2. Emotional Responses
This presentation concerns the emotional
responses of careers working with
traumatized people.
The effects that these emotions have on
careers.
And some ideas about managing the
negatives effects and enhancing the
positives effects.
Emotional Responces 2006 2
4. Definition of Trauma
Dictionary definition
trauma, n., pl. -mata -mas 1. Pathol. A bodily injury. 2.
Psychol. A startling experience which has a lasting effect
on mental life; a shock. - traumatic, adj. The Macquarie
Dictionary New Budget Edition (1985).
Working definition
trauma: an inescapably stressful event that overwhelms
people's existing coping mechanisms.
Emotional Responces 2006 4
6. Post Traumatic Stress Disorder
The essential feature of Post Traumatic
Stress Disorder is the development of
characteristic symptoms following
exposure to an extreme traumatic stressor
involving direct personal experience of an
event that involves actual or threatened
death or serious injury,
American Psychiatric Association (1994) Diagnostic and statistical manual of mental
disorders (4th edition) (DSM-IV). Washington DC.
Emotional Responces 2006 6
8. Acronyms
VT (Vicarious Trauma)
CT (Counter-transference)
STS (Secondary Traumatic Stress)
CF (Compassion Fatigue)
Burnout
Is the ‘devil in the detail’?
9. Terms
Compassion Fatigue
A general term for any one who suffers as a
result or serving in a helping capacity.
(Figley 1995)
Burnout
Describes anyone whose health is suffering
or whose outlook on life has turned
negative because of the impact of
overload of work.
Emotional Responces 2006 9
10. Terms
Primary Traumatization
The impact of traumatic incident on the
obvious victim of the incident.
Secondary Traumatization
Includes the family members and close
associates of the victim.
Also refer to therapists, and helpers who
are eyewitness to incident they are try to
mediate.
Emotional Responces 2006 10
11. Terms
Vicarious Traumatization
Even when a therapist has not witnesses
trauma they can still vicariously
experience the client trauma in their
nervous system. Even though they are not
exposed to the event they can feel it.
Barbette Rothschild Help the helper 2006
Emotional Responces 2006 11
12. “These constructs have not proven
empirically separable, and the consensus
view now is that they share many features,
but primarily in their affective domains,
which are self in-efficacy in relation to
burnout, and fear in relation to vicarious
traumatisation”
(Linley and Joseph 2007)
13. Vicarious Traumatisation
By witnessing or hearing about someone
else’s trauma, people can be vicariously
traumatized, hence the term vicarious
Traumatisation.
Pearlman, L. & Saakvitne, K. (1995) Treating
traumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disorders
in those who treat the traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 13
14. Secondary Traumatic Stress
Secondary traumatic Stress is a natural
consequence of caring between two people, one
of whom has been initially traumatized and the
other of whom is affected by the first traumatic
experience. Risk factors for (STS) are empathy
and exposure. Additional risk factors are the
care giver’s Previous trauma experiences and
the extent to which these have been resolved
(Figley 1995)
Emotional Responces 2006 14
15. Burnout
Being involved in emotionally demanding
situations over a long period can cause physical.
emotional and mental exhaustion. This is know
as burnout and is a cumulative process rather
than a fixed condition. Burnout begins gradually
and become progressively worse. The most
salient factor associated with the symptoms of
burnout include client problems- chronicity,
acuity, complexity-that are perceived to be
beyond the capacity of the service provider.
Emotional Responces 2006 15
16. What's most important to know?
Vicarious Trauma= symptoms of PTSD
Burnout = Depletion
Emotional Responces 2006 16
17. Burn Out Process and Experience
Process: A helper becomes overly
involved or overly extends him/herself in
their professional role.
The helper experiences overload
Emotional Responces 2006 17
18. Emotional Responces 2006 18
Emotional exhaustion
Feelings of being drained and empty that
is caused by excessive psychological and
emotional demands.
Depersonalization
The feeling of callousness and cynicism
and a reduced sensitivity towards others.
Reduced Personal accomplishment
The feeling that one’s action and efforts
are wasted and worthless.
(Schulz and Schulz 2006)
19. The difference, Burnout and VT
Burnout begins gradually
Vicarious Trauma can happen quickly
Burnouts main symptoms are around
exhaustion.
Vicarious traumas main symptoms mirror
Post traumatic stress.
Emotional Responces 2006 19
20. Stress Vs Burnout
Stress Burnout
Characterized by over-engagement Characterized by disengagement
Emotions are overactive Emotions are blunted
Produces urgency and hyperactivity Produces helplessness and hopelessness
Exhausts physical energy Exhausts motivation, drive, ideals and hope
Leads to anxiety disorders Leads to paranoia, detachment and
depression
Causes disintegration Causes demoralization
Primary damage is physical Primary damage is emotional
Stress may kill you prematurely, and you won't
have enough time to finish what you started
Burnout may never kill you, but your life may
not seem worth living
Emotional Responces 2006 20
21. Stressors uniquely associated with
counseling and other similar roles
include
Maintaining concentration, discipline
and skill. This intensity is rarely
understood by others not working in the
field.
The high level of continuous output of
energy.
Issues are often intense, painful and
sometimes irresolvable.
Emotional Responces 2006 21
22. Role expectations of counselors are often
out of proportion to what is reasonably
achievable.
Limited organizational support for
counselors.
Feelings of isolation and having
expectations placed upon them.
Feeling inadequate and having self-doubt
when outcomes are not achieved.
(Potter, 1987)Counseling-orientated problems, with other factors previously mentioned, have the
potential to place counselors at a high risk of burnout.
Emotional Responces 2006 22
25. Aspects of Alterations of Self:
Changes in…
Perceptions of self and other
Personal identity
Worldview
Spirituality
Personal capacities
Ego resources
Psychological needs
Sensory systems
27. Post Traumatic Growth
Positive changes have been reported by
people who experience psychological
trauma
Enhanced relationship and increased
compassion and altruism.
( Tedeschi and Calhoun)
Emotional Responces 2006 27
28. Improved view of themselves as be more
resilient, or more accepting.
Some report changes in life philosophy
and finding more appreciation in daily life.
( Tedeschi and Calhoun)
Emotional Responces 2006 28
29. Other factors to consider
As postgraduate training increases,
traumatic symptoms in workers decrease
Greater involvement and greater caseload
elevate levels of trauma symptoms
Women report more symptoms than men
Workers with administrative
responsibilities (multiple roles) and longer
service have more severe symptoms
30. Symptoms reduce with years of
experience
Under 2 years experience increased
symptoms
Personal history of sexual abuse /trauma
exhibit highest levels of symptoms (mixed
results)
31. Vicarious Traumatization
The transformation of the person’s inner
experience resulting from empathic exposure to
the client’s material (Pearlman, Saakvitne 1995)
Occupational hazard
Effects are cumulative and permanent
Vicarious traumatisation is a response to the
effects of traumatic exposure on our clients.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),
Compassion fatigue: secondary traumatic stress disorders in those who treat the
traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 31
32. Impact -Vicarious trauma
Includes changes in the person’s:
Sense of identity
Relationships with self/others/world
Beliefs about self/others/world
Tolerance of feelings
Psychological needs
Memory and imagery changes (vulnerable to PTSD
symptomatology)
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.),
Compassion fatigue: secondary traumatic stress disorders in those who treat the
traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 32
33. Impact of Vicarious traumatisation
Depression
Despair
Cynicism
Inability to find enjoyment
Alienation from self/others
Professional impairment
Re-enactment
Emotional Responces 2006 33
34. Organizational impact of Vicarious
Traumatisation
Reduced team effectiveness
High staff turnover
Reduced morale
Loss of hope/faith
Emotional Responces 2006 34
Figley, C. (1995) Treating therapists with vicarious traumatisation and secondary traumatic stress disorders. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.
Pearlman, L. & Saakvitne, K. (1996). In van der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body and
society. The Guildford Press: New York.der Kolk, B., et al. (Eds.), Traumatic stress: the effects of overwhelming experience on mind, body and society.
The Guildford Press: New York.
35. VT’s impact on clinical work
“” In Clinical Work secondary trauma( VT)
involves a violation of the therapists sense
of basic trust, where the therapists
assumptions are undermined or shattered.
As the assumptions are undermined, the
behavior of the therapist is likely to be
affected as well””
Charles Figley’in compassion fatigue 1995 Brunner/Mazel inc New York, New York
Emotional Responces 2006 35
36. Emotional Responses
Helplessness
Guilt
Anger
Hate
Erotic transference
Dread and horror
Idealisation
Personal vulnerability
Avoidance reactions
Fulfilment
Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered lives training guide. Victorian Foundation for Survivors of Torture Inc: Victoria. (p. 148-152)
Emotional Responces 2006 36
37. Flow on of Strong Emotions
Helplessness—loss of confidence—underestimation of
clients resources and increased advocacy,-- doing
everything leads to exhaustion.
Guilt—viewing survivors as fragile --- taking excess
responsibility—avoidance of painful topics
Anger—dismay at bystanders—identification with
destructive thoughts—perpetrator victim split—anger at
victim—for not being morally superior
Dread and horror—feeling of being overwhelmed by
Emotional Responces 2006 37
38. Flow on of Strong Emotions
Idealization—view survivors as superhuman—
minimizing pain in self and others.
Personal sense of vulnerability intolerance of
violence
Avoidance reactions—denial detachment—
disassociation—self medication
Fulfillment—growth , deeper awareness of
human condition
Emotional Responces 2006 38
40. Dadi Janki of India Wisdom Keeper 1992
Dadi Janki- “ to take on the their suffering
would be to double the amount of pain in the
world”
Interviewer- “how do you help then”
Dadi Janki- “I try to wrap the others persons
suffering in love”
Toxic Emotions at work, Peter J Frost Harvard Business school 2003 p107-108
Emotional Responces 2006 40
41. Dis-identification Exercise
Find a quit space
Take three deep breaths
Acknowledge your care and responsibility
Say tour full name and age
3 things you like about yourself
3 ways you are different from your client
Repeat a few times.
Emotional Responces 2006 41
42. Risk Factors
Too high demands from others and the situation.
Lack of resources, personnel and time.
Lack of control over the situation.
Lack of support from leaders, organisations,
colleagues.
Unrealistic expectations.
Lack of acceptance and acknowledgment.
Smith, B., Agger, I., Danieli, Y. & Weisaeth, L. (1996) Health activities across populations: emotional responses of
international humanitarian aid workers. In Danieli, Y. et al. (Eds.), International responses to traumatic stress:
humanitarian, human rights, justice, peace and development contributions, collaborative actions and future
initiatives. Baywood Publishing: New York.
Emotional Responces 2006 42
43. Contributing factors
Characteristics of work
- Clients with traumatic histories
- Clients who are continually exposed to danger
- Clients who are difficult to understand
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue: secondary traumatic stress disorders in those
who treat the traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 43
44. Contributing factors
Characteristics of the worker
- Vulnerabilities
- Experience of personal trauma
- Ideas, values
- Ability to attend to their own care
needs
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 44
45. Contributing factors
Characteristics of society
- Society’s tolerance of abuse
- Society’s attitude towards violence
and social justice e.g.. misogynist, racist and hetero-sexist
and victim-blaming contexts.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 45
46. Reducing Risk
PERSONAL STRATEGIES
Maintain a personal life
Use personal life
Identify healing activities
Attend to your spiritual needs
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York.
Emotional Responces 2006 46
47. Reducing Risk
PROFESSIONAL STRATEGIES
Arrange supervision
Develop professional connection
Develop a balanced work life
Remain aware of your goals
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York
Emotional Responces 2006 47
48. Reducing Risk
ORGANISATIONAL STRATEGIES
Attend to physical setting
Arrange for adequate resources
Create an atmosphere of respect
Develop adjunctive service
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York
Emotional Responces 2006 48
49. Overinvolvement-Underinvolvement Continuum
Towards working with survivors Away from working with survivors
• wanting to know
more
• empathy
• responsibility for
one’s behaviour
and the reactions
of others
• developing
strategies
• advocacy for
intervention
• ‘crusader’
approach
• doing it all
oneself
• excessive
responsibility for
people’s feelings
• excessive
accommodation
of people’s
difficulties
• observing faculty
• professional
detachment
• maintaining
boundaries
•involvement in a
range of activities
• preoccupation with
efficiency
• cynicism
• minimising contact
• no responsibility
for people’s
reactions
• insufficient
allowance for
problems
• displacement onto
other issues
OVER-INVOLVEMENT IDEAL RANGE UNDER-INVOLVEMENT
50. Self care
Physical
Psychological
Emotional
Spiritual
Workplace care
Balance
Emotional Responces 2006 50
51. Active Ingredients of self care
Intentionality
Connection
Self soothing
Self care
Exercise, meditation, nutrition, spirituality
Working harder creates an sense of entitlement and
can lead to a breach of professional boundaries.
Compassion fatigue: A crucible of Transformation Eric Gentry. PhD (Cand), Mt.Cac 2002 Haworth Press Journal of
trauma practice 1(3/4), 37-67.
Emotional Responces 2006 51
52. Active Ingredients of self care
Narrative timeline
Desensitization and reprocessing.
Nutrition
Sleep
Routine
Entertainment
Fun
Activity/Exercise
Talking about it
Compassion fatigue: A crucible of Transformation Eric Gentry. Phd (Cand), Mt.Cac 2002 Haworth Press Journal of
trauma practice 1(3/4), 37-67.
Emotional Responces 2006 52
53. “” when caregivers fail to maintain a life
that is rich with meaning and gratification
outside the professional arena then they
often look to work as the sole source of
these commodities.
In this scenario, caregivers interact with
their clients from a stance of depletion and
need, It is completely understandable that
this orientation would produce symptoms
in care givers””
Emotional Responces 2006 53
54. Making Meaning
“The making of meaning is the opposite of the erosion or
negation of meaning that results for VT.”’
Meaning can be found in simple activities
The pursuit of the aesthetic
Existential awareness here and now
Acceptance of change allowing for transformation
Emotional Responces 2006 54
55. Healing compassion fatigue
and burnout
Relaxation Perceived threat (when listening to clients or
when remembering experiences)
Building and maintaining relationships( getting support
allowing other to confront when symptomatic; telling on
ourselves when we breach integrity; accountability)
Sharing Narratives -Painful work experiences(with clients
and co-worker
Eric Gentry prevention and Resiliency for the Workforce
Emotional Responces 2006 55
56. Implications and Directions
Alterations of self may be inescapable if
not inevitable
Self (both personal and professional) is a
relational and contextual process
Worker ‘self-care’ is an ongoing collective
responsibility with implications for
organisations and systems
Positive growth is a potential alteration of
self given the right conditions
57. Implications and Directions
Alterations of self may be inescapable if
not inevitable
Self (both personal and professional) is a
relational and contextual process
Worker ‘self-care’ is an ongoing collective
responsibility with implications for
organisations and systems
Positive growth is a potential alteration of
self given the right conditions
58. “… Yet when addressing the distress of
colleagues, we have focused on the use of
individual coping strategies, implying that
those who feel traumatised may not be
balancing work and life adequately and
may not be effectively making use of
leisure, self care, and supervision”
(Bober and Regehr 2006)
59. Winnocott and supporting careers
1. Helping the primary care giver feel well cared
for and providing a sense of social security and
hope for the future.
2. Supporting the authority of the primary
caregiver while allowing for splits
3. Enrich the life of the one receiving care
through the personal quality, ideals and
knowledge and liveliness of the other.
Winnicott, D. W.1964 The child the family and the outside Wourld Reading Mass Addison Wesley
Emotional Responces 2006 59
60. Team care
“” a community absorbs –the traumatic
experience of an individual by diffusing its
effects among many people and
demonstrating that the survivors feelings
are understood””
Like direct trauma then secondary trauma
violates trust severs contact to community
and destroys meaning
Emotional Responces 2006 60
61. Team approach to VT
Team identifies trauma emergent patterns
Therapist with trauma patterns like a client may have a
narrowed focus and be unaware.
Team expects to see staff with traumatic behavior on a
regular basis and confront them as early as possible.
Team maintains supportive trusting community
environment
A community absorbs the traumatic experience of the
individual by diffusing its effects among many people.
Emotional Responces 2006 61
62. Three tenants of team based care
1. Acceptance of the reality of Secondary
trauma.
2. Acceptance of secondary trauma as a
natural and valuable process, rather then
a defect.
3.That others can accurately observe
workers responses to secondary trauma.
Munroe et al 1995
Emotional Responces 2006 62
64. Team Care
“a community absorbs –the traumatic
experience of an individual by diffusing its
effects among many people and
demonstrating that the survivors feelings are
understood”
Emotional Responces 2006 64
65. Self-care vs. Transformation
Self care approach address the stress and
applies self and soothing and stress reduction
methods.
Transformation addresses the need to transform
the negative beliefs, despair and loss of
meaning.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion fatigue:
secondary traumatic stress disorders in those who treat the traumatized. Brunner-Routledge: New York
Emotional Responces 2006 65
66. Transformation
Self Care
Nurturing activities
Escape
Create meaning
Infuse a current activity with meaning
Challenge your negative beliefs and assumptions.
Participate in community building activities
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion
fatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-
Routledge: New York
Emotional Responces 2006 66
67. What have Workers found Useful?
Based on a study by Harrison and Westwood
(2008):
Countering isolation
Supervision as relational healing
Training, professional development, and organisational
support
Diversity of professional roles
Developing Mindful Awareness
Embracing Complexity
68. What have Workers found Useful?
(cont.)
Active Optimism
Holistic Self-Care
Clear Boundaries and Limits
Exquisite Empathy
Professional Satisfaction
Creating Meaning
Harrison and Westwood (2008)
69. Ethical Considerations
Educate workers of risks to alterations of
self
Train how to cope with ‘exposure’
Train in empathic disengagement
Titrated exposure vs being thrown in ‘at
the deep end’
Evaluation of capacity to cope
70. Organisational Responsibilities
Organisational culture (sets expectations)
Workload (diverse and manageable)
Environment (safe, comfortable, private)
Education (duty to warn of VT, ongoing education)
Group support (informal peer debriefing)
Supervision (regular, with focus on impact on self)
Resources for self-care (stress-reduction, yoga etc)
71. “” For therapist, organizations, institutions,
the key to successfully working with
trauma victims is understanding
secondary trauma and the risks
associated with hearing traumatic material
and finding ways to process and cope with
it. “
.
Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSW
Clinical social work journal Vol 30, No3 Fall(2002)
Emotional Responces 2006 71
72. “It is not sufficient for employers…to
instruct their therapists to take care of
themselves off the job: active preventative
measures should be a regular part of the
work environment.”(Monroe 1999)
agencies should structure schedules to
allow ample time for supervision and avoid
dual relationships in which the supervisor
is the agency director Sommer and Cox (2005)
73. “Addressing secondary or vicarious
trauma is without a doubt in the
best interest of the recipients of
out services our--- clients.”
Secondary Trauma: how Working with Trauma Survivors Affects therapists , Amy R.Hesse CSW
Clinical social work journal Vol 30, No3 Fall(2002)
Emotional Responces 2006 73
74. “What is to give light must
endure burning”
Victor Frankel
“To keep a lamp burning we
have to keep putting oil in it”
Mother Teresa
75. References
American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th
edition) (DSM-IV). Washington DC.
Bustos, E. (1990) Dealing with the unbearable. Reactions of therapists and therapeutic institutions
working with survivors of torture. In Suedfeld, P. (Ed.), Psychology and torture. Hemisphere
Publications: New York.
Figley Charles R (1995) Compassion Fatigue, New York: Brunner/Mazel
Gentry Eric J. Phd cand Mt,Cac Compassion Fatigue: A crucible of Transformation, 2002 Haworth
Press incJournal Of Trauma Practice 1(3/4),37-67
Pearlman, L. & Saakvitne, K. (1996) in van der Kolk, B., et al. (Eds.), Traumatic stress: the effects of
overwhelming experience on mind, body and society. The Guildford Press: New York.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists. In Figley, C. (Ed.), Compassion
fatigue: secondary traumatic stress disorders in those who treat the traumatized. Brunner-
Routledge: New York.
Winnicott, D. W.1964 The child the family and the outside World Reading Mass Addison Wesley
Wilson, J. & Lindy, J. (1994) Countertransference in the treatment of PTSD. Guildford Press: New
York. (p. 15)
Horowitz, M. (1976) Stress response syndromes. Jason Aronson Publishers: New York.
Emotional Responces 2006 75