Evidence within trauma research has supported the notion that psychological distress affects more than just those who have been personally traumatized (Collins & Long, 2003; Figley, 1999; Pearlman & Saakvitne, 1995a). The psychological distress experienced by healthcare professionals in their work with patients who are suffering or who have been traumatized has been labelled vicarious traumatization (Pearlman & MacIan, 1995). Defined as the " [negative] transformation in the therapist's (or other trauma worker's) inner experience resulting from empathic engagement with clients' trauma material" (Pearlmann & Saakvitne, 1995b, p.151), vicarious traumatization results in the permanent disruption of the individual's cognitive schema. Researchers have suggested that ongoing exposure to graphic accounts of human cruelty, trauma, and suffering, as well as the healing work within the therapeutic relationship that is facilitated through 'empathic openness' (as is the case in compassion fatigue), may leave healthcare providers, including nurses, vulnerable to emotional and spiritual consequences (Dunkley & Whelan, 2006).
Additional factors beyond empathy have been identified as contributing to the development of vicarious traumatization. One factor considers the characteristics of healthcare professionals, including their previous personal history of abuse and/or personal life stressors, personal expectations, need to fulfill all patient needs, and inadequate training/inexperience. Another factor involves the characteristics of the treatment, such as invasiveness, life-threatening nature, and long-term effects, as well as its context, such as the type of patient and the political, social, and cultural context within which the treatment occurred and the traumatic event took place (Pearlman & MacIan, 1995; Pearlman & Saakvitne, 1995b). For example, ongoing advances in medical technology are now able to keep patients alive for longer periods of time, yet the eventual outcome is not altered. By this I mean that the patient still succumbs to the disease or injury; death has only been delayed. When a healthcare system places greater value on curative intent than on supportive care, situations, such as futility of care, may occur. For nurses involved in providing such futile care, the lasting imprint may be vicarious traumatization.
McCann and Pearlman (1990), and later Pearlman and Saakvitne (1995), used constructivist self-development theory (CSDT) to explain the "progressive development of a sense of self and world view in response to life experiences" (Pearlman & Saakvitne, 1995b, p.151). In other words, one's unique history of life experiences shapes how one will experience, interpret, and adapt to traumatic or highly stressful events. This CSDT interactive model attempts to take into account the variability of life experiences, suggesting that vicarious traumatization is unique to the individual (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995b). For example, if the nurse grew up in a home environment where one coped by dealing with stressful situations through escape/avoidance behaviour (a negative coping strategy), one would likely employ the same coping strategy in other stressful situations, such as that of witnessing ongoing patient suffering. If negative coping strategies are coupled with other contributing factors, for example lack of emotional support and/or unrealistic expectations of self in one's role as care provider, the risk for vicarious traumatization may be increased (Saakvitne, Tennen, & Affleck, 1998).
This theory argues that exposure to trauma, whether direct or indirect, disrupts one's frame of reference in one of five core areas of need, namely safety, trust, esteem, control, and intimacy (McCann & Pearlman, 1990). For example, disruption may occur whether the nurse witnesses the devastation of war first hand while serving in a MASH unit in Afghanistan or whether the nurse listens to her/his patient's eyewitness accounts of the devastation of war while providing care in a healthcare facility. As a result of either exposure the nurse may experience the following: (a) difficulty establishing and maintaining relationships with others; (b) loss of independence; (c) inability to tolerate extreme emotional responses to stressful situations; (d) intrusive memories of the traumatic experience (similar to post traumatic stress); and/or (e) an altered belief system.
CSDT emphasizes the importance of the individual's ability to connect with others, perceive the self as competent, cope effectively with stress over time, and interpret experiences in a meaningful way that allows the individual to draw on previous experience to manage new experiences successfully (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995b). Memory plays an important role in the development of vicarious traumatization by serving as a mental recording of life experiences and its interpretations. For example, healthcare providers may assimilate/integrate the patient's experiences of trauma and suffering as their own which, in turn, reshapes the provider's beliefs and values of self and of the world (McCann & Pearlman, 1990).
Although there is increasing evidence to support CSDT as an explanatory model for vicarious traumatization, more research is needed to demonstrate how, and in what way, the therapeutic relationship, individual core beliefs, and exposure to pain, suffering, and trauma may affect the psychosocial health and well being of healthcare professionals working in high-demand, intense, complex environments. Limitations of this theory include an inability to recognize the positive effects of trauma work and distinguish between awareness and disturbances in cognitive schemas (Dunkley & Whelan, 2006). For example, a disturbance in cognitive schema (beliefs) may occur when a hematological cancer nurse finds her/himself believing that all patients with hematological cancer die. Alternatively, heightened awareness occurs when an experienced hematological cancer nurse recognizes certain cues triggering the belief that a particular patient will do poorly but not that all patients will do poorly. Changes in cognitive schema may interfere with the development of empathy leading to vicarious traumatization rather than empathy leading to vicarious traumatization.
It should be noted that not every individual who works with those who have been traumatized will develop vicarious traumatization. If, as researchers have suggested, empathy and engagement, as fundamental elements of the therapeutic relationship, are key factors in increasing the risk for vicarious traumatization, then one would expect to see large numbers of healthcare providers negatively affected as a result of their work. However, studies have suggested that only a small percentage of individuals will manifest symptoms consistent with vicarious traumatization (Hafkenscheid, 2005), far fewer individuals than what McCann and Pearlmann (1990) had hypothesized. What is still missing is a clearly articulated theoretical framework and evidence demonstrating a cause-effect relationship between adverse effects and empathy. Future research is needed to identify which characteristics or qualities of working with suffering/traumatized patients might protect the healthcare professional and/or decrease the risk for adverse effects such as vicarious traumatisation.
Online J Issues Nurs. 2011;16(1) © 2011 American Nurses Association
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