Self-Care for Clinicians Treating

Trauma
Vicarious Trauma, Post-Traumatic
Growth, and Self-Care Practices

Samia Mazhar
“The expectation that we
can be immersed in
suffering and loss daily
and not be touched by it is
as unrealistic as expecting
to be able to walk
through water without
getting wet.”
(Remen, 2006)
WHAT IS TRAUMA?

UCSF University of California, San Francisco 3

 What is Trauma?
Trauma results from an event, series of events, or set of

circumstances that is experienced by an individual as physically

or emotionally harmful or life threatening and that may have

lasting adverse effects on the individual’s functioning and

mental, physical, social, emotional, or spiritual well-being.

- SAMHSA

UCSF University of California, San Francisco 4

 How does trauma effect the
individuals working with trauma
victims?
Trauma shapes the survivor’s and worker’s basic
beliefs about themselves, others, their world
view, spirituality.
 Who am I?
 The world is no longer safe
 Others can’t be trusted
 I have to protect myself no matter what
 I can’t believe in anything now.
 Basic capacities damaged by
trauma: continued

• Trust:
– Inability to trust
– Too trusting (can contribute to re-
victimization)
 Basic capacities damaged by trauma,
continued :

• Emotional extremes, difficulty modulating:

– Intense affect
– Hyper arousal, nightmares, flashbacks
– Dissociation, self harm
 Basic capacities damaged by trauma,
continued:

• Disrupted relationships, Boundary issues:

– Hard to assess safe relationships
– Reenact role (victim, perpetrator, bystander)
 How does trauma impact behavior
 Inappropriate  Failures to connect
behaviors cause and effect
 Failure to understand  Perfectionism
directions  Depression
 “Overreacting” to  Anxiety
comments or facial  Self-destructive
expressions behaviors
 Hypervigilance  Fear and Vulnerability
 Aggression  Feelings of
worthlessness

UCSF University of California, San Francisco 9

 Compassion

Have compassion for everyone you meet

even if they don’t want it. What seems
conceit, bad manners, or cynicism is always
a sign of things no ears have heard, no eyes
have seen. You do not know what wars are
going on down there where the spirit
meets the bone.

Miller Williams
UCSF University of California, San Francisco 10
 Taking a Closer Look...
• Trauma
• Traumatic stress
• Vicarious traumatization

OVC
 Vicarious Trauma
• Definition: a process through which one’s inner
experience is negatively transformed through
empathic engagement with a survivor’s trauma
material, which may mimic PTSD symptoms
(Figley and Pearlman, 1995)
• DSM-5 Criteria for PTSD
– Criterion A: Stressor can be repeated or extreme
indirect exposure to aversive details of the event(s),
usually in the course of professional duties
 Understanding the Difference Between
Traumatic Stress and Vicarious Traumatization
Traumatic Stress
•Extreme emotionality or absence of emotion
•Fearful, jumpy, exaggerated startle response
•Flashbacks

Vicarious Traumatization
•Overly involved with or avoidance of victim/survivor
•Hypervigilance and fear for one's own safety (the world
no longer feels safe and people can’t be trusted)
•Intrusive thoughts and images, or nightmares from
victims’ stories OVC
 Vicarious Trauma Toolkit Model
Work Related Trauma Exposure = Vicarious Trauma

Change in World View Spectrum of Responses

Negative Neutral Positive

• Vicarious • Impact Managed • Vicarious Resilience
Traumatization Effectively • Vicarious
• Secondary Transformation
Traumatic Stress • Compassion
• Compassion Fatigue Satisfaction
• Posttraumatic
Growth

OVC

UCSF University of California, San Francisco 14

 Risk Factors for Vicarious Trauma
1. Work Setting
- Type & number of clients & their traumas; social, political and
cultural contexts of their traumas and current work
• Complex, “difficult” clients
• Large caseloads – overextension due to work demands
• Large percentage of clients who have trauma histories
• Cumulative exposure to trauma clients over time
• Professional isolation (includes lack of peer support and
supervision)
• Work place strains: lack of resources, personnel and time to
complete work
 Risk Factors for Vicarious Trauma
Extent of Vicarious Trauma is Affected by the Unique
Interaction of:

1. Who you are:

- Your own personal history of trauma

- Current life stressors & support
- Lack of support system
- Being new in the field or in training
- Having unrealistic expectations of being able to save
or cure all of your clients!
 Why Do I have these Reactions
to Traumatized Individuals?
• Over-identification with the client and/or over-
involvement in helping them.
• Distancing from the person – in order to believe
“this couldn’t happen to me”.
• Anger that this has brought the lack of safety into
your environment, and anger at the systems that
allow these kinds of atrocities to continue.
• And …. Grief.
 Vicarious Trauma
• Factors increasing vulnerability or reducing
vulnerability:
– Over-identification with the victims
– Increased stress in our personal lives
– Bearing witness to cruelty inflicted on innocent
victims (e.g., children and others perceived to be
powerless to stop the injury/abuse)
 Risk Factors
Personal Professional
 Trauma history  Lack of quality supervision
 Pre-existing psychological  High percentage of trauma
disorder survivors in caseload
 Young age  Little experience
 Isolation, inadequate support  Worker / organization mismatch
system
 Lack of professional support
 Loss in last 12 months system
 Inadequate orientation and
training for role

(Bonach and Heckert, 2012; Slattery and Goodman, 2009; Bell, Kulkarni, et al, 2003; Cornille and Meyers, 1999)

19
 Vicarious Traumatization is …
• NOT a reflection of your inadequacy
• NOT a reflection of badness or toxicity of
client
• IS an occupational hazard
• CAN be cumulative … over time and across
clients
• CAN be addressed and transformed
 Prevalence of Vicarious Traumatization
Among Victim Services Workers
• 50 percent experience traumatic stress symptoms in the
severe range; 50 percent experience high to very high levels
of compassion fatigue.
(Conrad and Kellar-Guenther, 2006)

• 34 percent met PTSD diagnostic criteria from secondary

exposure to trauma.
(Bride, 2007)

• 37 percent experience clinical levels of emotional distress

associated with compassion fatigue.
(Cornille and Meyers, 1999)
OVC
Identifying Signs and Symptoms of Distress
Exercise
In what way can stress manifest for you in the
following domains?
• Body
• Emotions
• Thoughts/Beliefs
• Behaviors
• Relationships
 Examples of Vicarious Traumatization: Personal
•Physical •Rapid pulse/breathing, headaches, impaired immune system,
fatigue, aches
•Emotional •Feelings of powerlessness, numbness, anxiety, guilt, fear, anger,
depletion, hypersensitivity, sadness, helplessness, severe emotional
distress or physical reactions to reminders
•Behavioral •Irritability, sleep and appetite changes, isolate from friends and
family, self-destructive behavior, impatience, nightmares,
hypervigilance, moody, easily startled or frightened
•Spiritual •Loss of purpose, loss of meaning, questioning goodness versus evil,
disillusionment, questioning prior religious beliefs, pervasive
hopelessness
•Cognitive •Diminished concentration, cynicism, pessimism, preoccupation
with clients, traumatic imagery, inattention, self-doubt, racing
thoughts, recurrent and unwanted distressing thoughts
•Relational •Withdrawn, decreased interest in intimacy or sex, isolation from
friends or family, minimization of others’ concerns, projection of
anger or blame, intolerance, mistrust

(Adapted from J. Yassen in Figley, 1995)

OVC
 Examples of Vicarious Traumatization: Professional

• Performance • Decrease in quality/quantity of work, low motivation, task

avoidance or obsession with detail, working too hard, setting
perfectionist standards, difficulty with inattention,
forgetfulness
• Morale • Decrease in confidence, decrease in interest, negative
attitude, apathy, dissatisfaction, demoralization, feeling
undervalued and unappreciated, disconnected, reduced
compassion
• Relational • Detached / withdrawn from co-workers, poor
communication, conflict, impatience, intolerance of others,
sense of being the “only one who can to the job”
• Behavioral • Calling out, arriving late, overwork, exhaustion,
irresponsibility, poor follow-through

(Adapted from J. Yassen in Figley, 1995)

OVC
 How to Recognize Vicarious Trauma
• Identity

- Feeling disconnected from who you’ve known yourself to be

- Changed beliefs about the world
- Changing or fading spirituality
• Self Capacities
- Less grounded, can’t maintain balance
- Intense feelings – crying, irritability, intolerant, anxious, can’t
experience pleasure
- Numb, hard, distant, depersonalized, cynical
- Feeling others are feeling more negative about you than
normal

(Saakvitne & Pearlman, 1996)

• Vicarious Trauma

- Are less likely to make decisions in own best interest

- Make professional errors in boundaries, judgment
- Are less self-reflective and unable to sort out own
feelings and responses from those of client
- Fail to set limits, can overextend self, leading to
inevitable failure, resentment, exhaustion
- Are less able to notice, analyze, use own feelings to
guide us

(Saakvitne & Pearlman, 1996)

• Beliefs about Personal Needs
- Overprotective and fearful of children’s safety and
one’s own safety
- Concerns about betrayal by others and doubt in own
ability to judge
- Becoming overly controlling or giving in to
powerlessness and helplessness
- Less able to be open with others due to decreased
access to one’s emotions/other’s ability to
understand stresses of this work.
- Guilt about being sexual or intrusive thoughts conflict
with sexual desire or pleasure
• Memory and Perception

- Having intrusive thoughts, images, feelings,

somatic experiences

- Avoidance of above and their triggers

 Interpersonal Responses in VT:
Views of self or other can narrow to role of victim, rescuer, perpetrator, uncaring bystander

• Feeling others at work or home are intentionally hurtful,

malicious, uncaring, or alternatively, weak & less
capable
• Feeling hurt or disrespected by others
• Taking things personally
• Feeling weak and less capable
• Tending to view others as either a good person or a bad
person, forgetting we are all a mixture of both
• Observing that you tend to react more strongly with
anger, irritability, hurt, or anxiety to things people do
• Blaming our clients for being victimized
What is Self-Care?
Self-care is what people do for themselves to
establish and maintain health, and to prevent and
deal with illness.
‘It is a broad concept encompassing hygiene
(general and personal), nutrition (type and quality
of food eaten), lifestyle (sporting activities, leisure,
etc.), environmental factors (living conditions,
social habits, etc.) socio-economic factors (income
level, cultural beliefs, etc.), and self-medication.’
(World Health Organization, 1998)
(OVC)
Why is Self-Care Important?

“To keep the lamp burning we have to keep

putting oil in it”
- Mother Teresa
 Self-Assessment
Things I Love to Do How I Spend My Time

• How closely does the way I spend my time

correspond with the activities I enjoy doing?
• If they don’t match exactly, what changes do I need
to make so that the correspondence between the
two columns is greater?
• Which changes can I make right away, and which may
require more time and planning?
• What steps to I need to take to make these changes?
Domains of Personal Self-Care
• The Physical self
• The Nutritious self
• The Emotional Self
• The Humorous self
• The Playful self
• The Recreational self
• The Relaxation/stress reduction self
• The Solitary self
• The Spiritual self
Nurturing the Physical Self
• Get adequate rest and sleep
• Physical activity on a regular basis
• Fun physical activities
• Medical care/preventive health practices
• Massage/bodywork/physical therapy
• Take time off when you are sick!
• Take time to be sexual with self/partner
Nurturing the Nutritious Self

• Eat regular, healthy snacks and meals

• Never skip breakfast

• Your body and brain need water – at least 8

8oz glasses a day (caffeine doesn’t count)

• Be flexible and allow small indulgences for

long-term success
Nurturing the Emotional Self
• Doing what is comforting to you
• Finding things that make you laugh
• Praising and loving yourself – giving self
affirmations
• Allowing yourself to cry
• Expressing your outrage in social action,
letters
• Obtaining your own psychotherapy, support
groups, personal growth
Nurturing the Humorous Self

• Laughing in a serious environment was the

number one strategy listed in one study of
clinicians’ coping strategies

• It takes time to master the art of laughter at

work – look for opportunities
Nurturing the Relaxation Stress-Reduction Self
• Stress leads to nervous system over-arousal
• Progressive muscle relaxation, breathing
• Visualization and imagery
• Meditative practices
• Yoga
• Nature
• Massage
Nurturing the Solitary Self

• Caring professionals live a life of intense

interaction with people who need something

• There is a quality to being alone that is

incredibly precious once we can move beyond
the resistance we sometimes have

• Take time away from telephones, the

computer too!
 Nurturing the Spiritual Self
• Identify what is meaningful to you and notice
its place in your life
• Listen to inspirational music
• Include spiritual practices and rituals
• Find a spiritual community
• Beliefs help to understand painful human
realities
• Spend time in nature, retreat centers
Nurturing the Spiritual Self
• Be open to awe, inspiration, not knowing, not
being in charge
• Cherish your optimism and hope
Incorporating Self-Care

• If you can’t do it all, make some time for what

you love

• Have faith in yourself, and associate with

people who have faith in you.

• Operate from confidence, rather than fear and

insecurity
Ideas for Interpersonal Self-Care at Work

• Take time to give & receive support

• Develop a “buddy” system with a co-worker
• Catch yourself when perceptions shift or intense
feelings arise, and label if VT-related
• Engage in “debriefing” around difficult cases
• Admit it when you do not know an answer or make a
mistake.
• For helps who have their own trauma history, ask for
and accept comfort, counsel
Self-Assessment

• Are formal and informal meetings with my peers part

of my regular schedule?
• If not, how can I build them into it on a regular basis?
- Having a weekly breakfast or lunch together
- Joining an association of like-minded individuals
that meets on a regular basis
- Getting regular supervision or consultation, formal
or informal
- Attending seminars and other opportunities for
learning on a regular basis (conferences)
What are some of the barriers or obstacles that
may get in your way of self-care?
 Examples of Barriers in implementing better self-care:

Don’t have the time

Don’t feel I should have to
Feelings of shame about having problems or difficult time
with the work
Afraid others will think I can’t handle it
Don’t want to burden others, especially family and
friends
Change is hard
Beliefs that no one will understand or care
Feeling negative/defeated at work
Other Barriers in Implementing Better Self-Care:
• Lack of consistent supervision
• Difficult setting limits/boundaries in your work and
with victims
• Attitude of “I can do this on my own” – a denial of
stress or burnout or your own limits
• Blaming others and/or self
• Feeling powerless in changing things both with
clients, community
• Pattern of taking care of others first
How will you go about removing some of these
barriers to self-care?
Self-Assessment
• Which tasks do I not need to do at all?
• Which tasks can be made simpler and less
time-consuming?
• Am I using the simplest, least complicated way
to do my routine activities? (scheduling,
billing, note-taking, correspondence,
paperwork, other)
• If not, how can I simplify those tasks?
 Self-Care Strategies
at the
Organizational / Agency Level
 Organizational

• Creating a healthy work environment/organizational culture

• Providing supportive leadership
• Providing quality supervision
• Debriefing staff
• Hosting staff/team meetings, retreats, formal and informal
opportunities to socialize
• Encouraging formal and informal peer support
• Acknowledging stress and VT as real issues
• Providing training and education, including orientation to the
organization and role
• Encouraging staff health and wellness (e.g., practices, programs,
policies)
VOC
Peer and Supervisor Support

• Use effective communication

skills
• Encourage trusting, mutual
relationships
• Practice conflict resolution
• Emphasize collaboration and
teamwork

VOC
VOC
Vicarious Resilience and Post Traumatic Growth

Involves the process of learning about

overcoming adversity from the trauma survivor
and the resulting positive transformation and
empowerment through their empathy and
interaction.

(Hernandez, Gangsei, and Engstrom, 2007)

(OVC)
 Impact of Vicarious Resilience
• Greater perspective and
appreciation of own problems
• More optimistic, motivated,
efficacious, and reenergized
• Increased sense of hope,
understanding, and belief in
the possibility of recovery from
trauma and other serious
challenges
• Profound sense of
commitment to, and finding
meaning from the work (Hernandez, et al, 2007; Engstrom, et al, 2008)
(OVC)
 Acknowledging the Positive:

Compassion Satisfaction: is about the pleasure you derive from the

work. You may feel positively about the meaningfulness of your contribution to the
work or even to the greater good of society.

Vicarious Transformation: is an ongoing, intentional process by the

worker that results in a deepened sense of connection with others, a greater
appreciation of one’s life, and a greater sense of meaning and hope. This term comes
from researcher Perlman, who earlier brought us the phrase vicarious traumatization
—evidence of how this field is evolving.

(OVC)
 Vicarious Posttraumatic Growth
• Growth experienced through
engagement with trauma survivors.
(Allison)