or following the Sandy Hook Elementary School massacre). Additionally, other members of their community or people in their personal lives may have been affected by a mass trauma or tragedy. Clinicians have to make special decisions about the use Burnout In the ICD-11 (WHO, 2019), burnout is defined as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1. Feelings of energy depletion or exhaustion; 2. Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3. Reduced professional efficacy.” Importantly, the ICD specifies that burnout Vulnerability to Vicarious Traumatization As a therapist to trauma survivors, each clinician inevitably becomes aware of the existence or the potential for trauma in Paul, a seasoned clinician, recounted during supervision what a difficult time he had been having in working with an 83-year- old woman during her husband’s final illness with cancer and subsequent death. As part of his work with the woman, he had accompanied her to the hospital on one or two occasions to visit her husband. He began having intrusive dreams about her and started to feel anxious and depressed before and after sessions with her. In supervision, he was able to make the connection between her life situation and his own loss of his 84-year-old father just six months previously. He was still deep in his own grief process and taking care of his own elderly mother at the same time that he was working with this client. His countertransference feelings were triggered, making him more vulnerable to the effects of contagious grief and pain. After he became aware of this situation and made these connections, Paul was better able to maintain his boundaries and to develop some additional self-care strategies to help him through this difficult time. His intrusive nightmares and pre- and postsession anxiety disappeared. Working with the losses inherent in all kinds of trauma (not only death) can open up the clinician to their own grief. Factors that contribute to vicarious traumatization can include the specific content of the treatment session or sessions and the context, including the social, political, and cultural context in which the treatment and the traumatic events occurred. Additionally, working from an office setting, doing outreach work in the field, or working right at the scene of a disaster will differentially affect the clinician’s proximity to the trauma itself and to the daily lives of the clients who are directly impacted by it. If the clinician is closer to the physical or emotional trauma or trauma material, the risk of secondary trauma is greater. their own life. Case Example Personal identification with a client is also a factor in the development of secondary trauma. Clinicians can become particularly vulnerable to vicarious traumatization when they share similar attributes such as culture, ethnicity, race, gender, age, sexual orientation, family background, or marital or parental status, each of which may influence the degree to which a clinician personally identifies with a client. Additionally, Mirror Neurons and Internal Self-Regulation In his theory of somatic markers, Antonio Damasio asserts that the “gut” sensations that are elicited in response to various stimuli, including the feeling of empathy, are actually the experience of emotion (Damasio & Carvalho, 2013). In the mid-1990s, a team of Italian researchers who were studying the grasping behavior of monkeys came up with some startling results. Electrodes had been attached to the monkeys to see which part of their brain fired when they reached for raisins. While the electrodes remained attached to the monkeys, a researcher happened to reach for some raisins. The researchers noticed that the same part of a monkey’s brain lit up when the researcher reached for raisins as when the monkey reached for raisins. The exact same neurons fired when the monkey
of self-disclosure in such situations because the client already knows something personal about the clinician’s life. How to deal with boundaries in such situations may be an important topic to address in supervision or consultation. is specifically an occupational phenomena and should not be used to describe other areas of life. In behavioral health settings, high caseloads, lack of supervision, managed-care requirements, and challenging service provision all contribute to burnout rates. Burnout does not happen after one day, and the predictive characteristics are easily recognizable and preventable (Best Start Resource Centre, 2012). a clinician who shares a common history of similar trauma may experience a greater degree of personal identification with the client. Personal identification is different from shared trauma, in which both the client and the clinician have experienced the same traumatic events at the same time, as in the case of onsite workers during the aftermath of 9/11 or Hurricane Katrina. Such situations hold elements of actual exposure as well as the secondary effects of working with others who have experienced the trauma. Shared trauma, again, places the clinician at increased risk and necessitates scrupulous self-care and attention to reasonable boundaries. Traditional therapeutic boundaries are not possible after such events because the client already knows that the worker has shared the exposure. Careful delineation of appropriate boundaries that reflect shared humanity as well as professionalism need to be worked out, often in supervision or consultation. Empathy, attunement, and resonance are the major relational resources for the trauma worker to reduce the effects of traumatic stress. Importantly, though, these therapeutic processes open up the clinician to clients’ emotional states, thus making the clinician more vulnerable to the effects of vicarious trauma. Many clinicians have an experience of trauma in their own lives, whether of violence or of loss, and unresolved trauma in the clinician can be activated by reports of similar trauma in the client. Finally, children’s trauma tends to be particularly provocative, as it opens the clinician up to caretaking and protective instincts. Babette Rothschild (2006) speaks at length about the three regulatory systems in the clinician that are needed for optimum self-care. They are: ● The brain systems involved in interpersonal empathy ● A balance between the autonomic nervous system and the arousal system ● The ability for clear thinking that relies, at least in part, on a balanced functioning among all brain systems In short, the clinician needs to be able to balance their own empathic engagement, regulate their own autonomic nervous system and arousal threshold, and maintain the ability to think clearly during engagement with the client. observed the action as when he performed it. Similar brain cells in humans, which react in the same manner, were later called mirror neurons because these neurons in one person reflect the activity of the same neurons in another person (Cozolino, 2014). Research seems to show that mirror neurons are a factor in empathy (Ferrari & Coude, 2018), which has implications for clinical work because a clinician’s mirror neurons may reflect the emotions of the client. Empathy is both a cognitive and a somatic experience. Emotional contagion is felt through the body as a physiological response.
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