#96624: Vicarious Trauma and Resilience

Type I reactions involve the professional's seeking to do one or more of the following: minimize the trauma, shift the focus away from the trauma, denial of the existence of some of the symptoms of the client, and/or distancing themselves from the trauma and/or client. At times it may even involve some measure of hostility or blame on the part of the clinician toward their client.

Type I countertransference reactions can include any of the following types of empathic withdrawal or empathic repression, sometimes with a combination of several (or alternating between different reactions):

Therapists who have not experienced significant trauma in their own lives tend to be more vulnerable to developing empathic withdrawal in working with trauma survivors [1]. These therapists tend to view the world as a just and fair place. They may not have had intensive training about trauma and/or the treatment of trauma survivors. These clinicians, therefore, may not be adequately prepared to be exposed to the powerful experiences of death threats, significant loss, horror, physical and psychological pain, and other severe traumas of their clients. The therapist may develop a host of painful emotions as a result of listening to the trauma stories and witnessing the distress of clients in session (e.g., horror, terror, hostility, desire for revenge). These emotions may be extremely hard for the therapist to tolerate. In order to avoid the pain associated with these feelings as well as to avoid threats to their view of a decent and fair world, these therapists may unconsciously seek to distance themselves and withdraw from clients through various means, such as intellectualization, denial, isolation, disbelieving or disavowing the reality of the client's experience, and/or using a blank-screen façade with their client. As a result of empathic withdrawal on the part of the therapist, the survivor's integration of their trauma may be blocked and the therapist's inaccurate assumptions may lead to misinterpretations. Receiving appropriate and extensive training about trauma and post-traumatic stress reactions is generally very helpful as part of a plan to prevent or combat empathic withdrawal.

In the situation of empathic repression, significant unresolved personal conflicts or issues in the therapist are reactivated in the course of the work with the trauma survivor. The survivor's way of relating to the therapist may resemble their past relationships with other significant people in their lives; this transference often stimulates a reactivation in the therapist. The therapist becomes withdrawn and focused on personal issues or conflicts at the expense of being fully engaged with the survivor. Therapists with a history of significant trauma, especially those who continue to suffer from personal trauma related to that of their client, tend to be at most risk for developing empathic repression.

Case Study: Type I Countertransference Reaction

Mr. A is a psychotherapist who has worked at a community mental health clinic for the past 10 years serving adults with a wide range of presenting problems. He has been treating Patient M for the past six months. Patient M is a highly educated, married woman, 35 years of age, from a country in Latin America and has been in the United States for the past two years. She was referred to the mental health clinic by her primary care doctor because of her severe and frequent panic attacks, nightmares, seeing and hearing dead people talking to her, and severe depression. Over the course of the first several months of treatment, Patient M has shared bits and pieces of her story with Mr. A. He has learned that the patient was working as a teacher in her community and was active in one of the opposition political groups in her country. She fled her country after soldiers killed opposition party supporters and their families in her town one night, including her husband and child. She was at a distant neighbor's house when the massacre took place, tending to a sick friend, and she believes that is why the soldiers did not find her. She tells Mr. A that she is too afraid to return to her country and is seeking asylum in the United States.

Mr. A finds himself flooded with many painful emotions in and after sessions with Patient M. He often feels horrified and has desires for revenge as she discusses her memories of finding her dead husband and child when she returned home that night. He feels terrified by the thought that Patient M may be deported to her native country where her life may be in danger. Mr. A has not experienced much trauma in his own life and definitely does not identify with Patient M's experiences.

Mr. A finds it extremely difficult to tolerate the intensity of his feelings when working with this patient. In order to avoid the pain associated with these feelings, he unconsciously develops empathic withdrawal toward Patient M. Mr. A's countertransference reactions alternate between intellectualizing, blank-screen façade, and misconception of the dynamics with his client. For example, Mr. A has unconsciously distanced himself from Patient M and often blankly stares at her when she brings up anything related to her traumas. Mr. A's reactions have led him to neglect to thoroughly assess the patient's traumatic experiences and the origins of her current symptoms. This, in turn, has led him to inaccurately assume and interpret Patient M's experiences of seeing and hearing of dead people talking to her as psychotic symptoms rather than as possibly part of her post-traumatic stress reaction. Patient M has not experienced any significant relief of symptoms.

Reflection Questions

Clinicians who experience over-identification reactions may try to do things too quickly in their work with their client; engage in excessive advocacy on behalf of the client; have tendencies to rescue the client; become enmeshed with the client; develop a blurring of role boundaries; develop an unhealthy or "pathologic" bond with the client; or focus excessively on the client's traumatic experiences [1]. Type II countertransference reactions can include any of the following types of empathic disequilibrium or empathic enmeshment, or a combination of several. As with Type I countertransference reactions, the professional may also alternate between different Type II reactions:

Clinicians who experience empathic disequilibrium often develop increased physiologic and psychological arousal as a result of their countertransference reactions. For example, clinicians may develop distressing somatic symptoms (e.g., stomach pains, headaches, pressure in their chest, motor tension) and/or become overwhelmed by characteristic types of emotional distress (e.g., uncertainty about how to proceed with the treatment, feelings of vulnerability or insecurity about their own capacities or abilities, self-doubt, strong anxiety). They may also be flooded with graphic and grotesque images associated with the traumatic material of the survivor(s) they are working with.

Wilson and Lindy describe that therapists who are most vulnerable for empathic disequilibrium are those who are relatively naïve about the intense physiologic and psychological arousal reactions that they may experience associated with exposure to such aspects of the trauma as the inhumanity of man, the existential shame and horror evoked by the trauma, complex and multiple traumas, and the impossible choices faced by those going through the trauma [1]. In a state of disequilibrium, therapists find that usually effective defense or coping mechanisms no longer work for them. They tend to be beset by exhaustion and may start to despair. If not addressed, or if ineffectively addressed, therapists may become burnt out and even depressed. Therapists who find that they are experiencing empathic disequilibrium will usually benefit considerably from adequate rest, time to recuperate and rejuvenate themselves, proper supervision and support, and reducing their exposure to trauma and minimizing work with highly traumatized clients. If addressed effectively, therapists may be able to successfully move out of a state of empathic disequilibrium, although they may find themselves moving into a state of empathic enmeshment or withdrawal instead [1].

When a therapist experiences empathic enmeshment he or she is no longer acting in the therapeutic role or maintaining appropriate professional boundaries. The therapist typically becomes over-identified and overinvolved with the survivor or survivors to the extent of becoming pathologically enmeshed with the client(s). Wilson and Lindy suggest that therapists who are most at risk of developing this type of empathic strain are those who have their own significant history of trauma, particularly if they have not yet worked through or healed from their traumatic experience(s) [1]. Such traumatized therapists may try to rescue the trauma survivor(s) they work with as an indirect means of attempting to address or work through their own unresolved traumas. These efforts are unconscious and can greatly interfere with or derail treatment if not quickly and effectively addressed, and the client may become victimized again. There is also a danger that the client's original transference issues and challenges (e.g., fear of abandonment, fear of betrayal, difficulty trusting others, sense of control or safety, self-esteem, ability to control one's affect) may become worse in the process.

Case Study: Type II Countertransference Reaction

Ms. B is a relatively new therapist who works at a center that serves women who predominantly have experienced domestic violence and abuse as children. She is only one year out of graduate school and has not had extensive specialized training about trauma or the impact of trauma work on herself. She has begun to feel extremely overwhelmed in her work with Patient P, a young Cambodian woman, 19 years of age.

Patient P was referred to Ms. B's center by the Federal Bureau of Investigation (FBI) a month ago after they rescued her from a sexual human trafficking ring in a sting operation. The FBI has arranged for the patient to stay at a secure shelter, and they have certified her as a trafficking victim in exchange for her cooperation in prosecuting her traffickers. She should be eligible to be granted a T-visa, which would entitle her to legal status in the United States as well as work authorization because of her cooperation with the federal authorities. Patient P will be required to testify in court against her traffickers, something that frightens her considerably, particularly because they threatened to harm her and her family back in Cambodia if she ever reported them to the authorities. She worries that her traffickers may see her when she leaves the shelter to go to the store or to the center.

In the past month, Patient P has shared with Ms. B about the extensive emotional and physical abuse she experienced as a child—abuse that left her with a broken arm and two broken ribs. She was eventually sent by her parents to live with a distant aunt in the capital Phnom Penh. When Patient P was 16 years of age, her aunt lost her job and became financially destitute. The aunt told Patient P that she had found a well-paying job for her with a family, but when she showed up for her first day of work she quickly learned that her aunt had sold her into a life as a sex worker. Patient P initially refused to cooperate, and her traffickers beat her daily and drugged her in order to force her to submit to engaging in prostitution. They kept her locked up and, after several months, trafficked her to the United States, where she continued to be forced to engage in sex work, servicing up to 8 or 10 men per day, seven days per week. She developed gonorrhea and herpes and became pregnant. She had an abortion, and her traffickers forced her to return to sex work after only two days of rest.

Ms. B develops intense stomach pains and headaches during and following sessions with Patient P. She finds herself full of uncertainty about how to proceed with treatment and overwhelmed by intense anxiety and horror, as well as graphic images of the patient's repeated abuse. She is plagued by self-doubt and insecurities about her ability as a therapist to help Patient P heal from the traumas she has experienced and prepare psychologically to testify against her traffickers. Ms. B feels exhausted every day and at times feels despair; her countertransference reactions are illustrative of empathic disequilibrium.

Reflection Questions

While not all countertransference reactions are problematic, each of the discussed reactions would likely have a less than optimal impact on the therapeutic relationship and course of treatment of the survivor. It is an ethical duty, above all, for health and mental health professionals not to do harm to their clients and patients. Therefore, it is essential that clinicians strive to become aware of, understand, and develop the skills to address or make therapeutic use of the information provided by their countertransference reactions. Attending effectively and appropriately to one's countertransference reactions will also enhance one's professionalism and the quality of one's work.

A number of negative feelings can accompany feeling burnt out, including unhappiness, hopelessness, exhaustion, disconnectedness (including from the person you want to be), a lack of sustaining beliefs, feeling overwhelmed or bogged down, and feeling that your hard work never can make a difference [31]. These feelings are associated with difficulties one experiences over time in doing work effectively and may be amplified by a high workload or an unsupportive work environment [19].

Freudenberger has defined burnout as, "a depletion or exhaustion of a person's mental and physical resources attributed to his or her prolonged yet unsuccessful striving toward unrealistic expectations, internally or externally derived" [33]. It is important to emphasize that unmet expectations can have a variety of origins, not all residing within the person. Frequently, the sources of burnout from external sources are the most difficult to address and resolve, as they are outside of the individuals' scope of influence. These sources are systemic in nature. In the environment of economic downturn and crisis, when resources are scarcer than ever, this is particularly pronounced. Burnout typically emerges gradually as the person becomes increasingly emotionally exhausted over time.

Most health and mental health professionals enter their profession because they want to help others in need. They tend to have strong empathic skills and be compassionate people. Those who choose to work with survivors of trauma are no exception. The very capacity for empathy and compassion among these professionals, however, in combination with the intensity of their work, their own personal vulnerabilities, and the rather extreme situations in which they may be asked to intervene (often with inadequate training, support, and/or resources) can leave these professionals at risk for compassion fatigue.

Impact of Burnout on the Professional and the Therapeutic Relationship

Those who study psychotherapists who are impaired or no longer functioning effectively often consider burnout to be an end phase of severe distress [33]. Some professionals opt to quit or retire (perhaps taking an early retirement) when they reach this phase. Others soldier on doing the best they can, often hurting themselves and others in the process (by providing less than optimal care to themselves and others). Psychotherapists who are burned out may not have the energy to provide the care that client(s) need, or they may feel so overwhelmed that it compromises their ability to accurately assess the client's situation or needs or to implement the most appropriate treatment plan. All of these scenarios can negatively affect psychotherapists' relationship with the survivor(s) they serve and may in turn affect the survivor(s) ability to trust and form an effective therapeutic working relationship with other professionals.

Case Study: Anticipating and Preventing Burnout

Before Ms. C decided to apply for admission to a Master's in Social Work (MSW) graduate program, she reflected on whether this was a good choice for her or not. She had heard stories about social workers who burned out. Professionals, once passionate about their work with runaway teens or domestic violence victims, had become disillusioned and exhausted and had lost their passion and energy for their work. This gave Ms. C pause and made her worried. She was nervous about entering a profession that seemed to pose a high risk for burning out, but she was raised in a family where she was encouraged to pursue a career that she was passionate about and was surrounded by examples of family who remained energized and fulfilled in their work after many years. Ms. C was told that she had many options open. She had not had any significant contact with social workers up until then, and she was not sure if this would be a career she loved. She did know, however, that many jobs were definitely a poor match for her abilities and interests.

Ultimately, Ms. C decided to give social work a try and applied to graduate school. Before she applied to a MSW program, however, she developed a plan and commitment to herself that served her well over more than two decades in the field. Her plan was to check in with herself often about how she was feeling and functioning in relation to work and life in general. Ms. C vowed that if she ever found that she was starting to burn out, she would make a change by switching the population she worked with or changing her role and duties; she could leave clinical work altogether and do policy- or community-based advocacy, or she could combine clinical work with research and policy work. Ms. C was relieved to know that the options within the profession of social work were many. Just knowing that she had options and the power and ability to be in control of her choices and work life made a huge difference. Over the years, she made several changes in her work setting, role(s), and the populations served. Ms. C is pleased to report that she has successfully avoided burning out.

Reflection Questions

It is possible to recover from burnout, and compassion fatigue in general. Not all of the symptoms are extreme or long-term in nature. Burnout and compassion fatigue exist on a continuum of severity. It can be helpful when one becomes aware that they have developed a sign or symptom of burnout or compassion fatigue, as this could serve as a signal of the need to do something about it. Without such awareness, it is less likely for professionals to make positive changes in their lives to promote well-being. Ideally, however, professionals will develop plans to prevent becoming burnt out or developing compassion fatigue in the first place.

Prevention and Treatment of Burnout

Being aware of the factors that increase a professional's risk of burnout is very valuable in contributing to a prevention strategy. Contributing factors may be individual/personal, systemic, or frequently a combination of both. It is important to know what does not work (or what makes a toxic environment) first in order to prevent exposure and the associated fallout from such exposure.

A review of many of the possible contributing individual or personal factors has been discussed in previous sections of this course. Systemic risk factors include [3,18]:

It is possible to prevent or recover from burnout and compassion fatigue and even to be resilient in the face of conditions or environments that may make these conditions more likely to develop [34]. The more one is able to anticipate risk factors and identify early warning signs of burnout or compassion fatigue, the more likely it may be to effectively deal with the situation and even become resilient.

One tool that can be used to assess burnout is the Copenhagen Burnout Inventory (CBI). The CBI is a self-administered tool with 19 items that measure the frequency of symptoms of burnout using a five-point scale. It includes three subscales covering different domains of burnout: personal burnout, work-related burnout, and client-related burnout. A prospective study of more than 1,900 human service employees found that the CBI was effective in differentiating between human services occupational groups and responses were correlated with other measures of low energy and psychological well-being [35]. In addition, the three subscales accurately predicted persons who had sleep problems, used pain killers, intended to quit their jobs, and would be absent in the future due to sickness. Over the course of the prospective study, high percentages of the employees reported changes in their level of burnout. The CBI has high internal reliability and good predictive validity, has been used in many countries, and has been translated into eight languages [35]. A copy of the CBI can be viewed online at https://nfa.dk/da/Vaerktoejer/Sporgeskemaer/Sporgeskema-til-maaling-af-udbraendthed/Copenhagen-Burnout-Inventory-CBI.

Essential to preventing and treating burnout and compassion fatigue is creating and maintaining a healthy balance in one's life [34]. The need for self-care has been stressed, for example, in professionals who specialize in oncology, hospice, and palliative care [36,37,38]. This balance may be different from individual to individual and within a given individual over time. Common components to achieving balance and optimal functioning involve the following basic self-care strategies: taking time off work periodically to rejuvenate oneself; building in time in one's schedule to attend to one's own needs; regular exercise, keeping one's body healthy, and attention to one's overall health; getting enough sleep on a regular basis; and eating healthy foods regularly and maintaining a healthy weight. Caregivers who do not attend to these basic strategies are more likely to be physically and emotionally vulnerable and less resilient over time.

Health and mental health professionals who work with trauma survivors are mandated by law and ethics to keep confidential the identities of their clients and the content of their sessions or work with clients. This is frequently the very material or content that they would benefit from addressing with others as part of their plan to take care of themselves. Resilient trauma professionals are not isolated and have strong connections with and support from others, both in their personal and professional lives. Trauma professionals are encouraged to find appropriate outlets and venues for processing the impact of their work on themselves without violating the confidentiality of their clients, such as in confidential clinical team case conference meetings, in supervision, and in their own therapy.

Remaining vigilant to the signs and symptoms of burnout in oneself is essential in order to act to regain one's equilibrium and balance and prevent the situation from escalating. After symptoms of burnout have developed, steps can be taken to address these symptoms, including but not limited to [34]:

If, over time, a trauma professional is not able to regularly leave their work at work, then they are putting themselves at risk not only of becoming burnt out but also at risk for vicarious traumatization.

Compassion fatigue can also result when professionals or other caregivers become overwhelmed by exposures to the intense traumatic material or feelings of those they serve [3]. Vicarious traumatic stress refers to professionals' secondary exposure to very stressful and traumatic events through their work. Professionals may frequently or repeatedly hear trauma stories at work about horrible things that have happened to others (also known as vicarious trauma). This has been studied in many populations, such as lawyers, interpreters, those who work in oncology and palliative care, and other clinicians [13,17,19,39,40,127,128]. Characteristic symptoms of distress can develop as a result, including fear, anxiety, depression, pain, loss of energy, nightmares and other sleep disturbance, and intrusive traumatic thoughts.

Compassion fatigue usually develops over time, as a cumulative result of helping many clients in challenging circumstances. It can, however, develop quickly when a professional responds to a case that is especially traumatic or challenging, in which case the symptoms of vicarious traumatic stress may have a rapid onset [31]. The professional may become traumatized as a result of becoming strongly focused and concerned with the suffering of the client while he or she is in a state of strong anxiety. This possible traumatizing reaction has been called vicarious traumatization [3,31].

Trauma professionals may be directly and/or indirectly exposed to trauma on the job. For example, a police officer who is shot at while intervening in a domestic violence dispute experiences direct exposure. Other examples of primary trauma are found in combat soldiers or humanitarian aid workers working in war zones who are directly in danger. An example of vicarious exposure is when a police officer hears the traumatic details of what happened from a victim who was beaten by their partner. Child protective service workers or emergency room personnel are examples of professionals who are frequently exposed to indirect or secondary trauma.

The COVID-19 pandemic was a worldwide shared public health crisis that brought into sharp focus the intensity and challenges faced by helping professionals when they must navigate their own traumas while they respond to the quite similar traumas of their clients. This is not an isolated incident, as professionals working in the contexts of war or civil unrest, natural disasters, or other widespread community traumas are vulnerable to experiencing their own personal traumatic reactions as well as vicarious trauma [129]. These situations underscore the importance of self-awareness, effective addressing of countertransference reactions, and promoting self-care.

Vicarious Trauma and Countertransference

According to the World Health Organization, attention should be paid to self-care for providers who care for victims of intimate partner violence and sexual violence, including the potential for vicarious trauma.

(https://apps.who.int/iris/bitstream/handle/10665/85240/9789241548595_eng.pdf Last Accessed: May 25, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

Unlike with countertransference, a professional's pre-existing personal characteristics may not have a bearing on his or her reactions to a client's trauma story. Vicarious trauma and countertransference are different experiences or constructs, but they can affect one another. For example, countertransference reactions exist in all therapists (and, it could be argued, in other allied health and mental health professionals as well). Countertransference reactions are specific to each client and the individual therapist-client dyad. Vicarious traumatic stress's effects, on the other hand, are experienced beyond any given therapy relationship and develop due to the accumulation of experiences, generally across clinical relationships with multiple clients.

When vicarious trauma develops, it typically transforms the clinician (in some cases permanently) and affects not only professional life but personal life as well. Vicarious trauma in effect changes the very self of the clinician, and it is this self that is the context for the development of countertransference reactions. Clinicians who experience more pronounced vicarious traumatization may also have stronger countertransference reactions and may be less aware of these reactions given the effects of the vicarious trauma [1]. This situation may in turn be associated with more clinical error or impediments to the progress of treatment and can also result in even more vicarious trauma.

Associated Characteristics

Trauma professionals who are suffering from vicarious traumatic stress often find that they are preoccupied with thoughts about those they have tried to help. Helpers may feel overwhelmed, as though they are trapped or on edge, and contaminated by the trauma material of their client(s) [31]. Characteristics of vicarious traumatic stress can include increased forgetfulness about important matters, sleep disturbance, and challenges maintaining boundaries between one's personal and professional lives. Affected professionals may feel as though they are experiencing aspects of the trauma described by someone they have served, such as developing avoidance symptoms to triggers of the trauma (i.e., avoiding particular activities that remind them of the trauma) [31]. Vicarious traumatization occurs when a professional is changed deeply and negatively by their work with the suffering of others; this can manifest in many ways, such as a negative sense of self. Pearlman developed the Trauma and Attachment Belief Scale for use with trauma survivors, although researchers have also used this scale to evaluate the impact of vicarious trauma [41]. The scale assesses beliefs and cognitive schemas in five domains that may be affected by trauma: safety, trust, esteem, intimacy, and control.

Case Study: An Early Warning Sign

Ms. C's first job after graduating with her MSW degree was as a psychiatric social worker and trainer of paraprofessional refugee counselors in a first asylum camp for Vietnamese boat people on an isolated island in the Philippines. When she arrived, she found that she had the most mental health training of anyone on the island. The Filipino non-profit she worked for had psychiatrists on call for consultation by phone and would fly a psychiatrist in for several days every two months to assess and prescribe medications. There were very few telephones on the island, and Ms. C had to borrow another agency's phone to make a call. Often, the connection was poor, and it was hard to communicate with the psychiatrist. Ms. C had a caseload of more than 100 clients who had fled Vietnam by boat and had experienced multiple traumas. Many of the clients were suffering from severe mental health problems, and some faced ongoing violence. Ms. C found herself working with multiple cases of trauma with both the perpetrator(s) and victim(s) at the same time. She only had access to peer supervision, with only sporadic access to a more senior, experienced supervisor when they visited the island.

Within several months, Ms. C's sleep became routinely disrupted. She began to have frequent nightmares. When she examined her nightmares, she realized that they were not her own—they were those of her clients, especially those who had experienced atrocities on the high seas during their escapes from Vietnam. The nightmares were filled with images of Ms. C hanging on to driftwood, watching helplessly as her loved ones lost strength and drowned in front of her. She also saw images of herself being attacked by pirates at sea, shot, and left for dead in a pile of dead bodies, and pretending to be dead until the pirates left. She had a recurrent nightmare of watching her brother murdered by others on the boat and seeing them eat his corpse in order to stay alive.

Instead of becoming alarmed at this development, however, her anticipatory work prior to starting the MSW program (vowing to check in regularly with how she was feeling and functioning) proved protective and reassuring. Her approach was to view these nightmares as fortuitous, because it gave her the opportunity to develop and implement a prevention plan and recognize the importance of taking care of herself and creating balance in her life very early in her career. More than two decades later, she is still working with trauma survivors. Her role has evolved and expanded and the population she works with is different (survivors of state-sponsored torture from all over the world—no longer restricted solely to Southeast Asian refugees). She also reports that she no longer has the nightmares of her clients.

Reflection Questions

Many people (including trauma specialists) have experienced some trauma in their lives by the time they reach adulthood. There are a host of possible consequences of trauma exposure. Two of the most common psychological conditions among survivors are PTSD and depression. Stamm notes that while approximately half of all the people in the United States have been exposed to at least one traumatic event that would qualify as a trigger for PTSD, only about 8% develop the disorder [32]. The past 12-month prevalence rate of PTSD and depression in the general population is approximately 5% and 7.1%, respectively [42,121].

Professionals who work with trauma survivors may find that over time they develop some symptoms of PTSD or depression similar to those experienced by clients who were directly traumatized, even if they have not experienced significant trauma themselves [43]. The development of such traumatic stress reactions as a direct result of working with trauma survivors is known as vicarious trauma. It is important to note, however, that not all vicariously traumatized professionals will develop PTSD or depression [31].

Vicarious or secondary trauma refers to "a transformation in the therapist's (or other trauma worker's) inner experience resulting from empathic engagement with the client's trauma material" [44]. It is considered to be a natural and inevitable outcome of engaging in work with trauma survivors and involves the cumulative effect of this work on the feelings, memories, self-esteem, cognitive schemas, and sense of safety of the clinician.

Pearlman and Mac Ian studied the effects of trauma work on therapists and found that the development of vicarious trauma is not evidence of psychopathology in the therapist or the client [44]. It is normal and to be expected under the circumstances. Some studies have found that trauma professionals who have experienced trauma themselves or those who work longer hours with trauma survivors (e.g., child protective service workers) or have higher rates of exposure to traumatic material experience more vicarious trauma and compassion fatigue [2,45,46,47]. Professionals who have developed post-traumatic reactions from their own traumas may be more at risk of developing vicarious trauma, particularly if there are strong similarities between aspects of their own traumas and those of their clients. Some stories may be harder to hear or may stimulate longer lasting reactions than others. For example, a professional therapist who has a phobic reaction to snakes and works closely with a client who was tortured with snakes may develop more distressing post-traumatic symptoms, including nightmares or intrusive traumatic thoughts similar to their client's.

Therapists and other trauma practitioners who develop vicarious trauma may have their assumptions about the world and themselves disrupted as a result of their trauma work. McCann and Pearlman have found that this shattering of assumptions can result in long-lasting changes in the trauma professional's cognitive schema [43]. Trauma survivors are susceptible to a range of effects as a result of this disruption, including no longer believing that they are protected or invulnerable (the world becomes a frightening place and they are personally at risk); the world is no longer viewed as predictable, orderly, and easily comprehended—rather the world may appear as a chaotic place where trauma can randomly happen to anyone; and/or their prior healthy self-esteem may be negatively affected, resulting in feelings of fear and powerlessness [48].

Constructivist Self-Development Theory

According to Saakvitne and Pearlman, vicarious trauma as a concept is based on constructivist self-development theory [49]. Constructivist self-development theory was developed to be an integrative clinical theory, one that is based on a holistic view of the self in context, addresses the multiple aspects of the self that are seen to be affected by trauma, and emphasizes adaptation [50]. It is a personality theory that explains how the development of self is affected by traumatic events and their context(s). Clinical and empirical data drawn from a number of different trauma survivor populations were used in the development of this theory. It incorporates a number of existing theories, including psychoanalytic theory, cognitive development theory, social learning theory, and constructivist thinking, while also emphasizing the importance of the person's cultural, social, and developmental contexts [50,51,52,53,54].

According to constructivist self-development theory, there are five areas of the self that are seen to be affected by trauma [49,50]:

Trauma survivors typically strive to create meaning out of their experiences as they construct an individualized trauma narrative. Constructivist self-development theory recognizes personality development as a complex interaction of a number of factors, including in part one's core self-capacities (stemming from one's ego resources and one's early relationship experiences and attachments) and one's constructed schemas and beliefs (connected to the accumulation of one's life experiences and the meanings one associates with those experiences) that shape one's experience and perception [50].

An individual's adaptive response to trauma is seen as a function of the interaction between his or her distinctive personal and family history, development, personality, the traumatic event, and the sociocultural context and consequences of the trauma. The meaning of the trauma, the post-trauma reality, and the adaptive strategies employed are individually constructed by each survivor, and thus are unique to the particular survivor. The survivor's way of relating to self and others is seen to be deeply influenced by early development. Traumas are understood to be reconstructed and reinterpreted at each developmental stage. The symptoms expressed by trauma survivors are seen as adaptive strategies by constructivist self-development theory, strategies that help the survivor manage perceived threats to their safety and integrity [50].

For example, beliefs that appear to be distorted or irrational are viewed by constructivist self-development theory to be survivors' efforts to protect their meaning system and themselves from the threat of the trauma. Unlike many other theories, the constructivist self-development theory does not view the person's strategies in response to trauma as pathologic or emphasize stigmatizing diagnoses [49]. Instead, responses to trauma are considered to be protective according to this theory. The developers of the theory provide the example of adult survivors of childhood abuse to illustrate this concept. They describe that the adult survivor's persistent and intense shame developed initially as a child in response to being abused by parent(s) was functional and protective for the child, serving to protect the image of his or her parent(s) as good and right (and the child as bad and unworthy) [49]. They go on to explain that the child's belief that he or she is responsible for the abuse helps the child to feel less helpless, powerless, and fearful. The adult survivor's persistent shame and related guilt may no longer be adaptive and functional, and it may lead to self-destructive behavior. Of course, if not properly and fully understood by the trauma professional working with the adult survivor of childhood abuse, interventions may not be effective.

Constructivist self-development theory identifies areas that may be damaged by trauma but also areas of potential post-traumatic growth. It provides an explanation for and predicts how trauma can produce dysfunctional beliefs and adaptations as well as positive transformations in survivors [50].

Saakvitne and Pearlman describe how trauma professionals or other helpers will be affected in similar ways to the trauma survivor (as discussed), but note that the intensity and extent of the impact will be less than that experienced by the primary survivor [49]. They argue that if professionals do not have an appropriate theoretical framework, such as that of constructivist self-development theory, to understand the impact of the trauma on their client, including the meaning of the client's symptoms or coping strategies, efforts to treat the client will likely be unsuccessful. Furthermore, over time, with repeated lack of success, the trauma professional may become discouraged, despairing, and at risk for the development of vicarious trauma.

The interested reader is encouraged to consult Saakvitne, Tennen and Affleck, and Saakvitne and Pearlman for a much fuller examination and analysis of constructivist self-development theory [49,50]. These sources elaborate, among other things, on the contribution of constructivist self-development theory to informing research and clinical practice related to the impact of trauma and the possibility for post-traumatic growth and healing following trauma exposure and to the phenomenon of vicarious trauma. There is a growing body of literature documenting positive outcomes and growth after exposure to trauma [22,55,56,57]. Research by Bonanno, Westphal, and Mancini found that resilience is the most common outcome of potentially traumatic events [58]. The literature is mixed, however, on outcomes of trauma for those who live in contexts of ongoing war and chronic terrorism [59].

Why Vicarious Traumatic Stress Develops

Health and mental health professionals who serve survivors of trauma are trained and expected to exhibit empathy toward survivors and to engage with empathy with the traumatic material of their client(s). The helper is transformed in the process and their empathic stance puts them at risk for vicarious traumatic stress [49]. It is possible for vicarious trauma to appear to develop suddenly, even in seasoned trauma specialists who have not struggled significantly or at all with vicarious trauma after years of working with survivors. A sudden onset often leaves the professional feeling a sense of disruption or powerlessness, especially if he or she has been socialized to believe that professionals should be able to handle exposure to trauma. It is important to note that this factor varies widely depending on the profession and environment; some professions and work settings have cultures that promote "toughness" in trauma professionals, maintaining that they should not be affected by their work, while others are more open to acknowledging and normalizing the presence of vicarious trauma. Among those at particular risk are those who do not have specialized training or experience in working with trauma and those who are dealing with their own stresses and trauma in the context of a shared community trauma such as the COVID-19 pandemic [129].

It can be hard (at times seemingly impossible) for some trauma professionals to admit to themselves, their colleagues, or others that they are experiencing symptoms of vicarious trauma or burnout, particularly if they or their colleagues hold the view that trauma professionals should be above being negatively affected by their work. Admitting the impact of the work on oneself is actually an important strength and demonstrates a clinician's professionalism. It also provides the professional with an opportunity to improve on an established self-care plan and promotes his or her ability to provide better service to traumatized clients.

In addition to the role of empathy in the development of vicarious trauma reactions, there are a host of other possible contributing factors, such as [49]:

The overall outcome is the result of the interaction between these various factors. Of course, the result will be unique for each individual, just as life experiences, personality, and profile of contributing factors are unique. Weingarten developed a model to explain how various factors may affect therapists' reactions when they are exposed to violence in their work with survivors [60]. She hypothesizes that therapists who are aware of the meaning of the violent events experienced by clients but who find themselves helpless to take action or without any path for taking constructive action are the most at risk for developing vicarious trauma.

Impact of Vicarious Traumatic Stress on Self, Relationships, and Work

Vicarious traumatic stress can affect a trauma professional in profound ways, many of them similar to the impact of trauma on the client. In addition to the possibility of developing symptoms of PTSD (e.g., nightmares, intrusive traumatic images and thoughts) and/or depression (e.g., hopelessness, depressed mood, generalized despair), the experience of working closely with survivors of trauma, particularly survivors of human perpetrated trauma, can affect the professional in other significant ways. These clinicians have reported [19,49,61]:

Some of these effects can also have an impact on one's ongoing work with trauma survivors. For example, the therapeutic relationship can be damaged or compromised if one is less able to effectively empathize with one's clients or patients. In addition, a psychotherapist who develops distrust in others and no longer feels safe or in control may have a harder time assisting survivor clients with these same issues.

Providing direct care to patients with COVID-19 impacted social workers, nurses, and other health and mental health professionals in a variety of ways, including PTSD, strong grief reactions, burnout, and secondary or vicarious trauma, while some providers also reported experiencing compassion satisfaction [130,131,132]. Vicarious trauma reactions were also found in those who did not engage in direct care of patients with COVID-19, such as in non-direct care nurses [133]. Researchers and academics who teach about trauma and/or conduct indirect scholarly work with trauma survivors also are at risk for vicarious trauma [134,135].

Assessing Vicarious Traumatic Stress Reactions

Thankfully, it is rare for a trauma professional to develop full-blown vicarious traumatic stress. When it does occur, it can be quite disruptive and distressing. However, the effects of vicarious traumatic stress can be effectively addressed. A deeper understanding of and plan to prevent and address one's vicarious traumatic reactions can assist one in achieving vicarious transformation as well.

The first step in addressing vicarious traumatic stress is to assess one's situation thoroughly. A complete assessment will make it easier to develop an appropriate strategy and plan that is likely to succeed. A commonly used measure to assist in the assessment of symptoms of vicarious traumatic stress is the Secondary Traumatic Stress Scale (STSS) (Table 2)[62].

The STSS was designed to be self-administered in less than 10 minutes and consists of 17 questions. It has strong psychometric properties, including construct, convergent, and discriminant validity. The STSS was developed to measure the presence of symptoms of the following in social workers and other helping professionals [62]:

Higher scores are indicative of greater frequency of vicarious traumatic stress symptoms and risk for burnout [62].

After compassion fatigue sets in, the professional typically displays signs and symptoms resembling, in part, those of PTSD. The cause of the symptoms of compassion fatigue, however, differs from those of PTSD. PTSD symptoms develop in some people after they are directly exposed to a significant trauma. The symptoms of compassion fatigue arise in those who help others, in relation to the traumas of the clients they serve. Frequently, professionals' attitudes toward their work or career changes, and they may become less enthusiastic and increasingly dispirited, hopeless, and/or cynical. They may find that they have become preoccupied or obsessed about a distressing case or client situation. Professionals may start to leave work early or call in sick, or alternatively, they may have the tendency to stay late [67].

A complete list of signs and symptoms associated with compassion fatigue is undoubtedly long and affects all realms of a person's life, including the physical, cognitive, emotional/psychological, interpersonal, sexual, behavioral, spiritual, and outlook on life and humanity. It is beyond the scope of this course to provide an exhaustive list. However, a few of the more common physical symptoms are [19,49,61]:

Emotional/psychological effects are also many and can include such symptoms as [19,49,61]:

Potential cognitive effects include, but are not limited to [19,49,61]:

Interpersonal and sexual challenges include [19,49,61]:

Behavioral symptoms can include [19,49,61]:

Spiritual effects may include [19,49,61]:

An important element that contributes to a person's reactions and way of dealing with stress is their level of resilience [88]. Resilience is often defined as positive adaptation to stress or trauma and is thought to be associated with a wide range of strengths and positive mental states found in some people. Measuring resilience in individuals with post-traumatic stress responses (including but not limited to PTSD, other anxiety reactions, and depression) is used as a treatment outcome measure in some cases. A survivor's improved resilience over time may indicate a better prognosis.

Some health and mental health professionals who work in the trauma field are more vulnerable to stress than others. This vulnerability, as well as the level of resilience in the face of trauma and stress, can be measured and tracked over time.

The following sections will outline some of the most cited and commonly used measures of resilience and vulnerability to stress. However, it is important to note that it remains to be determined if the different resiliency scales are measuring similar constructs or not.

Connor-Davidson Resilience Scale

The Connor-Davidson Resilience Scale (CD-RISC) is a well-validated measure, is easy to use, and the various versions have been found to have strong psychometric properties [88,89]. A number of studies have used the CD-RISC scale with a wide range of populations, such as Turkish earthquake survivors, Chinese earthquake survivors, and in undergraduate students in the United States [90,91,92]. The CD-RISC is effective in distinguishing between those with different levels of resilience and showed that resilience can improve over time. The CS-RISC had good sensitivity to treatment effects, such that an increase in the score on the CD-RISC was associated with more treatment improvement as well as greater global improvement in an individual's clinical state. The CD-RISC can be self-rated, allowing for a person to easily monitor his or her own resilience over time. A nonspecialist can be trained to use the scale in the field quickly and easily. Connor and Davidson initially developed a 25-item resilience scale and tested it in a variety of adult populations (i.e., community sample, general psychiatric outpatients, primary care outpatients, and in clinical trials of PTSD and generalized anxiety disorder) [89]. Each of the items is rated on a five-point scale (scored 0 to 4); higher scores indicate greater resilience. Over time, other versions of the CD-RISC were developed, including a 10-item and an abbreviated 2-item version [92,93]. Analysis of the original 25-item version yielded five separate factors, labeled as personal competence and tenacity; trust in one's instincts and tolerance of negative affect; positive acceptance of change and secure relationships; control; and spiritual influences [89]. A later factor analysis conducted by Campbell-Sills and Stein with more than 1,700 undergraduate students yielded only four factors: hardiness; social support/purpose; faith; and persistence [92]. Further work by Campbell-Sills and Stein led them to propose a modified version of the CD-RISC that consisted of only 10 items with stronger psychometric properties [92].

Vaishnavi, Connor, and Davidson developed a two-item version of this scale that they called the CD-RISC2 [93]. The two items were "able to adapt to change" and "tend to bounce back after illness or hardship," as the original scale developers viewed these two items as representing the essence of resilience. The CD-RISC2 is a brief, self-rated resilience measure with relatively strong psychometric properties. It may be valuable and practical in clinical settings as a brief screening measure or a measure of treatment progress, or in research contexts as a brief outcome tool.

Resilience Scale for Adults

The Resilience Scale for Adults (RSA) was developed in Norway as a measure of the presence or absence of interpersonal and intrapersonal protective resources thought to facilitate tolerance to stress and adverse negative life events and facilitate adaptation and promote resilience in adults. The RSA consists of 33 items that are organized in six categories [94,95,96]:

Responses are scored using a 7-point semantic differential scale with a total possible score ranging from 33 to 231. The RSA has good psychometric properties, and it was found to be a useful, versatile, and valid instrument to reliably predict individual differences in self-reported stress and pain [96]. It has demonstrated protective effects against life events that are stressful in a laboratory context as well as in real-life settings [96]. One example incorporating the scale is utilizing the RSA in a clinical setting with individuals suffering from chronic pain. Friborg and colleagues conducted a study of resilience as a possible moderator of pain and stress and concluded that the RSA may be useful in identifying individual differences in overall functioning, the experience of pain, and perhaps also in the use of pain medication [96]. These researchers also suggest that pretreatment scores on the RSA may predict treatment effects, including the effects of psychological treatment [96].

The Resilience Scale for Adolescents

The Resilience Scale for Adolescents (READ) is a 28-item measure of resilience, originally validated on a representative sample of 6,723 Norwegian senior high school students between 18 and 20 years of age [97]. It was found to have strong psychometric properties and to load on five factors considered by some to cover the central aspects of the construct of resiliency: personal competence, social competence, structured style, family cohesion, and social resources. The authors advocate it as a useful tool for research examining risk factors and resilience [97].

The Adolescent Resilience Scale

The Adolescent Resilience Scale (ARS) was developed for use with adolescents to measure their "mental recuperative power" [98]. The 21-item version of the ARS scale has three sub-scales related to novelty seeking (i.e., ability to demonstrate concern about and interest in a variety of events), emotional regulation (i.e., ability to control one's emotions and remain composed), and positive future orientation (related to one's goals for, outlook toward, and dreams about the future). It is meant as a measure of potential protective factors rather than as a measure of resilience as an outcome. It has strong psychometric properties.

Resilience Scale

The Resilience Scale (RS) is a 25-item scale, with an optional 26th item, that has been translated into at least 15 languages, with more being translated [99]. It has been used for people from 13 to older than 100 years of age and is deemed suitable for those with a 6th grade equivalent level of education. The original 25-item version of the RS has been used for two decades and has strong psychometric properties. A shorter 14-item version is relatively new but has demonstrated very good psychometric properties as well. Studies have found the RS to be associated with self-management of illness and strong health-promoting behaviors. The RS measures the following characteristics of resilience: perseverance, self-reliance, meaningful life, existential aloneness, and equanimity [99]. Higher scores on the RS are considered to be indicative of fewer symptoms of anxiety, depression, and stress. Better potential for illness self-management is thought to be associated with moderate to moderately high scores on the RS. More information about the resilience scale, including how to obtain the scale and its user guide, can be found on the official scale website at https://www.resiliencecenter.com.

Core Self-Evaluations Scale

The Core Self-Evaluations Scale (CSES) was developed in 2003 and is comprised of 12 items that measure the following traits: self-esteem, locus of control, self-efficacy, and emotional stability [100]. It has been argued that these traits represent a common quality, are similar conceptually, and play a contributing role in the processes of stress and coping [101]. Specifically, the core self-evaluations have been seen to be related to the use of less avoidance coping strategies and less perception of strain and life stressors and is thought to represent traits that may link coping, stress, and resilience. The CSES has good internal and test-retest reliability and acceptable validity scores [100]. It has been found to correlate with other measures of life satisfaction, job performance, and job satisfaction. This scale has been found to be easy to administer, is not proprietary, and does not require permission for use.

Sheehan Stress Vulnerability Scale

The Sheehan Stress Vulnerability Scale (SVS) is a one-item, self-rated visual analog scale with 11 points that can be used to monitor one's perceived vulnerability to the impact of stress over time [102]. Greater vulnerability to stress or impaired resilience is associated with higher scores on the scale. The SVS is easy to self-administer and translate and has been found to have good validity and reliability.

Vicarious Resilience Scale

The Vicarious Resilience Scale (VRS), developed by Hernandez-Wolfe and colleagues, is the first scale to measure vicarious resilience [103,119]. This scale may be a valuable resource for clinicians and others who work with trauma survivors in assessing the positive impact of their work and tracking it over time. Used in combination with scales to assess vicarious trauma and self-care, practitioners will be able to assess the impact of their work more holistically, allowing them to build on their vicarious resilience while developing targeted plans to care for themselves.

The VRS has demonstrated solid psychometric properties and can be used in supervision, training, and self-assessment by practitioners. The scale measures seven domains [119]:

I remember being on the stand in court as an expert witness in the asylum hearing for a torture survivor and the judge stated that I must find my work to be very depressing. I recall responding that no, I did not find it to be depressing but rather inspiring because so many of the torture survivors I work with have enormous strengths and are resilient people. This same feeling is recounted by the clinicians studied by Hernandez, Gangsei, and Engstrom, who reported that they became inspired and gained strength and a sense of meaning from their work with survivors of severe trauma [8,9]. This is perhaps what enables some professionals to work with survivors of torture and other forms of severe trauma for years and decades.

Professionals who work with trauma survivors should strive to continually update their knowledge and skill set for both ethical and practical reasons, especially given that the field of traumatic stress is constantly evolving. For example, the last several years have seen new developments in brain research related to knowledge about the impact of trauma on the brain. In addition, the knowledge base about emerging, promising, and best practices with diverse traumatized populations is ever growing. Numerous scientific meetings and conferences abound around the world each year and contribute to the dissemination of research and clinical knowledge in the field of traumatic stress. One example is the annual conference held by the International Society for Traumatic Stress Studies (ISTSS). This organization's website (https://istss.org) provides updated information about conferences and learning opportunities related to trauma. In addition, there are a number of professional journals that publish findings in the traumatic stress field. More information is available in theResourcessection at the end of this course.

Engaging in one's own personal therapy used to be promoted, and at some schools required, for graduate students studying to be psychotherapists. Trauma treatment providers who wish to become certified trauma specialists through the Association for Traumatic Stress Specialists are required, as part of their qualifications, to certify that they have received at least 50 hours of counseling. This personal counseling is encouraged in order for trauma specialists to explore, enhance their awareness of, and address any issues that may negatively or positively affect their ability to work with trauma survivors.

Trauma professionals are strongly encouraged to continue to obtain ongoing supervision throughout their career in addition to engaging in their own psychotherapy. This supervision should ideally be provided by more seasoned and expert trauma specialists, or supervisors who have expertise relevant to the population(s) with whom the practitioner is working. Saakvitne and Pearlman recommend five key components that should be covered in the supervision of trauma therapists [49]:

In addition to individual supervision, it can also be valuable to participate in peer group supervision. This can provide an effective avenue of support for preventing and attending to negative impacts of the trauma work as well as fostering vicarious resilience [106].

The practice of mindfulness has emerged as a key component of various approaches to working with survivors of complex trauma, including in Briere's Self-Trauma Model. Briere has expanded his model to include more emphasis on mindfulness [107,108]. Meditation and other mindfulness practices have been proven effective in supporting the well-being of trauma professionals and other care providers, including helping to prevent them from experiencing compassion fatigue [109]. Trauma professionals are encouraged to consider adding mindfulness practices into their repertoire for enhancing their professional quality of life.

Compassion Meditation for Caregivers

Buddhist meditators and meditators from some other traditions strive to achieve and maintain a state of equanimity from moment to moment through mindful meditation. Equanimity is an evenness of mind, especially under stress. Mindfulness can be defined as a receptive and non-judgmental state of mind in which an individual observes his or her feelings, sensations, and thoughts with acceptance, without trying to change, suppress, or deny them. It is a way of knowing, seeing, and being. When one is in a state of mindfulness, one is acutely focused and aware of the reality of the present moment, moment by moment, acknowledging and accepting it as it is [110].

Several studies have been conducted with experienced meditators in an effort to better understand these phenomena and the impact on health and well-being [109,111]. Empirical studies over the past two decades suggest that meditation and other contemplative practices can help to relieve the symptoms of burnout and compassion fatigue, including such symptoms as anxiety, depression, weakened immune system, and insomnia [109]. The well-being and resiliency of caregivers has been found to be strengthened through these practices as well. Meditation, in particular, is associated with the development of the following five qualities that appear to help prevent and address compassion fatigue and burnout: compassion and self-compassion; resilience; self-awareness; metacognition and attention; and meaning [109,120].

Neuroscience research has found that similar parts of the brain are activated in the person who feels empathy for another who is suffering and in the person who is suffering [109,112]. Early findings of studies with Buddhist monks suggest that it may be empathy, if present without accompanying compassion and altruistic love, that puts us at risk for becoming burnt out [112]. This area of research shows promise for caregivers and trauma professionals who are at risk of becoming burnt out.

Lipsky lays out a number of suggested exercises that professionals can use to develop a practice of attending to and exploring The Five Directions related to work with trauma survivors [10]. A few of these exercises are included here in the hope that they may help inspire the incorporation of trauma stewardship into practice.

Choosing One's Focus (East)

Write down three things about a challenging work situation that you found made it particularly challenging as well as three things that you appreciated about the situation. As you review your lists, ask yourself what you are most likely to focus on (the challenging parts or the parts you appreciated) and why [10].

Identifying and Moving Toward an Alternate Plan (North)

Develop a list of five things you could do over the next five weeks that would move you nearer to making your alternate plan a reality. Ask what you would love to do if you were not doing your current work [10].

Building a Supportive Community (South)

Who is in your microculture? Reflect on how well they help to nurture integrity, hopefulness, and accountability in you. Are they strong role models for you or could you use stronger role models in one or more of these areas [10]?

Finding and Creating Balance (West)

What one thing would you love to incorporate into your daily work life or routine to help you find or create more balance, but you fear you could not? Marshall all your powers to make it happen [10].

Centering Yourself (Center)

Ask yourself each night what you can be done with and do not need to hold onto or focus energy on for another day. Then, before going to sleep, put it down and do not pick it up or focus on it the next day [10]. You might also try doing something similar to this exercise each day as you leave your office or finish your work for the day.

Putting trauma stewardship into practice consistently and in a way that can be sustained over time is an art rather than a science. By definition, it is a very personal process that evolves over time and involves finding one's own unique path and direction.

I was originally introduced to meditation as a high school student by my school principal. Years later, as a professional social worker working with traumatized refugees, two colleagues encouraged me to further explore and deepen my study of meditation. I had already experienced some benefits of meditation in my daily life and for some years had worked with Buddhist refugees in refugee camps in Asia and in the U.S. I had seen for myself the benefits that some of my clients experienced from meditation practice in coping and living with the impact of their traumas and other life challenges.

As my meditation practice deepened, in addition to setting time aside in my day to formally "sit" and meditate, I began to integrate it into my clinical sessions with survivors of state-sponsored torture. At first, I was not aware that I was doing this. Soon I began to notice that I was focusing on my own breath, particularly during the portions of sessions when I would be talking with survivors about their histories of torture and other traumas and when they were expressing extreme distress in session. I would split my awareness and continue to attend carefully to my client while at the same time focusing a portion of my awareness on my own breath, as I had learned to do in my meditation practice. I spoke with several meditation teachers about what I had discovered that I was doing in session, and they encouraged me to consciously expand what I was doing to include not only an awareness of my breath but also my physical sensations during sessions with my traumatized clients. As I became more adept at doing this with practice, I found that it was quite beneficial in various regards. It seemed to make it easier for me to remain calm, composed, nonreactive, and centered even while listening to horrific details of torture or while my clients were experiencing flashbacks to their torture or expressing utter hopelessness and suicidal thoughts in session. This in turn appeared to contribute to a calmer and safer atmosphere for the clients, one in which they seemed to be able to more fully express themselves (including about particularly gruesome details or events that were taboo or considered deeply shameful or stigmatizing in their culture and society) without feeling that they were harming or contaminating me or being harshly judged.

The calmer state of mind I experienced when using these meditation skills made it easier for me to think clearly and calmly about how to proceed in session. I was better able to access my professional knowledge and experience and intervene appropriately. Integrating an awareness of my breath and sensations during sessions with trauma survivor clients appears to promote my ability not to take my work home with me in that I am better able to attend to and process my distress in the moment as I am with my clients. Utilizing these skills in session with my clients also appears to enhance my ability to be aware of my countertransference reactions. This increased self-awareness in turn enables me to be less likely to be unconsciously driven by my countertransference in negative ways and facilitates my ability to respond professionally.

I also find these same tools extremely valuable in helping me to manage my performance anxiety and function better during stressful moments as I am cross-examined in court, where I often testify as an expert witness, or when I am presenting in front of a challenging audience. Several of my colleagues employ similar meditation skills in session with their trauma survivor clients with great success. If you are not already an experienced meditation practitioner, it may help to obtain some instruction in meditation first and have a meditation teacher available to consult with you in the early phases of experimenting with these techniques.

For many years, starting as a youth, I practiced the time-honored tradition that is widespread in the United States of making New Year's resolutions. Not just one resolution a year, but a list of things I would do differently or goals I would achieve each year. Inevitably, I would not be successful and would eventually, one by one, abandon most, if not all, of my resolutions as the year marched on. Some years, I achieved success or partial success, but in hindsight my efforts seemed haphazard. Clearly, my old approach was not working for me. I, like many people I know, grew to laugh about and expect this as inevitable. Some friends and colleagues gave up or never developed New Year's resolutions at all.

Some years ago, I decided to adopt a very different approach to New Year's and use it as an opportunity to recommit myself to taking care of myself, something that was so important to my personal and professional lives. What I have found works the best for me is to adopt an overall theme of "self-care" instead of a more traditional New Year's resolution. My plan includes routinely and frequently checking in with myself and asking myself if whatever I am doing or planning to do is in keeping with my self-care. I have found that this strategy is profoundly more helpful and easy to follow and stick with. It supports my setting boundaries and limits and makes it easier for me to weed through the many emails I receive each day and requests for my time in an efficient manner.

I spend much less time agonizing over how I can juggle my schedule to accommodate conducting a training course, attending an interesting workshop, or squeezing in another meeting. I used to have a harder time saying no when I was asked to do something that I knew I had the skill set to do or something that inherently interested me but conflicted with my other responsibilities. Now I find it generally easy to say, "Sorry, I do not have time right now to do that," or "I am overextended as it is and I cannot take that on right now."

An important component of my new strategy includes being gentle and not overly harsh or critical with myself if I slip in my self-care occasionally. I am going for an overall commitment to self-care for the long-haul, as a lifestyle change. Beating myself up if I have a bad day or neglect myself occasionally is, after all, antithetical to self-care. I use that opportunity as a wake-up call to assess what happened and rededicate myself to taking care of myself.

https://istss.org

The International Society for Traumatic Stress Studies (ISTSS) is an international professional membership organization that was founded in 1985 for trauma professionals from multiple disciplines to network and share information related to the effects of trauma. The ISTSS focuses on the development and dissemination of knowledge about traumatic stress, including such topics as the scope and consequences of traumatic exposure, trauma programs and services oriented to preventing and reducing traumatic stresses and their negative consequences, trauma theory, research methods for studying trauma, and policy initiatives. It has also published traumatic stress treatment guidelines.

ISTSS members come from a variety of professional backgrounds and settings. The ISTSS advocates for its members and the field of traumatic stress with other international and national organizations. Interested readers can explore the many resources available on the ISTSS website and learn more about the ISTSS' annual conference and other trauma related conferences and resources worldwide. The ISTSS has affiliate organizations based in Argentina, Australia, Canada, France, Germany, Japan, and the Netherlands (i.e., the European Society for Traumatic Stress Studies). The ISTSS has helpful information about traumatic stress for the general public and the media in addition to resources for trauma professionals (including materials related to self-care). The ISTSS also publishes the Journal of Traumatic Stress monthly.

https://www.isst-d.org

The ISSTD is an international, professional, non-profit association focused on the development and dissemination of information and resources related to trauma and dissociation. This association works to achieve one of its primary goals, education about trauma and dissociation, by holding conferences and training programs and through the publication of the Journal of Trauma and Dissociation.

https://www.ptsd.va.gov

The National Center for PTSD, with seven divisions across the United States, is part of the U.S. Department of Veterans Affairs and it seeks to promote better understanding of and advance science related to traumatic stress. It uses research, education, and training about PTSD and trauma in order to assist United States veterans and others.

https://www.ptsd.va.gov/ptsdpubs/search_ptsdpubs.asp

In addition to using more general search engines, readers are encouraged to explore the PTSDpubs Database (formerly known as PILOTS), the largest electronic index to the traumatic stress literature in the world. The National Center for PTSD established and manages PTSDpubs.