Opinion

The haunting

10 January 2022

Ann Guindi examines how vicarious trauma can affect health workers and what steps can be taken to help these ‘wounded healers’.

Reflection in nursing is well embedded in practice and has been recognised within clinical supervision since 1995, when legacy organisation United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), now known as the NMC, published definitive guidelines for nurses and health visitors (UKCC, 1996). Various models of reflection are used within nursing. One is Borton’s three-stage sequence of reflection, the ‘what, so what, now what’ model (Borton, 1970), which was later adapted by Driscoll (2007).

Another is Kolb’s four-stage reflective cycle, which moves from concrete experience through reflective observation and abstract conceptualisation to active experimentation. Kolb’s model is based on his learning theory (Kolb, 1984) and is applied in safeguarding supervision practice and training. Kolb’s approach is implemented in the training delivered by the NSPCC and is a recognised course for nurse supervisors. Gibbs’ model is also reflective and uses a cyclical five-stage approach that involves describing the event, the feelings evoked, and then evaluation, conclusion and action (Gibbs, 2013).

Reflection is an important part of nursing practice as nurses are now having to include reflective work as part of the revalidation process (NMC, 2021). This reflective piece of work is on the vicarious trauma (VT) that we may experience as supervisors in carrying out our work. I will be using Borton’s model of reflection.

My background

Since I was a child, I knew I wanted to work with children. After leaving school, I became a nurse for sick children and continued working with children and families as an HV for most of my career. I so wanted to help others that I decided to study a master’s degree in therapeutic counselling. I realised I was drawn towards being a counsellor to heal my own childhood wounds. I grew up with domestic abuse (DA), and for the first 10 years of my life I lived in fear of my father hurting my mother. This trauma stayed with me throughout my childhood and into my adult life.

This paper reflects on the impact of growing up with DA and how it has led me to the work I do today.

It is no surprise to me that my practice concerns safeguarding children, with a view to hearing the voice of the child and to advocate for having that voice heard. But in taking on this role, I have exposed myself to VT. Pearlman and Saakvitne (1995) define VT as the ‘transformation that occurs in the inner experience of the therapist (or worker) that comes about as a result of empathic engagement with clients’ trauma material’.

Traumatic events not only affect the victims but also those who witness and subsequently engage with survivors of trauma

Stage one: reflecting on what happened

Part of my role as a safeguarding specialist is to deliver safeguarding supervision to practitioners on the frontline. This reflection was triggered following a supervision session in which a practitioner/supervisee was recounting their experience of a parent who had been killed by her partner in front of her child. As the supervisee told the story to me, I kept getting intrusive thoughts and memories of my own experience of growing up in a home where DA took place.

Howlett and Collins (2014) state: ‘Traumatic events do not only have an impact on the victims but also on those who witness and subsequently engage with survivors of trauma.’ According to Mairean and Turliuc (2013), psychological trauma can be caused by direct exposure to traumatic events or via indirect exposure as a result of listening to others relate the trauma inflicted on them.

I felt such empathy for this supervisee and what she had endured in supporting this family. As the emotion built up, I could feel a lump in the back of my throat and wondered if I could contain my emotions without them spilling over. As a trained counsellor I was consciously aware of the transference that was taking place between me and this supervisee. I immediately thought about my own mother and her past experiences of DA. Transference is a key concept in the psychodynamic counselling approach adopted by Freud (Feltham, 1999). It refers to the way in which feelings from past relationships can be brought forward into present relationships. This transference of feelings can be a positive or negative experience.

According to Freud, transference is a central theme in therapeutic work. However, if transference is negative it can interfere with the healing process (Jacobs, 1999). Although I was aware of what was happening to me, my supervisee did not know why I was reacting in the way that I was. As a safeguarding supervisor, I frequently draw on my counselling skills in my work with supervisees. My preferred style of counselling is to use a person-centred approach as adopted by Rogers (1995). This approach employs three elements:

  • Empathy
  • Unconditional positive regard
  • Congruence.

I often share my own experience with my supervisees when I get into a highly emotional state, and did so with this supervisee. It enables me to build rapport and trust with those that I supervise, and also allows the supervisee to see my vulnerability, which is part of being congruent and transparent in the supervisory relationship. I realise that in sharing personal content I run the risk of countertransference. Countertransference is the mirror image of transference, and could cause a supervisee to also see me as a victim. If I were to help this supervisee through their trauma, I would need to be mindful of the impact of what I shared. I did not want my supervisee turning into my counsellor. There is a fine line between moving closer to the supervisee and maintaining professional boundaries (Bell, 2003).

However, I was unable to sleep that night as flashbacks of my own childhood haunted me. It made me question whether my job was the right job for me. Would I be able to cope with the emotions it was stirring up within me?

On reflection, I realised that I had chosen this job for a purpose, which was becoming more evident: I was still working through my own childhood experiences. I was acting in the mode of the ‘wounded healer’. Sedgwick (2009) states: ‘The patient’s illness must activate the personal wounds and/or the wounded healer archetype within the analyst.’ 

The next stage: so what happens now?

According to Howlett and Collins (2014), VT often mirrors the symptoms of a therapist’s clients with responses such as anger, pain and distress. So it should not have been a surprise to me that these feelings surfaced when listening to this supervisee share her experience.

Mairean and Turliuc (2013) suggest that some practitioners are more predisposed to VT than others, and that this is dependent on the following factors:

  • The nature of the traumatic event
  • Organisational factors
  • Personality factors
  • Coping variables.

They demonstrate this by using McCrae’s five-factor model of personality (McCrae and John, 1992) to help identify those who are more susceptible to VT. The five personality factors are:

  • Neuroticism
  • Extraversion
  • Openness
  • Agreeableness
  • Conscientiousness.

Their research suggests that extraversion, openness, agreeableness and conscientiousness are protective factors against VT. Other protective factors included self-efficacy, hardiness and self-esteem (Mairean and Turliuc, 2013; Bell, 2003). By contrast, neuroticism was deemed a risk factor for VT.

Looking at my own personality, I was aware that I had three protective factors and two risk factors. It raised a question for me as to whether I was more vulnerable to VT.

If this is the case, it may be worthwhile to establish a form of personality profiling for frontline staff seeking to work in positions that have a high risk of VT. But this would not address the problem, as we cannot change our personality. The focus should therefore perhaps be on enabling staff to cope with the negative effects of VT and for this to be addressed in safeguarding supervision.

The negative impact of VT has been widely researched since it was first identified by McCann and Pearlman in 1990 (Sommer, 2008; Trippany et al, 2004). McCann and Pearlman state that VT can negatively disrupt a person’s beliefs about safety, trust, dependency, esteem, control and intimacy. Other researchers state shifts in cognition, including disturbances in identity, spirituality and worldview as well as changes in self-perception, ego resources and psychological needs (Aparicio et al, 2013).

It has been suggested that the impact and severity of a worker’s reaction will depend on their past experience of trauma (Lerias and Byrne, 2003), with those who have experienced trauma fairing worse than those who have not experienced it. However, Bell (2003) disagrees with this suggestion. Other researchers support her in this – Schauben and Frazier (1995) and Follette et al (1994) found there was no evidence to suggest mental health workers who had experienced trauma were more susceptible to VT than those who had not (Bell, 2003). My feeling is that a mixture of personality and past trauma experience probably contribute towards VT, and both could be deemed risk factors for VT that workers and employers should be more aware of.

If workers are to cope better with the effects of VT, this must be addressed in training (Agllias, 2012). The more experience that a worker receives in trauma work during training will also affect their ability to cope (Adams and Riggs, 2008).

Training should include strategies for self-care, social support and resilience (Howlett and Collins, 2014). This is supported by Agllias (2012), who describes four safety strategies that trainee social workers should adopt or be provided with (that HVs can learn lessons from):

  • Ongoing recognition of and education about self-care and VT
  • Development of a supportive culture in the classroom
  • Accessible avenues of personalised support and debriefing
  • Providing a transparent and diverse curriculum.

Agllias goes on to state that ‘undergraduate social work courses should include material about working with clients exposed to violence, trauma and disaster.’

According to Steed and Downing (1998), early recognition of signs and symptoms of VT must be observed and taken seriously. This is achieved by rigorous supervision and mentoring (Williams et al, 2012). Jankoski (2010) states:

‘Training for supervisors must address supervision style and communication skills. They must be made aware that helping their colleagues to heal is more important than the paperwork that must be completed.’

There is also evidence to suggest that feeling appreciated by an organisation can make a difference and help protect against VT (Howlett and Collins, 2014) along with effective supervision:

‘Effective supervision will also allow a more intimate space for the positive aspect of this work to be emphasized and for commitment to be praised’ (Howlett and Collins, 2014).

This is echoed by Agllias (2012), who suggests that access to debriefing and supervision has been shown to reduce stress, burn-out and symptoms of trauma in human service workers.

Supervision should provide a place of safety for professionals to process feelings of VT and be able to work through them

There is very little in the existing literature around VT in health visitors or school nurses other than the work of Dillenburger (2004). Her research looked at occupational stress in childcare workers, social workers, HVs and allied health professionals. She suggests that in the past the cause of stress was placed within individuals, thereby implying that it was the fault of the individual or resulted from a weakness of character. This of course led to feelings of guilt and inadequacy within the worker (Dillenburger, 2004). This blame culture is not helpful, in my opinion; it prevents the worker from bringing their concerns and feelings into safeguarding supervision. It also poses a risk that feelings can be internalised and lead to ill-health and sickness.

But more concerning is that children may be put at risk as professionals fear being judged in not being able to cope with the workload. According to Dillenburger (2004), this may be one of the main reasons for absenteeism and high turnover in the workplace. Supervision should provide a place of safety for professionals to process feelings of VT and be able to work through them. This was evident in my previous research paper, published in Community Practitioner (Guindi et al, 2019), in which practitioners stated that feeling safe and/or having a safe environment was the most important aspect in the safeguarding relationship with their supervisor.

According to Mairean and Turliuc (2013), ‘a person’s level of vulnerability to vicarious traumatisation could depend on the extent to which he or she is able to engage in a process of integrating and transforming the traumatic experience.’

It is therefore of the utmost importance that staff have access to high-quality safeguarding supervision to process these difficult emotions. According to Aparicio (2013), improving education and supervision around VT would have a significant impact on work with clients.

Stage three: now what? Conclusion and recommendations

The evidence is clear: employers need to be more aware of the impact of VT on their workers, including those who work in safeguarding as they are exposed to very traumatic events. As VT is not preventable, it is inevitable that workers will suffer to some extent when exposed to traumatic content. They should have measures in place to help workers to cope with its effects:

  • Providing adequate training and development for the post in question
  • Providing the necessary support and high-quality access to safe supervision
  • Encouraging stress-relieving strategies to promote health and wellbeing
  • Ensure that debriefing is offered following a traumatic event
  • Access to a psychologist as part of the service offer.

To date, most of the research on VT has been carried out either on counsellors, social workers or mental health workers. More research needs to be conducted specifically in the field of health visiting, school nursing and with safeguarding practitioners and their supervisors. There also needs to be more research and evidence around how effective safeguarding supervision is for health professionals working in the field of safeguarding children. 

Ann Guindi is a safeguarding nurse consultant and specialises in delivering safeguarding supervision and training.


References:

Adams SA, Riggs SA. (2008) An exploratory study of vicarious trauma among therapist trainees. Training and Education in Professional Psychology 2(1): 26-34.

Agllias K. (2012) Keeping safe: Teaching undergraduate social work students about interpersonal violence. Journal of Social Work Practice 26(2): 259-74.

Aparicio E, Michalopoulos LM, Unick GJ. (2013) An examination of the psychometric properties of the vicarious trauma scale in a sample of licensed social workers. Health & Social Work 34(4): 199-206.

Bell H. (2003) Strengths and secondary trauma in family violence work. Social Work 48(4): 513-22.

Borton T. (1970) Reach, touch and teach. McGraw Hill: New York City. 

Dillenburger K. (2004) Causes and alleviation of occupational stress in child care work. Child Care in Practice 10(3): 213-24.

Driscoll J. (2007). Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals. (2nd edition). Bailliere Tindall Elsevier: Edinburgh.

Feltham C. (1999) Understanding the counselling relationship. Sage: London.

Follette VM, Polusny, MM, Milbeck K. (1994) Mental health and law enforcement professionals: trauma history, psychological symptoms, and impact of providing services to child sexual abuse survivors. Professional Psychology: Research and Practice 25(3): 275-82.

Gibbs G. (2013) Learning by Doing: A Guide to Teaching and Learning. Oxford Brookes University: Oxford.

Guindi A, Hassett A, Callanan M. (2019) Safeguarding supervision: on the frontline. Community Practitioner 92(9): 45-7.

Howlett S, Collins A. (2014) Vicarious traumatisation: risk and resilience among crisis support volunteers in a community organisation. South African Journal of Psychology 44(2): 180-90.

Jacobs M. (1999) Psychodynamic Counselling in Action. Sage: London.

Jankoski JA. (2010) Is vicarious trauma the culprit? A study of child welfare professionals. Child Welfare. 89(6): 105-20. 

Kolb DA. (1984) Experiential Learning: Experience as the source of Learning and Development. Prentice Hall: New Jersey.

Lerias D, Byrne M. (2003) Vicarious traumatization: symptoms and predictors. Stress and Health 19(3): 129-38.

Mairean C, Turliuc MN. (2013) Predictors of Vicarious Trauma Beliefs Among Medical Staff. Journal of Loss and Trauma 18(5): 414-28.

McCann IL, Pearlman LA. (1990) Vicarious traumatization: a framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress 3(1): 131-49.

McCrae R, John O. (1992) An introduction to the five-factor model and its application. Journal of Personality 60(2): 175-215.

NMC. (2021) Revalidation. See: nmc.org.uk/revalidation/ (accessed 13 December 2021).

Pearlman LA, Saakvitne KW. (1995) Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors. WW Norton & Co: New York.

Rogers, CR. (1995) On becoming a person: A therapist's view of psychotherapy. Houghton Mifflin: New York.

Schauben LJ, Frazier PA. (1995) Vicarious Trauma: The Effects on Female Counselors of Working with Sexual Violence Survivors. Psychology of Women Quarterly 19(1): 49-64.

Sedgwick D. (2009) The Wounded Healer: Counter-Transference from a Jungian Perspective. Routledge: London.

Sommer C. (2008) Vicarious Traumatization, Trauma-Sensitive Supervision, and Counselor Preparation. Counselor Education and Supervision 48(1): 61-71.

Steed L, Downing R. (1998) A Phenomenological Study of Vicarious Traumatisation Amongst Psychologists and Professional Counsellors Working in the Field of Sexual Abuse/Assault. The Australian Journal of Disaster and Trauma Studies 2(2): 225-35.

Trippany R, White Kress V, Wilcoxon SA. (2004) Preventing Vicarious Trauma:What Counselors Should Know When Working With Trauma Survivors. Journal of Counselling and Development 82(1): 31-7.
Williams A, Helm H, Clements E. (2012) The Effect of Childhood Trauma, Personal Wellness, Supervisory Working Alliance, and Organizational Factors on Vicarious Traumatization. Journal of Mental Health Counselling 34(2): 133-53.

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