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Understanding and Responding to Vicarious Trauma: Relational Care for Carers

John Digney and Jenna Gabriel

‘Life's challenges are not supposed to paralyze you,they're supposed to help you discover who you are’.

Bernice Johnson Reagon, Professor, composer, historian, musician, and scholar.

Working with children, youth and families is one of the most rewarding professions a person can have, especially when we can work ‘relationally’ with them and being effective calls for practitioners and carers to attend to the many ‘threads’ that contribute to relational practice (Digney, 2024). These threads include concepts such as ‘Being Other Focused’, ‘Being Pain & Hurt aware’, ‘Being Trauma Informed’ and being endlessly ‘Empathetic’. Each of these on their own calls for a certain degree of giving of ourselves, and unless we properly monitor and manage these, it is possible that we could be at risk of some degree of emotional injury (emotional trauma).

Although it remains true that the work is rewarding, longevity in the career can quickly become a battle of working with yourself as much as you work with the youth. Whether you carry personal experiences with trauma or not, it remains true that working with the trauma of others often calls for the ability to heal personal trauma alongside the trauma of others.

The closer we get to achieving ‘Relational Practice’, the higher the expense becomes for emotional involvement, because it means managing our existing trauma responses while also being available for those who are managing their unique trauma responses. For Child and Youth Care Workers (CYCWs), Social Care workers and Social Workers this may feel like a doubling of the compassion expense and an overall acceleration of the emotional costs associated with the professional requirements of the work, if unprepared for the self-care requirement of this work. It is in this regards that we introduce the concepts of compassion fatigue, vicarious trauma, and/or burnout.

What we are dealing with

When looking at these issues, understanding the complex nature of this type of work adds important context. Children and youth living within the care system are recognized by society and government as a vulnerable and high-risk population due to their exposure to lifestyles that are abnormally dangerous and inappropriate for children. Although not always, this frequently impacts youth in care where their early exposure to danger is reflected toward others through their current understanding of interpersonal skills. When these youth interact with workers and carers (strangers from their perspective), they often challenge the substantially different interactions with their existing understanding of interpersonal interactions. This can often present as high-risk behaviours towards others.

When discussing the impact of compassion fatigue, it is imperative to remember that using a relational approach with those exhibiting high-risk behaviours (some of which present as high aggression towards others, high levels of social promiscuity with sex and drugs, and unhealthy interpersonal skills of verbal, emotional and psychological abuse towards others) requires an ability to recognize dysfunctional interaction, manage threats, assault and to be able to engage in healthily responses, with high-risk conversations – all of which usually occurs without warning in daily conversations in the profession. The timelines and demand for professional accuracy when engaging with this population is immediate and strives for a level of emotional regulation that is often difficult to achieve repetitively and consistently.

Psychology describes this difficulty as lying somewhere within the repeated depletion of emotional regulation resources, without adequate environmental resetting or ample time away from stress to allow for replenishment. This often results in ‘flat affect’ response, or over-stimulated reactions (i.e. exhaustion-based trauma responses from carers), as they become and remain desensitized or over-sensitized to repetitive bids from children and youth for emotional responses.

It's all in the name

The terms compassion fatigue, vicarious trauma and burnout are often used interchangeably to describe this desensitisation or over-sensitisation, and it can be quite difficult to find definitions and explanations of each that are universally accepted. In this paper we will be drawing from the 2012 paper by Bhutani et al. who inform us that compassion fatigue is a broad term comprising two other components (i) burnout and (ii) secondary traumatic stress.

Compassion Fatigue

Compassion fatigue refers to the personal physical, emotional (and even spiritual) di’stress’ that occurs in people who work with those in distress - especially when that other person may be reluctant to accept their help, be resistant to treatment, or who acts in ways that are worrying or anxiety inducing. Figley (1995) described the concept of Compassion Fatigue as the ‘cost of caring’, which is characterised by a physical and emotional exhaustion. Austin et. al. (2009) said that a sign of compassion fatigue was when the carer felt they were distancing themselves from their clients and described having a pessimistic view of the future, which is summed up as a ‘loss of empathy’. However, lived experience in the profession allows us to argue that this is likely more closely attributed to seeking distance from stress rather than from clients.

In most situations the defining features of this condition are typical ‘symptoms’ (or ‘signals’) of chronic stress. In fact, Portnoy (2011) said that compassion fatigue is, caused by empathy and is a natural consequence of stress resulting from caring for those who have been traumatized or are otherwise and similarly suffering. In other words, compassion fatigue involves the reduced capacity to empathize with others and is the stressful result of becoming overwhelmed and in many cases preoccupied by another’s traumatic or stressful experiences. This is often exaggerated in carers when the traumatic or stressful experiences are closely linked to personal experiences of the professionals.

Vicarious Trauma and Secondary Traumatic Stress

Becoming traumatised can occur as a result of direct, or indirect events, which are experienced in such a way as to leave a significant troubling emotional effect. Direct trauma (see below) can occur when a person experiences the trauma event/s first hand, events such as physical or sexual assault, unexpected loss, or during conflicts/war. Indirect trauma can occur when a person is exposed to the trauma of others. The latter type talks to the idea of vicarious trauma (VT).

VT is sometimes called Secondary Traumatic Stress (STS), although the two ‘conditions’ are somewhat different in genesis and consequences. Both are conditions that can be characterized by a gradual ‘lessening’ of compassion over time (compassion fatigue), although STS tends to have other, more significant effects.

VT occurs when someone experiences harmful changes in their view of themselves, others, and the world, because of exposure to the graphic material or experiences of their clients. VT is brought about through the culmination of increased stress reactions which occurs due to prolonged empathic engagements which can expose someone to the ‘trauma’ of others.

STS is acquired through exposure to persons suffering the effects of trauma and has a symptomology that is quite like that of Post Traumatic Stress Disorder (PTSD), where one suffers from intrusive thoughts, avoidant behaviors, and alterations in arousal. The symptoms of STS can have a more rapid onset and is typically associated with a particular event.

Although these ideologies are separated for definition purposes, the reality can oftentimes be a more intertwined experience, resulting in resurfaced trauma responses in carers when similarities in the lived experience of the traumatized child/youth are found within their own memories.

Burnout

A term associated with compassion fatigue is burn out (BO), which is often defined as a feeling of hopelessness and of having difficulties in dealing with work or in carrying out one's job effectively. Whilst vicarious trauma is the direct result of hearing about (and internalising) the experiences of others, burnout can result from work with any client group. The ‘symptoms’ of burnout can include exhaustion, depersonalization, cynicism, and reduced efficacy, and are not necessarily out of the relationship between the professional and the client.

These negative emotions (and thoughts) associated with burnout often have a gradual onset and can stem from the feeling that your efforts are not making any difference or be associated with a very demanding workload, non-supportive work environment, or just hearing about other people’s ‘negativity’.

Direct Trauma

Direct (Primary) Trauma can occur when we witness traumatic events ourselves firsthand, and being the victim of abuse or assault can mean that you have had experiences that can lead to direct trauma. The same can be said for those who have been directly affected by events such as natural disasters, violence, or war related events and those who have suffered the unexpected or traumatic loss of someone close to them, can also be said to have experienced a direct trauma event. That said, many people who experience events such as car accidents, unexpected deaths, and natural disasters do not go on to suffer long lasting negative effects or symptoms.

There are many ‘resilience’ or protective factors that can come into play, but in essence one is more likely to experiences such an event as ‘traumatizing’ when they have an overwhelming sense of horror or terror accompanied by a feeling of helplessness (they are without a sense of personal power or support of trusted other/s). Their stress response system is activated by their amygdala and tends to remain ‘switched on’ in a flight, flight, or fold response.

Compassion Fatigue or Trauma?

In the world of living and working with troubled and vulnerable children, youth and families, the anecdotal informal diagnoses given to those who are affected by the work often relate to the ‘secondary trauma’ types of impacts. We hear of people who leave the work because of ‘burnout’ or ‘compassion fatigue’. However, living and working in that world open us up to the potential for not only CP, VC or BO – but it also opens us up to becoming directly traumatised.

It is also important to recognize the different workplace structure for caring staff and foster carers, compared to other professionals. They exist and work within a ‘life-space’, rather than a workplace, and the work can hold the potential for and/or actuality of assault, accusations, and so called ‘poor outcomes’, all being types of events that can be experienced in a way that have a very real risk of leading to feelings of fear and helplessness.

In recognizing the workplace atmosphere where these incidents occur, there is a need to be careful not to undermine the fact that these events occur in the life space of our clients, not solely a workplace for the professional. So, when we hear people being described as ‘tired’ or ‘not like themselves’, it could potentially be that these individuals are closer to feeling ‘burned out’ or ‘compassion fatigued’, and it is important to also be open to the possibility that they are in fact directly traumatised.

Why is this important

It might seem like semantics to some but understanding the real reasons that cause someone to decide to leave this type of work and caring are as important as correctly diagnosing a medical illness, because this will help set the ‘treatment plan’. Additionally knowing the impacts of other people’s trauma and the impact of living and working in a challenging environment can entail organisational planning to mitigate the damage that can result to one’s sense of felt safety (physical, emotional, and psychological), competence, and associated anxiety.

If we can identify the actual driving forces behind the negative feelings carried by many people in this caring field, we are better able to offer ways of help, support, mitigate, and hopefully remedy the high rates of turn-over and low rates of retention in the profession, for without addressing the cause of high turn-over and low-retention, the caring professions will remain emotionally overwhelming and continue to negatively impact new-comers who are joining the profession with keen and healthy ambition.

Smart & Digney (2016) described a conversation with workers and staff who expressed frustration and loss of hope. When asked for one word each to describe their underlying feelings, they offered the following: annoyed, angry, wrecked, anxious, distressed, upset, frustrated, concerned, exhausted, troubled, done in, and stressed. Of course, dealing with challenging behaviour can be ‘draining and exhausting’ as one uses up their energies in the short-term, without immediate reward. They spoke about wanting to be caring, but that a sense of despondency filled their interactions at times, and they had lots of self-doubt about their ability to make a difference and this was based on their perception that things were not progressing well and that they (the carers) seemed to be on-edge a lot of the time and were susceptible to subtle changes in mood and behaviour (hypervigilant).

They also went on to say that the demands being made of them, not only by society, but also from professional policies and regulations (i.e. overwhelming documentation requirements, ineffective general protocols, understaffing, and staffing based on organizational needs rather than youth relational needs), were unrealistic, artificial and added to the stress they were feeling. This was in addition to being directly affected by the behaviours they were dealing with on a day-to-day basis, as well as indirectly, and hearing about the trauma of others (abuse, neglect and rejection suffered by the young people).

What can we do?

Mathieu (2007) proposed a two-pronged approach that included both an organisational and a personal strategy, believing that open discussion and recognising concepts such as VT and BO as possibilities for occurring within the workplace. This realisation can assist workers and carers to understanding that it is a common occurrence and requires proper supports to prevent escalation. Abu-Bader (2000) put forward a list of protective factors such as, ensuring good relationships among colleagues, seeking & receiving additional supervision and support, and finding opportunities to be recognised and valued. Not rocket science perhaps but supports and practices that are glaringly missing from many organisations, or are merely given ‘lip-service’.

hen researching self-care, there are a number of recurring recommended areas of focus that can be organized differently, but include:

Physical self-care (e.g. nutritional, sleep/rest, medication/supplements, breathing, exercise).
Mental/emotional self-care (e.g. positive self-talk / mentality / beliefs, acceptance / processing of feelings, journaling, visiting positive memories, psychotherapy / counselling).
Spiritual self-care (e.g. prayer / meditation / contemplation, spiritual community, forgiveness of others and self, finding purpose and meaning, mapping out core values, yoga / mind body connections, manifestation / mantras).
Environmental/lifestyle self-care (e.g. structure / routine, relaxation, setting goals, organizing and tidying living spaces, positive pleasure-seeking).
Social/people support (e.g. family, friends, support groups, therapists, spiritual leaders, community service).
Recreational self-care (spending time in nature, traveling even short distances alone or with company, reading, playing games or doing puzzles, watching media, listening to music).
Financial self-care (investing in your future, paying bills/tracking finances, saving finances, setting financial goals).

These areas alone can inform personal self-care plans to mitigate the impacts of mental health on caring professionals. These need to be dissected a little more to see how personal and organizational efforts can assist workers and carer’s ability to practice and maintain their personal self-care plans with organizational support and encouragement.

Personal Strategies

When starting out in this line of work it is important to have a high focus on navigating the self-care aspect of this work to find strategies that work personally for each carer to help them remain regulated through the challenges.

Vigilance of Self: Being properly ‘tuned into’ all that is going on within us is essential if we are to have any chance of warding off such serious consequences and this ‘vigilance of self’ is another of the relational threads discussed by Digney (2024). Being vigilant of self is not only essential if we are to engage in reflective and reflexive practice, but it is also essential if we are to ‘work in the present’ and remain tuned into our own body and mind, recognising not only our unconscious biases, prejudices, and value, but also out thinking and feelings as we make our way through each day and each moment of each day, including any feelings and thinking we have when we encounter adversity (be it our own or that of others).
Empathy, leading to Kindness and Generosity: Understanding what makes a difference, what works in our profession, seeing the power of ‘doing for others’ and helping to show a better way. Having empathy can contribute to stress, VT, and direct trauma, but it may also be part of the solution. Seligman (2002) in his discussion about emotional intelligence advises ‘love includes kindness, generosity, nurturance, and the capacity to be loved as well as to love’.
Gratitude: This is not a passive construct – it is the act of expressing appreciation, and on that emanates quite often from having great hope and an optimistic viewing lens. This gratitude can be for who you are, the people in your life, the purpose you have found and the kindness you might receive from others. According to Harvard Health Publishing (2021), from a Positive Psychology standpoint, gratitude is strongly associated with greater happiness and seems to support the ability to ward off negative responses to adverse events. It can help us feel more positive emotions, appreciation positive experiences, enhance health, and build resilience. As individuals, if we can prioritize and promote gratitude as a coping mechanism, we should be better able to reduce instances and levels of VC / CF and BO.
Spirituality: This can be viewed as a belief in or search for a higher power, or a cause that is beyond us – a transcendent aspect of life. Having a good sense of our own spirituality can be helpful to buffer the effects of a traumatic events or experiences. It can even be a wonderful source of reassurance in times of adversity. Kucharska (2020) believes that spiritual support has been found to be generally related to better functioning after trauma, including posttraumatic growth and aspects of vicarious trauma. The understanding of this is that it might occur because people find a great sense of purpose in life (collaboration with a ‘higher power’) to solve problems, or perhaps because it can place an emphasis on forgiveness (of self or others). Contemplating our purpose in a higher order manner can help explain the inexplicable and address our role as part of a solution to the problem in life.
Compassion satisfaction: This counterpoint to compassion fatigue refers to the positivity and sense of achievement that we derive from being able to do our work well and to help ‘facilitate positive change’. Having a good understanding of our role as ‘change agents’ and the processes associated with ‘managing change’ is essential, as this can help us manage expectations and appreciate the impact of ‘little adjustments’ to how kids think and feel about themselves.

Organisation Strategies

As this work is so all encompassing and ‘full on’ it can be challenging for staff and carers to prioritize self-care and even make the time (and headspace) for this. In this regard, organisations need to step-up to the mark to unsure as best they can that staff and carers are not only supported to care for themselves, but that also consider approaches to managing, mitigating, and even intervening to share the responsibility of caring for those who are already struggling with the work and are already dealing with survival instincts and reacting to stressors, rather than responding to needs. Managers and colleagues who are in a ‘healthier state of mind’ should be encouraged to help them empathize and think rationally about solutions. Possible approaches include:

Cultures of Caring: Creating a ‘Culture of Care’ within organizations is about ensuring that all staff and carers are comfortable sharing and talking about the challenges they are experiencing and confident about requesting additional support when needed. This can be supported by developing a supportive environment that encourages informal debriefing, breaks and peer support.
Having a ‘trauma-based awareness’ model: Where organisation invest in applying a trauma-informed approach and trauma aware model, that would benefit employees as well as clients. If introduced and applied to staff in the same manner as applied to the youth they care for, we would see organizations that show supervisors caring for staff in similar ways that staff care for children and youth. The wellness model (Swarbrick, 2006) is an approach to care that focuses on various dimensions of wellbeing. It has been widely used and adapted by various organisations tasked with working with vulnerable people and their families. These types of organizational supports can help to monitor stress levels of staff and offering support before burn-out starts to impact performance specifically when considering workplace avoidance/anxiety. The Substance Abuse and Mental Health Administration (SAMHSA, 2016) considers eight dimensions of wellbeing that should ideally be considered amongst staff in occupations that deal directly with mental health issues in clients. These are like the self-care areas of focus listed above and include the areas of emotional, spiritual, intellectual, physical, environmental, financial, occupational, and social wellbeing.
Formal Debriefing: In most cases where potential trauma inducing events (behaviours) are experienced, having an outside perspective is useful and sometimes necessary for breaking the cycle of abusive dynamics. Debriefing is an important role for organizations to take, especially when considering confidentiality requirements of our work, which can sometimes create a gap in one’s ability to adequately perform self-care. ‘Talking it out’ is not always an option outside of organizational supports and sometimes we need workplace guidance and support when talking through significant incidents to address any issues with lack of self-confidence in workplace performance that can be a result of Compassion Fatigue, VT/STS and BO. It must be noted that requesting this type of support can be stigmatised and considered a failing with those who are new to the profession. Messaging from organizations to ensure that this perspective is not supported is, equally as important as offering the support.
Mental health meetings/check-ins: It is suggested that there should be more organizational responsibility to monitor mental health of those who work in the lifespace of others and to intervene when environmental or relational stressors begin to impair a staff’s ability to perform. Mental health is recognized within workplace ‘hazard models’ in many regions around the world, and there is evidence to support the position that performing under excessive stress for extended durations will have significant physical impacts, organisation need to consider their role in this regard. A resource for regular and expected opportunities for to speak one-on-one with a support member within organizations about the topic of their mental health could be effective in mitigating stress before staff become overwhelmed to the point of experiencing CF, VT/STS, and/or BO.
An important element of offering regular and predictable check-in points is that these conditions often have a gradual on-set and symptoms can be frequently unnoticed or otherwise excused until they become unmanageable. Having third-party stress monitoring, takes the responsibility away from the person approaching a state of mental health crisis to recognize and plan for improvement, when they are already trying to continue performing in high-stress environments. This will create opportunity for helpful strategies to be implemented early.

The work of supporting, protecting and nurturing children and youth within a care system is fraught with potential stressors, some obvious and some not. It is a job that requires the staff and carers to be the best possible version of themselves, in thoughts and feeling and behaviour. But when the monitoring of staff’s stress (and possibly trauma) levels are left for them to do themselves much can be missed. The warning signs might only be visible to others or might even be actively hidden as people struggle and try to make sense of what is going on for them. If we are to lower the frequently of crisis intervention, requiring intrusive recovery strategies (i.e. extended time off, leaving the environment to a new workplace, or career change and loss of staff), help and support much come earlier, preferably at the prevention level.

Having a good understanding of the mechanisms of trauma, including vicarious trauma, as well as having a relational approach built in to and across all levels of the organisation is essential if we are to build resilience and strengthen our staffs abilities to deal with the trauma of others, the stressors of the work in general and keep them able to provide the care and support needed to the young people they have responsibility for.

References

Abu-Bader, S. H. (2000). Work satisfaction, burnout, and turnover among social workers in Israel: A causal diagram. International Journal of Social Welfare, 9 pp 191-200.

Austin, W., Goble, E., Leier, B., & Byrne, P. (2009). Compassion fatigue: The experience of nurses. Ethics and Social Welfare, 3, pp 195-214.

Bhutani, J., Bhutani, S., Pal Singh Balhara, T., & Kalra, S. (2012). Compassion Fatigue and Burnout Amongst Clinicians: A Medical Exploratory Study. Indian Journal Psychological Medicine. Oct-Dec; 34(4) pp. 332–337.

Digney, J. (2024). The Fundamentals of Relational Practice: The Art of Relational Weaving. Relational Child & Youth Care Practice 36 (2) pp 22-35.

Figley, C.R. (Ed.). (1995) Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Harvard Health Publishing. (2021). Giving thanks can make you happier. Retrieved on 5th April 2024 from: https://www.health.harvard.edu/healthbeat/giving-thanks-can-make-you-happier?first_registration_source=https%3A%2F%2Fcalmerry.com%2Fblog%2Fgrief-and-loss%2Fpost-traumatic-growth-the-unexpected-outcome-of-traumatic-experience%2F

Kucharska, J. (2020). Religiosity and the psychological outcomes of trauma: A systematic review of quantitative studies. Journal of Clinical Psychology, 76(1), 40-58.

Mathieu, F. (2007). Running on Empty: Compassion Fatigue in Health Professionals. Rehab & Community Care Medicine.

Portnoy, D. (2011). Burn Out and Compassion Fatigue: Watch for the signs. Health Progress, (July-August 2011).

Rocky Vista Health Centre. (2024). 8 Areas of Self Care and How to Practice Them. Available at: https://www.rockyvistahc.com/8-areas-of-self-care-and-how-to-practice-them

SAMHSA. (2016). Creating a healthier life: A step-by-step guide to wellness. Department of Health and Human Services, USA. Available at: https://store.samhsa.gov/sites/default/fi les/d7/priv/sma16-4958.pdf

Seligman, M. (2002). Authentic Happiness. Boston: Nicholas Brealey.

Smart, M., & Digney, J. (2016). Exasperation and Inclination. CYC-Online, 204 pp21-27.

Therapistaid (2024). Self-Care Assessment Worksheet. Available at: https://www.therapistaid.com/therapy-worksheet/self-care-assessment