Vicarious traumatization: implications for the mental health of health workers?

Abstract

It has been suggested that a unique feature of some mental heath practitioners' work is exposure through their role as therapists to clients' descriptions of and reactions to trauma, and that these experiences may actually indirectly cause distress and traumatization to the therapist. This proposed phenomenon has been termed “vicarious traumatization” (VT) and is the focus of the current review. The concept of VT, together with other related concepts such as “burnout,” “compassion fatigue,” “secondary traumatic stress” (STS), and “work stress” are appraised. Psychological mechanisms that might be theoretically involved in VT are considered. The measurement of VT is reviewed alongside the limited research evidence supporting its existence. Factors such as direct trauma exposure and the personal attributes of mental health workers, which have been suggested to be associated with VT, are also assessed. It is concluded that the evidence to support the existence of VT is meager and inconsistent. Future research needs to be directed at distinguishing VT from other sources of distress arising within the workplace. Finally, the organizational relevance of VT and its possible implications for the management of mental health workers are critically appraised.

Introduction

Healthier workplaces have been identified as part of recent government initiatives in the UK (Department of Health, 1998), with one of the aims being to “ensure that people are protected from the harm to their health that certain jobs can cause” (p. 51). The mental and physical health of UK National Health Service (NHS) staff has also recently been discussed in a government consultation paper (Department of Health, 1999), which highlights the importance of prioritizing good-quality working lives for NHS staff in aiming to provide good quality of care for patients. Similarly, in the United States and other countries around the world, occupational health projects are highlighted as important both for staff well-being, productivity, and performance (National Institute for Occupational Safety and Health [NIOSH], 1999). Research reported by NIOSH (1999) suggests that between 26% and 40% of workers find their jobs often stressful and the effects of work stress on health are well documented. People working in the caring professions are among the occupational groups identified as being at high risk of work stress (Smith, Brice, Collins, Matthews, & McNamara, 2000). Research on occupational stress in health service staff have found levels of stress and minor psychiatric disorder to be higher in the NHS than for other occupational groups in the UK Borrill et al., 1998, Wall et al., 1997.

A number of explanations could be given for the high levels of staff stress and psychiatric disorder in health service staff and include aspects of organizations, job role, demands and characteristics (Borrill et al., 1998), workload (Wheeler, 1998), work environment (Briner, 2000), or individual personality characteristics (Zellars, Perrewe, & Hochwarter, 2000). It is possible that several of these general occupational factors combine to cause working in the health service to be inherently stressful (Leary et al., 1995) and could account for these findings. However, there may be specific aspects of working within a health service itself, such as the caring nature of the work, which could be involved in increasing staff stress. Such a role involves talking and listening to patients and carers, many of whom might be significantly distressed, as part of everyday work. Figley (1995a) has recognized this aspect of healthcare work and states, “There is a cost to caring. Professionals who listen to clients' stories of fear, pain and suffering may feel similar fear, pain and suffering because they care” (p. 1). Therefore, it is likely that it is not just organizational or workplace factors that contribute to stress and ill health in healthcare workers, but also the aspects of the type of work that they are required to do.

Unfortunately, few data exist relating work stress to either the nature of the caring role or the characteristics of the care groups looked after and their clinical problems. For example, Melchior, Bours, Schmitz, and Wittich (1997) conducted a meta-analysis of variables related to burnout in psychiatric nursing and noted the lack of studies that looked at the impact of working with certain groups of patients. Staff stress studies often group staff in terms of their profession (Wall et al., 1997) or location (Carson, Leary, de Villiers, Fagin, & Radmall, 1995) when assessing mental health or burnout, without taking into account the types of patients or client groups the staff work with. An exception to this is where staff groups have been exposed either to death and dying (Wheeler, 1998) or to emergency situations and trauma generally (Figley, 1995a). With respect to the latter, considerable evidence exists (e.g., Hodgkinson & Stewart, 1991) to indicate that emergency services personnel may be traumatized due to the nature of their work, particularly following a major traumatic incident. Alexander and Atcheson (1998) found that 48% of nursing and medical staff from departments dealing with physical trauma (accident and emergency, intensive treatment, orthopaedic, and plastic surgery units) experienced emotional difficulties due to work. Moreover, it is also possible that healthcare workers who deal with the emotional aftereffects of traumatic experiences may also be affected negatively, and it is this issue that forms the focus of this review.

The DSM-IV diagnostic criteria for posttraumatic stress disorder (PTSD) acknowledges that learning about traumatic events experienced by a family member or a close friend can in itself lead to symptoms of PTSD (American Psychiatric Association, 1994, p. 424). Similarly, some have argued that such symptoms might also arise in therapists exposed to narratives of traumatic events. The potential adverse impact of working directly with clients who have histories of trauma (including sexual and physical abuse, experiences of military combat, and single traumatic incidents) has been discussed within the psychological literature for at least two decades, using a wide number of definitions and concepts. These terms include “burnout,” “compassion fatigue,” “secondary traumatic stress” (STS), and, more recently, “vicarious traumatization” (VT). Many of these terms have also been used interchangeably. In this review, VT has been broadly defined and encompasses the concept of “secondary traumatization/traumatic stress.” The term “trauma work” is used to describe working with clients who have experienced traumatic events (both physical and psychological) and have subsequent psychological difficulties.

There have been claims of wide-ranging and potentially severe consequences of VT, with authors such as Pearlman and Saakvitne (1995a) asserting that “the effects of vicarious traumatization are widespread; its costs are immeasurable” (p. 281), and suggesting that “Vicarious traumatization can affect anyone who engages empathically with trauma survivors—journalists, police, emergency room personnel, shelter staff, prison guards, clergy, attorneys, researchers etc.” (p. 281). Statements such as this have been taken very seriously and resulted in a number of publications discussing the impact of VT (e.g., Blair & Ramones, 1996, Clark & Gioro, 1998, Neumann & Gamble, 1995, Sexton, 1999, Stamm, 1997) along with self-help books and chapters for professionals who experience it Herbert & Wetmore, 1999, Saakvitne & Pearlman, 1996. In contrast, the evidence base to support either the existence or prevalence of VT is modest, to say the least, and will be reviewed later. Similarly, few studies have examined the construct validity of VT and associated concepts (Jenkins & Baird, 2002). Accordingly, it might be argued that the prominence given to VT may be premature and not supported by the evidence.

Lessons learnt from the literature surrounding “psychological debriefing” following traumatic events suggest the importance of accumulating and critically evaluating a body of research evidence before devising interventions to treat or prevent it (Rose, Bisson, & Wessley, 2002). Concerned organisations implemented debriefing programs for a range of different types of traumas before there was sufficient robust research evidence for the effectiveness of this treatment Raphael et al., 1995, Rose et al., 2002. When randomized controlled trials were carried out, there was little consistent evidence for debriefing reducing later PTSD (Rose et al., 2002) and some evidence that debriefing may actually be more harmful than helpful Bisson et al., 1997, Hobbs et al., 1996. Drawing on this experience, we therefore realize the importance of assessing the evidence for VT before implementing training programs or organizational schemes to address it.

Even if the existence of VT can be established, the question remains whether we need a new construct to describe these various symptoms of distress arising from involvement in trauma work. Although it is possible that VT could be a very important factor in the well-being of health service staff, it is also possible that the effects reported could be generally related to the demands of a stressful job and therefore the action needed to address this may be different. Moreover, it has been argued controversially that PTSD itself might best be conceptualized as socially constructed rather than psychopathological (Summerfield, 2001), and that psychological debriefing may “medicalise” normal distress (Rose et al., 2002). VT, therefore, might also be seen as an unhelpful and inappropriate pathological descriptor for normal distress that arises from hearing traumatic material while fulfilling a caring role. To label this distress as PTSD-related symptoms might also further stretch the diagnostic limits regarding PTSD and the requirement that, generally, individuals need to be exposed directly to trauma. This review, therefore, will attempt to disentangle VT and its proposed PTSD symptoms from alternative explanations involving normal distress to trauma and occupational stress arising within the workplace. The search strategy for the review was restricted to papers published in journals,¹ peer-reviewed e-journals, and books. There were also a number of dissertations and theses that are related to VT and STS, but these have been excluded.²