Service providers Tips
Tips for Caregivers Providing Trauma Services
In the best-case scenario, caregiver response to trauma work can be the balm that guides the healing process. Unfortunately, this is not always the case and becoming aware of common responses that result in therapeutic failures can increase our ability to provide the best services possible.
There are at least four critical issues to consider when determining the source of recurring problems with critical care-giving work, including: emotional preparedness for work; acclimatization of listening skills; identification of the traumatic history; and the therapeutic environment. Each of these issues is discussed in greater detail in the four sections that follow:
1. Emotional preparedness for work
We must remember that doing trauma work is difficult and can have repercussions for the therapist. Given the risk of secondary response to trauma work professionals must be prepared to meet their own needs and identify weaknesses in order to maintain their ability to provide the best services.
Compassion Fatigue, Vicarious Traumatization, and Secondary Traumatic Stress.
In 1995, the term "Compassion Fatigue" gained recognition through an edited book of the same title (Figley, 1995a). The term provides a language for feelings familiar to many front line workers dealing with traumatized populations (i.e., psychologists, social workers, lawyers, nurses, psychiatrists, medical doctors, and emergency responders among others). Related terms include Vicarious Traumatization (McCann & Pearlman, 1990); Secondary Traumatic Stress (Figley & Kleber, 1995; Stamm, 1995); and Burnout (Maslach, 1982).
Compassion Fatigue is defined as a union of Secondary Traumatic Stress and Burnout in the lives of helping professionals and other care providers (Figley, 1995b). It is understood as a compromise in personal and professional functioning that comes as a direct result of exposure to clients who have first hand exposure to extremely distressing life events. Symptoms have been known to mimic the trauma response of clients but to a lesser degree.
The work of trauma specialists is highly rewarding but has the potential to trigger strong emotions among professionals as a result of their work. There are certain factors that lead to a latent vulnerability to Compassion Fatigue. One of these factors is previous exposure to trauma in the professional's life. Furthermore, caregivers who work in environments that are unsupportive or emotionally toxic combined with first-hand exposure to trauma may experience an even greater susceptibility to the symptoms of Compassion Fatigue (Gentry, Baranowsky & Dunning, 1997; Pearlman & McCann, 1995).
2. Acclimatization of listening skills
Becoming accustomed to work with client trauma requires a maturing process that includes the ability to "bear witness" to experiences that we may have no frame for understanding. The care-giver needs to develop a superior ability to listen to stories of greatly disturbing events. Without this ability therapeutic efficacy will be noticeably impaired. An inability to attend to trauma materials was explored by Danieli (1985) through the term "Conspiracy of Silence" and later by Baranowsky (2005) as the "Silencing Response".
The Conspiracy of Silence
Traumatic stories have the potential to spill over onto the clinician resulting in a significant impact upon the professional caregiver. When these narratives become too difficult to hear the clinician may unintentionally redirect the client's focus to milder topics in order to buffer themselves from exposure to horrific stories. Danieli (1985) skillfully exposes the challenge of attending to traumatic material while conceptualizing the "Conspiracy of Silence". She explores the difficulty that professionals, family members, and friends have when attending to the traumatic stories of Holocaust survivors (Danieli, 1984). She concluded that, therapists often felt unable to cope with the trauma encountered by this group and the resultant tendency, among mental health professionals, to encourage their patients to leave their stories out of the therapy sessions. In effect, this left the survivors with the continued burden of incomplete mourning. The implications of these findings are alarming, as unless the therapist is able to approach the issues most salient to the client there is little possibility of a successful therapeutic outcome (Rosenman & Handelsman, 1990).
The Silencing Response
In later work, Baranowsky (2003) uses the Silencing Response to identify an inability to attend to client' stories and/or experiences and instead to redirect to material that is less distressing for the professional. This occurs when client' experiences/stories are overwhelming, beyond the professional's scope of comprehension and desire to know, or spiraling past their sense of competency. The point at which we may notice our ability to listen becoming compromised is the point at which the Silencing Response has weakened our clinical efficacy. Preliminary research suggests a correlation between Compassion Fatigue and the Silencing Response (Baranowsky, 2003).
A series of assumptions have been identified that appear to increase the clinician's susceptibility to the use of the Silencing Response. These are as follows:
- I can't do anything about it. Listening won't help so I don't want to hear about it.
- If we touch on the traumatic event the person will fall apart or be destroyed. The main notion is that talking about the trauma will only make things worse.
- I will be destroyed if I hear about the traumatic event. The clinician fears hearing about the terror that the individual has experienced.
- Good things happen to good people, therefore, you must be bad for this to have happened to you.
- This is too terrible to be true.
- This violates my assumptive world (i.e., my neighborhood is safe therefore this couldn't have happened here.)
- A strong need on the clinician's part to have the client "Just get over it".
- If it happened to you it could happen to me. This vulnerability to terrible events might lead the clinician to feel that what happened could be contagious.
There may be other reasons for the selective listening or active avoidance of traumatic memories that will become evident with the evolution of this construct. Being aware of these assumptions assists the clinician to recognize their own defenses and thereby enhances their ability to challenge their concerns and subsequently to more directly attend to the needs of the client.
3. Identification of the traumatic history
A thorough intake interview can provide an excellent source of information and a base upon which to proceed with well-suited therapeutic interventions. Once the client history is properly investigated it is more likely that an accurate source of client distress will be identified.
Developing strong assessment skills is an essential part of work with trauma survivors. Once the source(s) of distress is established the professional can make a reliable assessment and chose the interventions that best fit the needs of the individual. Without this well informed base from which to prepare treatment plans important areas of disturbance may go unrecognized and lead to misguided assessments and poor treatment plan choices.
Poor interpretation of the client' problems relates to the challenge of identifying and addressing the source of difficulties for the client. Without a close attention to the precipitating factors for current deficits in functioning the ability to establish appropriate treatment protocols will be compromised. This can be addressed with a good intake history and the use of some relevant assessment instruments. This provides a good base from which to identify symptoms and disorders as well as to identify client readiness for such work.
4. The therapeutic environment
In 1992, Herman wrote her well-received book "Trauma and Recovery". She explored and endorsed the use of a triphasic model of trauma treatment that included safety, remembrance and mourning, and reconnection as essential elements. Safety can be established through the client-therapist relationship as well as within the client's personal life environment. Both of these areas need to be secured in order for the client to achieve the greatest benefit from therapy. Trauma Practice: Tools for Stabilization & Recovery (Baranowsky, Gentry & Schultz, 2005) offer a comprehensive tool kit for treating trauma.
Limited therapeutic alliance
The issue of client-therapist rapport can be addressed through an understanding of the importance of client's feelings of safety within the therapeutic relationship. Without this there is little hope of therapeutic alliance and subsequent client investment in the therapeutic "techniques" used by the clinician. While it is possible to work as a talented technician, if the therapist is not able to join with the client treatment efforts may be futile.
Lack of Safety
Once safety has been established in the client-therapist relationship it becomes important to reinforce client feelings of security within their personal lives. This prepares the individual to move forward to trauma review while enhancing treatment outcome. Ensuring that the client has adequate coping resources and is safe from harm from self (i.e., suicidality, self-injurious behaviors) and others (i.e., spousal abuse) further promotes the likelihood of proficient treatment.