Reducing the Cost of Caring: Indirect Trauma Exposure on Mental Health Providers

Professional Quality of Life and Vicarious Trauma

In recent years, researchers have been encouraged to examine protective factors in the treatment of trauma as it relates to agency infrastructure provided by employers (Spangler et al., 2012). The gold-standard theory for addressing both positive and negative effects of treating trauma is the concept of Professional Quality of Life (ProQOL; Stamm, 2010). The ProQOL model can be divided into two constructs: compassion satisfaction (CS) and CF. CS is described as the satisfaction individuals derive from performing their work-related tasks and is proposed to offset the negative aspects of their work (Hooper et al., 2010). Conversely, CF is an acute, affective phenomenon that engenders emotional strain on trauma-treating professionals and may resemble clients’ symptoms (e.g., avoidance and numbing; Figley, 1995; Rauvola et al., 2019).

In addition to effects of indirect trauma, a recent study revealed that counselors had higher rates of adverse childhood experiences (ACEs) for all 10 adverse experiences measured by the ACEs questionnaire, created to study early childhood trauma and deprivation experiences, than the original Felitti et al. (1998) ACEs study (Brown et al., 2022). For the sample in this study, the authors indicated that 43% scored four or more ACEs (Brown et al., 2022), which may be relevant, as previous research has revealed that mental health clinicians may be drawn to treating traumatized populations potentially because of their own personal history (Conteh et al., 2017; Leung et al., 2022). ACEs have been shown to be a predictor of compassion fatigue. Emphasizing the positive aspects of ProQOL can represent a protective factor in terms of a clinician’s longevity in the field, and VT represents a significant risk factor. Furthermore, VT can be especially detrimental when considering the role of organizational politics (e.g., stressful conditions and workplace bureaucracy), caseload size, and the influx of acute patients who have experienced multiple forms of trauma (e.g., dual diagnosis centers; Garcia et al., 2016; Somoray et al., 2017). As suggested by Grimmet and Galvin (2015), there are multiple factors that must be considered when identifying potential reasons that influence a clinician’s decision to continue or discontinue eye movement desensitization and reprocessing (EMDR) as a practice. There are pertaining factors (e.g., previous training and loyalty to other modalities), training factors (e.g., adequacy of training structure, confidence in trainer, and funding of training practices), post-training (e.g., consultation availability and inability to integrate concepts with previously learned modalities), and socioenvironmental factors (e.g., employment setting, lack of supervision/consultation, and employer facilitating participation in EMDR support activities).

Compassion Satisfaction

Larsen and Stamm (2008) proposed CS to be the sense of accomplishment or joy that mental health professionals gain from doing their jobs well. CS is composed of three elements: (a) the level of satisfaction that a person derives from their job; (b) how well a person feels they are doing in their job, related to the levels of competency and control they feel; and (c) the level of functional and structural social support that a person has (Stamm, 2002).

Herman (1992) reported that mental health professionals working with trauma populations felt a deepened sense of integrity, allowing them to better understand others while also feeling more inspired by their clients’ courage. CS has been found to reduce compassion fatigue as it provides motivation, stamina, interest, and a sense of accomplishment in aiding clients to overcome trauma (Bride et al., 2007); suggesting that CS may be the reason that many people enter helping professions. These benefits are heightened performance, positive attitude toward work, enhanced value, or greater hope for positive outcomes (Kulkarni et al., 2013).

Compassion Fatigue

Mental health professionals are taught to be compassionate and empathic toward their clients. However, to view the world from the perspective of suffering, there is a reasonable probability that they also suffer. This emotional cost to clinicians can be profound and is characterized by CF, which is the experience of exhaustion, anger, and irritability in response to the engagement with clients’ trauma narratives (Mathieu & Taylor, 2007). Mental health clinicians experiencing CF may express a jaded outlook on their profession and reduced effort to ameliorate clients’ traumatic symptoms, resulting in poorer treatment outcomes (Molnar et al., 2020). Clinicians may also engage in detrimental isolating behaviors, such as decreased consultation with colleagues and decreased support-seeking with friends and family (Naturale, 2015).

Factors found to increase the risk of developing CF include continued exposure to patients’ stories, heightened emotions of family members, burnout, trauma-related stress, failure to maintain self-care, and practitioners’ empathy levels (Collins & Long, 2003; Figley, 2002; Fox & Carey, 1999; Sodeke-Gregson et al., 2013).

Trauma Treatments

The literature has suggested that utilization of evidence-based practices produces statistically significant decreases in compassion fatigue (burnout and secondary traumatic stress) and increases in compassion satisfaction (Craig & Sprang, 2010). Nevertheless, few researchers have investigated how being trained in a particular evidenced-based practice for treating trauma can be utilized to mitigate the damaging consequences of indirect trauma. Several different sources have collectively identified the following trauma treatments as the most consistently recommended practices: EMDR therapy, trauma-focused cognitive behavioral therapy (TF-CBT), and prolonged exposure (PE) therapy (Benish et al., 2008; Blankenship, 2017; Cusack et al., 2016; Nisenoff, 2008; Wilk et al., 2013). Thus, the present study will focus on the three treatments for trauma that have been widely studied to be highly effective.

EMDR therapy was developed by Francine Shapiro (2017), and she stated that EMDR therapy is “an interactive, intrapsychic, cognitive, behavioral, body-oriented therapy” whose goal is “to rapidly metabolize the dysfunctional residue from the past and transform it into something useful” (pp. 50). The model on which EMDR therapy is based, Adaptive Information Processing (AIP), posits that much of psychopathology is due to the maladaptive encoding and incomplete processing of traumatic or disturbing adverse life experiences, which impair the ability to integrate these experiences adaptively. EMDR therapy, via bilateral stimulation (BLS), facilitates the effective reprocessing of traumatic events or adverse life experiences and associated beliefs to an adaptive resolution (Shapiro, 2017).

EMDR therapy consists of a three-pronged approach that works on the past, the present, and the future through an eight-phase model consisting of history taking, preparation, assessment/activation, desensitization, installation, body scan, closure, and re-evaluation (Shapiro, 2017). Additionally, a factor distinguishing EMDR therapy and other trauma treatments is the notion that listening to the trauma narrative is not necessary for a client’s remission of symptoms. Not having to hear a client’s trauma narrative repeatedly is a potentially protective component. According to McCann and Pearlman (1990) and Pearlman and Saakvitne (1995), it was thought that clinicians’ exposure to graphic and traumatic material might influence their level of vicarious traumatization. In comparison, other trauma treatments such as TF-CBT (Cohen & Mannarino, 2015) and PE (Eftekhari et al., 2006) both stated in their manuals that listening to the trauma narrative is an essential step in treating trauma. TF-CBT is a variant of cognitive behavioral therapy (CBT), a therapy aimed at changing the way a person thinks about themselves, others, and the world. This model is composed of psychoeducation, relaxation, affective expression and modulation, cognitive coping and processing, and a trauma narrative.

Moreover, PE therapy is an exposure-based form of CBT that is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (Hembree et al., 2003). This treatment involves education about common reactions to trauma, breathing retraining, development of a hierarchy of feared situations, repeated in vivo exposure to situations or objects that the client is avoiding because of trauma-related distress and anxiety, and repeated, prolonged imaginal exposure to the trauma memories in detail (i.e., revisiting the trauma memory in imagery; Foa et al., 2013). Through in vivo and imaginal exposure, clients are hypothesized to habituate to trauma-related fears and the traumatic memory by repeatedly recounting the memory until their fear declines gradually. Thus, like TF-CBT, PE may also expose a mental health clinician to trauma vicariously due to the repeated and prolonged exposure to the client’s trauma memories.

The Present Study

There is evidence to support that trauma-treating mental health clinicians are negatively impacted (Jimenez et al., 2021), which can be referred to as the “cost of caring.” Clinicians experiencing symptoms of VT have a negatively altered worldview and may find it difficult to separate work life and personal life. To address the complexity of the adverse effects of indirect trauma on mental health professionals treating trauma, this study explores the degree that CS, CF, and VT vary as a function of the type of trauma treatment provided. It was hypothesized that clinicians who provide EMDR therapy, as compared to TF-CBT and PE, would have lower scores on VT and CF, as well as higher scores on CS. Additionally, it was hypothesized that the approach of trauma protocols (e.g., extent of sharing trauma narratives in sessions) would influence how trauma-treating clinicians conceptualize the role of therapist-directed, versus client-centered, healing (Zabukovec et al., 2000); therefore, the empirically supported ProQOL model (Stamm, 2010) would predict VT in TF-CBT and PE clinicians, but not in EMDR therapy clinicians.

Participants

Approval for this study was obtained from the California State University, Fullerton Institutional Review Board (IRB). There were 54 participants between the ages of 25 and 72 (M = 44.91, SD = 12.26) recruited through emails, Listserv, and Facebook groups (for demographics, see Table 1). Participants were trained clinicians with years of experience (M = 22.21, SD = 8.04) in at least one of the following trauma treatments: EMDR, TF-CBT, and PE. Most respondents reported being in supportive work environments with at least three or more supports (85.2%; e.g., workshops, conferences, and support groups) and most respondents (90.7%) also reported engaging in at least three or more self-care activities outside of work. As such, the presently recruited sample was deemed to be fairly healthy in terms of work–life balance and integrated systems to ease work-related distress.

Materials

ProQOL is theoretically composed of two constructs, CS and CF and can be measured using the 30-item Scale (ProQOL-5; Stamm, 2005). A combination of high CS and low CF, scores is the most favorable result, and the reverse indicates significant work distress. The ProQOL-5 is a self-report instrument and has a response format ranging from never (0) to very often (5) and has three subscales: CS, Burnout, and Secondary Traumatic Stress (STS; Heritage et al., 2018; Stamm, 2010). According to Stamm (2010), CF is composed of two associated constructs: Burnout and STS. CS (α = .87), Burnout (α = .72), and STS (α = .80) were all found to have good internal consistency in the normative sample (Stamm, 2005, 2010; Sprang et al., 2019). In the present sample, CS (α = .88), Burnout (α = .70), and STS (α = .78) were also revealed to have acceptable internal consistency.

VT was measured by the Vicarious Trauma Scale (VTS; Vrklevski & Franklin, 2008), an 8-item self-report survey. The measure is scored on a 7-point Likert scale from strongly disagree (1) to strongly agree (7). Scores of each of the eight items were summed for an overall score ranging from 8 to 56. In the present sample, the VTS was revealed to have good internal consistency (α = .80).

Procedure

Participants were sent an email that contained an invitation to participate in the study and a link to the informed consent, demographic survey, and the study instruments (administered via Microsoft Forms). The estimated time to complete the survey was 30–45 minutes. One of the initial questions asked participants, “Which form of trauma treatment do you provide?” Eight reported providing more than one of the included trauma treatments and were thus excluded. Each scale represented discrete constructs. Higher scores on the CS scale indicate a higher level of functioning and a greater degree of gratification from one’s ability to be an effective caregiver (Stamm, 2005). Higher scores on the burnout and STS scales indicate that the person is at higher risk for CF (Stamm, 2005). Scores were calculated by reversing the ratings on some items and summing the items for each subscale. Per the recommendations of the ProQOL manual (Stamm, 2010), all scores were converted to standard scores using the t-distribution. Each scale was standardized on a t-distribution (M = 50, SD = 10).

Limitations and Future Directions

This study acknowledges that the modest sample size may need to be considered when interpreting the results. A larger sample size may have increased the statistical power to detect a significant difference between the groups of clinicians in terms of CS. Furthermore, the Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) agree that in addition to EMDR therapy, PE, and TF-CBT, cognitive processing therapy (CPT) is also a strongly recommended empirically supported trauma treatment, which has two separate protocols that either include discussion of a trauma account or not (Watkins et al., 2018). According to Garcia and colleagues (2016), CPT with the account (CPT-A) was stressful and indirectly traumatic for clinicians who provided this treatment daily to veterans within the Veteran’s Health Administration. Thus, future studies may benefit from acquiring more information on how CPT without the account (CPT-C) influences VT and ProQOL. Future studies on larger samples will be helpful to investigate the influence of demographic factors, possibly as covariates or in a moderation analysis. Future studies may also benefit from gathering participants directly from specialty clinics that only provide EMDR therapy as one method of controlling treatment fidelity, or directly operationalizing and measuring “client disclosure of trauma narrative.” These additional considerations and future directions may help provide more protective factors and approaches to reduce the cost of caring for mental health professionals.

Since EMDR therapy’s methodology could effectively treat clients without repeated exposure of traumatic material while avoiding the responsibility to co-narrate (identify, correct, and restructure cognitive distortions), the pessimistic perspective shift of VT could be minimized. EMDR therapy clinicians may not have to balance their perceptions of being able to do their job well with symptoms of VT. EMDR therapy clinicians have been taught that clients do not need to share their trauma narratives and clients are given instructions to “let whatever happens, happen,” and to “just notice” the trauma, without interruptions from the clinician (Shapiro, 2017). It may also be that the eye movements or other forms of bilateral stimulation draw both the client’s and the clinician’s attention away from the distressing material just enough to allow for an “integrated cognitive-affective inner exploration” balancing both the “there and then” with the “here and now” (Matthijssen et al., 2021; Shapiro, 2017). Due to the de-emphasis of exposure to the client’s trauma narrative, detailed descriptions, and cognitive fallacies, EMDR therapy may reduce the risk of VT and, ultimately, premature resignation from the field compared to other trauma treatments (i.e., PE and TF-CBT).