Health and mental health practitioners frequently work with individuals and families who have been exposed to trauma in their lives, in some cases multiple traumas (e.g., cancer patients, survivors of child abuse, survivors of domestic violence, torture survivors who may also have experienced community violence and war trauma). However, significant trauma exposure is not limited to health and mental health professionals. It is also experienced by other professionals who interact with trauma survivors on a regular basis, such as immigration lawyers and judges who work with asylum seekers and routinely hear stories of torture and severe persecution and professional interpreters who work with trauma survivors [11,12,13,14,15,16]. Vicarious trauma reactions are found in legal and emergency service professionals and others who are exposed to significant trauma; these reactions are similar to those experienced by health and mental health professionals. In this course, the emphasis is on the experience of health and mental health professionals, although much of what follows may be relevant to other professionals as well.

Health and mental health professionals, and those they serve, benefit when they are aware of their own reactions to listening and working with those clients who have been traumatized and understand how these reactions and experiences may either facilitate or impede the therapeutic process and recovery of their clients. These reactions include countertransference and vicarious trauma reactions [1,2,17,18]. Vicarious or secondary trauma involves a transformation of the helper's inner experience, resulting from empathic engagement with clients' trauma material. The health or mental health professional may develop some symptoms that mirror the post-traumatic stress disorder (PTSD) or depression symptoms experienced by clients who were directly traumatized [19]. Over time, professionals may be at risk of developing compassion fatigue (burnout or vicarious traumatic stress), such as when the sense of ineffectiveness is dominant and the clinician's sense of efficacy is challenged [3,4]. Burnout is a condition of feeling exhausted or worn out. Compassion fatigue is often seen as one of the costs of caring for those in emotional distress; this concept has been well developed by Figley and further developed in recent years by Stamm and Figley [3,19]. Rather than being a one-time event, burnout is a form of compassion fatigue that develops as a result of gradual processes that build over time.

It might be asked why busy health and mental health professionals who work with trauma survivors should spend their hard-to-find time studying vicarious trauma, resilience, and self-care, especially if they are not able to use or supported in using work time to do so. At a basic level, it is because we matter and the quality of our lives matter, too. Health and mental health professionals are often oriented toward prioritizing the well-being of their clients or patients over themselves. They may feel guilty if they give priority to themselves and their own needs. It is sobering, however, to examine what the alternative might be. If healthcare professionals burn out, it may have an impact on clients, colleagues/agency, family, friends, and on their own health and well-being. Professionals who do not examine or attend to these issues and take care of themselves effectively not only harm themselves (including possibly developing health and mental health problems), but are at risk of engaging in incompetent or unethical professional behavior—perhaps not consciously, but they are at risk of this nonetheless.

Traditionally, the client or patient is seen to develop transference reactions toward their therapist that can include symbolic role relationships, emotional states, and behavior [1]. The transference reactions may be related to experiences and relationships clients have had at any point or points in their life that they have not resolved or integrated, including traumatic experiences they may have had (i.e., trauma-specific transference). A traumatized client may unconsciously assign a trauma-related role to their therapist. For example, the client may relate to their therapist as though the therapist was their perpetrator, a collaborator, a fellow survivor, or their rescuer. Countertransference develops in the therapist or other helping professional in the process of interacting with their client or patient. The therapist may feel or act as if they had taken on the role assigned to them by their client. The impact of client and therapist on one another, and the accompanying transference and countertransference processes, is reciprocal in nature.

Traditionally, the client or patient is seen to develop transference reactions toward their therapist that can include symbolic role relationships, emotional states, and behavior [1]. The transference reactions may be related to experiences and relationships clients have had at any point or points in their life that they have not resolved or integrated, including traumatic experiences they may have had (i.e., trauma-specific transference). A traumatized client may unconsciously assign a trauma-related role to their therapist. For example, the client may relate to their therapist as though the therapist was their perpetrator, a collaborator, a fellow survivor, or their rescuer. Countertransference develops in the therapist or other helping professional in the process of interacting with their client or patient. The therapist may feel or act as if they had taken on the role assigned to them by their client. The impact of client and therapist on one another, and the accompanying transference and countertransference processes, is reciprocal in nature.

The therapist's countertransference is characterized by emotional reactions that develop due to the interaction between multiple factors, including the therapist's own unresolved inner conflicts, the stories the client shares with them (including of trauma), and the client's behavior and personal characteristics [6,7]. Unless a therapist's countertransference causes overt problems, they may not be aware of it. Those who develop vicarious trauma, a topic covered at length later in this course, may experience stronger countertransference reactions [21]. In addition, they may have less awareness of their countertransference and be prone to making more clinical mistakes as a result. As is routine in good clinical practice, the clinician is encouraged to actively explore and become aware of their countertransference reactions. These reactions inevitably arise in clinical practice and can be a very valuable source of information relevant for assessment and treatment purposes.

The trauma stories told by survivors are personal and are influenced or colored by many factors including, in part, the survivors' unique life experiences, cultures, family and psychosocial histories, religious or spiritual orientations, and personalities. These same factors influence the therapist or other professional working with the trauma survivor, along with their particular professional role and orientation. These factors in the survivor and professional interact with one another during the therapeutic process. The recovery from trauma is promoted when the survivor experiences the therapy environment as a safe and secure place to integrate and work through the trauma and its effects. One of the key tasks (and challenges) of the therapist in this endeavor is to sustain empathy for the client throughout the process. Empathy involves the capacity to understand, be aware of, and vicariously experience the world and perspective of another and feel their distress [1,21,23]. The clinician's capacity to maintain their empathic stance and stay in tune with the client can become strained as the survivor shares more and more pain and details of their traumatic experiences [1]. Factors that stimulate empathic strain vary from clinician to clinician. While empathic strain can result from a variety of sources, one of the prominent sources is countertransference reactions.

Whether objective or subjective in nature, empathic strain is a type of countertransference reaction that can compromise clinicians' ability to be empathic with the trauma survivors they work with. The therapeutic relationship and clinician's response to the survivor is injured, weakened, or stretched beyond its appropriate boundaries [1,20].

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.

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.

The enjoyment and gratification that professional trauma helpers feel when they are able to perform their work well is referred to as compassion satisfaction [31]. Helpers who experience compassion satisfaction typically feel that they are able to handle new protocols and technology as they emerge, feel successful and happy with their work, and want to continue to engage in their work. They feel satisfied and invigorated by their job and from the act of helping itself. Some helpers may experience enormous pleasure or contentment when the traumatized survivor or community they have worked with heals or is able to function better. Helpers may develop positive feelings toward their co-workers or feel optimistic about their ability to make a constructive difference in their work environment or the larger community.

Compassion fatigue is comprised of two components: burnout and vicarious traumatic stress [19]. The first component consists of characteristic negative feelings such as frustration, anger, exhaustion, and depression. The second component, vicarious traumatic stress, may result when the professional is negatively affected through vicarious or indirect exposure to trauma material through their work.

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.

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.

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 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.

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.

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.

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 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].

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 formulation of the concept of vicarious resilience was informed by clinical theory and practice as well as by research findings. It recognizes that clinical trauma specialists are affected vicariously by and can learn from the experiences and stories of their traumatized clients. For many years, experts in the field have focused on the negative affects only, such as vicarious traumatization, burnout, or compassion fatigue [3,4,49]. Those who developed the concept of vicarious resilience have brought attention to the fact that clinicians can also be vicariously affected in positive ways. They contend that it appears to be necessary for clinicians to have empathy toward their trauma survivor clients in order for vicarious resilience to develop [9]. In particular, they outline several factors that they believe contribute to the development of vicarious resilience, including the dynamics of the therapist-client relationship; the nature and extent of clinicians' connection with their clients' growth, resilience, and pain; empathic attunement with the client; and what has been termed "core empathic capacities" (i.e., tolerance, resistance, endurance, capacity) [8,9,68]. Overall, the authors argue that the literature and research has focused largely on the negative effects of empathy in trauma work and further research is needed to more fully explore and document empathy's role in creating vicarious resilience, thereby positively transforming the experience of trauma professionals.

The construct of resilience is used rather widely these days in the field of psychology, although it has been defined and measured in a variety of ways. It is generally considered to be a complex phenomenon involving multiple factors or dimensions [73,81,83]. Resilience is frequently described as a defense mechanism that makes it possible for people to thrive when confronted by adversity [84]. Enhancing one's ability to be resilient and live well after facing significant stress or adversity (or increasing one's resilience and positive health and mental health) has become a valued outcome and focus for treatment [85,86].

Hernandez, Gangsei, and Engstrom argue that there are valuable pragmatic reasons for further developing and promoting the concept of vicarious resilience in the traumatic stress field among those who work with survivors of political violence. The six reasons they identify are [8]:

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]:

Trauma stewardship is another relatively new concept in this field, one offered to assist those who work in many different capacities with trauma. A general dictionary definition of stewardship is "the office, duties, and obligations of a steward" or "the conducting, supervising, or managing of something; especially the careful and responsible management of something entrusted to one's care" [113]. Trauma stewardship, as conceptualized by Lipsky, is [10]:

A daily practice through which individuals, organizations, and societies tend to the hardship, pain, or trauma experienced by humans, other living beings, or our planet itself. Those who support trauma stewardship believe that both joy and pain are realities of life, and that suffering can be transformed into meaningful growth and healing when a quality of presence is cultivated and maintained even in the face of great suffering.

Lipsky encourages trauma practitioners to learn how to live fully while still being able to bear witness to trauma [10]. She urges professionals to cultivate self-awareness and mindfulness, staying fully present and grounded in the realities of the present moment without judging oneself or others. She introduces the concept of trauma stewardship as a means for trauma practitioners to enhance their understanding of the ways in which trauma impacts them and the important factors that protect themselves and others from the negative effects, such as becoming numb, drained, exhausted, cynical, and overwhelmed to the point of feeling helpless and hopeless. A humorous video by Lipsky that depicts the various ways professionals can be affected by trauma work is available at https://www.youtube.com/watch?v=tAKPgNZi_as. Rather than pathologizing these effects, however, Lipsky normalizes them as natural and universal reactions to trauma, similar to the approach that trauma therapists generally take with survivors [10]. Lipsky calls this universal reaction the "trauma exposure response" and identifies a path that will sustain trauma professions so they can work for change and a better society, one free from privilege and oppression, for decades and generations to come [10].

The concept of trauma stewardship is relevant not only for health and mental health professionals, but for all who work with the pain, suffering, and trauma of other people or the environment [10]. These workers include, but are not limited to, social workers, domestic violence and animal shelter workers, police officers, firefighters, medical and public health workers, teachers, spiritual advisors, members of the military, international relief workers, biologists, ecologists, environmentalists, and activists for social change.

Trauma stewardship reminds practitioners to never forget that it is a gift to accompany survivors on their path to healing from trauma and also of their responsibility to take care of themselves and cultivate their capacity to serve [10]. Trauma stewards are called upon to uphold the highest standards of professionalism, integrity, and ethics at all times in their work with survivors who have entrusted them to safeguard their deeply painful and personal stories and their lives.

Lipsky created a tool that she calls "The Five Directions" to help those who work with trauma survivors to make choices and assess how they are doing and what they need to take care of themselves as practitioners and as people [10]. She envisions that everyone must find their own unique path and that The Five Directions serve merely as a compass to guide professionals and offer suggestions along the way rather than being a specific set of step-by-step instructions. This compass can be referred back to in order to check in with oneself and reassess needs and direction over time.

The fifth direction stands for the centered self. This direction encourages practitioners to maintain a daily practice of centering oneself through connecting with "innate qualities of wisdom, free will, compassion, and balance" [10].

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.

Many experts in the field emphasize the importance of developing one's own self-care plan and provide helpful models and suggestions for doing so. This is critically important, and some approaches to this will be reviewed in the following sections. As well thought out and promising as any self-care plan may be, however, it may not be effective if there are not simultaneous changes or improvements in key structural factors contributing to the professional's vicarious traumatic stress or burnout. It is essential, therefore, to incorporate structural strategies into one's plan and to seek support from other professionals or organizations in advocating for such changes. There can be strength in numbers, particularly when the group is able to frame the issue to the institution in compelling terms of the opportunity costs of not addressing the structural factors that contribute to a toxic or unhealthy work environment. This may also involve helping those running the institution engage in a full cost-benefit analysis that includes the potential benefits of improving work conditions.

Many experts in the field emphasize the importance of developing one's own self-care plan and provide helpful models and suggestions for doing so. This is critically important, and some approaches to this will be reviewed in the following sections. As well thought out and promising as any self-care plan may be, however, it may not be effective if there are not simultaneous changes or improvements in key structural factors contributing to the professional's vicarious traumatic stress or burnout. It is essential, therefore, to incorporate structural strategies into one's plan and to seek support from other professionals or organizations in advocating for such changes. There can be strength in numbers, particularly when the group is able to frame the issue to the institution in compelling terms of the opportunity costs of not addressing the structural factors that contribute to a toxic or unhealthy work environment. This may also involve helping those running the institution engage in a full cost-benefit analysis that includes the potential benefits of improving work conditions.

The components of a self-care plan vary from individual to individual depending on their needs, abilities, personal styles, personality, culture, and preferences. There are several tools available to assist professionals in assessing their attitudes toward self-care and their needs, including the tools included throughout this course. Baker has developed a questionnaire for psychotherapists to use to assess and identify what they need to promote their well-being [61]. This questionnaire guides practitioners to examine their professional self, their experience with therapy, and emotional demands and stresses in their life. They are asked to reflect on the challenges they have faced as a professional and whether they have ever considered leaving their profession (and if so, why). They are guided to examine various aspects of self-care, such as [61]:

Acknowledging the importance of having a self-care plan, identifying what a plan may include, and developing a plan for self-care are not sufficient. The most important step is actually implementing the plan. There are many potential challenges that may emerge when one is seeking to implement a self-care plan. It is important to anticipate and examine what may impede self-care, or more specifically, impede the components of one's self-care plan and put a proactive plan in place to prevent or overcome these obstacles. This approach is similar to how effective clinicians work with clients toward achieving their goals.

Ideally, one's approach to self-care should be comprehensive and multipronged, encompassing the multiple dimensions of one's professional and personal lives. If not, it is harder to achieve optimal well-being and a healthy balance between the personal and professional. Strategies should be developed to address key challenges or symptoms of distress in the physical, emotional/psychological, behavioral, interpersonal, and spiritual realms of one's personal life. At the same time, attention to major stressors in the workplace or professional life must also be addressed. Overall, enhancing one's self-awareness and ability to regulate stress both personally and professionally is an important goal. This may seem (and be) daunting. It is essential to be realistic, tackle only one or two changes at a time, and implement changes gradually in steps over time if there is to be lasting substantive improvement. This is similar to the approach advocated by some weight-loss experts who share the benefits and wisdom of making healthy lifestyle changes that can be sustained over time when trying to achieve and maintain weight loss. It may help to save the most challenging strategies and changes, those that will likely be more difficult to achieve, until later. Starting with easier changes first is likely to boost your morale and motivation to tackle the harder issues [117].

Ideally, one's approach to self-care should be comprehensive and multipronged, encompassing the multiple dimensions of one's professional and personal lives. If not, it is harder to achieve optimal well-being and a healthy balance between the personal and professional. Strategies should be developed to address key challenges or symptoms of distress in the physical, emotional/psychological, behavioral, interpersonal, and spiritual realms of one's personal life. At the same time, attention to major stressors in the workplace or professional life must also be addressed. Overall, enhancing one's self-awareness and ability to regulate stress both personally and professionally is an important goal. This may seem (and be) daunting. It is essential to be realistic, tackle only one or two changes at a time, and implement changes gradually in steps over time if there is to be lasting substantive improvement. This is similar to the approach advocated by some weight-loss experts who share the benefits and wisdom of making healthy lifestyle changes that can be sustained over time when trying to achieve and maintain weight loss. It may help to save the most challenging strategies and changes, those that will likely be more difficult to achieve, until later. Starting with easier changes first is likely to boost your morale and motivation to tackle the harder issues [117].

The intervention strategies advocated by Saakvitne and Pearlman are compelling and effective in addressing each realm of the trauma professional's life [49]. For example, in the professional realm, they suggest the importance of:

Ultimately, after all the planning is in place, it is valuable to make a firm personal commitment to oneself—not one that is taken lightly or is easily set aside. Without such a serious pledge it is less likely that the plan will be successful or sustainable. Some professionals have a hard time justifying to themselves (or others) that they deserve to make their own needs a priority; some might even call that a common professional liability.