/himself as a savior. These feelings are often confusing and overwhelming for
trauma therapists. Fox and Carey (1999) provide another way to view
countertransference issues in working with survivors of trauma. According to Fox
and Carey (1999), collusion can occur as a result of countertransference.
Collusion is when the therapist begins to work with a traumatized client, and the

therapist’s sense of being vulnerable is triggered and helshe defends against this

by working to lower anxiety rather than by helping the client alleviate his or her
current distress. These authors believe that countertransference issues such as
collusion will always occur but that it is the knowledge of it that helps the
therapists to not negatively impact the client. As Fox and Carey (1999) note,
“when therapists are unaware of their own internal responses, they may either
over-identify with the client, seeing the world too much from his or her perspective
or may under-identify, responding un-empathicelly or constructively to the
client’(p. 189). Although these authors attend to the possible outcomes of
countertransference with trauma survivors, they do not recommend ways a
trauma therapist might detect when countertransference issues are occurring and
how to remedy these issues.

Neumann and Gamble (1995) discussed the unique countertransference
issues of therapists working with trauma survivors. Unlike the previous article,
these authors illuminated the special countertransference issues that can occur in
response to working with trauma survivors and how to work with these issues.
Neumann and Gamble (1995) identified four common countertransference
themes therapists may encounter when working with trauma survivors. The first
theme is best characterized as the rescuer/hostage role. The therapist may have
fantasies of being the one person who can save or rescue the client from his or
her pain. In addition to rescue fantasies, the therapist can also feel like a hostage
to the client’s pain. In this role, the therapist feels unable to challenge or disagree
with the client due to the intensity of feelings. The second theme occurs when

the therapist’s worldview is altered by hearing the traumatic material of the client.

Neumann and Gamble (1995) noted that, as a result of this altering of his or her
woridview, therapists may attempt to minimize or discount the experiences of
their clients. A third countertransference theme is the voyeuristic response. This
occurs when the therapist is fascinated by the horrific stories that he or she may
hear from clients. Neumann and Gamble (1995) stated that much of this
voyeurism may be unconscious to the therapist, but when the therapist is aware
of these feelings, guilt and! or shame can arise. In response to this guilt,
therapists can then become mean or angry towards their clients. The final
countertransference theme identified by Neumann and Gamble (1995) is the
“container countertransference” (p. 342). This theme occurs when the therapist
becomes overwhelmed with the emotional lability of his or her client. Many times
therapists are witnesses to the client’s constriction and flooding of emotions as he
or she begins to address the trauma (Neumann & Gamble, 1995). In response to
these countertransference issues, Neumann and Gamble (1995) suggested that
each therapist have supervisory support as well as organizational and collegial
support. Similar to the other literature on STS and vicarious traumatization, the
literature on countertransference and trauma therapy is limited. Qualitative
methods may provide more of an opportunity to discuss countertransference
issues, and thus aid in our understanding of the impact of countertransference
issues in trauma therapy.
Smut

In keeping with the trend of limited research, the concept of burnout has been

well developed in general therapy issues, but is limited when specifically

addressing trauma therapy. Despite the limited research conducted on burnout
and trauma work, the concept of burnout is discussed frequently when
addressing the impact of trauma work on trauma therapists.

According to Fox and Carey ( 1999), trauma therapists may experience
burnout as characterized by: emotional exhaustion, a sense of not being able to
help the clients, developing cynicism, feeling emotionally numb, and feeling
isolated. Therapists who become overwhelmed by their work may feel unable to
share with colleagues their feelings, or there may be limited avenues to gain
support. There appears to be a small unspoken rule that therapists, just as
physicians, should be able to heal themselves, so reaching out to someone and
admitting that the work Is overwhelming may not be viewed as an option.
Maslach (1976) writes that isolation and withdrawal often exacerbate the burnout
syndrome.

As noted in the previous sections, several studies have included data on
burnout. However, burnout alone has not yet been addressed in the trauma
literature. One study by Brown and O’Brien (1998) explored burnout in shelter
workers. Ninety—one shelter workers completed the Maslach Burnout Inventory,
the Perceived Social Support Scale, the Job Stress Index, the Shelter Stress
Inventory, and the COPE (measures emotion-focused and problem-focused
coping styles and strategies). Brown and O’Brien (1998) found that, although the
workers did not meet the criteria for burnout, they did experience moderate stress
as a result of working with trauma survivors. This study also found that there was

a positive relationship between coping mechanisms and bumout. For example

emotional exhaustion and depersonalization were positively correlated with the
coping style of mental disengagement. These authors also discovered that
perceived social support from both supervisors and family and friends was
negatively correlated with emotional exhaustion and depersonalization. The
results of this study supported the importance of providing supportive supervision
and having a good outside of work support network. Another important result of
this study is the type of coping skills used by the shelter workers. According to
these findings, it is less helpful to use disengaging types of coping styles, and
would appear to be healthier to stay engaged and involved to help reduce
burnout. This point could possibly strengthen the idea that isolation and being
withdrawn lead to higher levels of burnout, as Pines and Maslach (1976)
hypothesized. However, given the correlational nature of the results, the data
may also support that isolation and being withdrawn do not lead to higher levels
of burnout.

In the study by lliffe and Steed (2000), twelve of the eighteen participants
identified experiencing symptoms that are consistent with burnout. lliffe and
Steed (2000) reported that the participants noted long hours with high numbers of
trauma clients on their caseloads as being the primary cause of burnout. Lack of
training and isolation were also cited as reasons for burnout.

This study provides a good example of a qualitative study that explores the
impact of trauma work on the therapist. One limitation of the study is that the
interview questions were based on criteria for vicarious trauma, and this may

have been too specific to allow for information that may illuminate other types of

30

responses. Despite this critique, the study did produce a great deal of
information that is important to the literature of traumatology, such as how
specific circumstances may impact a therapist’s level of burnout.

Two studies that were mentioned earlier in the review of vicarious
traumatization also addressed burnout. Schauben and Frazier (1995) found that
burnout was not correlated with percentage of survivors on the caseload.
However, there was a strong positive correlation between percentage of survivors
on caseload and PTSD, vicarious traumatization, and disruptions in schemes.

The researchers also calculated correlations using the Maslach Burnout
Inventory and most commonly endorsed c0ping strategies. Emotional support
and burnout had the most significant negative correlation. The findings also
showed that active coping and planning were also negatively correlated to
burnout. These findings support the hypothesis that a counselor may be less
likely to feel the effects of burnout if helshe utilizes active, planned, and
purposeful coping strategies.

Now that the literature shows that therapists can and often do become
affected by working with trauma survivors, the next question seems to be how do
therapists mediate these effects? The literature suggests that there is a strong
association between trauma work and the various ways a trauma therapist may
be impacted. One area that has not been accounted for in this relationship is
what may intervene or help to protect the trauma therapist from effects of working

with trauma survivors. One area to explore as possibly moderating or buffering

for the trauma therapist is self—care skills. It is hypothesized that a therapist’s self
care skills may serve as a buffer to the impacts of working with trauma survivors.
Self Care

The literature on self care of the therapist is scarce. When attempting to find
self care in the databases, the majority of the literature focuses on self-care and
the client. The literature on self-care and the therapist is anecdotal, theoretical,
and rarely empirical. Faunce (1990) defined self-care as “...attending to all the
domains of our existence: the emotional, physical, play, and cognitive areas in
particular” (p. 124). Although the existing literature on self-care does address
each of these domains, more in depth research is warranted to further illuminate
the critical need for healthy self-care skills for a trauma therapist.

In their book, Trauma gnd the therafi, Pearlman and Saakvitne (1995)
devote an entire section on self-care techniques for the therapists. Pearlman and
Saakvitne ( 1995) identify supervision and consultation as being two of the most
important ways a therapist takes care of self while working with trauma survivors.
”We believe all therapists have an ethical as well as personal responsibility to
engage in regular, frequent clinical consultation on their psychotherapeutic
work...” (Pearlman & Saakvitne, 1995, p. 360). Pearce and Pezzot-Pearce
(1997) also agree that sharing the work with colleagues is very beneficial. They
note that “these relationships provide therapists with emotional support and the
opportunity for case discussion and consultation” (Pearce & Pezzot-Pearce,

1997,p.335)

32

Besides supervision and consultation, the authors suggest setting limits to the
amount and extent of exposure to traumatic material (Pearlman & Saakvitne,
1995). By not allowing themselves to become over exposed to traumatic
material, therapists may be less overwhelmed and better able to provide good
services to their clients (Pearce & Pezzot-Pearce, 1997). Another suggestion is
to attend to empathy. Pearlman and Saakvitne (1995) note that by attending to
empathy with clients, therapists may be less likely to become overwhelmed with
feelings, and thus do their clients a disservice. Naming reenactments is another
suggestion for self-care and lowering vicarious traumatization (Pearlman &
Saakvitne, 1995). Participating in reenactments with clients can feel confusing
and overwhelming if the therapist is unaware of the need for this intervention with
clients, and/or feels uncomfortable doing this type of work. Pearlman and
Saakvitne (1995) state that naming the intervention as a reenactment and
understanding its importance in trauma therapy will help the therapist to lower
vicarious traumatization and to take care of self.

Setting limits within the therapeutic relationship is another self care technique
that can assist in lowering or ameliorating vicarious traumatization (McCann &
Pearlman, 1999; Pearlman & Saakvitne, 1995). The therapist is better able to
maintain a sense of self and to not become over extended or involved by being
consistent with clients regarding beginning and ending time of sessions, phone
calls apart from sessions, and availability of the therapist apart from regularly
scheduled sessions. Another issue to address within the therapeutic relationship

is setting realistic treatment goals (Pearce & Pezzot-Pearce, 1997). Because

33

trauma survivors can be a difficult population to work with, it is important for the
therapist to be realistic in his or her goals and desired outcomes. This work is
often times slow and may be terminated before long term goals can be reached
(Pearce 8: Pezzot-Pearce, 1997). A part of these goals is the realization by the
therapist that this therapy time may not be all that the client needs. The client
may need to come back later in life to revisit these issues (Pearce & Pezzot-
Pearce, 1997). This does not mean the therapy was a failure or not useful but
perhaps an intervention introduced at a wrong period in the clients recovery
course.

Other self—care techniques that were suggested are maintaining professional
connections such as, continuing education and support groups (Pearce & Pezzot-
Pearce, 1997; Pearlman & Saakvitne, 1995). As noted by Pearce and Pezzot-
Pearce (1997), “given the complexity and demands of this work, therapists with
limited and narrow training or those who are just beginning to explore this area of
work should seriously evaluate whether they have the requisite skills, experience,
and knowledge to function independently” (p. 331). Not only will increased
training of the therapist benefit the client but the therapist will be better able to
manage some of the difficult aspects of the therapy if he or she is knowledgeable
about the dynamics.

Creating balance in one's practice was another suggestion. Pearlman and
Saakvitne (1995) believe that creating balance by doing other types of work
besides therapy, or by working with families and couples not just individuals can

help to reduce vicarious traumatization. Spirituality is another area that is

34

believed to be an important self-care technique (Pearlman & Saakvitne, 1995).
Developing or cultivating an already existing spiritual life can help restore hope to
therapists who may not feel hopeful after hearing the horrific trauma material they
hear often. Saakvitne and Pearlman (1995) also support therapists participating
in their own therapy as a way to care for self and lower vicarious traumatization.
“The importance of personal therapy for the therapist cannot be overemphasized,
and has been recommended by others as a way of remaining open to ourselves
and our clients” (Pearlman & Saakvitne, 1995, p. 394). Pearce and Pezzot-
Pearce (1997) concur that attending to personal issues is an important strategy
to use in combating vicarious traumatization. By being aware of personal issues,
therapists will better be able to assist their clients. Identifying within themselves
when a client’s disclosures are very close to their own, can help therapists to
obtain their own therapy or to just share with someone before they harm self or
their client. Maintaining a good sense of humor is suggested by Pearce and
Pezzot-Pearce (1997) as a way of lowering vicarious traumatization. Allowing the
therapist’s personal world to be healthy and separate from their work world is
another way to reduce vicarious traumatization (Charney & Pearlman, 1998;
Pearce 8: Pezzot—Pearce, 1997). By not bringing home work, the therapist is
setting boundaries and helping to maintain one area of his or her life that is
relatively free from trauma material.

As mentioned earlier, vicarious traumatization disrupts five major areas of the
individual: frame of reference, self-capacities, ego resources, psychological

needs and cognitive schemes, and imagery (McCann & Pearlman, 1990).

35

Pearlman (1995) wrote an Important chapter that highlighted various self care
techniques that would address these five major areas. Self care techniques to
help with a disruption in a therapist’s frame of reference include: “...balancing
work, play, and rest helps us to remain grounded in various aspects of our
complex identities. Practices that renew a cherished sense of identity or that
expand one’s identity beyond that of trauma therapist are helpful in this realm”
(Pearlman, 1995, p. 54). The next area that can become disrupted as a result of
doing this work is the self capacities. These are capacities that help the therapist
maintain a sense of well being and self esteem. Pearlman (1995) suggests that
by meditating, praying, or joumaling a therapist can reconnect or remain
connected with the side of him or her self that is connected and loving towards
others. This is the area where a therapist may find him or her self wanting to
disconnect from clients due to the intense emotions found in trauma therapy. Ego
resources are the third area that may be disrupted. These are “those inner
abilities that allow us to meet our psychological needs and to manage
interpersonal relationships...” (Pearlman, 1995, p. 59). Some suggestions by
Pearlman (1995) for combating a disruption in this area are to give and receive
supervision and to use humor to alleviate some stress. The psychological needs
and cognitive schema domain address the issues of trust and intimacy. Self help
strategies include professional and personal connection (Charney 8. Pearlman,
1998; Pearlman, 1995). Psychotherapy is often done in isolation from other
therapists, especially when the therapist is in private practice. Attempting to

connect with other therapists and discuss the effects of trauma work can help

36

lower the disruption in this area. Also, making connections with peOple in the
therapists' private world will help to keep work and home more separate
(Pearlman, 1995). Intrusive imagery is something that visits both the therapist
and the client (Pearlman, 1995). The therapist must try to understand what is
being triggered by the intrusive imagery as well as try to reach out and connect
with others (Pearlman, 1995). Sharing that the therapist is having intrusive
images allows the therapist to not suffer alone and/or to receive assistance if this
becomes necessary. The intrusive images may occur either In the workplace or
at home, and many times occur in both areas. The therapist will be using good
self care techniques by reaching out to someone and not suffering alone
(Charney & Pearlman, 1998; Pearlman, 1995). In general, although the above
mentioned self care techniques are useful, a therapist could and should utilize
self care techniques that are most helpful and easily accessible to them.
Bell-Gadsby and Siegenberg (1996) promote the idea that each therapist
should create a '...personally relevant path of self—care” (p. 224). Each therapist
will not benefit from all self care techniques, and the therapist should take time to
create techniques that work for him or her. Bell-Gadsby and Siegenberg (1996)
suggest several techniques that can be used. Guided meditation that is used in
'...assesslng, clearing, and rebalancing both the body and the mind” (Bell-Gadsby
& Siegenberg, 1996, p. 224). A second technique is called metaphorical
meditation (Bell-Gadsby & Siegenberg, 1996). This meditation is similar to
guided meditation but focuses on helping the therapist to ward off integrating

client trauma material into his or her own stories.

37

The empirical research on self care is rather limited in scope. Most of the
literature found addresses coping strategies, not specifically self care. Although
coping strategies are one form of self care, there are many other forms that are
not addressed in the literature at this time. One study that was described above
explored the coping strategies of therapists (Follette, et al, 1994). This study
assessed coping strategies by using the Therapist Response
Questionnaire(TRQ). A small portion of the questionnaire asked about various
coping strategies used by the therapist. The mostly frequently endorsed coping
strategies were: education related to sexual abuse, supervision, consultation,
and humor (Follette, et al, 1994). Only a small group of respondents endorsed
using self care techniques like meditation and yoga or prayer (Follette, et al,
1994) to lower vicarious traumatization. This study shows that most
professionals use a more intellectual form of self care rather than an effective
one. Sadly, this study does not provide any information regarding why a therapist
may be more likely to seek intellectual avenues to address vicarious
traumatization. It would be beneficial to the literature to know how therapists
viewed their use of coping strategies, and whether or not these have changed as
a result of working with trauma survivors for a period of time. It would also be
helpful to understand why a therapist may use intellectual forms of self care like
the coping strategies identified in this study versus more personal forms of self
care.

The Schauben and Frazier (1995) study described previously also contained a

section that addressed coping strategies and self care. In this study therapists

38

were first asked to respond to a 15 item questionnaire about coping. The results
showed that the majority of respondents used active coping such as working to
reduce the problem, seeking emotional support, and planning some form of action
(Schauben & Frazier, 1995). These findings are consistent with the above
mentioned study in that more intellectual forms of coping were used primarily as
opposed to more effective forms of coping.

Schauben and Frazier (1995) also allowed the respondents to write in any
other strategies or activities that were used to c0pe. Four strategies were most
common: activities that promoted health, such as exercising and eating healthy;
spiritually oriented activities such as meditating; participation in leisure activities;
and seeking emotional support from friends and family (Schauben & Frazier,
1995). These activities are more specific than the general active or passive
coping strategies that are often elicited on a questionnaire or a survey. It is
noteworthy that therapists find more personal and specific self care techniques to
be crucial to their coping and functioning. As with many of the studies, there was
no attempt made to understand how or why these self care techniques
developed. The question is still unanswered as to how these techniques may
have developed over the course of a therapists’ career.

There are several studies that address self care of the therapist but that are
not Specifically targeting work with trauma survivors. Nevertheless, the findings
have direct implications for the research on self care and the trauma therapist.

Medeiros and Prochaska (1988) conducted a study on the coping strategies

used by therapists working with stressful clients. The majority of clients were

39

diagnosed as borderline personality disorder, with the other clients ranging from
depressed to psychotic. Six hundred therapists were mailed packets that
included a demographic and general infonnetion questionnaire, a stress
questionnaire and a COpIng scale. The response rate was 41%. The researchers
found that therapists reported using self-reevaluation and wishful thinking, humor,
optimistic perseverance, social support, seeking inner peace, and contingency
control and avoidance as coping strategies when working with stressful clients.
This study would be strengthened by providing the respondents a way to share
how they viewed these COpIng strategies. Also by allowing the respondents to
share about their experiences in another format other than paper and pencil
measures, more information could be gleaned about the context for using these
caping strategies, and whether there were other coping or self care techniques
that are also used by the therapist.

Mahoney (1997) conducted a study of therapists and their self care patterns.
Each therapist was given a questionnaire that asked about personal problems
experienced during the past year as well as self care practices over the year.
The most commonly reported personal problem was emotional exhaustion, and
concern about the severity of their caseload was second (Mahoney, 1997). The
self care patterns noted ranged from engaging in a hobby to religious activities.
Personal therapy was a commonly reported self care strategy. Although these
findings are not directly related to trauma work, the results can be used to identify
techniques that help alleviate stress for the general practitioner, and may work

with the trauma practitioner as well. This study was very simplistic in that it did

40

not go into greater detail regarding how the therapist came to use these
techniques or if these techniques were used on a continuous basis or only during
times of crisis. Also, as the author noted, there are some limitations to the self -
selection of the respondents as well as the self-report instrument (Mahoney,
1997). Since the respondents all self-selected to participate in this study, there
could be a characteristic they all share that may have direct influence on the
results obtained. A random sample of respondents would help to alleviate this
possible bias. In addition, a range of instruments that were not all self-report may
also help to lower any response bias. Despite these limitations, this study did
support therapist use of self care techniques in alleviating job related stress.
Future research could begin to focus on how therapists develop these
techniques.

Norcross (2000) wrote an article compiling the various self care strategies that
he reports learning about directly from other clinicians, research, and his own self
care techniques. He identified ten self care strategies. The first strategy is to
recognize that psychotherapy can be hazardous. Norcross (2000) noted in this
section that many therapists do not discuss or identify the toll of doing this work.
The second strategy was to identify various techniques or strategies to use when
the therapist feels overwhelmed or taxed by the work. The third was increased
self awareness as one basis for good self care. Norcross (2000) stated that
knowing the self ls crucial. A fourth strategy was to become less tied to
strategies prescribed by a particular theoretical orientation. He reported that

many therapists will become attached to a theoretical orientation but that

4l

strategies outside of this orientation may be very helpful to the therapist. The fifth
strategy was to use stimulus control and counterconditioning as self care
techniques. Norcross (2000) felt that therapists should alter the environment to fit
their individual needs as opposed to changing their needs to fit the environment.
Counterconditioning techniques were identified as diversion, cognitive
restructuring, assertion, relaxation, and exercise (Norcross, 2000). Norcross
(2000) commented that action oriented techniques were very effective. Reaching
out to others for support or as Norcross (2000) stated ”emphasize the human
element” was the sixth strategy. Therapists need not view themselves as alone
but should utilize the relationships available to them. Personal therapy was the
seventh strategy, and was noted as being one of the most beneficial and most
utilized self care technique. The eight strategy was to avoid self blame and
wishful thinking. As stated earlier, Norcross (2000) believes that more action
oriented techniques were more effective than these two passive examples. A call
to diversify the clientele or type of work the therapist undertakes was the ninth
strategy. Norcross (2000) noted that he has heeded this advice, and found it to
be useful. The final strategy, and one that appears to get lost for many
therapists, is to appreciate the rewards of doing this work. Norcross (2000)
reminded the reader to look around and notice that most therapists feel good
about this work, and find it important both professionally and personally.

In sum, the current literature on the Impact of working with trauma survivors is
young and growing. The literature has begun to identify concepts such as

vicarious traumatization, countertransference, secondary traumatic stress, and

burnout as important areas of study. However, more attention to this area is
needed. Currently practicing therapists rarely discuss or are provided with
information regarding the possible effects of working with trauma survivors, nor is
there much information dispersed regarding ways to help reduce or alleviate
these effects (Norcross, 2000). The field of psychology provides a great amount
of information regarding ways to cope for clients, but information for therapists on
ways to cope with being a therapist is still in its infancy. There are theoretical
writings on trauma work that include chapters and articles on the need for self-
care. Although the traumatology field is growing, psychologists are still more
adept at focusing on client issues and not therapist issues, especially not on
issues involving the impact of trauma work on the therapist. By understanding
the difficult nature of trauma work, the questions about how a therapist is coping
with this work seem necessary. I will use the current information on the impact of
trauma work on therapists as well as the input from trauma therapists to add to
this literature. I believe that a crucial next step in the literature is to solicit directly
from trauma therapists descriptions about how this work affects them

professionally and personally, and how they cope with the work.

43

Chapter Three
Methodology
9.9.8491)

There are several types of qualitative designs. Many of these designs have
specific characteristics that inform how the data will be collected and analyzed, as
well as how to write the finished project. This study was conducted using a
modified analytic induction design. “The procedure of analytic induction is
employed when some specific problem, question, or issue becomes the focus of
research. Data is collected and analyzed to develop a descriptive model that
encompasses all cases of the phenomena” (Bogdan & Biklen, 1982 p. 66). This
procedure is often used in open-ended interviewing, which is why I believe it was
the most appropriate design for my study. Analytic induction allowed me the
opportunity to form an initial hypothesis, and then to begin to develop a
description of the impact of trauma work on trauma therapists. Schwandt(2001)
adds that analytic induction allows for a hypothesis to be created and re-worked
based on the data. My process deviated from the pure use of analytic induction in
that I began with a hypothesis, and did not necessarily refine it based on the
individual cases but on the information gained from all of the cases. I was able to
look case by case at the data, and then to look across cases to find
commonalities as well as differences. The subsequent interviews were then used
to further form my model (figure 1). After all the interviews were conducted, a

descriptive model of the impact of trauma work on trauma therapists was

44

completed. Based on my initial hypothesis, the model describes the impact on
the therapist as well as the self care skills developed and used to help alleviate

the stress of trauma work.

W

The data were collected using face-to—fece interviews. I conducted an initial
sixty to ninety minute interview with each participant. l was prepared with
questions to help the therapist talk about his or her experiences as a trauma
therapist. I took notes during the interview and audiotaped. The audiotapes
were then transcribed and later destroyed.

A week after each interview I contacted the participant again to explore any
other information the person wished to share about our initial interview. This
allowed the participant the opportunity to think about the interview and to possibly
add more information or describe further his or her thoughts and feelings
regarding subjects talked about previously. This second contact also provided for
debriefing. l was prepared to provide support and resources if needed to each
therapist. I anticipated that some therapists would need this second opportunity
to talk further, whereas others would feel our first meeting was sufficient.

I allowed the participant to request material not to be audiotaped, but was
prepared to ask if I may continue to take notes. I would have reassured the
person that no direct quote of this particular section would be used in the final
document. As part of the follow up contact I tried to describe in more detail how I

was going to use the information they shared with me.

45

Partig'gants

Participants of this study were either Master's— or Doctoral-level therapists
who were currently working with clients. These therapists had at least one client
who identified as a survivor of trauma. The client was a survivor who had
experienced some form of trauma firsthand. For this study trauma was defined
as an event, either man-made or naturally occurring, that taxes the individual’s
ability to cope, and results in various psychological disturbances (APA, 1994). I
used my professional contacts to invite therapists to become a part of this study.

I used purposeful sampling to obtain my participants as well. Purposeful
sampling is when “you choose particular subjects to include because they are
believed to facilitate the expansion of the developing theory” (Bogdan & Biklen,
1982 p. 67). My sample was six participants. One held a Ph.D. in psychology,
four held a Master's degree in Social Work, and the sixth held a Master’s degree
in Psychology. Three participants identified themselves as Caucasian, one as
Jewish, one as African American, and one as Bi-racial. Their age range was from
early 40’s to early 50’s. Each participant had over five years of clinical
experience. One participant identified herself as having a disability. There were
five women and one man in this pool.

I contacted participants after our mutual colleague had asked for initial
permission for me to call. I hoped that by having a mutual colleague, the therapist

would be more likely to participate in the study as well as be more comfortable

46

with me since we were connected by someone. I offered to meet at an office or
an area that was comfortable and private for the participant.
Data Analysis

I began my study with a hypothesis about the impact of trauma work on
trauma therapists as well as the role of self care skills for this population based
on my professional experiences and the current literature. Throughout data
collection I modified my hypothesis based on the information from each case. At
the end of data collection I was able to identify a beginning description about the
impact of trauma work and self care skills for trauma therapists. I analyzed the
data as an ongoing process.

After an interview I transcribed the audiotape. I then read the transcript and
made preliminary notes in the margin while the material was fresh. The notes I
took included my first impressions that fit with my initial hypothesis as well as
information that were different. I also created general codes that helped to group
my data so that I could begin to develop a description about the impact of trauma
work and trauma therapists’ self care skills. The general codes were created
based on summarizing the data provided. I did this case by case, and then
looked across cases to create general codes that encompassed similar ideas
where possible. This enabled me to look across cases for similarities with ease.
I then created various two dimensional models to help further illustrate the
connections between cases, as well as to provide a visual model of the data to
aid in writing of the results. These models provided me the ability to determine if

writing the results would best be served by using a case by case style or a theme

47

by theme style. Given the many similarities across cases, I felt writing by themes
would best illustrate the complexity of the data but would also still provide the
opportunity to illuminate the differences between the cases.

Generalizabilig

The role of this multi-person case study was not to provide a description that
would generalize to all trauma therapists. I conducted this study to provide a
description for the therapists that participated in the study. Some aspects of what
was found may be generalizable to other settings and to other therapists. As
Erickson (1985) noted, ”the search is not for abstract universals arrived at by
statistical generalization from a sample to a population, but for concrete
universals, arrived at by studying a specific case in great detail and then
comparing it with other cases studied in equally great detail” (p. 130). Although
my study used only six therapists, some of the information gleaned will be
applicable to the majority of therapists, but most will be specific to this small
group. Erickson (1985) clarified this point of generalizability by remarking that
some aspects of trauma work in this case will generalize to other situations of
trauma work just by nature of commonality across humans.

My task according to Erickson (1985) was to determine “...the different layers
of universality and particularity that are confronted in the specific case at hand-
what is broadly universal, what generalizes to other similar situations, what is
unique to the given instance. This can only be done by attending to the
details of the concrete case at hand. Thus, the primary concern ...is

particularizebility, rather than generalizability” (p. 130). I identified the themesl

48

believed were common to the larger group of trauma therapists as well as the
themes that were specific to each case and this study in particular.
Role of the Researgher

The role of the researcher in qualitative studies is explicit and involved. My
role as the researcher was a vital component of the data gathered and analyzed.
As Creswell (1994) noted, the biases, values, and judgment of the researcher
become stated explicitly in the research report” (p. 147). In this study I provided
information about how my past experiences affect my familiarity with the topic and
the material (Creswell, 1994). By making explicit my role in the research, my
values and biases become a critical part, rather than a stumbling block in
understanding the experiences of the therapists.

l have experience working with trauma survivors, and this is where the interest
in the impact of trauma work on therapists originated. At the time, I had no words
to describe the impact on me. I realized how the therapists at my place of
employment supported each other as we tried to do this hard work with trauma
survivors. I also began to hear from other therapists the ways in which doing this
work had affected them. This knowledge of how the work affected me was just
beginning. It was not until after the birth of my first child that I could truly
appreciate how the work affected me. I believe that it was a combination of new
mother stress and the work I was doing that affected me. I remember needing to
seek extra support from my supervisors and colleagues. I also can recall
wondering if I should keep doing this type of work. I believe I was fortunate to be

in an environment where l was supported and nurtured as a new trauma

49

therapist, or else I might have found myself transferring to a different area of
therapy.

These personal factors were important for me to attend to throughout the
study so that l was careful of imposing or over emphasizing similar issues from
the study participants. Throughout this research, I sought support and
supervision from trusted people who understood and supported my efforts, even
though they did not always agree with my interpretations.

Another area that was important for me to attend to while conducting these
interviews was my role as an African American female who has worked with
trauma therapists. These characteristics could influence the relationship I build
with the therapists in many ways. For instance my gender and race could have
negative and positive meanings for each therapist. This would be an element
that would be difficult to identify as that was not the focus of this study. However
it is important to keep this in mind when wondering how I as an interviewer may
have impacted the interviewees. My role as a therapist may have also created an
atmosphere that would not have been present if I were merely a researcher
without trauma work experience. This, too could have positive and negative
meanings for the therapists. It would seem that l was included in this small group
of trauma therapists because the assumption was that I knew firsthand what each
may have been experiencing. This seems to be a positive outcome but again
since this information was not directly sought, I can only speculate and leave it as
a possibility. However, the therapists viewed their interactions with me, positive

or negative, my role as an African American female with trauma therapy

50

experience is bound to have an affect. Another researcher may not have elicited
the same types of responses. This is the positive and sometimes the negative of
qualitative research.

In sum, this qualitative study used a modified version of analytic induction
design to explore the impact of trauma work and the subsequent self care skill
developed and utilized by trauma therapists. I used the information from each
interview to help create and define a description of the impact of trauma work and
the self care skills used by trauma therapists. I had an initial hypothesis that was
modified as needed, case by case, to help inform my thoughts. Throughout the
research process I kept a journal documenting important information gleaned
from the respondents as well as from myself. I have provided a description of
the impact of trauma work and how self care skills play a role for trauma
therapists. I hope my project helps to increase support and understanding of the

difficult work that trauma therapists provide.

SI

Chapter Four

Results

The therapists

In an effort to maintain confidentiality, only a brief description of each therapist
will be provided. Therapist one and Therapist five worked primarily with sexual
abuse survivors but also provided therapy to survivors of other types of abuse as
well. These therapists worked in settings that also served other populations.
Therapist one is in her fifties, and has been working with this population for over
fifteen years. Therapist four is in her forties, and has been working with this
population for approximately ten years. Therapist two and Therapist three
worked in settings that were trauma specific. These two therapists worked with
survivors of all types of trauma. Therapist two is in her forties, and has been
providing therapy to survivors for over fifteen years. Therapist three has been
working with survivors for twenty years and is in his fifties. Therapist four was in
private practice, but prior to this worked for an agency. The client population in
her practice ranged from abuse survivors to people with disabilities. She has
been working with survivors for twelve years, and is in her forties. Therapist
four’s case load was heavily weighted with survivors of sexual abuse, but she
also worked with survivors of other types of abuse as well. Therapist six worked

in an agency that saw a full range of client issues. She worked with clients who

52

were survivors of many types of trauma, as well as clients without a trauma

history. Therapist six is in her forties, and has been doing this work for ten years.

Initial hypgthpsis

My initial hypothesis about the impact of trauma work on therapists was much
less complex than what has unfolded here. I believed that the impact of the
trauma work would be greatest at the beginning of a person’s career, and that
over time with increased self care skills, this impact would lessen. I also believed
that each therapist would say that he or she entered this field due to a sense of
altruism as I would have hypothesized for most people entering a helping field.
My hypothesis also included that the impact of trauma work would penetrate both
the professional and personal worlds of the therapists.

Several main themes emerged from the date. The data also illustrated the
individual characteristics of each trauma therapist. This chapter will first discuss
the main themes that represented a majority of the therapists, and then will
address other themes that emerged, but only for a few of the therapists. As a
conclusion this chapter will provide an outline of a model (figure 1) of how trauma
work impacts trauma therapists and the self care skills that may be elicited.

Main Thgmes

Thirteen main themes emerged from the data. The main themes as explained
in the previous chapter arose directly from reading and re-reading the direct
transcripts. Of the thirteen, six themes were evident in what all six of the

therapists said. These themes are titled skills, emotional toll, circumstances, self

53

care skills, and support. The next level of themes was represented by five of the
therapists. These themes were opportunity, altruism, benefits, and growth. The

next four main themes provided more information about individual therapists than
these therapists as a group. The final level of themes is application of emotions,

core values, personal history, and hope.

In addition to the main themes, the data provided information about the
different areas that can be affected. These areas that can be affected by trauma
work were defined as domains. The three main domains were self, family/others,
and work. After continuing to read the transcripts it became apparent that each
therapist found the impact of this work entering home and work. I further divided
home into “family/friends”, and “with the self’. This occurred because some of the
information provided by the therapists showed how trauma work may affect them
individually, then how this work affects the therapist’s relationships, and then
finally how this work impacts them on the job. Although not all of the therapists
clearly discussed the influence trauma work has in these three domains, it
provided enough beneficial information to be included.

_S_k_ilis The set of skills that these therapists identified as being a direct or
indirect result of working with trauma survivors ranges from very general to a
specific set of skills. For instance several therapists discussed an increased
ability with certain skills in assessment of trauma survivors from working directly
in therapy with this population. For example, this therapist noted that these skills
are not typically acquired in training:

From a training standpoint I feel competent in assessing
individuals for trauma, and I feel that that’s an area that a lot

54

clinicians aren't trained in and that they don't assess for it or

when they hear it they don't deal with it...l feel there is a large

portion of therapists out there who don't do that, and I feel

frankly pretty cool that I can do that, and I feel good about that

(Therapist Four, personal communication, August 2000).
One person noted that learning how to work with a group is a skill that has been
enhanced. Learning how to be a facilitator of the client’s stories, and knowing
how to process this with the client has also emerged. The ability to work with
suicidal clients better was also noted. One therapist identified that for her it was
being able to assess the clients quickly and accurately in order to determine if a
referral was most appropriate to someone who would be able to work with this
client for an extended period of time.

On the other hand doing just this work has really helped me to

develop an understanding of resources to offer to this client

papuletion. So that that minimizes the impact

sometimes...(Therapist Five, personal communication, 8/00).
More specific skills that one therapist acknowledged were increasing in
understanding, patience, tolerance, and being more tenacious in his work with
this population. These skills appear to have emerged in response to the often
difficult presentation of people with trauma histories, such as people with acting
out behavior, personality disorders, etc..

It has I think shaped me in being perhaps more of an advocate for

consumers than I see my peers in other settings. I think it has shaped me in

terms of being more understanding, more tolerant. I talk to people in private

practice and they say no way would they put up with what we do, or put up

with the long drawn out treatment or the repetitive attack from clients. So I

think if anything it’s made me a little more tenacious; sticking with

clientele...(Therapist Three, personal communication, August 2000).

Larger systemic skills also were noted as being developed since working with

this population. Advocacy emerged as a common skill that was born out of

trauma survivors oftentimes needing someone to fight for them at court, at home,
or even at work.

I think this is just good social work, to take on an advocacy
role. Still, with clients knowing that especially in this arena
they are faced with a lot of technical struggle with the other
systems..foster care, the courts that kind of stuff..where I can
be fairly effective far more than they can be. So negotiating the
system for them is something that

I’m willing to do on that advocacy level (Therapist Three,
personal communication, August 2000).

One participant recognized that her voice as a woman, worker, citizen, and
person outraged with violence has become louder as a result of working closely
with this population. An increased political stance was also discussed as a new
skill that has accompanied working with this population.

I think it’s helped me professionally. One impact is that for me

to have a louder voice... one example was just last week I

went to the press conference in Lansing, and the only reason I

went was because I wanted to ask him why he has not signed

on to the violence against women act yet and this press

conference was developing this task force, this state wide task

force to address the issue of GHB, and well that’s all well and

good and you know if you are so concerned about sexual

assault and those issues why isn’t your name on this

legislation? And that’s just, in some ways, that's really unlike

who I used to be. So it has given me a louder voice I guess

that is part of the impact..(Therapist Two, personal

communication, August 2000).

While most of the participants noted an increase in specific skills, one
therapist remarked that her confidence in her skills was decreasing. She
wondered if this was directly related to the population or if it was related to age.
Part of her speculation as to why her confidence in her skills has decreased was
about the often overwhelming needs of the clients to know if as the therapist you

are doing the right intervention with them.

56

Now, feel less confident in my own skills. Second guess myself, maybe due
to age but may also come with this population, being on the edge with them.
Clients really wanting to know if you have done the correct thing with them
(Therapist One, personal communication, June 2000)
It appears that this questioning of the therapist over time may lead him or her, in
this case her, to begin to doubt her skills and her ability to work well with this
population.

Emotional Toll The next main theme to emerge from the data was the
emotional toll that work with trauma survivors can cause. Each of the therapists
was able to discuss how this work has affected them. This emotional toll appears
to occur not only at work but at home with significant others as well as personally
for the therapists. This is one of the examples of how the domains of self,
family/friends, and work emerged from the data. When looking at the information
gleaned, although the emotional toll is great regardless of domain, the domains
do provide a way for the reader to fully appreciate how far-reaching the toll can
be.

The emotional toll of working with trauma survivors can be seen in all three
domains of the therapist; at work, at home, and alone. The effects of trauma
work on the individual, the self, can be as simple as having difficulty with the
details of the stories to impacting the behavior of the therapist. One area that
several therapists discussed was how this work can trigger personal issues. As
one therapist noted, it has become very important for her to be able to identify

what are her issues, and what are her client’s issues. As these issues become

more similar it would be difficult to know in the moment how to separate them.

57

This interaction of client issues and therapist issues led this therapist to note that
part of doing good work is working to understand his or her own personal issues.

Therapist six also acknowledged that she felt more affected by her own
personal issues earlier in her career.

Other times, when it triggers other stuff, and so I have to spend energy
working on my stuff. Making sure that it whatever stories I’m listening to,
whatever presenting issues I’m faced with in my work with clients, that when
I get home I know what is my stuff and I know what is their stuff, and so I
make sure I deal with that, take care of that personally (Therapist Six,
personal communication, March 2001).

One speculation about this could be that as a therapist becomes more
seasoned in the field, the information heard is not as disturbing or difficult to hear,
and the therapist becomes less affected and can simply work with the client.
Whereas, when a therapist is new to the field, all the information is novel, and
perhaps the therapist gets lost in this information more easily, and the resulting
confusion or melding of issues then more directly triggers his or her own personal
histories.

Feelings of responsibility were another issue identified by one therapist as
being a carry over from her professional work. She noted that when she first
began this work she saw people more in a victim role than as a survivor and that
this lead to her taking more responsibility in the therapeutic relationship. As she
began looking more closely at her personal relationships she saw this same
dynamic occurring, her need or desire to take more responsibility for others than

was warranted. As this dynamic began to change in her professional life she saw

it changing in her personal life as well.

58

I think it has come over into my personal life some earlier I was more... I
took more responsibility for other people and that goes along with seeing
them as a victim, you’re a victim and I’m a helper, I’m more responsible.
Where I think the change in how you view people in even like in my family
system, the change in how I view people really has freed me from the
responsibility. If you want help I’m here, if you don’t well that is okay too, you
have a right to be in whatever space you are going to be in. And this is not
the right time for you to change, and all I can do is this piece of it. So I think
that I have become less entrenched in my own thinking about my own
responsibility pieces. 80 I am probably a lot less pushy (Therapist Six,
personal communication, March 2001).

Other ways that this work has impacted the therapists is by crossing over into
their personal worlds when uninvited. Some examples of how trauma work
crosses over into the personal worlds of the therapists are by coming into their
dreams, fear for their own children, inability to connect fully with their families, and
changing their behaviors. One therapist spoke at length about trying to separate
his work role from his home role and how this has been very difficult and has had
a tremendous impact on him. He noted that being with clients and providing them
with patience, support, guidance, and tolerance all appear to come so easily for
him. However, at home he recognized that, in order to fully separate himself from
his work persona, these beneficial skills are often left at work as well.

My work persona is kind and patient and understanding and
waiting and persevering and all that good stuff, and in the
effort to separate work from home, sometimes leave that good
stuff at work and don’t bring it home with me where I certainly
should. Not a good thing when I go home. My wife is not
crazy about that (Therapist Three, personal communication,
August 2000).
This distancing lends itself to strained, distant, and difficult relationships. This

therapist appeared to have a good understanding of this process and works to

change how this dynamic unfolds in his life. As he noted, he has learned to be

59

more conscious of what he does at home so that he can more fully participate in a
reciprocal emotionally intimate relationship with his family.

And that is kind of a tough shift to have to be here and feel like

I have to do everything, and then go home and be able to go

home and share. And when I am being taken care of, and that

is probably one of the biggest impacts on my personal life, I’m

very difficult to take care of...(Therapist Three, personal

communication, August 2000).
As this therapist discussed the difficulty becoming aware of this strain occurring in
his life, it led me to wonder what can happen to a therapist and his or her family
when there is no awareness of this inability to fully connect with people at home.
A person without this awareness may simply feel pulled and perhaps isolated at
home due to this inability to connect fully. While this issue appeared to impact
the family, it also impacted the therapist as an individual because he must identify
the ways this work has pulled him and affected his ability to relate to others and
himself.

Most therapists noted that feeling overwhelmed and tired were common
responses to providing therapy to trauma survivors. These therapists noted that
feeling overwhelmed was in direct response to identifying the many needs of their
clients, and recognizing that these were oftentimes too much for one therapist to
handle. One therapist identified that much of her work with her clients paralleled
what she was providing to her own children due to the same developmental
levels and needs. She was able to identify that this often feels like too much, and
attempts to pull away from re-parenting with her clients. As she attempts to

separate some emotions from work and home, feelings of resentment occur as

her clients fight these attempts. It is clear to her that family comes first, but

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oftentimes needy clients or clients in crisis are unable to respect these
boundaries. This apparently leaves her feeling overwhelmed and feeling unable
to continue on in this fashion.
Not interested in doing the longer term work-because what I have found is
that given the age difference between me and my students/clients most of
them could be my own children. The age difference is appropriate. And what
I find is that I end up reparenting. And I’ve had students call me from Europe
when they were doing study abroad because they don’t have a family, don’t
have a mother, and l have my own family and l have just felt too pulled in
terms of having to raise too many young adult children...(Therapist One,
personal communication, August 2000).
There are many different ways this work has impacted the therapist’s ability to
continue to do this work. One of the common effects of working with this
population is noted as being a feeling of tiredness and at times feeling
overwhelmed. One therapist identified this feeling of being tired as a result of
having many cases in one day that were all dealing with trauma.
I had a bad day already before that appointment because I
was really feeling, I had a lot of cases, just tired and
overwhelmed...(Therapist Five, personal communication,
August 2000).
Another therapist commented that emotionally she feels very tired after sessions,
and that she also often feels she wants to cry with her clients or for her clients.
Emotionally, I guess the impact is tremendous and sometimes
I'm very tired after a session, I'm worn out and I want to cry
with my clients and I do occasionally and its difficult hearing
these stories...(Therapist Four, personal communication,
August 2000).
This feeling of being tired while tied to specific events for these therapists carried
more of a pervasive feeling when they each spoke of it. Feeling tired seemed to

carry more than just a physical connotation but an emotional one as well. I truly

6i

sensed this when one therapist remarked how having to teach a person to
depend on herself and help to increase her self esteem was something that she
experienced with not just one client but many of her abused clients. How she
described feeling as if this were something she had to do over and over again
really put in words this pervasive feeling of being tired.

Then not only do I have to turn around and give that to the
person, but also teach that person to do that for themselves
because probably no one else is going to do it now they are a
grown up. And they probably shouldn't be dependent on
anyone also doing it for them this late in life, so they really
need to do that for themselves, and its over and over that I see
it and that gets to me...(Therapist Five, personal
communication, August 2000).

I wondered if the therapists felt tired from seeing the same presentation, the
same effects of trauma everyday. The converse feeling like he or she could take
on more was also expressed by one therapist. One person called this the
superman complex, feeling invincible, able to handle whatever arises. This led to
that particular therapist needing to find balance between the personal and
professional life.

And that was probably, it was the superman complex. Like I'm the be all and
end all for her anyway, for this client. I’m the only one that could help her, I
was naive and I was young and I wasn’t playing this the way I should. But it
was I think more so than what I already talked about to the exclusion of my
marriage, my friendships, and everything else it became very pivotal in
terms of time I was going to devote to my personal life. I was already
working 12 hours a day and then these hour two hour long phone calls at
home were not sitting well with my spouse. And I would just dismiss her, I
have to do this, without explaining it it was like you just have to understand
this, so in some ways it was a badge of courage to show how important I,
I’m keeping peOpIe alive, but I lost sight of all the other important things that
I also have to balance in my life. So the impact was kind of negative at this
point, and it was only afterwards trying to regain that sense of intimacy with
my wife that I had to really do some evaluating of what my priorities were.
And in some ways It spurred me on to say you better take another look at

how you are living your life because it was all work and that wasn’t working
out for the people around me (Therapist Three, personal communication,
August 2000).

The ways in which this toll affects the family and friends can also be varied
and great at times. One therapist identified how this work has made her a more
cautious person, and how her husband is fearful she will pass this on to their
daughter. She stated that she disagrees with her husband on this point and sees
herself as being more pragmatic and simply helping her daughter to be more
aware and careful.

It’s made me very cautious. My husband says I’m too

cautious. He says I’m going to make our daughter a fearful

person. I don’t agree with him. I think he is naive. There are

dangers out there, and bad things do happen, and that we do

have to be cautious and careful (Therapist Five, personal

communication, August 2000).
Another therapist shared this concern for what she has learned as a trauma
therapist and how this has made her worry about her own children and that she
may have become more cautious and protective of them.

(At a) psychiatric hospital for kids and 99% of the kids had

some kind of traumatic event-it was just huge amount. My

children were small when I worked there, sol guess it

impacted me personally because I was always afraid

something would happen to them...(Therapist Four, personal

communication, August 2000).
Given that many of the therapists hear about what happened to children, it is not
surprising that this would affect how they view their own children and the issues
of safety and protection. Another therapist provided a slightly different
perspective by identifying how the emotional toll of this work has affected his

relationship with his wife. One area that he noticed was in communication. He

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identified that there is a work and a home persona, and the home persona is not
as patient or as tolerant as the work one. He understands how this is not
something his wife particularly appreciates but that it happens. This therapist
also shared that his views on emotional intimacy have been shaped by trauma
work and how this probably contributes to the struggles he experiences allowing
himself to be cared for at home as opposed to doing the caring work. While the
ability to allow himself to be cared for does not come automatically, it does occur
but with a sufficient amount of self talk.

Work is automatic for me, the home stuff still isn’t. and I’ve

been with my wife for 25 years. and it‘s not automatic for me

to connect with her on an emotional level as it is here. Not that

it is forced, but I have to think about it..think about not being a

therapist and think about letting her take care of

me..(Therapist Three, personal communication, August 2000).
One therapist shared how in an attempt to separate the work from his personal
world he often leaves many good qualities at work. This inability to share these
qualities appeared to be closely related to how much the therapists give to their
clients, and that perhaps at the end of the day the ability or the desire to do this
with other people is low. This was consistent with how one therapist views
separating work from home also. He noted that he feels it is either all or nothing
in terms of what he is able to provide in the form of caring. And since the majority
of the day is spent providing this level of caring to his clients, it is his home life,
and perhaps himself that do not benefit from this level of caring.

I have less patience when I know the history and I know that

there is not trauma back there. I have expectations that are

pretty high, and I think part of dividing personal and private
life...there’s probably some very good parts of myself in terms

of tolerance that I leave at work and don’t take home with me
(Therapist Three, personal communication, August 2000).

One therapist related that the largest emotional toll this work has taken on her
is feeling as if her clients need her to reparent them, and this feels too close to
what she needs to do in her personal life for her children that she has become
less interested in taking on these types of clients. Her work now is more focused
towards crisis intervention where she can provide support and help in the
recovery process but it does not create the same type of strain that providing
services to long term or ongoing clients often entails. Another toll for this
therapist was found when a client is in crisis and she is also needed at home.
She noted how this creates anxiety for her and can turn into resentment as she is
being asked to make these types of choices. Her decision is that family comes
first but this obviously can create some dissonance in that she still has a
responsibility to her clients. Her attempts at managing these situations appeared
to be quite dependent on her clients being able to work through the dilemma but
when they are not she may be left with anxiety and decisions she does not want
to make.

I have teenage children, they have busy schedules, things are
planned for them by their school, by their work, by their
activities, that I cannot change. And so if I have a client in
crisis five minutes before I’m supposed to go to my kids choir
concerts, that produces a very high level of stress, and anxiety
for me. And those kinds of situations can create in me a real
sense of resentment-my family comes first and yet I have
these longer term clients who have the sense that I’m their
family. They have decided I’m their mom-well I’m not -when I'm
able to do that with them I don't mind, but when l have my own

life going on and their needing something outside of regular
work stuff, I do have some resentment about that and I don’t

65

like it...(Therapist One, personal communication, August
2000)

Many of the therapists discussed the importance of separating work and home,
but as we can see now this separation is blurry and ill defined and perhaps
occurs at a cost to the therapist and/or his or her relationships. Similar to
balancing the physical demands of working outside of the home and inside of the
home, balancing the emotional demands in these two areas is difficult. Perhaps
as more workers identify that there is an emotional toll to the work they provide,
more support and or information for these difficulties will be created.

Anger is one emotion that was identified by three therapists as how this work
has impacted them. This anger and its source were identified directly by one
therapist. The other two therapists did not identify this anger and its source in a
direct fashion. The anger can stem from just knowing that there is child abuse
occurring, or this anger appears to come from having to cope with the difficult
information the clients bring and how clients may impede on the therapist’s
personal time. One therapist noted feeling rage at the perpetrator, still angry at
abuse...”(personal communication August 2000).

Resentment seemed to grow from this anger of being contacted by the client
or asked to give more of him or herself to the client in addition to what occurs in
sessions.

I really have come to resent it spilling over into my personal
life-through dreams about it, having calls at home from people

in crisis, its ok but I resent it spilling over...(Therapist Two,
personal communication, August 2000).

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Several therapists identified how this work has shown them the ugly side or
the evil side of people. Hearing how people can be so vicious to each other has
impacted their ability to view the world as a wholly safe and secure environment.

Probably it impacted me personally the same way having this
job for a while impacted me personally, I get a real look at the
ugly side of the world. And I get a real sense that these things
can and do happen to people and that people who are minding
their own business sometimes get horribly and viciously
attacked. That it could happen to anybody and sometimes
there is just noting you can do about it. You are just in the
wrong place at the wrong time and that's kind of scary. But you
don’t want to think about that everyday on a daily basis
because you couldn’t function (Therapist Five, personal
communication, August 2000).

One therapist concurred, that doing this work continues to erode her beliefs in a
just world. She identified that when she views people hurting others so
maliciously it further strengthens her beliefs that the world is not just, and this
affects her greatly.
I think it goes down to that just world phenomenon, that will, continually.
when we work with trauma people that we are reminded that it is just not a
just world. It is not fair, and even if we face it everyday in our offices, to see
that as happening to lots of people, in lots of ways, still cuts at the core, and
those are the times I am reminded that I want it to be a just world (Therapist
Six, personal communication, March 2001).

Several therapists noted that the impact of this work could be seen in their
dreams during particularly difficult cases. One person noted that at the beginning
of her career the dreams were less about cases but more about her anxiety over
competence to handle the cases. Whereas another therapist had dreams that

were in response to the trauma material of her clients.

I have dreams about situations..it has definitely caused me to
view my own safety in a different way.. I without a doubt

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recognize my own vulnerability and I get frustrated that my
husband doesn't entirely get it, as far as locking doors and that
kind of thing...(Therapist Two, personal communication,
August 2000).

Hypervigilance to the environment, anxiety, and inability to control the
memories of the stories told by the clients were other impacts that some of the
therapists identified.

l was in the shower and heard a door closing, probably a neighbor, it startled
me. I went into all the stories that begin with doors closing behind them.. far
more into it, go to when startled/afraid, harder to clear those things now. I
have increased anxiety around some things, like doing new things, being in
unfamiliar situations, being in large groups... might not be able to move
freely (Therapist One, personal communication, June 2000).

These experiences were very similar to the types of things the victim may
experience after the trauma. The parallel process between the therapists growth
and coping with being trauma therapists is beginning to look very similar to the
recovery and healing a victim may experience.

Another common theme was feeling sad and hurt not only for what the client
has or is experiencing but for the persuasiveness of abuse. One therapist in
particular noted how it was the sadness that took the most out of her.

And I truly feel sorry, I’m deeply saddened by their experience.
So I think that is when it affects me personally is l have, I
experience deep sadness, and hurt for the client. I've cried
about my patients after work, might have to get up and go to
the bathroom and collect myself, or I've cried in the session
with them-l don't lose it with them, but I have gotten tearful-
...(Therapist Four, personal communication, August 2000).

Cirpumstances During the interviews it became apparent that the emotional
toll that this work can take can be very situation dependent. For example, when

asked to describe a key event in his or her career, each therapist quite easily was

68

able to generate an event and discuss its impact at the time and currently. Most
of the therapists discussed a specific case and how that particular case has
stayed with them and why. One therapist discussed how her key event was her
introduction into her job and her agency, and how this has impacted her feeling
supported. In each of the cases discussed it was not necessarily the entire case
that stood out for the therapist but it was one particular aspect. One common
characteristic of the cases was that each had a component that felt out of the
ordinary or extreme for each of the therapists.

One therapist described a young girl with a disability who had very little family
support. As the case unfolded over time the therapist learned more about the
family dynamics which were impacting this young girl and her ability to cope with
her disability. This case involved physical abuse and alcoholism. This therapist
identified that one major aspect of this case that had significance for her was that
she too is blind and understands completely the need for people in her life to be
aware of and to attend to basic needs of a person who is blind. For example she
related how this young girl’s family placed her in an environment where the
physical structure was always changing due to remodeling. This therapist
identified how taxing this can be when a person who is blind cannot rely on the
fact that her environment will be constant in terms of furniture, the walls, floors,
etc. This therapist was particularly struck by how the family was unable to
understand the importance of this to the young girl's well being.

Mother was not handling the disability issues too much,, and
her responses to having a child with a disability were not

received well by her family. The whole family system became
estranged from one another, so she was essentially isolated

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from this mother who was not coping with the child’s onset of
disability. And so mom started drinking, step dad was drinking
all along, abusively, at some point the, paternal grandmother
thought enough is enough, convinced the father to petition for
custody of the child... blind 15 year old girl who saw her father
three times a year now was taken from her mother. Moved to
her father’s who is building in his house, so part of the
significance of this case is I am a blind person ...(one) of the
caping mechanisms is you don’t move things around because
it takes too much energy to figure out where you‘re
traveling...(Therapist Six, personal communication, March
2001)

Another case that this therapist shared was also about a person with a disability
who found his environment hostile as well. This man was beaten by the police
because they saw his walking cane as a weapon. The therapist noted that in
each case it was the environment that was creating a great deal of the stress that
these individuals were experiencing. For this therapist these aspects felt
overwhelming and additive to an already chaotic and stressful life, and helped to
make these cases ones she has carried with her for years.

Another therapist recalled a case where a young girl had been raped, her
brother was murdered by the rapist, and she and her mother were still grieving
and in a great deal of pain two years later. This therapist identified this case as
being significant for her for two reasons. The first was that the facts of the case
felt to her were quite horrific and not a common presentation for her clients. The
other reason was that the family’s level of pain was such that it was beyond
normal grieving. She noted that it appeared the family had received no
counseling for the event, and were not really aware that they could feel

differently. This therapist felt that what the family was experiencing was far

outside of what would normally be expected.

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The people who were calling me on the phone from mental
health, those therapists were distraught, they were
emotionally affected by what they heard. I read the newspaper
account and the family talked to me about what they had been
through. I felt very much that this was the most horrible thing I
had ever heard of and seen. This family was grieving as far as
I can see onwards of two years and more because they for
one, had not really sought any treatment when it happened, I
guess they didn’t know they could or if they should or what is
the difference between abnormal grieving and normal grieving,
so they were still grieving bitteriy, so that case still stands out
for me...(Therapist Five, personal communication, August
2000)

One of the therapists recalled a case of a young boy who entered the hospital
due to severe sexual abuse. The part that stood out for her was that a gun was
used during the abuse by family members. She can recall how she reacted as
well as how her staff reacted. Everyone’s reaction was one of horror and a sense
of this was way too much for anyone to handle. Again it appears to be that what
caused her to recall this event was that it felt too overwhelming and outside of
what she and her staff normally hear or experience.
A child at the hospital who was held at gun point and sexually
molested a number of times throughout his childhood. When
we talk about the gun point I think that was the thing that blew
me out of the water because there was absolutely no way the
person could get free. And the other reason that description
remains with me is because of the staff reacting to this intake.
And a couple of times and a couple of different staff walked
into my office and cried. One of the staff said to me was I
would like to take a gun to that guys head. And I think the fact
that there was gun point is what set everybody off...(Therapist
Four, personal communication, August 2000).

Two other cases were relayed that both dealt with a child not being believed

when the abuse was disclosed. This therapist noted that it was not so much that

71

they were not believed but that they were then punished for speaking the truth.
This punishment is what makes these two cases stand out for her.

Another of the therapists recounted the story of a suicidal woman and how he
talked with her on the phone for hours trying to help her stay safe. The next day
the woman came to his office and gave him the vial of cyanide. He recalls
leaving work with the cyanide and thinking to himself “this is odd work to say the
least” (Therapist Three, personal communication, August 2000). Outside of
dealing with the extreme lethality of her suicidal plan, he reflected more on the
feeling of not knowing what to do with a person who was this suicidal, not telling
him where she was, and feeling as if what he said or did would make the
difference if she lived or died. This overwhelming sense of responsibility appears
to be what marks this case in his mind.

Lots of years ago I was working with a woman who was an
adult survivor of some pretty horrific abuse I didn’t know all of
her history at that point I just knew that she was suffering
tremendously and very suicidal. and there was several events
with her but I think the one that stands out the most was earlier
in my involvement with her because it was probably my
first..she was having a hard time staying at home and she was
a mother of six kids..older kids, she called me from a
campground at like 3 am in the morning called me at home,
then I was young and naive at that point in my career and gave
her my home number..and she called me and she had worked
at a chemical plant, and she had some cyanide and she was
going to kill herself..it was a little packet she stole from the
labor something like that..so I, that this 2 hour phone
conversation where l was envisioning her sitting in her station
wagon next to a payphone in a campground someplace..l
didn’t know where it was she wouldn’t tell me.. and we
probably talked for 2 hours from 3-5 in the morning I was
sitting on my kitchen floor I remember that..and what was
really going through my head was, I don’t know what the hell
I'm doing here how am I going to keep this woman alive? She
is clearly in pain and wanted me to do something for her..and

 

I’m not sure what I can do..(Therapist Three, personal
communication, August 2000).

This final therapist’s case also supports the hypothesis that what keeps these
cases fresh in a therapists mind is the sense of being overwhelmed and that this
is outside of the norm, even for what these therapists hear on a daily basis. As
part of her job, this therapist will go directly to the hospital to meet with people
who have been sexually assaulted. This case involved an 82 year old woman
who was severely beaten and raped. This therapist can recall how she felt
walking over to the hospital, and what it was like to see an elderty person in this
situation. She noted that the woman had not been cleaned up yet and so all of
the physical signs of abuse were still visible. This case touched this therapist in
how there truly must be evil in the world for this to happen. As well as touched
the idea of this happening to someone elderly who for all practical purposes
should be enjoying the last years of her life.

They hadn’t cleaned her up yet..she had blood coming out of

her ears, her eyes were blackened, her hands had been tied

and her hands were purple, it was just horrible, just bruises

everywhere and I think. you know I have no other way to

explain this besides evil and you know on some level I can sort

of get date rape but this I have no way to understand except

evil...(Therapist Two, personal communication, August 2000).
Other cases that represented the out of the ordinary for this therapist and stay
with her are the ones involving reported cult abuse. She noted how these cases
stay with her because of the infrequency with which they appear but also how
they impact her feelings of safety. One of the clients of the reported cult abuse

expressed several times how she was frightened for the safety of the workers

because she believed the cult would know she told and would want to harm the

73

people helping her. This therapist noted how this is not something that she will
hear from other clients and thinking about her own safety from her client’s
perpetrators is also outside of the norm for her.

Each of these key events held a specific meaning for the therapists, and these
meanings are different for each one. It also was different how the therapists
coped with these experiences. But what was similar was that the cases were not
the normal abuse cases that these therapists would encounter. Therefore these
cases stood out in terms of the unusual circumstances, and how the therapists
made sense of them, and how this then impacted his or her recalling these cases
as key events, even though they may have occurred several years ago.

For one of the therapists the key event was how she was hired into her
current job and the circumstances around that, and how this has impacted her
ability to do her job. This therapist noted that she was told she was hired under
much controversy, and this led her to believe she must prove herself as worthy of
having this position. So in her words she noted that she never said no to a
referral, and over worked herself. It took several years and a lot of processing
before she was able to let go of this sense of having to prove herself, and realize
that she could not prove herself to these people because the issue was not about
her ability to do the work. She later realized the issues had very little to do with
her. These realizations led her to set limits and to only do what was appropriate
for her to do in this setting. This therapist recognized that these limits helped her
to take better care of herself personally and professionally.

One of the things that happened earlier in this position that
what I was lead to believe, and now I’m not so sure its

74

accurate, but I was lead to believe that when I started here
that there was a lot of conflict in the selection committee to hire
me. And that for the most part I wasn’t really the person they
wanted. So I came here thinking that I needed to prove
something. So what it was that I did to try to prove that was to
never say no, to take on every client that came in w a crisis.
And I wasn’t clear about the set up of my program. Who it was
that I had to report to, and so the person that I thought I had to
report to, had me doing all kinds of other stuff. And so I
thought that was what I was supposed to do. That all sort of
came to some resolution about 2 years ago in terms of my
realizing that there was nothing I could do to prove myself to
these people who didn’t want me here. They still didn’t want
me here and it had nothing to do w my work and that my work
was just fine and I didn’t need to see twice as many clients as
those who worked here. So I stopped doing that and I set
some appropriate limits in terms of who I could see and who I
couldn’t and what I would do and what I wouldn't do. And that
has really helped me in terms of self care...(Therapist One,
personal communication, June 2000).

While this key event was very different from the specific cases provided by the
other therapists, one element was similar which was that this situation felt out of
the norm of what this therapist expected by coming to work for this agency.

I believe these examples illustrated how each therapist comes to this work
with an expectation that he or she will hear and experience things that are horrific
and devastating, but that there are still areas that can reach even outside of
these boundaries. There are experiences that will tax the coping of a person who
is expecting to hear the worst possible examples of human experiences. For each
therapist the key event stood out because of a particular aspect. Each case or
situation identified stood out because there was a component that felt out of the
ordinary or extreme. Upon reflection, I wondered if these therapists would

recount these events as trauma experiences or just part of being a trauma

75

therapist? Regardless of how each therapist viewed these events, It is clear that
they each see the events as having an impact on them.

Self Carp Skills The self care skills that the therapists have in place to handle
personal crises sometimes are similar to the ones used to handle work crises but
oftentimes are distinct. The self care skills that the therapists use in their
personal lives range from being set to being in a state of transition. Most
identified that over time their self care skills have changed, some say in a positive
direction whereas one therapist noted that her self care skills have deteriorated.
The range of self care skills was large. What appeared to be similar for each
therapist is that self care skills are ever evolving and changing to fit life
circumstances and needs.

Taking private time at home after work is one way in which a participant takes
care of self. Another therapist described one of her self care skills or ways of
caping is by shutting down. She noted that she will often get quiet or go away as
she is trying to handle a significant stressor in her life.

I shut down- when I have a problem I withdraw too— I become
very quiet-very thoughtful- I think I sometimes get
overwhelmed. So I become quiet and thoughtful to regain
some ground. Sometimes it takes me days, not a hermit, but
I’m in a process of trying to work things out. At night in bed,
before bed, when I’m exercising when I’m on the phone with
my friend or my support person I typically don't share a lot.
Oftentimes I'll do it myself, the shutting down thing, the thinking
thing. When I become quiet I'm really processing because with
my own stuff not as good with it, and so I probably have to
have that shutdown period. With someone else I can work
through that with them quickly, my stuff I'm just not as
equipped to deal with it. I'm just not, but yeah there is a

difference...(Therapist Four, personal communication, August
2000).

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Several therapists stated that eating is one way that they deal with stressors,
with each of them noting that this is not necessarily their preferred method of self
care. One of the therapists also noted that physical exercise is another method
of coping with stress.

I joined a health club in December and I have been there twice. So there’s a
ways to go on thatll The ideas are there, it’s just scheduling the time to be
there (Therapist One, personal communication, June 2000).

Sharing with friends and family was another way that several therapists cope
with personal life stresses. One person described this as just telling her husband
about her bad day not the specifics necessarily but simply sharing her feelings is
helpful.

I will say to my husband I had a really tough case but you
know I never really tell him the cases- he doesn't know the
cases- its really first of all none of his business, and I need to
protect the client’s confidentiality- and I don't think he's in a
position to deal with the trauma anyway, so I just say I had a
sexual abuse case and it shock me up or something- it
knocked the breathe out of me or something like that- so that's
about It...(Therapist Four, personal communication, August
2000).

There also appeared to be self care skills that have emerged for at least two
therapists that were noted by them as being less ideal than other strategies used.
These therapists noted that drinking was one form of releasing stress at home.
One therapist described using a form of avoidance in his personal life when it
comes to dealing with heavy material. He noted that he looks for avenues to

have fun not to deal more deeply with emotions or problems. He described

recreational activities, zoning out, building things, or just escaping. It appears

77

 

that his primary self care skills are the exact opposite of the types of skills he
needs to use with his clients.

Personally I escape, I go boating, l zone out, I do wood work, I
drink, just ways—I don’t drink a lot, I hang with my friends, what
has made my friendships tend to be fun-based we do things
together we don’t just sit and talk..my friendships aren’t like
that they really are escapes...(Therapist Three, personal
communication, August 2000).

One therapist identified that her self care skills were at a crisis level several
years ago. She stated that since that time she has worked to increase her self
care skills and sees this as an important area of her life. She stated that she tries
to eat well, exercise, and to play hard. She was able to identify that part of her
inability to increase her self care skills Is a reflection of her lack of time away from
work, her need to care for her family, and just simply putting other things ahead of
herself. This therapist can clearly identify how in the past she believes she had
better self care skills that entailed eating well, exercise, and rest but that her
changing work role affects the time she has to devote to these.

I would say that my self care skills were sort of at crisis level 2
years ago. Since then I have been working at improving self
care skills. One of the problems that l have with self care skills
is that some areas in my life over which I have very little
control-... but in terms of my own personal self care it could be
a lot better, a lot lot better-it just seems like that when I look at
the priority list a lot of it not my choice because of the positions
by my family and other responsibilities, that my needs are at
the bottom in terms of what I need to do-but some of the things
I have changed over the past 6 or so months is planning
better-in terms of eating better, making sure I have nutritious
food available to me- (Therapist One, personal
communication, June 2000).

At work the self care skills the therapists use were a little different. This

seems appropriate given the different setting, and perhaps the different issues

78

that need to be addressed. The most common form of self care for these
therapists appeared to be taking a break from their schedules. For one therapist
this means taking a brief walk or getting some coffee in between sessions and
trying to understand what about that particular session is causing her to feel
overwhelmed.

In the moment when I’m feeling its been really difficult, I take

that 10-15 minutes between sessions and go get a cup of

coffee or sit by the fountain if its summer. And I find time to be

alone, and what I do in that time, I process whatever piece of

it...(Therapist Six, personal communication, March 2001).

Another therapist noted that she tries to distract herself and this may mean
getting really busy with other work or taking a break by leaving her office.
Another common coping strategy appeared to be actually writing the progress
note about the case. One therapist noted that this helps to get it out of her head
by writing it down. It appears that by writing down the events of the session help
to diffuse the impact that session may have caused. What seemed interesting to
me was to note that each therapist was rather limited or restricted in the types of
self care they engaged in during work. It was unclear if these limitations are self
or other imposed. I would imagine that the setting drives the types of activities a
person can choose. One therapist did note that since she is at work she can’t run
down the hall screaming when she has a bad day, so this may speak to the limits
that are natural to the work setting.

One therapist did speak of setting limits around the types of work she will

engage in outside of regular work hours. She noted that while she would enjoy

79

participating in other trauma related teams, she finds the stress far outweighs the

benefits and finally had to limit these activities.
But I also find that things I’m drawn to in terms of
extracurricular activities is all related to trauma work-this is the
stuff I like-those are the kinds of books I read-I did try to get
more involved with the staff here but I don’t find them to be
emotionally supportive. l have withdrawn from some of the
professional commitments in the community that I would have
done, that are related to this work-enough is enough-that is
stressful for me—doing the debriefing isn’t stressful to me—
responding to a crisis is not stressful for me, but dealing with
the personalities on the team is highly stressful to me. Sol
don’t do it-but there is a loss in that too-not being able to do
that work...(Therapist One, personal communication, June
2000)

Supmrt Another common form of self care reported by these therapist was
sharing the stories or the experience with someone else. This appears to be in a
formal or informal manner but telling another person about the situation or the
feelings that are being evoked by that situation are common for these therapists.
This theme of gaining support from others was so prevalent that I felt it stood
alone outside of self care skills.

When discussing self care skills, each therapist identified how either gaining
support or not having support impacts his or her ability to manage this type of
work. One therapist identified how when a particular case became too stressful
and she felt overwhelmed that what helped was calling in other professionals to
help manage different aspects of the case. For example, having an attorney deal
with all of the legal aspects felt freeing to her. She could then be certain the
client was getting her needs met, but that this therapist did not feel as if meeting

all of these needs rested on her alone.

80

So what I did with that, was I pulled in an attorney and actually
the director of the agency that I worked with and managed it
that , that way I felt like I had more support and I didn’t have to
take on all of it...(Therapist Six, personal communication,
March 2001).

The other ways that getting support were discussed were in terms of needing
to just share that the person was having a bad day or had just met with a very
upset client.

It is usually a mutual kind of thing, and I’m typically looking for
an opening to share. I don’t necessarily, and this may be part
of being the director piece, I don’t necessarily go and lean on
people but I start talking with them and look for opportunities to
share in a mutual kind of way. But I think it probably is fairly
rare for me after a hard therapeutic day to not be able to
process it on some level with somebody before I am out of
here, it is not something I do at home...(Therapist Three,
personal communication, August 2000).

 

Sometimes it appears that the conversation or the support is directly related to
the case. It may be that the therapist is in need of advice or just support in his or
her intervention. In other instances the support appears to be just needing
contact with another human being, and not talking about trauma. One therapist
stated that on a particularly stressful day she sought out another person and they
talked about nothing in particular but that this was very helpful.

Sometimes it is not a particular case that you need to

regurgitate with another human being. Just for another human

being to be available to you so you can say ‘boy this is tough,

or I’m tired, or this one got to me’. If you say it out loud maybe

its less scary, or if another human being knows about it it’s not

so mysterious or powerful- all those kinds of things...(Therapist

Five, personal communication, August 2000).
All of the therapists identified that their first action is probably to informally talk

about the case with colleagues but that if they discover a more formal process is

 

81

needed they will seek this out. Some discussed paying for supervision or using a
consultant to the agency to process the case. Others mentioned that their
agency had a built in case conference that occurred on a regular basis that can
be utilized when needed. In general, support echoed throughout these interviews
as a basis for being able to continue to do this work.

There is a natural progression-after a while gets to be a heavy

burden, you never get used to it, so important to have

someone to consult with—have someone to lift you

up...(Therapist Five, personal communication, August 2000).

One therapist did share how she felt unsupported and undermined by her
administrators, and how this affects her work and her feelings of worth as a
therapist in that agency. As a result she seeks outside supervision for support.

I feel not only unsupported, but I feel undermined by the

administration here. There is a lack of caring, we are just cogs

on a wheel so to speak. I tend to become less emotionally

involved in certain things if I can control that, and usually I can

control that...(l’herapist One, personal communication, June

2000).
Although the majority of self care skills appear to be related, each therapist was
able to identify specific self care skills that did not necessarily mimic another
therapist. The use of support provides a common thread for all of the therapists.

The next level of themes that I identified from the transcripts were not
necessarily endorsed by all six of the therapists, but for each theme at least five
of the six made statements that were encompassed under these themes.
Opportunity, altruism, benefits, and growth are the second level of commonality

among the six therapists. As found with the first level of themes, the therapists

can be viewed using the three domains I found: self, family/friends, and work.

82

Opportunity Five of the therapists talked about how he or she entered the
field of trauma work. It was interesting to note that it was typically less plan full,
and more based on opportunity or being in the right place at the right time. One
interviewee noted that her interest in trauma work stemmed from a very personal
case of trauma that affected the students she taught. Her recollection of the
event was that, based on what she saw her students experiencing, it felt very
natural for her to work with them on the grief issues. It seems that from there she
felt more drawn to the field of psychology, and returned to school to quench this
interest. This interviewee related that while she did not pursue a direct course of
study in traumatology, she did inadvertently steer herself to working with an
overly traumatized and under noticed population, people with disabilities. This
work was born out of her own disability as well as her being a women of color,
and being able to identify trauma in her own history as a result of being a member
of two underrepresented populations. Her account of how this transition from one
career to another follows:

I didn’t choose it, it happened naturally... it was a natural
response to do some grief work with them, and as time went
on I found myself more inclined to hang out with the
counselors than with the other teachers. .And noticed that I
preferred the one on one pieces, not that I didn't like teaching,
I did but I naturally did counseling. And because I had that
early experience, and because of who I am, as an Indian
woman who is blind, I chose to do a master's in rehabilitation
counseling. And people with disabilities typically have some
kind of trauma story...(Therapist Six, personal communication,
March 2001).

Other interviewees found that they were working in various areas of

psychology or social work and had a passing interest or view of work with trauma

83

 

survivors. Some noted how the work they did with this population was rewarding
and interesting, and it felt right to pursue this avenue further when the opportunity
arose. One interviewee found that she was working with juveniles and found a
great deal of trauma in their histories, and that gaining the knowledge there led to
opportunities further down the line in this specific area. What was interesting was
that she noted the interest was not necessarily there at the beginning to work
specifically with trauma but it did emerge later. She stated so the why is, there
is no why, it just kind of fell I think but then the interest came..."(Therapist Four,
personal communication, August 2000).

Another participant reported that when applying for his current job, the
description of the work was not made available except that the work involved
children and families. Based on this description, the position sounded good, but
when it became apparent that this work specifically targeted trauma survivors,
this participant noted that it did not scare him off and that is how he has remained
in that position to this day.

I don’t know if coming out of school I chose to. So it wasn’t necessarily a
choice, although when I found out about it, it didn’t change anything. It’s just
kind of something that happened, and I think it scared me when I found out
exactly what the position was. It didn't ever occur to me to self exclude,
because it was familiar (Therapist Three, personal communication, August
2000)

My; Although the therapists appeared to be hesitant to view themselves
as altruistic, but more as people with skills who can help, altruism did surface in
five of the interviews. What I have viewed as altruism in five of the therapists is

the desire to help for the sake of helping, with very little identified secondary

gains. l was impressed by the sentiments of several therapists that simply

84

 

expressed the desire to want to help people who were suffering. As one person
commented, it was important for her to reach out and teach women that they
were valuable. This statement speaks to me of someone who sees a need and
wants to help fill this need based on her beliefs and desires for other women to
increase their sense of worth. Another therapist simply stated she just wanted to
do something about child abuse because now that she knew its prevalence, she
felt she wanted to contribute in some manner to its ending. One therapist talked
about the importance of doing this work for her was that she was able to
understand how this impacted the victim and wanted to be an advocate for him or
her to others who did not understand the impact or significance of the trauma.

Because I recognize the impact the trauma that sexual assault

has on victims and their families, and I think it’s an issue that

the general public doesn’t understand a family member might

say this happened a month ago why isn’t she over it? and I feel

like its important to me because I understand why she is not

over it, and so l think that's probably the main reason. just

recognizing the impact that that kind of trauma has and the

long lasting nature of it..even the victims themselves

recognizing themselves its ok that I’m not over it and I don’t

have to pretend to be over it to make it ok for my family

member...(Therapist Two, personal communication, August

2000).
Being an aide during the process of recovery was another way one therapist
discussed why this work was important to her. She noted that she finds this work
interesting and stimulating but that she could also be of help to someone. While
all of the therapists appear to have many altruistic qualities, one therapist
explicitly noted that he did not necessarily enter this field to help. He was
interested in the research side of human development as opposed to the

clinical/practice oriented side. As a result of working and learning more about the

85

 

 

field, his desire to help others increased and now fuels what he does. This sense
of just wanting to help to make an impact in the recovery of others may not be
specific to trauma work but it does apparently play a large role because this was
expressed by five of the therapists interviewed.

_B_§_r1e_fi_t_§_ Given the emotional toll and the difficulties found in working with
trauma survivors, the question of what keeps these therapists in this field
becomes eminent. It seems that the answer is in the benefits that the therapists
have received. The benefits of doing this type of work are not always readily
apparent to outsiders, ones not working with trauma survivors. However for five
of the therapists, the benefits of doing this work were many, and were often what
kept each of them doing this work with enthusiasm and energy. One benefit that
was noted by two participants was being able to provide a specific skill or having
a niche within his or her agency. As one participant stated, being able to service
her community was important and a benefit of being able to do this work.

It also has helped fill a niche where I am at in my agency

because a lot of times people come in specifically with

diagnoses PTSD or adjustment disorder related to some

particular event, and so the agency is happy to have

somebody that is competent to handle that kind of presenting

issue (Therapist Five, personal communication, August 2000).

For other participants the benefits of this work came on a smaller scale and were

slightly more personal. For example one person noted that being able to work
with a very suicidal client, and provide that support and be the person that helped

her make the choice of living, was pivotal in keeping him in this work. This

Participant also noted that it gave him a sense of success and perhaps a glimpse

86

 

In

at how impactful his work can be on others, not just the client but her family as

well.

The whole notion of I can save lives, I was like yeah, I’m going
to stay with this. So it was pivotal, in the sense that l think,
one it felt very much like a big success. It was affirming of
whatever skill I had at that time, and there was a rush that was
connected to it, in terms of we can keep working and l kept her
alive. That I know I would never get in the school of social
work..so that really helped make a decision at that point in my
career. That I need to stay in here because as much as it is
giving of myself, which has rewards connected to it which are
few and far between, but when they come through they are
whoppers. So... and I had a few other experiences with her
that were similar to that, but that I think was probably the most
pivotal...(Therapist Three, personal communication, August
2000)

Another personal benefit identified by a participant was learning her limits and

being able to work within them. She noted that “...it let me know what my limits

are-it let me know that sometimes I need to lean on other people...” (Therapist

Five,

personal communication, August 2000).

A sense of being very fortunate with her life and her children and family was

found by one of the participants. Hearing the horrific things that people endure

helped to remind her that she is fortunate in many areas of her life, and she did

not want to take that for granted.

I hear stories, and I think wow, I am so fortunate I am so
blessed my children are so wonderful, my family is so intact. l
have been so at the right place at the right time in so many
ways, it reminds me of what I have...(l'herapist Six, personal
communication, March 2001).

One interesting benefit that parallels the benefits a client may have was when

one of the therapists became a participant in a program that helped to empower

survivors of trauma. this therapist was learning to provide this service to her

87

 

clients by direct experience. She noted that what she gained from this specific
experience and what has translated to other areas is a sense of empowerment,
the very thing trauma therapists would wish to instill in their clients.

I went through it as if I were a participant and climbed, rock

climbing, ropes course, solo overnight camping thing out in

God’s country all by myself. So that piece was really a

significant event for both professionally and personally, me

connecting with what I can do and what my body can do, really

empowering for me. I have had some good opportunities

here...(Therapist Two, personal communication, August 2000).
This parallel process can be seen in other areas as well. It seems that at times
the therapists experience similar emotions and difficulties as their clients, maybe
at a different rate or depth, but that each needs to heal or recover from this
experience.

gm The many strains and benefits that each therapist has shared can be
overlaid by his or her growth as a person and as a trauma therapist. Five of the
therapists identified his or her growth in self care skills, impact of hearing the
traumatic material, and just in general as a person. This reflection back over the
course of their careers seemed to help solidify some beliefs but it also appeared
to help illuminate other aspects that were at the time unclear.

One area that appeared to be consistently thought of when looking back over
their careers was how their view of people and trauma has changed. One
therapist noted how she sees people differently now, and how this is probably a
result both of doing this work but also a result of just getting older.

I see people differently, in the beginning I was in a different
place and I saw people as more negatively in the victim role

more helpless, more hopeless. And so where as now instead
of having that instant response that this is a victim, I think

88

 

 

about where is the resiliency factor. How did this person make
it here...so I’m less into sitting with the affect in regards to the
victimization, and more being proactive in getting into so how
did you make it through that..and how are you making it
through now. So really my focus has changed into building
more and thinking empowerment, than staying with that
victimization piece..(Therapist Six, personal communication,
March 2001).

A changing perspective on people and the ways in which they manage their lives
was noted by another therapist.

A greater appreciation or tolerance for the diverse ways that
people lead their lives..l don’t hold up an ideal standard to
which I measure success anymore..not wanting my clients to
achieve a certain level of healing..but an appreciation on my
part for the variety of ways that people recover..in a relatively
ok fashion and they need not meet my expectations. Think
abandoning those have been a significant change for me..l
think I came in with a notion of what health looked like..and yet
a lot of people don’t necessarily meet that, and yet are doing
ok. So I have come to appreciate the idiosyncratic nature of
healing for people, and achieving a resolution and that need
not look like anything I wanted for them (Therapist Three,
personal communication, August 2000).

 

One therapist identified how her ability to become shocked by this work has

decreased over time but has not led to callousness.

 

Being less shocked I guess is a good way..for the majority of
situations I hear about its like ok its horrible but yeah and then
there are some like the 82 year old woman that are still
shocking but I guess in the years of hearing stories I don’t
want to say that I’m not into it or have become jaded, because
it still affects me, but I guess I’m not shocked..even the
emotional impact, the intensity of it overall has decreased
except in a few cases that come up..(Therapist Two, personal
communication, August 2000).

A broader look at personal growth was also provided by these therapists. As I
listened to each describe how they have grown, l was struck by the insight and

level of growth that was experienced. One therapist explained how she has

89

changed personally over the years, and how this has impacted her work as a
therapist.

As a younger person l was less willing to, I don’t know if l was
less willing, but I don’t think I had a developed support system
that l trusted to bounce a lot of things off of. So as a younger
person I think I did more internal processing for a much longer
period of time, and as l have gotten older my life experience
and my work experiences have increased. l use that as my
first mode of operation but after that I am much more willing to
brag about it, talk about it. So that is something that has
developed over time..probably have increased my ability to '-.
trust too. l’m in a different place with different people so that
person-environment interaction...(Therapist Six, personal
communication, March 2001).

 

One therapist remarked that he has been working in this field for most of his
adult life, and how he does not know if the changes he has experienced are a
direct result of getting older or if they are specific to the job he does.

Probably changed in a lot of ways that have to do with being
older. It has been 18-19 years that l have been doing it, so
just maturing in general, not so much being a trauma
therapist..lots of changes not sure if it is a causal
factor...(Therapist Three, personal communication, August
2000)

Lastly one therapist noted how her growth has led to her feeling more
confident as a therapist with specific clients, and in general.

I have gotten wiser especially in terms of my DlD (Dissociative
Identity Disorder) clients that I’m more relaxed, I don’t take on
as much responsibility as I did with the other client, and so I
think I’m, l guess how l have changed is that l’m not as naive
and I’m more confident and I feel too that I’m better able to
challenge things with clients and not be so afraid to do that...
feeling like I’ve evolved as a therapist—gaining
confidence...(Therapist Two, personal communication, August
2000).

90

 

The final level of main themes were endorsed by a minority of the therapists.
The themes of application of emotions and core values were discussed by four of
the therapists. Whereas the themes of hope and personal history were
discussed by three therapists. The inclusion of these themes was based on
importance for these individual therapists, and also to help illustrate how
individual differences color the findings of the six therapists as a group.

Qgpjggwith emotion-application An area that was discussed by four therapists
was how doing this type of work impacts the decisions they make in regards to
their families. One therapist defended how she uses her knowledge of trauma to
talk with her daughter. She stated that she is not overly paranoid but that she
does talk with her daughter about being aware of her surroundings, the types of
people she associates with, and other safety techniques.

I don’t want to be paranoid, and I don’t want my daughter to

be, and I try not to go overboard. l don’t think I am, But I ask

her to be aware of her surroundings, and who she hangs

around with, and if she goes someplace to watch her drink,

and things like that (Therapist Five, personal communication,

August 2000).
While this may not be different from what other parents are doing given the
culture at this time, it does seem that her emphasis on certain aspects of safety
may be informed by the horrific stories she hears on a daily basis.

A second therapist identified that one of her copings strategies was to create a
safe and secure environment for her children. As she listened to the horrific

experiences of her clients, she was able to make what appears to be a mental

checklist of the ways she had created a safe environment for her children.

9!

 

The way I dealt with that is to say I have a structured

environment, I have good food, I have a safe house, there is

no one is abusing them in their lives and I know where they

are 24 hours a day seven days a week and I know the people

they are with, they are in a safe neighborhood and they don’t

talk to strangers, etc... so really putting in place and being sure

I had some things in place for them-maybe some

hypersensitivity with that-making sure things were in place for

them (Therapist Four, personal communication, August 2000).
Again, perhaps this style is truly no different than many other parents. This
therapist was able to identify specific areas where she may have responded to
something because it triggered a story or an experience one of her clients shared
with her. She also identified that she does not tell her children the stories or the
exact reason why she makes her decisions, because she feels its not important
to them and also she believes they don’t need to know the traumatic experiences
of others.

One therapist identified how her response to hearing the traumatic stories
leads her to think about how she is raising her daughter, and how this will be
impacted by the work she does on a daily basis. This therapist wondered if her
feelings would be different if her child was a boy versus a girl, but she reasoned
that they probably would not be different because trauma affects boys and girls.

The emotional toll that these therapists experience do not just affect sons,
daughters, and partners but friends as well. One therapist noted that as a result
of doing this work she is no longer sustained by superficial relationships. She

identified that part of this change is because she is trying to heal from the work

she does during the week, and that in her off time she just does not have the time

 

or energy to spend on superficial things. She articulately noted that if the
relationship is not going to be additive, she finds no use for it at the current time.

One of the things l noticed about my self since I’ve started this
work, I have become much more isolated and withdrawn from
other people, I have very little tolerance for superficial social
relationships, they just don’t sustain and interest me, and I
think a lot of that is because in my off time when l’m not
working I’m doing my own personal recovery work. In terms of
trying to cope with the intensity, the high emotional level, the
sadness and the horror of the stories I hear. So outside of
work if relationships aren’t going to add to my ability to cope,
then I’m not much interested. l’m an introvert anyway, so that
just adds to a pattern in my life, but l’ve noticed it is much
different now since starting this work...(Therapist One,
personal communication, August 2000).

 

These are the ways that the individual therapists identified and articulated how
the emotional toll informs decision making and their relationships with others. It
would probably be fair to speculate that there are other ways in which being
trauma therapists has impacted family and friends, that cannot clearly be defined
and/or discussed. Although similar thoughts were expressed under the main
theme Emotional toll, l created this minor theme to explicitly note how decision
making can be affected, especially as the decisions are about the therapist’s
children. I think it is also important to identify how the impact or emotional toll of
doing trauma work can be viewed as more mutually reinforcing rather than

through a single causal relationship. For instance, a therapist can be personally

 

affected by this work, and these effects can impact how he or she is in primary
relationships. From there, the changes in relationships can also be viewed as

then impacting the individual again, and the cycle or circle continues.

93

Core Values Another factor that helped to describe the therapist as an
individual is the core values or beliefs the individual held that not only informs his
or her life but the work with trauma survivors as well. Only four of the therapists
shared core values during the interview, but these values helped to further the
understanding of why trauma work is important to them.

These therapists discussed their core values or beliefs as part of what keeps
them working with this difficult population. One therapist noted that it is her belief
that helping one child is not in vain. So while she may recognize that she will not
end child abuse completely, she can make a difference with one child and this is
important to her. Another therapist echoed this sentiment by stating her belief
that this is a rectifiable situation. Resiliency was discussed by some of the
therapists as part of what helps them to keep working with this population. The
belief was that people are resilient, and can overcome or move past this type of
trauma. One therapist’s spirituality plays a large role in how she views the
problem, her clients, and her self. She noted that her spirituality provides the
basis for her beliefs that her purpose is to help where she can, to use the
knowledge that she possess to help another human being.

Spirituality is based on my value system, my rules for living,
my belief system about people, and my spirituality sustains me,
it’s what keeps me doing this work-it’s not religion based- not
based in any particular organized..where one group would be
able to identify me as a member-but it is based on very deep
values. What gives my life meaning and purpose is to be able
to give assistance and to be able to guide people through

experiences, to use the knowledge that l have...(Therapist
One, personal communication, June 2000).

94

 

These core beliefs appear to serve as a reminder to these four therapists
about what keeps them going and why, in addition to opportunity, this work
appeals to them and satisfies them even through the difficult moments.

Personal History Another factor that three therapists discussed was the role
of a personal trauma history or just his or her personal history that impacts who
they are as a person as well as why they continue to do this type of work. These
three therapists provided glimpses as to how past events have shaped or
impacted them. For example, one therapist simply noted that she had a very
sheltered life, and that hearing the types of stories that she did was completely
outside of what she would have expected other people to have experienced. She
related this to how hearing the trauma stories at first was very difficult because
she just never really imagined or saw this side of life. Another therapist noted
that the way she provides therapy to her clients, the clients she has chosen to
work with, and her beliefs about recovery and healing are cemented in who she is
as a person. She noted that she is a woman of color who has a disability. She
further identified that it was the intersection of these characteristics, the
environment’s response to her, and her own response to herself and the
environment that informs and impacts her work with trauma.

Occasionally things that somebody had experienced, like my
first blind client, brought back all kinds of stuff of what
happened with my loss of vision. And so I thought about her a
lot, but I wasn't really thinking about her as much as l was

remembering my own stuff (Therapist Six, personal
communication, March 2001).

95

 

 

The other therapist that spoke clearly about a personal trauma history noted
how she is impacted by the trauma and how even now her behavior is altered
from having experienced this trauma. As she relayed the traumatic event, she
was able to identify having an acute knowledge of some of the emotions that her
clients may share as a result of their trauma.

it seems less important whether the therapist has a specific trauma history in
his or her work. What does seem to be important is for that therapist to be able
to understand what is it about him or her that impacts the work that occurs with
the clients. I think that these therapists are aware of what about themselves
impacts and informs the work with their clients. I see this in their descriptions of
core values, personal histories, and how they entered this work and how they
describe what this says about them as peOple.

Hope in addition to the general benefits and the skills that some of the
therapists identified as being reasons why each continues to stay in this field, a
sense of hope, of giving hope to the clients appeared to be another part for four
of the therapists that keeps them working.

One therapist spoke in a heartfelt manner about her beliefs about hope:

There is another part of this that l really tried to impart to those
clients I was working with at the time, not being in their shoes
its really hard to do this, but these horrible things happen and
we are supposed to survive them, life is supposed to go on,
we can’t totally stop functioning and become different people
than we were before this happened. We are going to be
affected by it forever and ever, never forget it, this going to
hurt but we shouldn’t stop living. And I look at what happened
to that family and I look at the other families and look at some
people who try to put the pieces back together of their lives

and go on, and that’s what should happen, if things can go well
that’s what should happen, and l have to try to remember that

96

 

and I think all of us have to try to remember that...Yes, its hard
but its probably, the thing I like doing the best, really, because
l’m trying to reach a side that I see, trying to get them to see
that they haven’t done anything wrong, that they are a decent
person, they have friends, they have done kind things to other
people, and people like them, respond to them, and come
back, so they are doing some things right but they are not
counting them as valuable and when I get them to see that,
that’s rewarding they may be surprised by it, but there it
is...(Therapist Five, personal communication, August 2000).

Another therapist echoed this sentiment, that providing hope to clients is one
of the many joys of doing this work.

I think it has just been really powerful to store that and to know
that there is that kind of hope to getting on the other side of the
trauma. And that in times when people are so hopeless and so
desperate, just knowing that and providing them and trying to
share my hope with them, that you can you will get on the
other side of this, and I think that has probably been the most
important part of that for me...(Therapist Two, personal
communication, August 2000).

 

A third therapist shared what she specifically tries to impart to her clients, and
how important this is to her was felt as she spoke.
lt translates very directly, the primary focus of my work is to help my clients
even if just one session see that there is hope, and see that they can
change. That they are not stuck where they are, that they can be come the
person they want to be, they do anything that they want to , that is my
general approach with clients. And in the very beginning with them is that
what’s happened in the past has happened to you but it is not a life
sentence, it is not permanent, you can recover...(Therapist One, personal
communication, June 2000).
The data collected from these six interviews was vast. There were many
points of agreement by these therapists. The level of disagreement was not
found so much in the answers to the questions but perhaps more so in the tone

or use of emphasis by the therapist. Much of the data collected was consistent

97

 

with the literature found currently, however the results did not fit neatly into any
one construct as outlined in the literature. The data from these interviews
appeared to go beyond any one construct, and encompassed many elements of
each.

In the next chapter, I will connect the results to the current literature. I will also
provide a discussion of the points of agreement as well as points of difference
between the cases. A model of the results based on the themes will also be
provided( Figure 1). Finally, l will provide limitations and implications for future

research.

98

 

 

 

Chapter Five

Discussion

The purpose of this study was to explore the impact that working with trauma
survivors has on the trauma therapist. The literature to date is growing in this
field. Although the majority of the literature exploring the effects of trauma
focuses on the client, there are several constructs that address the effects found
on the trauma therapist. The literature review found secondary traumatic
stress/compassion fatigue, vicarious traumatization, countertransference, and
burnout to address these effects on the trauma therapist.

Secondary traumatic stress or compassion fatigue is defined as the various
symptoms a therapist may experience as a result of working with trauma
survivors. F igley (1995) identified unwanted memories, a sudden re-expen'encing
of the traumatic event, feelings of detachment, difficulty concentrating, and sleep
disturbances as encompassing this construct. As the therapists in this study
described the emotional toll this work has had on them, some of Figley’s (1995)
elements of secondary traumatic stress/compassion fatigue were mentioned.
However, the full range of effects were not fully captured by this particular
construct

Vicarious traumatization coined by Pearlman and Saakvitne (1995) identifies
the various effects that trauma work has on the therapist as well, but this

construct adds that it is the cumulative effects of this work that provides the basis

99

 

 

for the emotional toll taken on the therapist. In addition to the behavioral
symptoms, vicarious traumatization addresses the cognitive schemas that are
affected also. The therapists interviewed for this study were able to identify how
they have been changed over the years by their work. However, this concept
also appeared to only provide a part of the entire picture of how trauma therapists
are affected by their work. The therapists in this study not only were able to
identify the cumulative effects of this work, but they also identified how a specific
case on its own affected them as well. Thus, combining several elements of

vicarious traumatization and secondary traumatic stress disorder.

 

Countertransference is the reaction of the therapist to the client’s responses to
the material that is discussed in therapy, and to the therapist as well (Wilson &
Lindy, 1994). According to this concept, the therapist’s reactions to the client’s
trauma story may be directly related to the therapist’s own trauma history, or
simply to the horrific nature of the client’s story. Wilson and Lindy (1994) note
that regardless of the reason, the therapist must take caution to address these
reactions with the client. Although some of the therapists in this study identified
examples of reactions to their clients, countertransference did not appear to be

the primary cause of the emotional strain each therapist mentioned.

 

The final concept that is often used to illustrate the effects of therapy on the
therapist is burnout. Burnout is described as the emotional exhaustion that can
result from close interpersonal relationships (Maslach, 1976). This concept,
along with countertransference, differs from the others in that it can be used not

only for trauma therapists but for general practitioners as well. The other

 

lOO

concepts were created to address the specific effects from work with trauma
survivors. Many of the therapists in this study provided comments that could be
identified as various levels of burnout. Similar to the other concepts, burnout was
not the only effect noted by these therapists.

The results of these six interviews clearly illustrated how a single concept or
phenomenon did not readily capture the experiences of all. What this study found
was that parts of each concept fit for many of the therapists, and this supports the
use of interviewing as a method for obtaining information that does not fall neatly
into a category. As the previous chapter illustrated, these six therapists spoke at
length about the various ways this work has affected them, and although there
were many similarities, each therapist’s response was unique. This uniqueness
in describing similar or related experiences also illustrates the weight or
importance each therapist places on his or her experiences. This point will be
further illustrated during the discussion of the model that was created from the
interviews.

The second area of inquiry was the self care skills of the therapist. The
literature to date on self care skills is in its infancy. Researchers have studied the
self care skills of the clients, but the self care skills of the therapist, especially the
trauma therapist, is new and rather limited. What has been found in the body of
literature is the importance of developing good self care skills for the trauma
therapist (Bell-Gadsby & Siegenberg, 1996). The studies on self care skills
identified various techniques such as, meditation, prayer, exercise, therapy, and

setting limits and boundaries at work. Although the literature supports the use of

10]

self care skills, no specific skill was identified as being the most beneficial to the
trauma therapists. What appears to be consistent for these six trauma therapists
is the use of a wide variety of self care skills, especially the use of support of
others.

What becomes clear after reviewing all of the transcripts, is that there are
shared experiences and feelings among these six trauma therapists. The
common threads that emerged from these conversations illustrated more clearly
that at least for these six therapists, there were several themes that were similar.
These themes emerged as emotional toll, circumstances, skills, support, and self
care skills. Emotional toll was defined as the impact of working with trauma
survivors. The emotional toll could be physical, psychological, or spiritual. The
toll could affect the therapist, family or home life, and/or work. The data showed
that for each of the therapists, the emotional toll had many similar components.
These shared components further support the literature that working with trauma
survivors does have an impact on the therapist. As Radeke and Mahoney (2000)
reported, “Therapists were more likely than researchers to feel that their work
depleted them emotionally, and yet that it also increased their capacity to enjoy
life” (p. 83). Some of the main examples of emotional toll were feeling tired and
overwhelmed, feeling very sad for the clients, or identifying the “ugly” or “evil” side
of human nature. Another way that one therapist noted the effects of this work
was the way it impacted his family relationships. Several other therapists also

noted that relationship issues were impacted by what they do for a living.

 

 

The next common theme for the six therapists was self care skills. Although
each therapist was able to identify the use of self care skills, the exact nature of
these skills was varied. They ranged from over eating to taking time alone, to
exercise. Many of these identified self care skills echoed what the literature
presented as being common self care skills. One study by Mahoney (1997) found
that therapists reported using a variety of self care skills to address personal
problems. Mahoney (1997) reported that, “pleasure reading, physical exercise,
hobbies, and recreational vacations...’ were cited most frequently by therapists
(p. 14). Mahoney’s (1997) study of how therapists use self care when dealing
with personal problems found that personal therapy was sought by 87% of his
sample. Of these therapists, women engaged in more personal therapy than
men. Mahoney (1997) also found that women used other self care activities such
as massage therapy and chiropractic services more frequently than men. Two
areas of divergence from the literature on self care skills was use of spirituality or
religion and use of personal therapy. One therapist spoke about her use of
spirituality but it was more in the context of what her beliefs were regarding
change. The use of personal therapy was not directly mentioned by any of these
therapists. The closest reSponses centered around use of formal supervision.

The most consistent self care skill discussed was gaining support. This
provided such a large amount of information that I allowed support to be its own
main theme. This too supported the current literature on what is helpful to
therapists. In an article by Norcross (2000), several self care strategies that in

his words are " clinician recommended, research informed, and practitioner

103

 

tested” were identified (p. 710). One of the self care strategies that Norcross
(2000) adds to the list is the use of support. Norcross (2000) noted that several
studies support the use of helping relationships for mental health therapists.
What is also similar to the findings of this project is that the use of helping
relationships can range from peers to family. 'As with any of these broad
strategies, the number and range of techniques are impressive—peer groups,
loving relationships, close friendships, clinical supervision, and so on” (p. 712).
All of the therapists in this current study endorsed either informal or formal
methods of gaining support. Use of supervision was mentioned as a way of
coping with the strains of trauma work. lnforrnal supervision, however, appeared
to be the primary use of support for these therapists. This level of support ranged
from seeking out a colleague for a quick “normalizing” conversation to seeking
out a colleague to discuss the specifics of a case. One therapist noted that the
use of formal case conference was built into her agency, and this was a second
way for her to gain support from colleagues. The therapists did appear to
differentiate from needing assistance on the specifics of a case from just needing
to release the information they heard from a client. This particular self care skill
appeared to be used both personally and professionally by the majority of the
therapists. It did not necessarily seem to be the first self care skill used, but it
was definitely identified as one that is used often.

Another main theme was the circumstances of a particular case. Each
therapist was asked to recall a key event in his or her career. Five of the six

therapists identified a case or an event. The common theme of each of these

104

 

cases was that the cases were historical, and each was filled with multiple layers.
It appeared that what made these cases stand out for each therapist was the
extreme amount of trauma or chaos that each case held. The feelings and
behaviors that were evoked by the therapists also appeared to be similar. Each
spoke either directly or indirectly of feelings of being horrified, overwhelmed, and
taxed. The literature to date is directed more to the cumulative effects of trauma
work, whereas these examples speak more towards the individual effect a
particular case can have on a therapist. Although each therapist did discuss how
doing this work for a long period of time does take its toll, the individual effects
are also important to consider. Perhaps the toll is due to both cumulative and
individual effects of working with trauma survivors.

The final main theme that was endorsed by all therapists was the area of
skills. This theme encompassed direct therapy related skills such as assessment
as well as larger more organizational skills such as boundaries and setting limits.
Two therapists discussed gaining a set of skills that helped them to work with a
specific subset of the trauma population, suicidal clients. Perhaps, given the
nature of work with trauma, being able to identify a level of skill is another form of
self care. If a therapist is able to easily identify skills that he or she has crafted,
then perhaps a sense of mastery or competence is then born. A sense of
competence would then seem to increase a therapist’s ability to cope with or
handle even the most overwhelming situations.

The next set of themes was endorsed by five of the six therapists. l viewed

these themes as being able to define this group of therapists as a whole even

105

 

 

though each theme was not necessarily endorsed by all. These next themes were
opportunity, altruism, benefits, and growth. It was very interesting to note that
these therapists entered this particular field because of opportunity. No one
sought out work with trauma survivors specifically. Each of these therapists was
working in a different area of psychology or social work, and learned of a job
opening working with survivors. Most noted that the interest in working with this
population grew as more trauma survivors presented on the case loads.

Although no one specifically sought work with survivors, a sense of altruism did

emerge. This theme of altruism stemmed from the ways in which individual

I . ._
:u‘
u

therapists discussed why they stay in this field, and why this field is important to
them. Some discussed the importance of this work as wanting to help others
understand their worth, to wanting to aide someone during recovery. Each of
these therapists was reluctant to explicitly describe his or her actions as altruistic,
but I felt this best encompassed what I heard.

As one therapist noted the benefits of this work were not always readily
apparent but when they were it was wonderful. This, too, was supported by the
literature. As Norcross (2000) identified, “most of our colleagues feel enriched,
nourished, and privileged in conducting psychotherapy” (p. 712). Personal and

occupational benefits comprised another theme. Some therapists identified

 

benefits as the good aspects of their own life. The other benefits were noted as
being able to fill a specific role in the community or agency. Another benefit was

noted as being the types of things that could be learned from working with trauma

106

survivors, such as personal strength and power. Other benefits were noted as
being more skill related such as setting boundaries and knowing limits.

Growth and change over time was the last common theme in this section. Five
of the therapists were able to identify ways in which they have changed either as
a result of doing this work, orjust naturally independent of being a therapist. This
area too is supported by the literature on how a therapist may grow and change
as a direct or indirect result of working with trauma survivors. Bugental (1978)
noted, ”i am not the person who began to practice counseling or psychotherapy
more than 30 years ago... And the changes in me are not solely those worked by
time, education, and the life circumstances shared by most of my generation. A
powerful force affecting me has been my participation in so many lives (p.
149). This echoed what one therapist noted which is he knows that there have
been changes in him, but he was unsure what exactly contributed to these
changes.

The final main themes were endorsed by only four of the therapists. I viewed
these themes as also being representative of this group but merging more
towards individual differences. There were two main themes that fell into this
area: coping with emotion-application and core values. Application of coping
was defined as the ways a therapist may use what he or she has learned from
working with survivors to inform parenting and relationships with others. llliffe
and Steed (2000) found that as a result of work with trauma survivors, the
therapists found themselves to be less trusting of others, and more aware of

power and control issues in relationships. These changes in beliefs can lead a

107

 

person to alter how he or she may have previously engaged in relationships.
Three of the therapists spoke about parenting issues and how these are
specifically impacted by the types of stories they have heard during their careers.
One therapist illustrated this main theme by discussing how she views
relationships, and how this is directly a result of the work she does on a daily
basis. The core values theme was derived from the information provided about
beliefs that helped the therapist remain in this field. This theme ranged in
examples from spiritual beliefs to beliefs about resiliency. Although this theme
was discussed less than others, the information gleaned was important enough to
warrant its own category and should be used to represent this group of trauma
therapists. Norcross (2000) supported this point in his article by reminding
therapists to recall why each entered the field, and that most therapists feel their
work is beneficial and satisfying.

Two main themes that I viewed as being more related to individual differences
were personal history and use of hope. Each of these themes was endorsed by
half of the therapists. The personal history category encompassed the sharing of
personal information in regards to a trauma history by the therapist. This
information was not directly sought but was provided during the interview by three
therapists. Although only one therapist provided a direct example, it was
important to note that at least half thought about the ways in which a personal
history may impact or affect work with trauma survivors. The literature on trauma
therapists often questions the existence and the impact a personal trauma history

may have on the individual therapist (Elliot & Guy, 1993; Pearlman & Maclan,

108

 

1995; Schauben 8 Frazier, 1995;). This project did not support or refute this
body of literature which has mixed findings regarding the possible impact. This
project did however provide support for the speculation that a trauma history may
play a role in how, and why, a person works with trauma survivors.

The final theme identified in this study was hope. This theme was created to
incorporate the three therapists remarks on how they use hope in their personal
and professional lives. Hope was viewed as something that is instilled as well as
cultivated. It was also discussed as something that was found in the therapist,
and how it sustains them when doing this work begins to take a negative
emotional toll. Schauben and Frazier (1995) allowed each respondent to write in
coping strategies that were used most often. Spirituality was one of the most
commonly written coping strategies. The therapists in this study who discussed
h0pe, identified hope as being a feeling they have or something they hope to
instill in their clients. This category while not directly mentioned appears similar
to a sense of spirituality identified in the Schauben and Frazier (1995) study.

The differences between the therapists can be noted as themes that were not
addressed by all. One therapist did not identify areas that fit under the
opportunity, benefits, or personal history themes. This therapist’s comments
were found to be more geared to the difficulties she encountered in her work
setting. This therapist appeared to feel less supported and more alone in her
work environment than was mentioned by the other therapists.

A second therapist’s comments met all the criteria for the themes except for

the core values theme. This therapist was noted as being quite insightful into her

109

 

work with trauma survivors. This particular therapist spoke a great deal about the
political voice that was born out of working with trauma survivors, and how she
was usually not a very out spoken person. This specific change in self was not
noted by other therapists.

Therapist three did not provide comments that fit in the hope, coping with
emotions, or personal history themes. What appears to separate this therapist
from the others is gender. Although many of his comments were similar to the
other therapists, it was noted that he appeared to take on a more active role than
his counterparts. Perhaps this was related to gender or merely personality
differences. Future research would do well to address these gender issues more
fully.

Therapist four’s comments encompassed all the themes except for the hope
theme. Although no specific comments addressed hope, this therapist’s tone and
what appeared to be underlying sentiment was hopeful. Similar to therapist two,
this therapist was very expansive and elaborate about her work and it’s meaning
to her.

Therapist five’s comments did not address growth, personal history, or core
values. This therapist appeared more reserved and introspective and was
provided with prompts to help elaborate on comments. This reserved nature
appeared to be more personality type than wariness of the research or
researcher. However, given that the focus of this study was different, this was

not addressed directly.

110

 

Therapist six’s comments were encompassed under all categories except for
hope, altruism, and coping with emotion. This therapist was quite open and
elaborated a great deal, thus her not discussing these areas appeared to be due
to a different focus in her comments. Therapist six focused a great deal on the
interactions between herself and her clients, and the ways this affected her.

These differences among the therapists are difficult to identify as being more
than just personality differences, and/or differences in emphasis based on the
questions asked. However, these differences may warrant further research. The
differences between male and female therapists would be an important addition
to the literature. Research on the impact of individual differences specifically in
the area of trauma may also be of importance. Although this study did not identify
any differences based on client population served or type of agency, these would

also be interesting lines of future inquiry.

111

 

The Model of the Impact of Working with Trauma Survivors on the Trauma
Therapist

 

The model of the impact of working with trauma
survivors on the therapist, and the self care skills

 

 

 

          

Main themes

 
  

Secondary themes

   

   

    
   
  
 

   
      
  

 
   
 

 

 

°Skills , Tertiary themes .1 -
-Ernotional t0" 00pportumty f Coping with emotions-
Circumstances oAltrulsm i capplication
'S upport ~Benefits 1‘ ~Core values
~Self care \ 'G rowth ~.
..(Personal i I
, . f ‘ ; Ho
,History I’\ * l a pe
. .- - Therapist ” ‘ -

 

 

 

 

 

-_ Greatest amount of weight

Moderate amount of weight
Minimal amount of weight
Least amount of weight

 

 

 

Figure 1

The model (figure 1)

ln sum, this model of how trauma work impacts these six therapists, and their
self care skills is mutually reinforcing rather than a single causal relationship.
Emotional toll, circumstances, support, self care skills, and therapy skills were
main themes that provide information about these six therapists, how this work
impacts them, and how they attempt to cope with the effects. Each of these main
themes appeared to interact with each other, leading to a more mutually
reinforcing model for these therapists. The other main themes should be used to
further identify common themes that can be found among these trauma therapists
but do not fully include them all. Although the results showed the similarities
among the therapists, the weight that each therapist would place on these
themes was not determined. Therefore, it would be in error to assume that each
therapist would place the same weight or importance on the same main themes.
Given that each of these therapists have remained in the field thus far, it would
seem that more weight is placed on the positive aspects of this work rather than
the negative aspects. But within the positive aspects there are several, and thus
the importance for each therapist may be different.

In addition to the previously identified themes, the issue of parallel process
became apparent when viewing the data. There were several times when the
effects on the therapist appeared to parallel what generally occurs for the client
during the process of therapy and recovery. For instance, a client may have an
increase in symptoms related to the trauma, then as therapy progresses the client

is assisted in developing new skills and strategies to address these symptoms.

113

 

The client is provided ways to receive support from others who have experienced
similar traumatic experiences. Several therapists identified these similar
experiences in their work with trauma survivors. There at first is the emotional toll
of this work, and then the therapist learns to develop and utilize more effective
coping and self care strategies. The self care skill support is identified as being
the most utilized by the therapists, which is similar to the client seeking out others
with similar experiences. The need to talk with others who have had similar
experiences is shared by the therapist and the client.

Another example of the parallel process was when one therapist identified that
the work she does with her clients often mimics the types of parenting strategies
she uses with her own children. She identified how this is quite difficult to endure
given the difficult and taxing nature of both trauma therapy and parenting. This
therapist noted that the similarities are there due to the clients being close in age
to her children both chronologically as well as emotionally.

These examples of a parallel process provide good information about the
needs and experiences of the trauma therapist. This information can be used to
inform new therapists of possible effects of doing trauma work. Training and
supervision may also benefit from understanding the presence of parallel

processes in trauma work.

114

“ may!

 

Interaction of domains and themes

 

 

 

 

Themes
Domains
ain Secondary Tertiagy
Self X X X
Family/friends X X X
Work X X X
X Heavily weighted
X Less weighted W
Table 1

Another layer of this model was where each therapist identified the main
themes as occurring(Table 1). The three domains identified were self,
family/friends, and at work. Although several therapists differentiated how each
of these domains were impacted, there was no overriding consistency among the
therapists in this area. Table 1 provides a visual clarification of how each of the
three main themes(see Figure 1) may be captured in the three domains.

Therefore, the model provides clarification that work with trauma survivors affects

 

the therapist in all three domains, but that there is not a consistent pattern that
emerged. What this information does provide, is the knowledge that trauma work
can invade all areas of a therapist’s life, and should be monitored.

Returning to my initial hypothesis that work with trauma survivors would have
an impact on trauma therapists, and that their self care skills would help lessen
this effect, l realize now that l was initially too simplistic in my thinking. This many
level interactional model supports a more complex relationship than cause and

effect. I believe that in addition to my initial hypothesis being too simplistic, so too

115

 

is it simplistic to believe that the effects of trauma work can be encompassed by
one construct or theory. As noted earlier, these therapists identified many
aspects of all of the constructs that were created to identify the effects of trauma
work on the trauma therapist. Therefore, it would stand to reason that the
prescription or the intervention for the therapist, would also be multi-faceted and
varied. This supports the literature on self care skills which as reported
previously, states that no one self care strategy is more beneficial, but that it is
important for the therapist to be comfortable with the self care strategies that are
chosen.
Limitations

There were several limitations that I identified as being specific to this project.
First, the pool of therapists was identified through personal and/or professional
contacts. This group of therapists may have more in common with each other
than another group of therapists as a result of my contacts and relationships.
Although the therapists did not necessarily know each other, they each knew of
another person who is a contact of mine. This could have impacted my findings
indirectly by including a common characteristic of the therapists that could change
the findings. A second limitation of this project is that all of the therapists are
from either central or western Michigan. This could have implications for the
standard of practice that is provided in these areas. Perhaps therapists from
other regions would have a different set of norms by which they practice which
may influence responses to the questions. For example, the prevalence of

managed care, length of time trauma survivors engaged in therapy. or multiple

116

 

 

 

 

agencies that specifically served trauma survivors. These regional differences
could influence how a trauma therapist views his or her work. A third limitation is
specific to interviewing. Although every attempt was made to provide consistency
among interviews, these interviews were not standardized. There may have
been subtle differences between the interviews that led to different responses or
disallowed certain responses. A fourth limitation may be the types of questions
used during the interviews. This can have both positive and negative effects. I
provided clarification as needed to each therapist during the interviews but
recognized that each question was essentially left to the individual interpretation
of the therapists. Although the questions appeared to be rather straightfowvard,
the individual interpretations could have resulted in different responses that had
little to do with the information gleaned and more to do with the way in which the
question was asked. A fifth limitation for this project is the lack of more male
therapists. Although there tends to be more female therapists than male
therapists working with trauma survivors, the unique experiences of the male
trauma therapist should be identified. Perhaps if more male therapists were used
in this study, more could be said or learned about these unique experiences. The
sixth limitation is generalizability. Although the aim of qualitative designs is not to
provide a statement that is generalizable to the greater population, generalizability
can be extended to a smaller group (Erickson, 1985). This project illustrated the
impact for this specific group of trauma therapists, and should be viewed with
caution as representing the entire population of trauma therapists. However,

given that there is literature support from quantitative designs that do support

117

 

 

some of this project’s findings, some of the characteristics of these trauma
therapists can help inform, in part, how the impact of work with survivors can be
seen in other therapists. Firestone (1993) provides support for qualitative
designs having adequate generalizability, especially when the researcher uses
the data to generalize to a theory, and not necessarily to a population. Firestone
(1993) refers to this as analytic generalization. He notes that,
Analytic generalization has more promise, partly because there are more
ways to make links between cases and theories. One can look for threats
to generalizability within cases. Critical and deviant cases can be used to
explore or extend existing theories (p. 22).

This definition of generalizability is fitting for this project in that I used the
various cases to illustrate how the current concepts, regarding the impact of
trauma work on trauma therapists, possibly do not provide the full explanation for
what occurs for trauma therapists alone. Therefore, the issue of generalizability
becomes less prominent under F irestone’s (1993) use of analytic generalization.
Implications

This project does provide implications for future research as well as ideas that
could be incorporated in trauma training workshops and in educational settings.
Future research would benefit simply from more projects that addressed the
needs and concerns of therapists who work with trauma survivors. This field is
growing, and the hope is that this area will gain more knowledge that can be used
to support these therapists. Radeke and Mahoney (2000) illustrate this point by

the following statement:

118

“lama-1

 

 

Persons considering a career in psychotherapy should be

informed that it will be likely to result in changes in their

personal lives. Their development may be accelerated,

their emotional life may be amplified, and they are likely to

feel both stressed and satisfied by their work. In continuing

professional education, there should be a sensitivity to the

demands of clinical work and the complexities of life as a

practitioner. Given those demands and complexities,

therapists should be encouraged to prioritize their own self-

care and to establish networks of support for one another

(p. 83).
Given that an emotional toll was found among these therapists, education
regarding the possible hazards of this type of work, and identified buffers would
be warranted. This could come in the form of basic master’s or doctoral
education, or in trauma specific workshops and conferences. A review of self
care skills and the importance of cultivating these would also be beneficial in the
training of new therapists. Another area that was briefly touched on by this
project was the agency or administrative support that is needed by therapists
working with this population. Several studies provided support for administrative
support of trauma therapists (Kramen-Kahn & Hansen, 1998; Pearce & Pezzot-
Pearce, 1997). Issues such as supervision, collegial support, vacation, and work

hours may be ways that an agency could provide support for therapists. It also

119

 

 

seems that providing a built-in informal or non case—driven group supervision
would fit well with what these six therapists identified as means of coping.

Future research would also benefit from a longitudinal study that addressed
where these therapists are in regards to work as well as self care skills in a year
from this study. This would help identify what keeps people working in this area,
and would also provide beneficial information regarding what is helpful in regards
to education, the agency, and peer support in helping people stay in this field.
mm

The task of interviewing these six therapists was intriguing and inspiring.
Listening to the open and honest stories of the therapists, and how this work
affects them was fascinating. The ways in which each of the therapists made
sense of their experiences both the positive and the negative was commendable.
it was clear that doing this type of work had many drawbacks yet each found
ways to stay engaged and helpful to the clients. The desire to help others who
were in crisis was apparent. It also became increasingly more clear that each
therapist held a great deal of respect and admiration for the types of adversities
the clients overcame. The sense of being privileged to be a part of the recovery
process was also evident. Through this project I became aware that for these six
trauma therapists this was not just work to be done but it was work that they were
passionate about, and work that they each felt was truly important not only to

them but to their clients as well.

APPENDICES

APPENDIX A

Consent Form

Consent Form

You are being asked to participate in a research project, which will provide
information about the impact of working with trauma survivors on the clinician.
Brooke VanBuren-Hay from Michigan State University is conducting this project.
The project involves a face-to-face interview that will last approximately ninety
minutes. Each participant will be contacted one week later for follow-up. This
second contact will be done by phone. During the interview, you will be asked
about your work with trauma survivors, and its impact on you. All interviews will
be audiotaped, and notes reflecting therapist responses will be taken during the
interview by the researcher. Your name will not be on the audiotape or interview
notes. Audiotapes and notes will be identified by codes assigned to interviewees.
Your privacy will be protected to the maximum extent allowable by law. Audiotape
responses and interview notes will be kept in a locked cabinet while not in use.
Audiotapes will be destroyed once data have been transcribed, and tapes are no
longer useful.

Your participation is voluntary, you may refuse to answer any question and you
may withdraw from the study at any time. If during the interview you choose to
share information that you do not want audiotaped, the recorder can be turned
off. A summary of the results of this study can be requested by contacting
Brooke VanBuren-Hay, MA, 927 Cleo, Lansing, MI 48915 after July 2001. If you
have any concerns about this research project, you can contact Brooke
VanBuren-Hay at (517)485-1795 or at the above address. Any concerns or
questions regarding your role and your rights as a subject should be directed to:
UCRIHS Chair: David E. Wright 355-2180.

Please sign both copies of this form, keep one for your records and return the
other one to the interviewer.

I, (Print), voluntarily

agree to participate in a study about the impact of working with trauma survivors.
As a participant in this study, I will meet with a researcher from Michigan State
University for an interview that will last approximately ninety minutes, and I
understand the nature of the questions that will be asked during this interview.
Brooke VanBuren-Hay will contact me one week later for follow—up. Interviews
will be audiotaped and the researcher will take notes during the interview.

k

(Signature) (Date)

 

 

APPENDIX B

Research Questions

Research Questions

1. Describe how and why you chose to work with trauma survivors? Why is this

work important to you?

2. Describe the impact that working with trauma survivors has had on you-

professionally and personally.

3. Describe a key event in your career/work as a trauma therapist that stands out
for you. Describe the event in detail, what did you do, what were you thinking
and feeling during the event? How did this event impact you personally and

professionally? Did this event change you in any way? How?

4. Describe the ways in which you take care of yourself at work when you have a
hard day, or hear a particularly hard story. How similar/dissimilar are the ways
you take care of yourself from your personal life? How have these changed

over the years you have been working with trauma survivors?

5- Describe how you have changed, if at all, over the years from the time you

began work as a trauma therapist to now.

REFERENCES

 

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: APA.

Bell-Gadsby, C., & Siegenberg, A. (1996). Reclaiming herstorv: Erickaonian
solution focuseg therapy for aexual apuse. New York: Brunner/Mazel.

Bogdan, R., & Biklen, S. (1982). Qpalitative research for education: An
introduction to theogy and methode. Boston: Allyn and Bacon, Inc.

Brown, C., & O’Brien, K (1998). Understanding stress and burnout in shelter
workers. Professional Psychology: Research and Practice, 2._9_(4), 383-385.

Bugental, J. (1978). Psychotherapy and prpeesa. Massachusetts: Addison-
Wesley.

Chamey, A., & Pearlman, L. (1998). The ecstasy and the agony: The impact
of disaster and trauma work on the self of the clinician. In P. Kleespies (Ed.),

Emergencies in mental health practice: Evaluation and management.(pp 38-64).
New York: The Guilford Press.

Creswell, J. (1994). Researeh geaign: Qpalitative & Quantitative approaehee.
Thousand Oaks: SAGE Publications.

Danielli, Y. (1988). Confronting the unimaginable: Psychotherapists’
reactions to victims of the Nazi Holocaust. In Wilson, J., Harel, Z., & Kahana, B.
(Eds.),H mana a ti ntoe me tressfr m HI u ttoVr tn m. (pp.
57-76). New York: Plenum Press.

Elliott, D., & Guy, J. (1993). Mental health professionals versus non-mental
health professionals: Childhood trauma and adult functioning. Professipnal

Psycholpgy: Reaearch app Practiee, 24, 83—90.

Erickson, F. (1985). Qualitative methods in research on teaching. In M.

Wittrock, (Ed), mpgpppk of reaearph on teaching. (pp. 119-161). New York:
Macmillan.

Faunce, P. (1990). Self-care and wellness of feminist therapists. In H.
Lerman & N. Porter (Eds), Feminist ethiea in psychotherapy. (pp. 75-99). New
York: Springer Publishing Co.

D CF- B.I. (1998). Statistics of violent crimes. Department of Justice, Washington,

 

REFERENCES

Figley, C. (1995). Compassion fatigue: Copimith secondarvtraumatic
stress disorder in those who treat the traumatized. New York: BrunnerlMazel.

Firestone, W. (1993). Alternative arguments for generalizing from data as
applied to qualitative research. Edpcational Researcher, g2(4), 16-23.

Follette, V., Polusny, M., & Milbeck, K (1994). Mental health and law
enforcement professionals: Trauma history, psychological symptoms, and impact
of providing services to child sexual abuse survivors. Professional Psychology:
Research ang Practice. 25, 275-282.

Fox, R., & Carey, L. (1999). Therapists’ collusion with the resistance of rape

survivors. Clinical Social Work gopmal 27(2), 185-201. I

lliffe, G., & Steed, L. (2000). Exploring the counselor’s experience of working
with perpetrators and survivors of domestic violence. Journal of lnterperspnal
Violence. 15(4), 393-412.

Johnson, C., & Hunter, M. (1997). Vicarious traumatization in counsellors
working in the new south Wales sexual assault service: An exploratory study.

Work Q Strese, 11(4), 319-328.

Kramen-Kahn, B., & Hansen, N. (1998). Rafting the rapids: Occupational
hazards, rewards, and coping strategies of psychotherapists. Professional

Psygiolpgy: Reaearch and Practice, 29(2), 130-134.

Mahoney, M. (1997). Psychotherapists’ personal problems and self-care

pattems. Prefeaaional Esyphplmy: Besearph and Practiee, 28(1), 14-16.
Maslach, C. (1976). Burned out. Human Behavipr, 5, 16-22.

McCann, l.L., & Pearlman, L. (1999). Vicarious traumatization: Aframework
for understanding the psychological effects of working with victims. In M.

Horowitz (Ed), Essential pagrs on msttraumatic strees disorder. New York:

University Press.

McCann, I.L., & Pearlman, L. (1990). Vicarious traumatization: A framework
for understanding the psychological effects of working with victims. qurnal of

\Traumatic Stress, an), 131-149.

REFERENCES

Medeiros, M., 8 Prochaska, J. (1998). Coping strategies that psychotherapists
use in working with stressful clients. Professional Psychology: Research and
Practice. 19(1), 112-114.

Morse, J. (1991). Approaches to qualitative-quantitative methodological
triangulation. Nursiflg Research, 40(1), 120-123.

Neumann, D., 8 Gamble, S. (1995). Issues in the professional development
of psychotherapists: Countertransference and vicarious traumatization in the new
trauma therapist. Psychotherapy/312(2), 341-347.

Norcross, J. (2000). Psychotherapist self-care: Practitioner-tested, research-
informed strategies. Professional Psychology: Research and Practice, 31(6),
710-713.

Pearce, J., 8 Pezzot-Pearce, T. (1997). Psychotherapy of abused and
negleeted chilpren. New York: The Guilford Press.

Pearlman, L. (1995). Self-care for trauma therapists: Ameliorating vicarious
traumatization. In B. Stamm (Ed.), Second traumatic tress: elf carei ues
for clinicians, researchers, and educators. Lutherville: Sidran Press.

Pearlman, L., 8 Maclan, P. (1995). Vicarious traumatization: An empirical
study of the effects of trauma work on trauma therapists. Professional
Psychology: Research and Practice, 26, 558-565.

Pearlman, L., 8 Saakvitne, K. (1995). Trauma and the therapist:

Countertransferenee and vicarious tragmatization in psychotherapy with ingest
eprvivors. New York: WW. Norton 8 Co., Inc.

Pearlman, L., 8 Saakvitne, K (1995). Treating therapists with vicarious
traumatization and secondary traumatic stress disorders. In R. F. Charles (Ed.),
Compassion fatigue: Cepingwith secondam traumatie streas dieorger in these
who treat the traumatized. Brunner/Mazel psycholpgical stress seriea, No. 23.
(pp. 150-177). New York: Brunner/Mazel.

 

 

Pines, A., 8 Maslach, C. ( 1978). Characteristics of staff burnout in mental

health settings. Hospital and Community Eeychiatgy, 29.

Radeke, J., 8 Mahoney, M. (2000). Comparing the personal lives of
psychotherapists and research psychologists. Professional Psycholpgy:

Research and Praetiee, 31(1), 82-84.

REFERENCES

Saakvitne, K (1995). Therapists’ responses to dissociative clients:
Countertransference and vicarious traumatization. In Lewis, M. and Cohen,
J.(Eds.), Dissociative identity disorder: Theoretical and treatment controversies.
(pp. 467-492). New Jersey: Jason Aronson, Inc.

Saakvitne, K, 8 Pearlman, L. (1996). Transfonningthe pain: A workbook on
vicarious traumatization. New York: WW Norton 8 Company.

Schauben, L., 8 Frazier, P. (1995). \ficarious trauma: The effects on female
counselors of working with sexual violence survivors. Psvchologyof Women

Quaflerly, 19, 49-64.

Schwandt, T. (2001). Dictionary of qualitative inquiry. London: Sage
Publications.

 

Wilson, J., 8 Lindy, J.(Eds.). (1994). Countertransference in the treatment of
ESQ. New York: Guilford Press.

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