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Course # 96622 • Vicarious Trauma and Resilience

CASE STUDY 1

Mr. A is a psychotherapist who has worked at a community mental health clinic for the past 10 years serving adults with a wide range of presenting problems. He has been treating Patient M for the past 6 months. Patient M is a highly educated, married woman, 35 years of age, from a country in Latin America and has been in the United States for the past 2 years. She was referred to the mental health clinic by her primary care doctor because of her severe and frequent panic attacks, nightmares, seeing and hearing dead people talking to her, and severe depression. Over the course of the first several months of treatment, Patient M has shared bits and pieces of her story with Mr. A. He has learned that the patient was working as a teacher in her community and was active in one of the opposition political groups in her country. She fled her country after soldiers killed opposition party supporters and their families in her town one night, including her husband and child. She was at a distant neighbor's house when the massacre took place, tending to a sick friend, and she believes that is why the soldiers did not find her. She tells Mr. A that she is too afraid to return to her country and is seeking asylum in the United States.

Mr. A finds himself flooded with many painful emotions in and after sessions with Patient M. He often feels horrified and has desires for revenge as she discusses her memories of finding her dead husband and child when she returned home that night. He feels terrified by the thought that Patient M may be deported to her native country where her life may be in danger. Mr. A has not experienced much trauma in his own life and definitely does not identify with Patient M's experiences.

Mr. A finds it extremely difficult to tolerate the intensity of his feelings when working with this patient. In order to avoid the pain associated with these feelings, he unconsciously develops empathic withdrawal toward Patient M. Mr. A's countertransference reactions alternate between intellectualizing, blank-screen façade, and misconception of the dynamics with his client. For example, Mr. A has unconsciously distanced himself from Patient M and often blankly stares at her when she brings up anything related to her traumas. Mr. A's reactions have led him to neglect to thoroughly assess the patient's traumatic experiences and the origins of her current symptoms. This, in turn, has led him to inaccurately assume and interpret Patient M's experiences of seeing and hearing of dead people talking to her as psychotic symptoms rather than as possibly part of her post-traumatic stress reaction. Patient M has not experienced any significant relief of symptoms.

Reflection Questions

  • What might be the impact on Patient M if the course of therapy and Mr. A's reactions continue in the same manner as it has up until now?

  • What can Mr. A do to address his counter-transference reactions and positively affect the course of his treatment with Patient M?

  • Have you ever found yourself intellectualizing or otherwise empathically withdrawing from a trauma client?

  • What did you do when you realized that this was happening?

  • Did you notice any negative impact of this in your work with your client?

  • Did your countertransference reaction(s) shift or change during the course of your work with a given client? If so, what was/were the shift(s)? What factors seemed to be associated with the(se) shift(s)?

  • What one strategy could you employ on an experimental basis to either enhance your awareness of your countertransference reactions or address the impact?

CASE STUDY 2

Ms. B is a relatively new therapist who works at a center that serves women who predominantly have experienced domestic violence and abuse as children. She is only one year out of graduate school and has not had extensive specialized training about trauma or the impact of trauma work on herself. She has begun to feel extremely overwhelmed in her work with Patient P, a young Cambodian woman, 19 years of age.

Patient P was referred to Ms. B's center by the Federal Bureau of Investigation (FBI) a month ago after they rescued her from a sexual human trafficking ring in a sting operation. The FBI has arranged for the patient to stay at a secure shelter, and they have certified her as a trafficking victim in exchange for her cooperation in prosecuting her traffickers. She should be eligible to be granted a T-visa, which would entitle her to legal status in the United States as well as work authorization because of her cooperation with the federal authorities. Patient P will be required to testify in court against her traffickers, something that frightens her considerably, particularly because they threatened to harm her and her family back in Cambodia if she ever reported them to the authorities. She worries that her traffickers may see her when she leaves the shelter to go to the store or to the center.

In the past month, Patient P has shared with Ms. B about the extensive emotional and physical abuse she experienced as a child––abuse that left her with a broken arm and two broken ribs. She was eventually sent by her parents to live with a distant aunt in the capital Phnom Penh. When Patient P was 16 years of age, her aunt lost her job and became financially destitute. The aunt told Patient P that she had found a well paying job for her with a family, but when she showed up for her first day of work she quickly learned that her aunt had sold her into a life as a sex worker. Patient P initially refused to cooperate, and her traffickers beat her daily and drugged her in order to force her to submit to engaging in prostitution. They kept her locked up and, after several months, trafficked her to the United States, where she continued to be forced to engage in sex work, servicing up to 8 or 10 men per day, seven days per week. She developed gonorrhea and herpes and became pregnant. She had an abortion, and her traffickers forced her to return to sex work after only two days of rest.

Ms. B develops intense stomach pains and headaches during and following sessions with Patient P. She finds herself full of uncertainty about how to proceed with treatment and overwhelmed by intense anxiety and horror, as well as graphic images of the patient's repeated abuse. She is plagued by self-doubt and insecurities about her ability as a therapist to help Patient P heal from the traumas she has experienced and prepare psychologically to testify against her traffickers. Ms. B feels exhausted every day and at times feels despair; her countertransference reactions are illustrative of empathic disequilibrium.

Reflection Questions

  • What are the factors that appear to have made Ms. B at risk for developing empathic withdrawal?

  • What might be the impact of Ms. B's countertransference reactions on Patient P?

  • Have you ever found yourself experiencing signs of empathic withdrawal or another Type II countertransference reaction? If so, what were they? If not, what factor(s) do you think helped to protect you from developing these reactions?

  • How did you handle or address any Type II countertransference reactions you may have developed?

  • Were your efforts at addressing these reactions successful? Why or why not?

  • Would you do anything differently the next time you found yourself in such a situation? If so, what would you do differently and why?

While not all countertransference reactions are problematic, each of the discussed reactions would likely have a less than optimal impact on the therapeutic relationship and course of treatment of the survivor. It is an ethical duty, above all, for health and mental health professionals not to do harm to their clients and patients. Therefore, it is essential that clinicians strive to become aware of, understand, and develop the skills to address or make therapeutic use of the information provided by their countertransference reactions. Attending effectively and appropriately to one's countertransference reactions will also enhance one's professionalism and the quality of one's work.

CASE STUDY 3

Before Ms. C decided to apply for admission to a Master's in Social Work (MSW) graduate program, she reflected on whether this was a good choice for her or not. She had heard stories about social workers who burned out. Professionals, once passionate about their work with runaway teens or domestic violence victims, had become disillusioned and exhausted and had lost their passion and energy for their work. This gave Ms. C pause and made her worried. She was nervous about entering a profession that seemed to pose a high risk for burning out, but she was raised in a family where she was encouraged to pursue a career that she was passionate about and was surrounded by examples of family who remained energized and fulfilled in their work after many years. Ms. C was told that she had many options open. She had not had any significant contact with social workers up until then, and she was not sure if this would be a career she loved. She did know, however, that many jobs were definitely a poor match for her abilities and interests.

Ultimately, Ms. C decided to give social work a try and applied to graduate school. Before she applied to a MSW program, however, she developed a plan and commitment to herself that served her well over more than two decades in the field. Her plan was to check in with herself often about how she was feeling and functioning in relation to work and life in general. Ms. C vowed that if she ever found that she was starting to burn out, she would make a change by switching the population she worked with or changing her role and duties; she could leave clinical work altogether and do policy- or community-based advocacy, or she could combine clinical work with research and policy work. Ms. C was relieved to know that the options within the profession of social work were many. Just knowing that she had options and the power and ability to be in control of her choices and work life made a huge difference. Over the years, she made several changes in her work setting, role(s), and the populations served. Ms. C is pleased to report that she has successfully avoided burning out.

Reflection Questions

  • Do you check in with yourself regularly to assess how you are feeling and functioning at work and in other realms of your life?

  • Are there particular aspects of your work to which you feel you are well suited? What are those and why?

  • Are there particular populations, issues, settings, or roles that you think may be difficult for you to work with or in? Why or why not?

  • Is there anything that you have found to be helpful in preventing you from burning out in your work?

  • Do you have a burnout prevention plan in place? If so, what is it? If not, what would the first step be to develop one?

Ms. C's first job after graduating with her MSW degree was as a psychiatric social worker and trainer of paraprofessional refugee counselors in a first asylum camp for Vietnamese boatpeople on an isolated island in the Philippines. When she arrived, she found that she had the most mental health training of anyone on the island. The Filipino non-profit she worked for had psychiatrists on call for consultation by phone and would fly a psychiatrist in for several days every two months to assess and prescribe medications. There were very few telephones on the island, and Ms. C had to borrow another agency's phone to make a call. Often, the connection was poor, and it was hard to communicate with the psychiatrist. Ms. C had a caseload of more than 100 clients who had fled Vietnam by boat and had experienced multiple traumas. Many of the clients were suffering from severe mental health problems, and some faced ongoing violence. Ms. C found herself working with multiple cases of trauma with both the perpetrator(s) and victim(s) at the same time. She only had access to peer supervision, with only sporadic access to a more senior, experienced supervisor when they visited the island.

Within several months, Ms. C's sleep became routinely disrupted. She began to have frequent nightmares. When she examined her nightmares, she realized that they were not her own—they were those of her clients, especially those who had experienced atrocities on the high seas during their escapes from Vietnam. The nightmares were filled with images of Ms. C hanging on to driftwood, watching helplessly as her loved ones lost strength and drowned in front of her. She also saw images of herself being attacked by pirates at sea, shot, and left for dead in a pile of dead bodies, and pretending to be dead until the pirates left. She had a recurrent nightmare of watching her brother murdered by others on the boat and seeing them eat his corpse in order to stay alive.

Instead of becoming alarmed at this development, however, her anticipatory work prior to starting the MSW program (vowing to check in regularly with how she was feeling and functioning) proved protective and reassuring. Her approach was to view these nightmares as fortuitous, because it gave her the opportunity to develop and implement a prevention plan and recognize the importance of taking care of herself and creating balance in her life very early in her career. More than two decades later, she is still working with trauma survivors. Her role has evolved and expanded and the population she works with is different (survivors of state-sponsored torture from all over the world—no longer restricted solely to Southeast Asian refugees). She also reports that she no longer has the nightmares of her clients.

Reflection Questions

  • Have you ever developed nightmares that include images from your clients' traumatic experiences or themes related to these experiences?

  • Have you experienced other signs or symptoms of vicarious trauma?

  • Are there particular settings or situations that tend to trigger your vicarious trauma reactions? If so, what are these?

  • Have you switched populations, work settings, or professional roles as a result of developing symptoms of vicarious traumatic stress?

  • How do you address your vicarious trauma reactions?

  • Have your efforts been successful?

  • Are there things you would like to try differently to address these reactions or, in general, to take care of yourself?

CASE STUDY 4

I was originally introduced to meditation as a high school student by my school principal. Years later, as a professional social worker working with traumatized refugees, two colleagues encouraged me to further explore and deepen my study of meditation. I had already experienced some benefits of meditation in my daily life and for some years had worked with Buddhist refugees in refugee camps in Asia and in the U.S. I had seen for myself the benefits that some of my clients experienced from meditation practice in coping and living with the impact of their traumas and other life challenges.

As my meditation practice deepened, in addition to setting time aside in my day to formally "sit" and meditate, I began to integrate it into my clinical sessions with survivors of state-sponsored torture. At first I was not aware that I was doing this. Soon I began to notice that I was focusing on my own breath, particularly during the portions of sessions when I would be talking with survivors about their histories of torture and other traumas and when they were expressing extreme distress in session. I would split my awareness and continue to attend carefully to my client while at the same time focus a portion of my awareness on my own breath, as I had learned to do in my meditation practice. I spoke with several meditation teachers about what I had discovered that I was doing in session, and they encouraged me to consciously expand what I was doing to include not only an awareness of my breath but also my physical sensations during sessions with my traumatized clients. As I became more adept at doing this with practice, I found that it was quite beneficial in various regards. It seemed to make it easier for me to remain calm, composed, nonreactive, and centered even while listening to horrific details of torture or while my clients were experiencing flashbacks to their torture or expressing utter hopelessness and suicidal thoughts in session. This in turn appeared to contribute to a calmer and safer atmosphere for the clients, one in which they seemed to be able to more fully express themselves (including about particularly gruesome details or events that were taboo or considered deeply shameful or stigmatizing in their culture and society) without feeling that they were harming or contaminating me or being harshly judged.

The calmer state of mind I experienced when using these meditation skills made it easier for me to think clearly and calmly about how to proceed in session. I was better able to access my professional knowledge and experience and intervene appropriately. Integrating an awareness of my breath and sensations during sessions with trauma survivor clients appears to promote my ability not to take my work home with me in that I am better able to attend to and process my distress in the moment as I am with my clients. Utilizing these skills in session with my clients also appears to enhance my ability to be aware of my countertransference reactions. This increased self-awareness in turn enables me to be less likely to be unconsciously driven by my countertransference in negative ways and facilitates my ability to respond professionally.

I also find these same tools extremely valuable in helping me to manage my performance anxiety and function better during stressful moments as I am cross-examined in court, where I often testify as an expert witness, or when I am presenting in front of a challenging audience. Several of my colleagues employ similar meditation skills in session with their trauma survivor clients with great success. If you are not already an experienced meditation practitioner, it may help to obtain some instruction in meditation first and have a meditation teacher available to consult with you in the early phases of experimenting with these techniques.

CASE STUDY 5

For many years, starting as a youth, I practiced the time-honored tradition that is widespread in the United States of making New Year's resolutions. Not just one resolution a year, but a list of things I would do differently or goals I would achieve each year. Inevitably, I would not be successful and would eventually, one by one, abandon most, if not all, of my resolutions as the year marched on. Some years, I achieved success or partial success, but in hindsight my efforts seemed haphazard. Clearly, my old approach was not working for me. I, like many people I know, grew to laugh about and expect this as inevitable. Some friends and colleagues gave up or never developed New Year's resolutions at all.

Some years ago, I decided to adopt a very different approach to New Year's and use it as an opportunity to recommit myself to taking care of myself, something that was so important to my personal and professional lives. What I have found works the best for me is to adopt an overall theme of "self-care" instead of a more traditional New Year's resolution. My plan includes routinely and frequently checking in with myself and asking myself if whatever I am doing or planning to do is in keeping with my self-care. I have found that this strategy is profoundly more helpful and easy to follow and stick with. It supports my setting boundaries and limits and makes it easier for me to weed through the many emails I receive each day and requests for my time in an efficient manner.

I spend much less time agonizing over how I can juggle my schedule to accommodate conducting a training course, attending an interesting workshop, or squeezing in another meeting. I used to have a harder time saying no when I was asked to do something that I knew I had the skill set to do or something that inherently interested me but conflicted with my other responsibilities. Now I find it generally easy to say, "Sorry, I do not have time right now to do that," or "I am overextended as it is and I cannot take that on right now."

An important component of my new strategy includes being gentle and not overly harsh or critical with myself if I slip in my self-care occasionally. I am going for an overall commitment to self-care for the long-haul, as a lifestyle change. Beating myself up if I have a bad day or neglect myself occasionally is, after all, antithetical to self-care. I use that opportunity as a wake-up call to assess what happened and rededicate myself to taking care of myself.

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