Vicarious Trauma: Down in the black hole

“I’m sorry to hear that”, “That sounds bad for you”, “it could have been worse at least”.

When someone tells you something painful, when they share their darkest moments, it can be hard to know what to say. When we give statements like this, we are being sympathetic. We are acknowledging that person’s pain, we feel bad that they have that pain, but we are disconnecting ourselves. We step back and try to put some form of positive spin on it. Sympathy drives disconnection.

When a patient tells you they have cancer, that they have lost a child, their marriage is falling apart, they have been abused. We don’t offer sympathy. When a patient has fallen down a dark hole that they can’t see a way out of, what does a therapist do? We grab our metaphorical ladders, and we climb down into the black hole too. The black hole full of their trauma, distress and pain. We feel what they feel, we understand. We empathize with that person. Empathy drives connection.

A good therapist will build that open, trusting partnership with that patient in order to work through their difficulties and cultivate change. It isn’t just the one patient though. Once that session has come to a close, we take our ladders and we jump down another hole, and another hole and another hole. All the while, empathizing, understanding, and feeling all of those emotions. Being able to care for someone and support someone to recovery is extremely rewarding and a huge motivation for why we choose to do this. However, there is a darker side of caring for so many people.

Ask yourself this question, Can you walk through water and not get wet? Can we climb down into the black hole and leave unchanged?

Compassion fatigue is a term coined by Figley (1995) used to describe the negative symptoms caregivers acquire from trauma exposure. Vicarious trauma refers to secondary trauma (when we empathize with people who are experiencing trauma). Compassion fatigue is usually the outcome of repeated, ongoing exposure to trauma. Reading a patient’s notes, talking to them on the phone or seeing them in person can all be classed as exposure to secondary trauma. An act therapists engage with many times a day across the working week. Over time, delivering care and empathy in the context of human suffering wears the therapist down and can lead to an array of symptoms.

Compassion fatigue can look like; a person who is unable to manage their emotions, someone who is shutting down/ numb, irritated and snappy, difficulties with concentration or brain fog, body aches/ pains, difficulties sleeping, loss of interest in things, reduced resistance to illness. All of these things can coincide with the symptoms of depression and anxiety. As Sanso et al 2015 recognized the practitioner is a “powerful but vulnerable tool in the caring process” that requires attention and care. Highlighting the word ‘vulnerable’ because the work of a therapist makes them more susceptible to their own ill health. Ignoring the impact on therapists not only affects the therapist, but the patients they are trying to support.

According to Van Dam et al (2011) research into interventions designed to support practitioners suffering from compassion fatigue shows limited or no positive impact at all. Therefore, the focus has shifted onto how to prevent compassion fatigue, if we find it hard to resolve it once it has started. This poses the question, are we really protecting our practitioners if they are expected to support 21 patient contacts per week in the NHS? Is it safe for the practitioner and the patients to jump from one black hole, to another black hole, to another? Hearing each person’s most distressing, difficult and painful times and working through those symptoms. Can we continue to empathize and give ourselves when we can’t concentrate, when we can’t sleep, when we feel on edge? In order to empathize we have to tap into our fight or flight response so we can respond most appropriately to anything that the patient could say. If that patient discloses that they feel suicidal we have to take action to safeguard our adrenaline and cortisol levels spike and this could happen multiple times a day.

‘Research has shown that the prevalence of burnout amongst PWPs could be as high as 68.6%, which is the worst in the mental health field’ Understanding more about compassion fatigue and vicarious trauma, these figures do not surprise me. Research conducted by Westwood et al (2017) noted that there are high levels of compassion fatigue in practitioners working in NHS IAPT services. They recommended the impact of the role needs to be evaluated and more support needs to be put in place. When there are waiting times for patients over a year, you can understand the pressures this has on a service. You can understand the devastating impact this has for the people accessing the services. But does this mean that each PWP should see 20 + clinical contacts per week? If they weren’t seeing this many patients a week, would that result in skillful, brilliant therapists staying in the service as opposed to burning out and leaving?

In closing, it is important to empathize with our patients, to understand their struggles and build that relationship. A therapist can change people’s lives for the better, which is incredibly rewarding. Nevertheless, there is a darker side of care. The practitioner is in a vulnerable position, and we have to be aware of this. We have to recognize the impact of vicarious trauma and the symptoms of compassion fatigue. Is the way PWPs work responsible and safe?