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Secondary and Vicarious Trauma: Implications for Faith and Clinical Practice

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Abstract

The paradox of the wounded healer—the one called to look after their own wounds while at the same time remaining prepared to heal the wounds of others—is a metaphor rich in biblical allusion, providing a profound entry point for those interested in contemplating the person and work of Christ (Nouwen, 1979). It is also a metaphor that captures the experience of many mental health professionals as they journey empathically alongside their clients. Figley (1995) was among the first to highlight what he described as the cost to caring—how mental health professionals (especially those who work extensively with survivors of trauma) who empathically listen to their clients’ stories of fear, pain, and suffering often find themselves feeling similar fear, pain, and suffering. In this paper, we review the literature on secondary trauma and vicarious trauma, drawing implications from the latest research on both faith and clinical practice.
Journal of Psychology and Christianity
2014, Vol. 33, No. 3, 281-286 Copyright 2014 Christian Association for Psychological Studies
ISSN 0733-4273
281
account for the possibility that the witnessing or
hearing of threatened death or serious injury
occurring to another individual may in itself con-
stitute a traumatic event (APA, 1994).
Secondary Traumatic Stress
Secondary Traumatic Stress (STS) is a term used
to describe reactions and symptoms observed
among trauma workers that run parallel to those
observed in people directly exposed to trauma
(Bride, Robinson, Yegidis, & Figley, 2004).
Understandably, a therapist might run the risk of
absorbing the sight, sound, touch, and feel of the
stories told in detail by the trauma survivor
(Richardson, 2001). These consequences are
understood to be the result of secondary or indi-
rect exposure to the traumatic material of clients
who experienced the trauma first-hand (Cieslak et
al, 2014). The symptoms of STS are nearly identi-
cal to those of PTSD and include all three symp-
tom clusters of PTSD—intrusive re-experiencing
of the primary survivor’s traumatic event, persis-
tent arousal, and the avoidance of reminders of
the traumatic event. Furthermore, it is believed
that STS can potentially develop immediately fol-
lowing just one exposure or incident (Figley,
1995). Because secondary exposure to trauma
can occur among persons having close contact
with a trauma survivor (regardless of whether or
not they are mental health professionals), STS
may also be present among members of the sur-
vivor’s primary social support network, such as
close family members (Jenkins & Baird, 2002).
STS can also be understood as the natural conse-
quence of caring between two people—one who
has been initially traumatized and the other who is
affected by listening to the former’s traumatic expe-
riences (Figley & Kleber, 1995). As such, Figley
(1995) at times expressed preference for the use of
the broader term, compassion fatigue, over STS to
decrease stigma and to normalize this reaction as a
common occupational hazard for those who con-
duct work in trauma. Compassion fatigue is
defined as a reduced capacity for empathy or client
interest manifested through behavioral and emo-
tional reactions from exposure to the traumatic
experiences of others (Adams, Figley, & Boscarino,
2006). Though related to STS, compassion fatigue
refers to a broader range of emotional or cognitive
consequences to secondary exposure—including
Secondary and Vicarious Trauma:
Implications for Faith and Clinical Practice
David C. Wang, Daniel Strosky, & Alexis Fletes
Biola University
The paradox of the wounded healer—the one
called to look after their own wounds while at
the same time remaining prepared to heal the
wounds of others—is a metaphor rich in biblical
allusion, providing a profound entry point for
those interested in contemplating the person and
work of Christ (Nouwen, 1979). It is also a
metaphor that captures the experience of many
mental health professionals as they journey
empathically alongside their clients. Figley
(1995) was among the first to highlight what he
described as the cost to caring—how mental
health professionals (especially those who work
extensively with survivors of trauma) who
empathically listen to their clients’ stories of fear,
pain, and suffering often find themselves feeling
similar fear, pain, and suffering.
In the past two decades, a growing body of
literature has formally investigated the effects of
trauma work on those who are working with
traumatized individuals. Trauma workers repre-
sent a population of special interest due to the
frequency of exposure to traumatic material
inherent in their work. This is the case in part
because empirically supported treatments for
Posttraumatic Stress Disorder (PTSD), such as
Cognitive Processing Therapy (CPT; Resick &
Schnicke, 1992) and Prolonged Exposure (PE;
Foa, Rothbaum, Riggs, & Murdock, 1991) typical-
ly involve the telling and retelling of traumatic
experiences in significant detail. This is done in
the hope of breaking through clients’ avoidance
of traumatic memories and reminders (Elwood,
Mott, Lohr, & Galovski, 2011), which is under-
stood to be a key component to recovery from
PTSD. As such, clinician exposure to distressing
material accumulates significantly as treatment is
provided to multiple clients concurrently over
time. Research interest in this area has been fur-
ther galvanized in recent history by a revision of
the diagnostic criteria for PTSD in 1994 to
RESEARCH INTO PRACTICE
Correspondence concerning this paper should be
addressed to David C. Wang, Th.M., Ph.D. at Rosemead
School of Psychology, 13800 Biola Avenue, La Mirada,
CA 90639; david.wang@biola.edu.
282 RESEARCH INTO PRACTICE
those that may not directly resemble PTSD-like
symptoms (Cieslak et al., 2014). Unfortunately, the
distinction between STS and compassion fatigue is
not always clearly delineated and the two terms
are frequently used interchangeably in the litera-
ture (Devilly, Wright, & Varker, 2009).
Vicarious Trauma
While secondary traumatic stress refers to the
experiencing of PTSD-like symptoms among indi-
viduals exposed to the trauma narratives of others,
vicarious trauma (VT) incorporates the pervasive
and cumulative effects of indirect exposure to
trauma over time, which often entails long-term
modifications to an individual’s way of experienc-
ing themselves, others, and the world (Pearlman &
Saakvitne, 1995; Trippany, White, & Wilcoxon,
2004). Vicarious trauma is further distinguished
from secondary traumatic stress in that the former
tends to be associated with trauma that is chronic,
repetitive and pervasive while the latter may be
associated with a single traumatic event (Jordan,
2010). Neumann and Gamble (1995) suggested
that VT represents a form of countertransference
stemming from inadequate differentiation between
the therapist and the traumatized client. Most
research on vicarious trauma, however, draws
from the Constructivist Self-Development Theory
(CSDT; McCann & Pearlman, 1990) as its theoreti-
cal framework, which posits that individuals con-
struct their own realities through the development
of cognitive schemas—that is, cognitive structures
that include a person’s beliefs, assumptions, and
expectations about themselves, others, and the
world. These schemas evolve over time, as new
information is assimilated from new life experi-
ences. However, if this new information is incom-
patible with existing belief systems and cannot be
readily assimilated into them, the original schemas
can become invalidated or shattered—as is often
the case when clinicians emotionally process and
make sense of the horror of their clients’ traumatic
experiences (Janoff-Bulman, 1992). When an indi-
vidual experiences vicarious traumatization, their
schemas are being modified in a manner that
heightens emotional distress and amplifies sensitiv-
ity to information that confirms negative beliefs
regarding their safety, power, control, indepen-
dence, esteem, and intimacy with others (Elwood
et al., 2011).
Empirical evidence suggests that the deleterious
effects of indirect trauma exposure on the therapist
include: greater emotional distress, lower levels of
self-trust, dissociative symptoms, and diminished
quality of interpersonal relationships (Betts-Adams,
Matto, & Harrington, 2001; Pearlman & MacIan,
1995). The findings of studies investigating the
prevalence and specificity of secondary trauma
symptoms in trauma clinicians are mixed, however,
as they often report symptoms that do not reach
clinically significant thresholds (Elwood et al.,
2011). Of the studies that did report clinically-sig-
nificant secondary traumatic stress, prevalence rates
varied across samples, ranging from 8-10% in
humanitarian aid workers (Shah, Garland, & Katz,
2007; Eriksson, Vande Kemp, Gorsuch, Hoke, &
Foy, 2001), 15.2% in social workers (Bride, 2007),
16.3% to approximately 20% among clinicians treat-
ing patients affected by cancer (Kadambi &
Truscott, 2004; Quinal, Harford, & Rutledge, 2009),
34% in child protective services workers (Bride,
Jones, & MacMaster, 2007), to 46-52% in clinicians
treating sexual offenders and sexual abuse sur-
vivors (Steed and Bicknell, 2001; Way, VanDeusen,
Martin, Applegate, & Jandle, 2004).
Several potential risk factors predicting greater
negative effects of indirect trauma exposure have
been identified, including: increased caseload and
severity of client trauma symptoms (Bober, Rege-
her, & Zhou, 2006; Craig & Sprang, 2010), fewer
years of clinical experience (Adams & Riggs,
2008), a self-sacrificing approach to psychological
defensiveness (Adams & Riggs, 2008), a lack of
available organizational support such as peer
supervision and consultation (Jordan, 2010), and
the use of clinical treatments that were not evi-
dence-based (Craig & Sprang, 2010). Notably,
studies investigating whether having a personal
trauma history predicted secondary trauma have
been inconclusive, with some reporting a signifi-
cant relationship (Bride, Jones, & MacMaster, 2007;
Jenkins & Baird, 2002) while others finding little or
no relation (Bober & Regehr, 2006; Michalopoulos
& Aparicio, 2012). Among the studies that did not
find a relationship between the two, Michalopou-
los and Aparicio (2012) suggested that part of the
reason why may be because those with a personal
trauma history typically received their own treat-
ment, which buffered them from developing not
only their own primary trauma symptoms, but also
vicarious trauma symptoms as well. Last, the type
of trauma being worked on also moderated the
impact of trauma work on the therapist. For
example, Bober and Regehr (2006) found that the
types of trauma that correlated most strongly with
secondary trauma symptoms included physical
assault on the wife, child abuse, child sexual
abuse, sexual violence, rape, and torture; however,
RESEARCH INTO PRACTICE 283
work with workplace trauma, victims of violent
crime, and unexpected death did not correlate
strongly with STS.
As previously noted, vicarious trauma may
entail negative long-term modifications to an indi-
vidual’s way of experiencing themselves, others,
and the world. For example, Cunningham (2003)
found that clinicians who regularly treated sexual
abuse clients endorsed greater disruption in their
own ability to perceive others as safe, trustworthy,
and esteemed. Although spirituality has been
suggested as a protective factor for vicarious trau-
ma (Trippany et al., 2004), Dombo and Gray
(2013) note that VT can also threaten a clinician’s
spirituality by compromising their ability to deriv-
ing meaning and purpose from their work, result-
ing in a greater sense of hopelessness and
internalized suffering of their client’s trauma.
Clinical Applications
Clinicians would benefit from identifying and
applying protective practices that mitigate the
risks of indirect traumatization. Harrison and
Westwood (2009) underscore how the ethical
responsibility to address the serious problem of
vicarious trauma is shared not only by individual
clinicians but also by employers, educators, and
professional bodies; this can be done in part
through the provision of consistent and support-
ive supervision as well as relevant education and
training opportunities, organizational policies that
promote work-life balance, opportunities for clini-
cians to take part in a diversity of professional
roles (e.g., teaching, supervising, and/or adminis-
tration in addition to direct practice), both profes-
sional and personal social support networks,
coping and self-care practices (e.g., sleeping prac-
tices, exercise, eating habits, anxiety manage-
ment), and referrals for clinicians to receive their
own personal therapy if needed (Jordan, 2010;
Trippany et al., 2004; Way et al., 2007). Concern-
ing the protective role of supervision on vicarious
traumatization, especially for new therapists,
researchers highlight the importance of early
detection, special supervisory attention on issues
relating to countertransference and potential
boundary violations between therapist and client,
and a safe, supportive environment where the
therapist does not feel ashamed to be experienc-
ing vicarious trauma but rather recognizes it as a
normal response for those who work with trauma
clients (Neumann & Gamble, 1995).
Six peer-nominated master therapists were
interviewed in a qualitative study conducted by
Harrison and Westwood (2009), where each ther-
apist was asked the question, “How do you man-
age to sustain your personal and professional
well-being, given the challenges of your work
with seriously traumatized clients?” Notably, the
authors found that most of the clinicians
described how intimate and empathic engage-
ment with clients sustained them even in their
trauma work; this was a surprise given that
empathic engagement was understood to be a
risk factor for vicarious traumatization rather than
a protective practice. This paradoxical finding is
an important one to consider as it underscores the
point that efforts to prevent vicarious traumatiza-
tion should not preclude the empathic bond
between therapist and client that is so fundamen-
tal to the therapeutic process. One research par-
ticipant in the study explained, “I actually can find
sustenance and nourishment in the work itself, by
being present and connected with the client as
possible. I move in as opposed to move away,
and I feel that this is a way that I protect myself
against secondary traumatization. The connection
is the part that helps and that is an antidote to the
horror of what I might be hearing.” (Harrison and
Westwood, 2009, p. 213)
Dombo & Gray (2013) also encourage the
implementation of spiritually based interventions
for vicarious trauma such as rest-taking, spiritual
collaboration, pro-spiritual support and supervi-
sion, meditation, and the maintenance of individ-
ual spiritual practices that bear personal
significance to the clinician—such as prayer, the
reading of sacred texts, and spending time out in
nature. Enhancement of therapist spirituality is
thought to reinforce several positive dispositions
and beliefs, including the conviction that people
are resilient and can heal, that growth can still
occur within the context of trauma, that there is
more to life than suffering, that their professional
efforts are indeed meaningful, and that they are
not solely responsible in their efforts to heal their
clients’ trauma (Harrison & Westwood, 2009).
Another approach to integrating the practice of
spirituality into the daily life of the therapist is to
cultivate greater mindfulness—and specifically, a
more mindful awareness of the interrelatedness of
one’s mind, body, and spirit (for further guidance
on the practice of mindfulness from a Christian
perspective, see Tan, 2011).
Because indirect exposure to trauma may poten-
tially lead to cognitive shifts that negatively influ-
ence therapists’ basic assumptions about the self
and the safety of the world (Janoff-Bulman, 1992),
284 RESEARCH INTO PRACTICE
as well as their beliefs concerning matters relating
to trust, intimacy, and control, supervision may also
provide an ideal context for these cognitive shifts
to be discussed openly (Trippany et al., 2004).
Moreover, for the Christian therapist in particular, it
may be especially important for supervision to
address potential shifts in religious and spiritual
cognitions. This is because religious beliefs com-
prise a substantial part of one’s global meaning sys-
tem (Park, 2005) and because they also address
issues of existential meaning, which may be called
into question through either direct or indirect
exposure to trauma (Janoff-Bulman, 1992).
The relationship between trauma and the prac-
tice of one’s Christian faith is complex, however,
with some trauma survivors relying upon their
faith as a significant resource for recovery, while
others finding it as a source of distress, and still
others abandoning their faith altogether (Harris et
al., 2008). This multidimensional impact of trau-
ma on faith can similarly be expected for Chris-
tian therapists indirectly exposed to trauma as
well. For instance, exposure to trauma may give
rise to different manifestations of spiritual discon-
tent (Pargament, Koenig, & Perez, 2000), such as
anger directed toward God, a sense of betrayal
from God, a questioning of God’s love, mistrust
toward God, or the feeling that one has been
abandoned by God. Just as such themes may
naturally arise within the trauma client over the
course of therapy, parallel themes may also
emerge within therapists as they seek to make
meaning of the traumatic experiences for them-
selves, often from within the context of their own
Christian beliefs. Notably, spiritual discontent has
been found to not only be related to PTSD symp-
toms (Exline, Yali, & Lobel, 1999), but also to
partially mediate the relationship between trauma
and PTSD symptomatology (Wortman, Park, &
Edmondson, 2011). As such, it is possible that
interventions targeting the specific impact of trau-
ma on faith (within the context of training, edu-
cation, and supervision, for example) can be
understood as not only a preventative measure
but also a possible treatment for vicarious
traumatization or secondary traumatic stress.
When someone personally experiences a trau-
ma or bears witness to another person’s trauma,
religious assumptions are likely to be disrupted as
belief in a benevolent, omnipotent God may
appear inconsistent with traumatization (Cadell,
Regehr, & Hemsworth, 2003). Said differently,
trauma may lead one to doubt whether God is
loving, whether God is all-powerful, or perhaps
both. To illustrate, a traumatic event may sensi-
tize an individual to their lack of personal control
over matters relating to their own safety or to the
safety of those they love. They may then choose
to compensate for their own perceived lack of
control by attributing the traumatic event to God’s
control (Kay, Gaucher, Napier, Callan, & Lauin,
2008). However, doing so would not only call
into question God’s kindness, but would also like-
ly not reduce trauma-related anxiety
either—because the perceptions of threat have
been merely redistributed from human forces to
spiritual ones (Wortmann, Park, & Edmondson,
2011). As the conviction that God is both loving
and all-powerful represent tenets that are funda-
mental to the Christian faith, it would be under-
standable for a Christian therapist—one who may
be seen within their spiritual community as an
exemplar of the faith and a spiritual guide to
many—to experience marked ambivalence in dis-
closing these personal doubts. Supervision
should therefore seek to be sensitive to and mini-
mize the potential impact of religious guilt and
shame inherent in expressing such uncertainties.
In doing so, it is hoped that therapists may begin
to more freely explore and discover how they
might newly relate to God in light of these trau-
matic events.
A Christian approach to making sense of trau-
ma must take seriously the mystery of the theodi-
cy paradox—that is, how so much evil and
suffering can exist in a world that was created
and is sustained by a good and omnipotent God.
An important starting point to this end would be
to avoid trivializing this paradox by presuming
that it can be rationally resolved or explained
away (cf. Job 18:5, Job 24:31-37). Part of the
reason why this is the case is because evil cannot
be adequately conceptualized in the abstract—it
can be experienced only in particular forms
(Boyd, 1997). And the full horror of evil that is
often experienced (whether directly or indirectly)
within the context of trauma often shatters any
previously held explanations of evil and suffer-
ing?theological or not. Therefore, phrases such
as “God has His reasons” and “His ways are not
our ways,” regardless of their possible theological
or philosophical merit, can be counterproductive
because they may represent superficial and trite
explanations that tend to disregard the profound
gravity of the trauma survivor’s lived experience.
Last, a Christian approach to trauma also makes
space for the powerful negative emotions that
arise at the hand of trauma-related injustice, grief,
RESEARCH INTO PRACTICE 285
and loss. Indeed, Scripture is steeped in the lan-
guage of lament (cf. Jeremiah 15:18, Psalm 10:1,
Psalm 13:1), which was modeled by Christ Him-
self (cf. Mark 16:34). Biblical lament language is
the language of the soul, of lived human experi-
ence, of uncensored feelings spoken freely and
audaciously before the presence of God. It is
spoken out of the conviction that God’s will is
not perfectly realized in this current age (Ladd,
1990), and as a response to this reality, petitions
that God’s Kingdom come and will be done on
earth as it is in heaven (cf. Matthew 6:10). And
in so doing, our work in trauma may take an
eschatological turn—because things such as sick-
ness, disease, war, death, sorrow and tears will
all come to an end when God’s Kingdom is con-
summated and every evil which causes such sor-
row, vanquished (Boyd, 1997).
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Authors
David C. Wang, Th.M. (Regent College), Ph.D. (Univer-
sity of Houston) is an Assistant Professor of Psychology at
the Rosemead School of Psychology, Biola University in
La Mirada, CA. He is also the Associate Editor of the
Journal of Psychology and Theology. His research focus-
es on trauma/traumatic stress, spiritual theology (spiritu-
al dryness and the Dark Night of the Soul), multicultural
psychology, and mindfulness.
Daniel Strosky, M.A. (Talbot School of Theology), M.A.
(Rosemead School of Psychology) is a student in the
Psy.D. program at the Rosemead School of Psychology.
Alexis Fletes, M.A. (Pepperdine University), M.A. (Rose-
mead School of Psychology) is a student in the Psy.D.
program at the Rosemead School of Psychology.
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H., Winskowski, A. M., & McMahill, J. (2008).
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... For example, research has shown that maintaining a positive image of God (e.g., benevolent) is related to greater psychological wellbeing, while maintaining a negative God-image (e.g., punitive) is associated with greater psychological distress (Silton et al. 2014). Moreover, it is also important to note that the emotional and spiritual impact of trauma may apply not only to the trauma survivor, but also to the family members and friends who bear witness to this trauma (Wang et al. 2014). Accordingly, what we would like to do for the rest of this paper is to offer a few considerations on how the sacred might be integrated into an NMT-informed approach to treating childhood trauma. ...
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