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WHAT ARE THE POSITIVE EFFECTS
Positive Effects of Trauma Work 107
Ability to Reframe Negative Experiences
Mental health professionals who work with victims of trauma may also find that they are better equipped to address negative experiences in a resourceful manner as a result of their work experiences. Another counselor, this one employed at a women’s shelter, states that whenever she is having a tough day, she watches the children or speaks with the women who live at the shelter. Their courage is inspir- ing to her, and she states that she can then revisit her problem, taking it on using the skills she teaches to her clients (Richardson, 2001). Another mental health professional stated that working with victims of trauma changes how you define a problem, and forces you to become less fearful and more resourceful when fac- ing your own problems (Hernandez, Gangsei, & Engstrom, 2007). It appears that the process of working with victims of trauma and observing them overcome seemingly insurmountable problems, whether tangible (such as loss of family or friends) or not (loss of innocence or world beliefs), helps the clinician reframe his or her idea of the significance of everyday stressors.
Vicarious Learning from Stories of Courage
Mental health professionals and others who provide services to victims of trauma may find motivation to continue engaging in their trauma work as a result of their professional experiences. For example, Eidelson and colleagues (2003) reported that a number of the mental health professionals included in their study found a renewed sense of purpose in their work as a result of working with individuals affected by the attacks of 9/11. Other clinicians may find motivation in the cour- age of their clients to overcome their difficulties and move forward with their lives (Hernandez et al., 2007).
Hope for Future
Perhaps one of the most important outcomes of providing services to victims of trauma is that of hope for future. The clinician who struggled to understand a world in which a child could be abused may find that witnessing first-hand the capacity of humans to heal emotionally and psychologically lends itself to yet another view of the world; one of hope, one of strength (Hernandez et al., 2007).
It is perhaps through this newly formed view of the world that clinicians are bet- ter able to find satisfaction and value in their work; and to continue to have hope for the future.
Case Examples
Case 1: Military trauma
“John” is a 29-year-old Canadian Forces veteran who returned home from deployment in the theater of war in Afghanistan in 2007. He was deployed for
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six-and-a-half months and had no prior deployment history. He was a member of the army for five years and was trained in logistics and transport. There is no major premorbid history of trauma or abuse, and he otherwise had a positive developmental history.
While abroad, John witnessed the accidental death of a close peer by friendly fire.
He also learned of the suffering and abuse of children for which he was unable to intervene. John was also involved in numerous fire-fights with the enemy and wit- nessed repeated casualties. These incidents occurred in the context of chronic stress associated with being amidst hostile groups and the uncertainty associated with a high probability for violence to occur specifically while he was being attacked.
Upon returning home, he took a parental leave and soon after noticed dra- matic changes in his mood and reactivity with normal domestic and childrearing tasks. He experienced hallmark features of posttraumatic stress disorder, including re-experiencing, nightmares, hyperarousal, and avoidance of most social interac- tions. He spent most of his time self-isolating in his basement, and feared that his partner would soon leave him because of his lack of interest in intimacy and very limited emotional expressiveness, other than irritability and anger.
John sought individual psychotherapy in 2009 in order to improve his increas- ing symptoms and functional impairments. He had taken to using marijuana to
“relax,” and found that he still had prominent insomnia and daytime fatigue. He disliked using prescribed antidepressants and felt that his inability to recover was indirectly a sign of weakness.
John embarked on prolonged exposure therapy (PE) at a specialized outpa- tient mental health clinic and reluctantly began to share specific details of his trauma-related experiences. John had an experienced therapist who was famil- iar with military trauma, as well as the events known to occur in 2006–2007 in Afghanistan. The therapist had previously helped similar soldiers who were deployed over this time-period. The therapist treated and discharged several mem- bers from this cohort and had previous knowledge of the well-publicized events in Afghanistan including the accidental air-strike on Canadian soldiers meant for the Taliban.
John required 15 treatment sessions of PE for his symptoms of re-experiencing to abate, and gains were also seen in returns to social activities, including public outings with his family. At the close of focal treatment for his PTSD symptoms, he was considering vocational retraining as a finishing carpenter. The therapist felt satisfied with John’s treatment progress and agreed to bridge therapeutic involve- ment to specialized resources that could aid in the transition back to work.
The therapist enjoyed his work with John and did not endorse any troubles with VT. He shared the successful outcome with his colleagues and in fact cor- responded with a former supervisor of his PE training about how well the pro- tocol had worked. The therapist reported feeling “buoyed” by John’s courage and indomitable spirit. He reflected how this facet of the human condition gives hope to anyone who has suffered needlessly at the hands of others.
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Positive Effects of Trauma Work 109
Case 1 Deconstruction
The traumatic experiences suffered by John were of a high magnitude in terms of intensity of horror suffered. The details of the events were also of a universal nature and many parallels could be made about how others suffer in everyday aspects of their lives domestically and in theater of war. Specifically, one could easily see the parallel about losing a close friend to accidental death. Child abuse too continues even in well-socialized communities in North America, and there are reports of gun violence happening on North American soil. So the events suffered were readily relatable and possibly transferrable to the therapist’s personal worldview.
So why would the therapist report feeling “‘buoyed’ by the indomitable spirit of the human condition”? Table 9.1 may help illustrate. Although there are numerous risk factors associated with developing VT in this case, the therapist also had a number of protective factors that likely promoted VR. In isolation, the risk factors alone give potential to an adverse course of over-identification and internalization of the traumatic material by the therapist. Certainly, if an individ- ual shared this account of their traumatic injury with a peer, the peer would recoil at the sheer level of distress encountered. What makes the therapist different?
Essentially, the therapist is as vulnerable as a “non-trained” peer when it comes to VT, especially if they’re unaware of the risk and protective factors.
The therapist has developed specific self-efficacy with trauma from his or her experiences training and successfully administering therapy. In the desire to act empathically, he or she is mindful of not over-identifying with the unique features of his or her client’s history. This is likely supported by not also having a personal trauma history, but even if this were the case, such therapists who have worked through their own mental health issues are more likely to be spared the impact of association in their own lives.
TABLE 9.1 Case 1 Protective and Risk Factors for Vicarious Resilience and Vicarious Trauma
Protective Factors Promoting VR Risk Factors for Developing VT
• Experienced therapist.
• Selection and use of Empirically Validated Treatment (EVT).
• Therapist had training and supervision in EVT.
• No personal trauma history.
• Therapist was familiar with known details of the geopolitical war.
• Therapist had experienced previous successful treatment outcomes among this population.
• Therapist demonstrated significant aspects of having trait resilience.
• High intensity traumatic material.
• Relatable universal themes of human suffering.
• Initial high symptomatic presentation of client, including complicating factors of marijuana use.
• Client’s family was initially at risk of dissolution.
• Client was initially reluctant to engage in treatment and offer details of the traumatic events.
• Client initially felt strongly that his suffering was intractable (i.e. that he was hopeless).
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While it seems obvious that clinicians should have worked through any resid- ual influence of trauma in their past in order to optimize their positive influence in therapy, this too is controversial. Macaskill (1988) found that personal therapy in the early stages of training may have a deleterious effect on the therapist’s work with patients: 15%–40% of therapists reported unsatisfactory outcomes or nega- tive effects from their own therapy on subsequent relations with clients. No evi- dence was found to support the view that personal therapy significantly enhanced therapeutic effectiveness. Once again, Pearlman and Mac Ian (1995) noted signifi- cantly more vicarious trauma symptoms in 60% of the therapists they surveyed who had reported a personal history of trauma. So, minimally, care must be taken when embarking on trauma therapy if the therapist has a trauma history—with or without a course of personal treatment.
Finally, the therapist believed that he was fundamentally “resilient” in nature.
He attributed this core belief to having a repertoire of bouncing back from adversity and practical challenges over his lifespan. He reflected and savored memories of having met the challenges of graduate school, as well as family and child-rearing responsibilities. This is consistent with recent modeling research by Bensimon (2012) in which participants with varied trauma exposure levels com- pleted measures of resilience, trauma history, PTSD, and posttraumatic growth.
Results of structural equation modeling showed that trauma increased PTSD and growth levels, whereas resilience was associated positively with growth and nega- tively with PTSD. It was concluded that salutogenic and pathological responses to trauma show differential associations with trait resilience. Salutogenic in this case is a term borrowed from medical sociology describing an approach focusing on factors that support human health and well-being, rather than on factors that cause disease. Engendering an overall competency with resilience is very likely protective and positively related to VR.
Case 2: Civilian Trauma
“Sarah” is a 33-year-old married mother of two children who was raped by a not formerly known assailant. She had also been sexually abused between the ages of 9 and 11 by an older brother. The details of the recent index trauma were graphic, and she required facial reconstructive surgery as a result of the violent attack. She continues to have chronic pain, as well as the typical PTSD symptoms of avoid- ance, hyperarousal, and nightmares. Despite this, she had testified against the assail- ant, and he was convicted of sexual assault and is now in prison. She is eager to commence treatment in order to get her life back on track. She expressed a belief that she was a strong person who was capable of overcoming adversity, and she in fact felt proud of how she worked through her prior child sexual abuse.
The therapist was assigned to Sarah as part of a criminal injury compensation package. The therapist is well-trained in family systems psychology but has little experience with adult sexual trauma. She has not been abused or traumatized
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Positive Effects of Trauma Work 111
herself, and otherwise is an adaptive coper with routine life stressors. She is intrigued by the victim’s symptoms and contracts for an open-ended course of supportive psychotherapy. They meet regularly and based on the supporting police and medical reports the therapist learns of the severe beating and sexual violation; the client is reluctant to share details of the assault fully and completely and the therapist supports her decision by focusing on positives since the attack.
Sarah begins to deteriorate as treatment progresses. She has become more distant from her children and husband, and has sharply increased her alcohol consumption. In therapy, there appears to be transient dissociative periods when she reports on the stressful impact of the assault. The therapist feels they are at a recovery plateau and she is at a loss to improve her symptoms. The therapist finds herself thinking a great deal about what it must have been like to suffer the assault;
conversely, she has begun to dread meeting with her client as she finds the inter- changes exceptionally draining. She feels guilt and self-reproach for backing away from her usual level of compassionate and empathic therapeutic engagement. She also has become generally avoidant of other aspects of her work role, and it now takes extraordinary effort for her to complete reports and liaise with other staff.
She has also been avoiding some aspects of sexual intimacy with her boyfriend.
Case 2 Deconstruction
The therapist has begun to experience caregiver burnout and is also showing symptoms of VT related to the trauma material. It has impacted related aspects of her professional work role as well as intimacy with her own partner. She feels powerless to help her client and this leads to global feelings of incompetence.
She is bewildered as to why her usual supportive and compassionate therapeutic approach is not effective. She has helped many other individuals in her usual role as therapist, but is not fully aware why her current PTSD client is languishing. She is also unable to see the connection between her own recent intimacy issues and the trauma material, as well as her self-doubt as a professional therapist.
Table 9.2 overviews the imbalance of risk and protective factors for Case 2.
In Case 2, there were reliable indicators that the client and therapist could in fact thrive in their therapeutic relationship. Prognostically, there were clinical factors to support a recovery, and the therapist was eager to undertake the assignment.
However, her limited history of working productively with this specialized clini- cal population did emerge as a principal factor in both the client failing to ame- liorate her symptoms, and her own VT impact on her professional and personal roles. The therapist’s lack of efficacy in influencing change began to clash with her previous level of confidence and perceived competence. This, as well as the specific trauma material, ultimately combined to adversely influence her own sexual intimacy.
Apart from reducing the known risk factors in this case example, the thera- pist may have additionally benefited from ongoing supervision. A colleague more
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TABLE 9.2 Case 2 Protective and Risk Factors for Vicarious Resilience and Vicarious Trauma
Protective Factors Promoting VR Risk Factors for Developing VT
• Experienced therapist.
• No personal trauma history.
• Therapist had experienced previous successful treatment outcomes (although not among this population).
• Therapist was familiar with known details of the trauma from collateral information.
• Client was initially eager to engage in treatment.
• Client initially felt that she was a strong person capable of overcoming adversity.
• Justice was served in prosecuting the offender.
• High-intensity traumatic material.
• Relatable universal themes of human suffering.
• Initial high symptomatic presentation of client, including complicating factors of alcohol use.
• Did not select and use an Empirically Validated Treatment (EVT).
• Therapist did not have training and supervision in (EVT).
familiar with the treatment of trauma would likely have been able to point out the risk factors. Additionally, they may have also acted with influence in normalizing the response to plateaus in recovery. In fact, an initial increase in symptom acuity is a known treatment effect of exposure-based trauma therapy. Foreknowledge in this area may have circumvented increased self-doubt and perceptions of incompetence.
Case 3: Mass Trauma
“Ross” is a 54-year-old married man, who earns his living as a farmer outside of a small town in a rural area. In 2011, the region was struck by an F4 tornado that resulted in the death of several members of his community, including Ross’s brother and a young girl who attended Ross’s church, and severe injury to a num- ber of others. Ross lost many of his livestock when the roof of his barn collapsed during the tornado, and experienced significant damage to his home; such that he and his wife “Charlotte” needed to seek alternative living arrangements until their home could be repaired several months later.
As a volunteer firefighter, Ross spent the days initially following the tornado assisting in the search for missing persons, clearing debris from homes and road- ways, and working in the temporary shelter that was established at the local high school for those who could not return to their homes. During this time, Ross was exposed to the graphic injuries of people that he knew and helped rescue, as well as the destruction of many of the homes and buildings in his community.
In the weeks that followed, Charlotte noticed that Ross was becoming socially withdrawn and increasingly irritable. He often had nightmares related to his role with the recovery effort, and stopped attending church on weekends, stating that he had trouble believing that a higher being could impart such destruction on the
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Positive Effects of Trauma Work 113
good people of his community. After a great deal of urging from Charlotte, Ross agreed to speak to a therapist in a neighboring community about his anger and frequent flashbacks of the tornado.
The therapist in the neighboring community was one of the few experi- enced mental health professionals in the rural area affected by the tornado. While his own community was not directly affected by the tornado and he was lucky enough to be spared any personal loss, he too knew a number of individuals who had been affected by the tornado and had since been providing services to several other members of Ross’s community.
Ross was reluctant to engage in the therapeutic process. He felt that, as a vol- unteer firefighter and farmer who has seen the impact of nature over the years, he should be strong enough to move on without talking about his feelings and experiences related to the tornado. He refused to discuss the events he witnessed as part of the recovery effort in therapy, instead wanting to focus on his anger, guilt for escaping some of the hardships fallen on his neighbors, and the displacement of his previously firmly held spiritual beliefs.
Case 3 Deconstruction
The therapist feels frustrated at Ross’s reluctance to engage in therapy, as he strongly feels that Ross would benefit from a course of trauma-focused therapy.
As one of the few mental health practitioners in the area, the therapist turns to some of his peers from the trauma-focused therapy training program he partici- pated in several years ago for consultation. Despite feeling slightly overwhelmed by the sudden increase in his caseload following the tornado, the therapist decides to offer Ross a time-limited contract of supportive therapy with the objective of moving on to a course of protocol-driven trauma-focused therapy if Ross so chooses when his supportive therapy contract comes to an end. He is optimis- tic that he can build enough of a therapeutic relationship over the time-limited course of supportive therapy to encourage Ross to try trauma-focused therapy.
The risk and protective factors for this case are covered in Table 9.3.
There are a number of protective factors in Case 3 that promote VR and sug- gest that a successful therapeutic relationship could exist. The therapist was opti- mistic that the client could achieve recovery following a course of trauma-focused therapy, something that he had a substantial amount of experience with, and had access to peers with similar training for consultation when necessary. The client, while not initially interested in therapy, was willing to discuss aspects of his reac- tion to the trauma and to work on select outcomes (e.g., anger management). The client also had the support of his family.
However, the therapist himself was indirectly affected by the traumatic event in question and lacked consistent opportunities for professional support with a supervisor or colleagues. These factors, combined with the recent increase in the therapist’s caseload as well as the graphic material of the trauma, may increase the therapist’s risk of experiencing VT.