Vicarious trauma is a profound shift that occurs in the inner experience of a healthcare worker that arises as a result of empathic engagement with a patient’s trauma. Anyone who provides care to people in distress can experience it, and in the midst of a global pandemic, vicarious trauma is affecting more individuals than ever, according to Bina Parekh, PhD, associate department chair/associate professor at the Chicago School of Professional Psychology in Irvine, CA.
“This empathic engagement is so intimate that it can actually lead to the caregiver being traumatized,” she said.
However, according to Dr Parekh, who delivered the keynote speech at the AONN+ 11th Annual Navigation & Survivorship Conference, this type of trauma can often pave the way to vicarious resilience for healthcare workers.
“The process of learning about overcoming adversity can be transformative,” she said. “In other words, when we’re able to see our patients become more empowered, we also become more empowered. Vicarious resilience does not come from disengaging with our patients; it actually comes from engaging more with our patients.”
The Prevalence of Trauma
Dr Parekh explained that vicarious trauma is slightly different from other terms that have been coined in the field, such as secondary trauma, compassion fatigue, and burnout. To elucidate the difference between these terms, she focused on the “profound shift” inherent to vicarious trauma.
Some individuals with vicarious trauma can experience secondary trauma (ie, the symptoms of trauma, like posttraumatic stress), some can experience compassion fatigue (a limited capacity to tap into one’s well of empathy), and vicarious trauma can certainly be impacted by burnout (from workplace stress, organizational trauma, or anything else that can affect one’s feeling of competency).
But vicarious trauma is unique because it affects a person’s entire sense of self as a helping professional, to the point that they may feel unqualified to do their job. “Trauma work forces you to witness the atrocities that are committed towards the suffering patient, the long-standing effect that this trauma has on the patient, and the self-destructive patterns that can emerge as a way to cope with that trauma,” she said. “Vicarious trauma is a cumulative experience; it’s not singular.”
According to the Substance Abuse and Mental Health Services Administration, 90% of patients/clients seen in public healthcare settings have experienced trauma, and between 40% and 80% of helping professionals develop vicarious trauma, compassion fatigue, and/or traumatic symptoms.
“In global studies, PTSD [posttraumatic stress disorder] is found in about 4.4% of the general population, but in first responders like firefighters, ambulance personnel, police, and nurses, the prevalence is much higher at 10%,” she noted.
Collective versus Vicarious versus Firsthand Trauma
Dr Parekh explained that trauma typically falls into 1 of 3 categories: collective trauma, vicarious trauma, or firsthand trauma. Collective trauma is defined as a traumatic psychological effect shared by a group of people of any size, up to and including an entire society. There might be no better example of this than COVID-19.
Quarantine, lockdown, job loss, navigating remote work and distance learning, civil and social unrest, and worrying about ourselves or our loved ones contracting the virus are all concurrently impacting the entire fabric of society and adding to the collective trauma, she said.
But added to this is the vicarious trauma experienced by the people who are caring for patients with COVID-19: worrying about getting infected, having enough personal protective equipment, bringing the virus home to family members, and seemingly insurmountable daily work stressors, all compounded by fatigue due to longer hours and round-the-clock shifts.
“Many nurses are the last people that their patients will see before they die; seeing the level of suffering that they’re seeing has a psychological impact,” she said. “This is a unique moment in history, where we’re seeing collective trauma, vicarious trauma, and firsthand trauma happening all at once. This will have an impact on our ability to provide care and kindness to the patients that we see, because we’re navigating all of these levels of trauma simultaneously.”
However, she noted that vicarious trauma in the context of COVID-19 is hard to disentangle from firsthand trauma (ie, contracting and becoming seriously ill from COVID-19). “They’re intermeshing at this point, and we’re not yet going to be able to understand all of the constellations of trauma that are co-occurring at this moment in time,” she added.
Signs and Symptoms of Vicarious Trauma
Vicarious trauma is characterized by symptoms such as loss of hope, negative outlook, withdrawal, anxiety, and self-loathing. “There’s a negative emotional numbness that occurs with vicarious trauma,” she said.
It also presents as exhaustion; nurses going through vicarious trauma often report poor sleep (whether they want to sleep too much or they sleep too little), as well as dysregulated appetite (eating too much or too little). “Often, people don’t even recognize that they are experiencing vicarious trauma,” Dr Parekh said. “It’s not something that we really talk about or we’re even trained to identify, but these signs and symptoms are very subtle, they’re very nuanced, and they do creep up all at once.”
Some of the seminal authors of vicarious trauma research, Laurie Anne Pearlman and Karen Saakvitne, said that there are 2 kinds of empathy: cognitive empathy and affective empathy. Cognitive empathy is a more intellectualized process of understanding what a patient is enduring or has endured. “But affective empathy is that real, significant connection that emerges from connecting with your patient,” she explained. “Affective empathy is really where the roots of vicarious trauma start to emerge.”
This can be incredibly disconcerting to healthcare professionals who went into the field because of their empathetic nature, but looking out for certain signs and symptoms of vicarious trauma can help to identify it early on, she said.
Vicarious Trauma—Effects on the Helping Professional
Vicarious trauma first affects a person’s sense of identity (“this is not me”), then their general mindset or worldview (from “sometimes people do terrible things” to “people are terrible”).
“One of the greatest things I think nurses and other healthcare professionals can offer is hope; hope is essential,” she said. “But what happens is their worldview shifts from a place of hope to a place of fear, mistrust, and cynicism.”
Then it erodes the spirit, or a person’s ability to find meaning in their work. Empathic engagement with patients is then avoided as it is seen as unsafe and overwhelming.
Next, self-soothing capacities are diminished, resulting in poor self-care or self-isolation. And with lockdowns and quarantines in effect, social isolation has become magnified over the past year, resulting in a higher prevalence of vicarious trauma, she noted.
Finally, cognitive capacities are clouded, often resulting in poor introspective capacities, lack of awareness, and poor judgment.
Vicarious Trauma and Resilience
But according to Dr Parekh, resilience is the key to overcoming vicarious trauma.
“Vicarious trauma, as difficult as it is, does not mean that there’s not a road to resilience,” she said. “Sometimes we have to go through trauma to get to a point of resilience.”
Vicarious resilience involves the process of learning about and overcoming adversity from the trauma survivor, resulting in positive transformation and empowerment through empathy and interaction.
Dr Parekh explained the “ABCs to Vicarious Resilience.” First, ACCEPT that an occupational hazard of trauma work is vicarious trauma; normalize it rather than pathologizing it. Accept limitations, accept incremental gains, and accept that the path to resilience is a process.
Next, BALANCE work and leisure (not just with each other, but within each of these categories, ie, balance your caseload with various types of clients). Finally, CONNECT with others, with your own spirituality, to the self and to the meaning of your work, and to optimistic perseverance (just do the best you can).
“Part of the journey is learning how to navigate this idea of vicarious trauma, and learning ways to understand that this is a normative process,” she said. “When I see a client who has traversed horrible firsthand trauma and they’ve been able to get to the other side, it makes me realize that moment is also an opportunity for me to transform.”
