Trauma Informed Self Care

The weight of constantly listening to difficult, harrowing, and upsetting events in other people’s lives can have negative impacts on therapists, especially for those who are inadequately trained or who have poor coping mechanisms. While most therapists deal with this strain, it is particularly true of those who work consistently work with patients who have experienced trauma. Trauma refers to an individual's exposure to actual or threatened harm, fear of death or injury, or witnessing violence. Common forms of trauma seen in therapy environments are rape, abuse, victims of crimes, accidents, and disasters. Trauma work requires specialized training and support in order to be effective for the clients and to help to deal with, minimize, and

avoid vicarious traumatization, compassion fatigue, and burnout for the therapist.

There are three levels of impact that trauma work can have that are important to understand when discussing interventions; vicarious traumatization, compassion fatigue and burnout. Vicarious traumatization is the first level. It refers to therapists experiences of trauma due to hearing about their clients experiences of trauma. It can have varying levels of impact depending on the therapist. For example, the more the therapist sees the original trauma of the client as possibly happening to them, the more likely they are to experience vicarious traumatization. Compassion fatigue is when a therapist feels numb or experiences difficulty in connecting to with their clients/providing compassionate care. In more seldom cases, a therapist can reach burnout where a therapist’s chronic overexposure to trauma without adequate coping mechanisms leads to a level of numbness or cynicism that makes it incredibly difficult to continue working with trauma patients. In some cases, burnout means therapists completely stop working in the field at all. All of these impacts on the therapist also have impacts on the clients that they see. For example a therapist who is struggling with vicarious traumatization may decenter the clients needs in a therapeutic setting in order to attend to their own trauma. Additionally a therapist experiencing compassion fatigue is less likely to push for a traumatic story when their client needs them to, and a therapist experiencing burnout is unlikely to be helpful to clients at all. Understanding these three levels of impact, can create a better understanding of the potential impacts that this has on clients and what training programs and support systems are attempting to prevent.

Specialized training for trauma work can include several forms and these forms can have varying levels of impact on outcomes. Training for therapists to practice trauma work can take many forms, especially due to the nature of the counseling field. For example, licensed or certified mental health providers could be from the fields of psychiatry, psychology, social work, marriage and family therapy, professional counselors, drug and alcohol counselors, and psychiatric nurse practitioners. But in several of these fields trauma training is not implemented into the core curriculum of graduate training. This means that the training of the people coming into trauma work can vary quite widely, and many are unprepared to treat traumatized patients. Some practitioners can and do seek training from sources outside their main program including workshops and outside classes. While this means they are more prepared for the field, the lack of comprehensive guidelines means the specialized training that practitioners receive before beginning trauma work can vary widely in quality, depth, and usefulness if they receive it at all.

Many clinicians do not feel that they have received adequate training in fact 81% reported that more trauma training would be beneficial (Hepworth & McGowan, 2013). This also has impacts for patients, in fact, many patients are not receiving trauma-informed treatment. In one study, two thirds of patients reported sexual, physical, or emotional abuse, but only 20% had even been asked about this abuse by their clinicians. Many of these clinicians avoided assessing for trauma because they did not feel competent enough to do so (Xiao et al., 2016). This is an example of collusive resistance between therapists and patients that is having a negative impact on patient wellbeing due to a lack of training for the clinician. There are several short term training programs that intend to remedy some of these issues. One example is the Trauma Psychology division of the American Psychological Association which offers training courses, conferences, and identifies higher education programs with a focus in trauma. It is important that clinicians receive this kind of training in order to be adequately serve their patients.

In clinical practice support for trauma work can take several forms, and central to this support are ideas around therapist self care.

One example of self care is Trauma-informed self-care which includes being aware of one’s own emotional experience in response to traumatized clients and planning positive coping strategies including supervision, trainings, teamwork, caseload and work life balance. This form of self care can be particularly beneficial when working with trauma. According to a study of 104 child welfare case managers, a group routinely exposed to multiple traumatic events, those who experienced higher levels of trauma informed self care experienced higher levels of compassion satisfaction and lower levels of burnout (Salloum et al, 2015) But in order for this type of self care to be beneficial there must be systems of support in place. However the amount of professionals who are regularly dealing with trauma that are experiencing compassion fatigue and burnout remains high, and an individual's ability to receive supervision, trainings, or modify their caseload or work life balance is highly variable. This can be seen in differences between burnout and compassion fatigue depending on setting and resources. For example self-care activities were lower and burnout and compassion fatigue were higher for those in agency and school settings than those in private practices (Star, 2013). Overall trauma informed self care for therapists can be highly beneficial in

avoiding compassion fatigue and burnout

In many cases, therapists benefit from therapy both before and during practice. Therapy before practice can help the therapist to prepare a therapist by helping them to gain a better understanding of the therapeutic process and to work through past trauma. Personal therapy during training can give trainees a model for the type of therapy they do and do not want to provide as well as ideas about how they can create therapy client relationships. It can also be particularly helpful for trainees who do have past experiences with trauma that could have an impact on their practice. Working through that trauma has the potential to lessen its potential impact. But personal therapy during training can also have its ethical issues. Many times trainees receive therapy from the faculty in the program without sufficient choice of therapist, and many feel that the dual relationship was not adequately addressed (McEwan & Duncan, 1993). Additionally, if the goals of the training therapy are not adequately discussed and communicated participation by the trainees can feel aimless and end up being less beneficial.

Therapist personal therapy during practice can be helpful because it can help to provide a therapist support than can help them to better treat their own patients, especially when working with and experiencing a lot of trauma. It also may feel easier to access or more helpful to some therapists than other forms of self care mentioned previously. In general therapists who do seek out personal therapy during practice feel that it had a positive impact on their own approaches to therapy and on their own affect (Oteiza, 2010). Other research found personal therapy is considered by therapists to be essential to training, but also important as ongoing support and to aid in maintaining authentic relationships with clients (Wiseman, H., & Shefler, G, 2001). These findings on therapist personal therapy are also important to consider with trauma work, when support, therapist affect, and maintaining client relationships become both essential and more difficult to maintain. But it is also important to consider the ethical questions involved. The main issue is one of confidentiality. While conversations with a personal therapist are also considered to be under the realm of confidentiality, the therapist should still maintain a level of obscurity when discussing the personal details of clients. Overall therapist personal therapy can have positive impacts both during and after training, and can be a place of support and learning for those in trauma work.

In conclusion, trauma work is a difficult field that requires increased training and support.

Helping these therapists to deal with, minimize, and avoid vicarious traumatization, compassion fatigue, and burnout leads to clients experiencing better treatment. But the level of training and support to minimize these varies widely by field and organization, which leads to varying levels of impacts. While self care can have positive impacts, overall organizational changes can lead to much greater impacts. Overall helping therapists to deal with trauma leads to happier therapists who are better at doing their job which means clients with more positive

outcomes.