Charles Nelson and Kate St. Cyr
In order to succeed, people need a sense of self-efficacy, to struggle together with resilience to meet the inevitable obstacles and inequities of life.
–Albert Bandura
When an infant cries, its mother rouses and attends to the needs of her child. Hav- ing then been held, nourished, and made comfortable, the child and the mother return to rest. The child learns there is a predictable pattern of assistance for his or her needs, and the mother learns that through her instrumental efforts she can alleviate any distress that her child may face. During our earliest formative years, we are socialized to communicate our distress to others around us. The evolu- tionary advantage of being able to communicate in an organized social structure has provided humans a superior edge. The experiencing of and suffering from traumatic events also requires a communication and acceptance of that person’s reality. Insofar as the event is shared and processed to a receptive individual who engenders competence, suffering is alleviated and there is a strong potential for both the victim and the competent listener to grow and flourish.
Vicarious resilience becomes possible through this dynamic—the victim and the helper interact, and through this interaction the shared experience meets with a positive outcome. Self-efficacy is enhanced because competence was chal- lenged, and with a successful outcome, mastery leads to growth. This phenom- enon predates the treatment of posttraumatic stress disorder and is foundational to all effective forms of psychotherapy. What becomes special about trauma is the magnitude of suffering. When a person suffers so and shares their experience there is a risk that the receiver can also become distressed. This is the germ that
Downloaded by [New York University] at 03:58 14 August 2016
leads to vicarious trauma and compassion fatigue. However, when competence is bolstered by successfully navigating through the mire and muck of trauma, and the victim demonstrates a return to adaptive functioning, the listener/helper can attain a higher level of mastery, and perhaps even a higher level of self-awareness.
In this regard, the helper knows they can tolerate learning of others’ distress, and even more so, they are in fact effective at bringing them back to health. With this exposure and then mastery, vicarious resilience can lead to posttraumatic growth for the victim and the therapist.
Despite the age-old process of challenge leading to mastery, the literature on vicarious resilience is new, even though the nuts and bolts of how this occurs has been well-studied. Bandura and Schunk (1981) in fact focused on this process during the last portion of their life-long research on vicarious learning. Today, greater numbers of clinical examples are being studied and emerging methodolo- gies are being employed to systematically evaluate the process.
This section focuses on the phenomenon of resilience in victims and among those who treat them. It also considers those known factors associated with vicar- ious resilience, as well as the positive effects of working with victims of trauma.
Finally, the section concludes with case examples and opportunities for observing vicarious resilience in everyday practice.
What Is Vicarious Resilience?
A review of some of the overlapping and sometimes confounding terms associ- ated with trauma and therapy are in order. Resilience is most generally concep- tualized as a process in which various resources or strengths engage and interact to shield an individual, family, or community from negative outcomes despite significant risks or trauma (Kragh & Huber, 2002). Vicarious resilience is often used synonymously with posttraumatic growth, and further work needs to be done within the field to develop a clear construct definition that can be used with consistency and meaningfulness. At present, vicarious resilience could be used to express the process of recovering from an experience of vicarious trauma. It could also be used to describe a unique process, by which a clinician experiences resilience vicariously through witnessing his or her own clients’ demonstrations of resilience, and benefitting from doing so. For the purposes of this review, we follow Hernandez and colleagues’ construct of vicarious resilience, which suggests that vicarious resilience occurs through a process by which clinicians experience positive transformation and empowerment through their empathic engagement with clients (Hernandez, Gangsei, & Engstrom, 2007). Our review of vicarious resilience, or VR, will frame the bulk of our analysis of this unique and beneficial treatment effect.
Prior to delving into VR, however, there is merit in briefly exploring the cor- ollary of vicarious trauma, or VT. Typically, the terms compassion fatigue, vicarious
Downloaded by [New York University] at 03:58 14 August 2016
Vicarious Resilience 95
trauma, secondary trauma, and secondary traumatic stress are used interchange- ably. Figley (1995) defined vicarious trauma as the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by another, and the stress resulting from helping or wanting to help a traumatized or suffering person. McCann and Pearlman (1990) describe vicarious trauma as the changes in an individual’s “inner experience as a result of empathic engage- ment with survivor clients and their trauma material” (p. 25). Both challenge our ability to remain objectively compassionate. The therapeutic emphasis on empa- thy and authenticity in validating another’s suffering may inadvertently render the therapist vulnerable. Once again, there may be a distinct role for mastery, or in the case of VT, diminished mastery in the genesis and maintenance of VT.
Suppose for a minute that as a well-intentioned therapist, you endeavor to aid individuals in the sharing and processing of their traumatic experiences. After all, in many cases attending to your clients’ struggles with their suffering within a gen- uine, authentic, and non-judgmental framework yields improvements in symptom reduction due to improved validation and acceptance. This is the foundation of humanistic psychology. However, unlike normal grieving, for instance, in which the events are self-limiting and the expression of grief allows most individuals to process the loss and move on, with the sheer intensity and often horror associated with traumatic experiences, the clinician is ill-prepared to both facilitate empathic listening and simultaneously process the traumatic material. Bad things happening to innocent people have rendered the helper helpless to improve the outcome.
The discrete event has come and gone and the victim remains symptomatic; the retelling of the event evoking as much fear and anxiety as the event itself.
In this regard, vicarious trauma is the unintended consequence of being a compassionate therapist.
References
Bandura, A., & Schunk, D. H. (1981). Cultivating competence, self-efficacy, and intrin- sic interest through proximal self-motivation. Journal of Personality and Social Psychology, 41(3), 586–598.
Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An over- view. In C. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1–20). New York, NY: Brunner/Mazel.
Hernandez, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46(2), 229–241.
Kragh, J., & Huber, C. (2002). Family resilience and domestic violence: Panacea or prag- matic therapeutic perspective? Journal of Individual Psychology, 58(3), 290.
McCann, I., & Pearlman, L.A. (1990). Vicarious traumatization: A framework for under- standing the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149.
Downloaded by [New York University] at 03:58 14 August 2016
PERSONAL REFLECTIONS
On September 11, 2001, I was in my seventh year as the medical director of a psychiatric day treatment program at St. Vincent’s Hospital Manhat- tan. The window outside my office faced south, the dominant sight being the twin towers of the World Trade Center, just twenty blocks away. This was a view I loved. As I tried to finish some work before a 9:00 a.m. meeting, a psychologist I worked with informed me that he heard a bomb went off at the World Trade Center. We rushed toward the window; I was fearful of what I might see. I remember the large hole, fire, and smoke emanating from one of the towers—I remember thinking this had to be more than a bomb. I called the director of the psychiatry department to inform him of what I had witnessed, anticipating a direction to respond to what we were quickly real- izing was a disaster. In the subsequent minutes, I stood by that window with other staff and some patients we were treating.
I do not remember seeing the plane strike the second tower. However, one of my patients informed me that we saw the second plane approach and I repeatedly stated, “Oh my God, oh my God.” I suppose I experienced the amnesia that sometimes occurs when witnessing a traumatic event. While some patients in the day treatment program suffered from disorders where there is a loss of reality, this particular patient was not one of them, and I believe his account. In fact, people with serious psychiatric problems often remarkably mobilize themselves when faced with crises and tragedies. Most of the patients in the day treatment program that day, plagued by the most severe and chronic psychiatric illnesses, coped with this situation as well as [the] staff. I had always known this from seeing how my patients reacted when faced with serious medical illnesses; the events of 9/11 just confirmed that belief.
That particular patient and I spoke about the terror attacks for years after- wards, right up until he died of cancer. I recall both patients and staff reacting to the horror and news that was coming in on the radio (our offices at St.
Vincent’s did not yet have computers). Someone mentioned hearing that the Pentagon was attacked and that Washington was being evacuated. I remem- ber feeling something terrible and unprecedented was happening, and fear- ing worse was to come. Quickly, we mobilized—I made sure patients who were to be seen that day had their prescriptions, other staff personnel stayed with patients in the day treatment program, and then I went across the street to a meeting in the main hospital building where the leadership was prepar- ing for how we would deal with this disaster. I tried, without full success, to call family and important people in my life. I wanted to confirm their safety, tell them that I was okay, and let them know that as a doctor at St. Vincent’s, the closest hospital to the World Trade Center, I would be very busy.
Downloaded by [New York University] at 03:58 14 August 2016
Vicarious Resilience 97
Tragically, many of the people who sought assistance at St. Vincent’s Hos- pital only required our psychiatric services, as the injured we expected in the ER never arrived, perishing with the fallen towers. In the following years, I participated in newly formed programs to treat people affected by 9/11, many with posttraumatic stress. I was the psychiatrist on call two nights after the attack, September 13, 2001, when ABC News interviewed me for a seg- ment that would precede the prayer service at the National Cathedral the following morning. Only a couple of minutes appeared on the air, but I was surprised at how inarticulate my comments were. Images of national cer- emonies and panned shots of grieving families were shown, and there I was, stammering about people needing to be with others at such times. I later realized, especially when St. Vincent’s closed in 2010, how important those comments actually were. All we could do in those weeks following 9/11 was be together—as a hospital, as a community, and as a country.
In 2012, after completing my first day on jury duty, I decided to take a walk from the courthouse to see the new 9/11 Memorial at the site of the twin towers. I was disappointed that I could not get in without tickets obtained in advance online. I was struck by the bustling activity and height of the new One World Trade Center tower, just one week away from once again becoming the tallest building in New York City. Things seemed so different than they were 11 years ago. As I tried to feel good about the rebuilding, an enormous sadness came over me and I had to leave quickly.
I remembered the horrific deaths that were met on that very spot. While so many people were traumatized on that day, I still cannot imagine—or even bear to think—what those who died went through before their deaths, what their loved ones experienced on that day, and what they will continue to live with for the rest of their lives.
Jeffrey B. Freedman, MD Chief of Psychosomatic Medicine Roosevelt Hospital St. Luke’s-Roosevelt Hospital Center New York, NY