“I find myself having images of my client’s sexual molestation invading my thoughts when I am trying to be intimate with my husband.”

“It is just too much. I just can’t take it any more. How many cases of child abuse can you see, before you’ve reached your lifetime limit?”

“Last night I laid awake almost all night, worrying that a client of mine who had a heart attack would die climbing the stairs to my office.”

“Sometimes I wonder about the ability to feel. I used to really feel what my client tried to express to me, I used to really care, now I just feel numb.”

Vicarious traumatization refers to the cumulative impact on the therapist as a result of exposure to client’s traumatic material. McCann and Pearlman first proposed the concept of vicarious traumatization in 1990 as a way of describing their observation that therapists were subject to similar symptomatology as that experienced by the clients they were treating, including similar symptoms of posttraumatic stress disorder. Drawing on constructivist self-development theory, they observed that trauma alters the cognitive schemas of the helping professional in the same way as it does for the victim, with respect to worldview, identity, psychological needs and beliefs.

As a relatively young administrator of mental health services at a children’s hospital, I frequently found myself wondering how I could best support the needs of the staff who were confronted with sometimes overwhelming feelings in the face of compelling tragedy. The most sensitive and caring staff members would candidly discuss their feelings, and indicate that they just didn’t know how much more suffering they could face. I found myself marveling at the skillful and empathic work of the pediatricians, nurses, physical therapists and social workers, and wondered if I was up to facing the human suffering they encountered daily. I had worked in adult hospitals for over 10 years at that point, but I found working in a children’s hospital was much more difficult. I spent the first few months in my new job hiding in my office, under the guise of preparing for an accreditation survey—a convenient excuse to keep me from facing what my staff faced every day.

Over time, and with the support of seasoned social workers willing to teach me about what life was really like in a children’s hospital, I gradually learned how to spend time with the patients and families. I learned to help a mother come to grips with the fact that her brother had molested her five-year-old daughter, to help parents face the death of their infant born with extreme prematurity; to help a five-year-old who survived unscathed in the accident that killed his mother; to help a mother face her husband after learning the death of her infant was the result of his brutal abuse.

As a mother of two- and four-year-old sons, I suddenly felt danger lurking everywhere in their lives, and found myself working overtime to protect them. I was becoming hypervigilant in the same way as my clients—just as McCann and Pearlman had described. I couldn’t stop thinking about my work. One of the social workers asked me at that time, “So what do you do to have fun?” Fun? I hadn’t thought about fun in a long time. So, at the core, I had lost my perspective about what I needed as a person, and as a mental health professional and administrator.

From Vicarious Traumatization to Vicarious Humanization: A Personal Journey

As a means of alleviating my own stress and that of other professionals around me, I tried to put programs in place that would support the mental health needs of the staff. I increased the number of counseling sessions available through the employee assistance program and I helped implement critical incident stress management programs (CISM) to provide 24-hour support to direct service providers for critical incidents. The difficulty with the CISM model (as so skillfully designed by Jeffrey Mitchell), however, was identifying the critical incident in a children’s hospital. By definition, a critical incident is one that has the emotional power to overwhelm helping professionals who are accustomed to dealing with human tragedy on a routine basis. In a children’s hospital, some instances could clearly be identified, often those which were accompanied by significant media attention: the brutal attack on a six- year-old by rottweilers; the murder of a child by her parent while hospitalized; the sudden death of a young nurse in the middle of her shift. Debriefings clearly helped with these situations, but they did little to help with the cumulative impact of exposure to trauma that affected the health and mental health professionals’ daily lives.

“I just can’t take it any more,” a particularly skilled pediatric intensive care social worker said as she submitted her resignation “How many cases of child abuse can one take before you’ve reached your lifetime limit?” I knew I didn’t have the answer to her question. I felt caught in the middle of a caring staff and an unsupportive administration that understood little about the real struggles of the direct service professionals who lived and breathed the tragedies of the families with whom they worked.

After five years of struggle, I found myself needing to find answers outside a system that didn’t seem to care about the staff that treated the patients. And I recognized that the employee assistance and critical incident stress management programs I helped to put in place were insufficient to transform the cumulative impact of working with so much suffering.

When recruited by a world-renowned children’s hospital for a senior administrative position, I turned down the offer, and accepted the challenge of making a professional career change. I made a decision to take my experience and heartwarming lessons and transform them into treating and training those who struggled with vicarious traumatization. I also made a conscious choice to do more psychotherapy with victims of torture and all forms of violence by becoming involved with assessing and treating immigration clients.

When I first began giving workshops on vicarious trauma, I was stymied to find the answers to the questions posed to me by workshop participants. The most compelling question was always the same: “Fine, we understand vicarious traumatization, we live vicarious traumatization, but what do we do about it?” In a workshop with seasoned child welfare workers, a particularly tenacious participant recently raised the question, “So what do you do to manage your vicarious trauma, I mean what do you really do, when you are confronted with a client’s vivid descriptions of their sexual molestation? I mean, in the moment, how do you deal with it?” The moment of truth had arrived; pat answers like diet, exercise, meditation, consultation, therapy, just didn’t satisfy these savvy trauma workers. But after leading countless visualizations, aimed at helping mental health providers identify and seek wisdom from their wise inner self, I felt I had found some genuine answers.

“ I have such a sense of wonder and gratitude that I do what I do for a living,” I began. ”I never lose sight of my clients’ strength and their resiliency, and it is seeing their remarkable strength in the face of adversity that helps with my own transformation. It is important to recognize what a phenomenal difference we can make if we allow a true connection to occur with our clients. Only by allowing ourselves to become exposed to their trauma, and allowing ourselves to feel their trauma, and letting them know that we feel it, can we help to transform their pain and suffering.”

I recognize that I have been inalterably changed as a result of the work that I do. It has not always been pleasant, or easy, but I am grateful for the change. I recognize that I am a vehicle that allows the client to bear whatever pain they need to bear. It is not my pain; and I am careful to keep that in perspective. I strive to keep boundaries and distance from their traumatic material, while allowing them to feel my presence. I encourage them to distance themselves from their traumatic past, so that they can gain greater perspective on it. I work from a strengths perspective, not a disease perspective. In the face of overwhelming tragedy, I see the client’s resilience, not their failings and, in seeing their resiliency, I see my own.

Traditional psychotherapeutic training may teach us that we are not managing our countertransference when we disclose that we are struggling with our grief or horror about a client’s situation. Who tells us that it is a normal response to struggle with our client’s trauma material? That it is okay to allow a tear to fall in a session when confronted with the most horrific aspects of a client’s pain? The most powerful therapeutic moments have been those in which I put down my therapeutic guard, and just allow myself to be who I am. I am a much better therapist when I allow the client to see how I feel…and to see that I feel.

Recently, I met with a Central American client who suffered from such severe PTSD that he could not discuss his history of torture and trauma without going into convulsive-like seizures. I sat next to him as he was frozen in dissociative flashback and simply touched his arm, and told him that I was there with him and that he was safe. He said afterward, “I heard you, I really believed you were there, and it was your voice that pulled me through it. For the first time in 15 years, I was able to go to that place in my mind that I have avoided. You are my angel, now, and when I feel myself going there, I just feel that you are with me, and I can face it.”

I am now more exposed to pain and suffering at a more intimate level, yet, I am able to comfortably manage my responses to the client’s trauma material. I no longer lose sleep at night. Through my eyes, I enable clients to see their own strength. I keep solid boundaries while I allow them to know that I can both feel and tolerate their pain. I am humbled daily by the work that I do. Rather than experiencing vicarious traumatization, I am now able to feel the gift of vicarious humanization.

Vicarious Humanization: Some Helpful Strategies

The wise strategies that I’ve discovered and learned from the therapists whom I’ve worked with and trained help to bring meaning into our lives and help us to ameliorate the painful aspects of our work with our clients. Here are some of them:

• Remember to feel gratitude for the ability to work with clients on a deep and profound level, and to appreciate that this has resulted in a positive transformation in your life.
• Recognize that being impacted by your clients is an expected part of the work of a therapist.
• Maintain a solid commitment to managing the impact of exposure to your client’s trauma material in your own life. It is your professional right and responsibility
• Work from a strengths perspective, not a disease perspective.
• Pursue your own psychotherapy and consultation throughout your professional career.
• Find a healing practice that helps to bring meaning into your life (meditation, yoga, writing, art).
• Bring laughter into your life every opportunity you have.
• Evaluate what is truly meaningful in your life and pursue those activities that are the most meaningful and bring the most joy.
• Re-evaluate the role of spirituality in your life, however you define it.
• Recognize and acknowledge the gift you have in working with others, and allow yourself to feel what it means to your clients to have made such an impact.
• Periodically evaluate the work that you are doing, and your satisfaction with your work. Don’t be afraid to make a change when needed.
• If a particular graphic accounting is upsetting to you, visualize the traumatic material moving through you, without impacting you. Replace a negative visual image with a positive image.
• Bring balance into every area of your life; strive for balance in all aspects of your personal and professional life.
• Assume as much control over your own work schedule as possible. Schedule breaks and lunches with colleagues.
• Take time for renewal with workshops, retreats, vacations.
• Avoid volunteer work that brings you too close to the work you do every day.
• When you take a walk, touch every leaf along the way.

Elizabeth (Betsy) Schenk will be completing her PsyD in 2005 at Ryokan College in Los Angeles. A licensed psychotherapist since 1985, she works extensively with therapists and health care providers and with survivors of trauma including torture, domestic violence and adult survivors of physical and sexual abuse. She has expertise with chronic illness, death and dying, and dissociative disorders. Email: bschenk@sfsu.edu Office: 4281 Piedmont Avenue, Oakland Phone: (510) 208-3450.

Reference: McCann I.L., & Pearlman, L.A. (1990) Vicarious Traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.

Note: This article reflects the opinions of the author and not necessarily those of
East Bay CAMFT.