31 July 2020
Do you tend to work with a steady and consistent range of the same type of client issues, such as weight management, phobias and general anxiety? You may find that you are so accustomed to working with these conditions, that they no longer ‘push any buttons’ for you. Any personal issues that may have arisen previously, you will have already worked through. For example, you may have had a phobia of spiders, yet after working with so many clients on this topic, you have ‘desensitised’ yourself and are no longer ‘triggered’ into an anxiety response by any mention of spiders. As an experienced therapist, you are likely to be aware of your own issues (if any) and how they may be affected by working with certain clients.
…but what about issues that you don’t have? Experiences that you haven’t had? How might you be influenced by a client, or a series of clients, presenting with trauma experiences? How will you cope with hearing the details of those difficult situations, often in fine detail?
Whilst discussing these experiences with your clients in an empathetic way, you can start to connect with the thoughts, feelings and emotions they went through at the time, and even perhaps are experiencing now. As a result, some therapists can have a vicarious experiencing of the same trauma/emotions, with some individuals more susceptible to the impact of this vicarious experience. For some therapists, they will listen, understand and recognise that it was a poor experience for the client and be focused on helping them work through the trauma and develop coping strategies. For other therapists, they can start to hold on to some aspects of the trauma themselves. So, how you then deal with this vicarious experiencing, or ‘Secondary Traumatic Stress’ (STS), which is the term that relates to trauma experienced indirectly, can lead to compassion fatigue (reduction in ability to empathise) and burnout (feeling drained or overwhelmed).
How you might be affected by STS can be different for each person, although it can have an adverse effect on the therapeutic relationship you have not only with the client experiencing the trauma, but other clients as well. As well as there being some overlap with compassion fatigue and burnout here, therapists suffering with STS may also be reluctant to engage with the business side of their practice, such as replying to email and voicemail enquiries and messages from existing clients. There can also be avoidance, in terms of a reluctance to book sessions with clients. Indeed, a therapist may start to avoid any potential clients who would wish to work with topics that the therapist regards as emotional or triggering.
A therapist’s behaviour within the therapy consultation may also change. They may start to avoid asking any questions relating to anything traumatic or that might generate high emotions. This may affect every aspect of the intake process, from the initial overview and exploratory questions, through to the details of the client’s experience or situation, and even any goals that the client may wish to work towards. They may also decide to obtain no information at all, and thus attempt to work ‘content free’ (which is not recommended), placing the responsibility for effective targeting of the work onto the client. As a result, a therapist may both experience a reluctance to formulate a treatment plan and/or have sufficient information in which to agree a beneficial treatment plan with the client.
STS may also affect how the therapist works with the client during the session. They may seek to avoid gaining any new information that arises during the session, so adopt a ‘one-way’ approach with the client, such as reading long scripts or giving the client little opportunity to share any new insights, thoughts, memories or emotions in a more collaborative therapeutic alliance, which is always preferable. Where there are discussions within the session, the therapist may seem distant or detached and the client may feel that the therapist isn’t fully engaged or fully present in the session. There are two potential consequences of this. Firstly, this can adversely affect rapport, possibly making the client shut down any further exploration of the issues. Also, the lack of objective analysis of relevant information gained during the session may impair ongoing solution-focused work.
Another undesirable impact on rapport relates to the emotions that the therapist is experiencing during the session that the client can become aware of; such as anger, irritation, frustration or resentment. As a result, these unhelpful emotions and behaviours of the therapist may lead to the client feeling the therapist is not supportive, and they may feel unheard and, as a result, can feel frustrated, thus also affecting rapport.
It can only take one poor session for a client to terminate therapy. Whilst they may move on to another therapist, the poor experience can lead to the client being reluctant to share their personal details again, a case of ‘once burned, twice shy’. Another negative consequence can be that the client does not engage in any further therapy, thus prolonging their experiencing of unpleasant symptoms.
How do you deal with STS?
A ‘prevention, identification and treatment’ strategy is useful for any therapist working with issues that may result in STS. From a prevention perspective, it can be useful for the therapist to consider any risks to development of STS, such as life experiences (e.g. a predisposition to burnout, past trauma), mental health issues (past or present) or symptoms, such as anxiety, stress or depression. You may also consider what strategies you are already employing to cope with these experiences and symptoms and how robust and effective those strategies presently are. Is there capacity to deal with more? What works well and what could be improved or strengthened? Some useful prevention strategies include:
Creating a strategy and developing sufficient skills to be able to respond when any signs of STS arise
Development of assertiveness, both in terms of maintaining boundaries and being able to say, ‘yes’ and ‘no’ appropriately
Enhancing written and verbal communication skills (e.g. being able to clearly say what you mean)
Positive creative expression, such as art, cooking or nature-based, such as gardening
Work-life balance with a diversity of interests and activities and managing both personal and professional time and resources
Mental relaxation, such as self-hypnosis, mindfulness or meditation
Maintaining professional boundaries can also aid prevention of STS, keeping to a realistic caseload and spreading complex cases throughout your week, as well as allocating sufficient breaks between clients who are working on trauma can make a big difference. Taking annual leave is also beneficial in giving a physical and emotional separation over a longer period of time, allowing a therapist to really let go of what they have been holding.
From an identification perspective, it is good practice for a therapist to be aware of their own emotional state prior to a session, so they know what is their own ‘stuff’ and what is the clients. In addition, at the end of the therapy session, reflective practice can help a therapist take a step back from the possible intensity of the session and consider the impact of what they have heard. As well as personal awareness and reflective practice, peer/group or therapy supervision can help you recognise and explore any STS. Flags for STS include:
Anticipation of poor outcomes or disaster
Avoidance of engagement with some clients or prospective clients
Avoidance of places, activities or people that are associated with client work
Disturbed or disturbing dreams about clients
Easily started or jumpy
Gaps in recollection of client sessions
Lack of positivity about the future
Reduced interest in other people
Reduced physical/psychological activity
Reliving experiences of clients
Stress sensations (e.g. heart pounding) when thinking about clients
Thoughts of work cause disturbance
When addressing STS (treatment), both personal and professional support can be beneficial. Boosting self-care and working on your personal psychological well-being is important. It may be that restructuring your working day, changing your working hours, or even taking a break can help you refocus. This is also a good time to draw on support from friends and family and increasing the amount of time you spend focusing on non-work topics. Both quantity and quality of self-care are important. On days when you are busy, then those 10 minutes reading a book, or chatting with friends can help you restore your personal balance. Particular strategies you may wish to explore include:
Increasing self-care, particularly relating to diet, exercise and sleep
Downloading thoughts and emotions into a diary (e.g. written, audio, video), with the option to review those entries later
Engaging in therapy as a client; such as working with a therapist who is experiencing in helping people with STS
Engaging in therapy supervision (A well-trained and experienced supervisor will be aware of strategies to avoid themselves also experiencing STS)
Contributing to a peer support group, and gaining insight into the coping strategies of others
Developing new self-care approaches, such as starting a new form of exercise (e.g. yoga) or other positive self-soothing techniques (e.g. progressive relaxation, or self-massage)
Ultimately, it is beneficial for all therapists to be aware of how they are working with clients and be observant for any signs of STS, and then take appropriate steps to address those, both in the interests of the therapist and for the clients with whom they work. We hope that this blog about therapist health and avoiding ‘secondary traumatic stress’ has been helpful. If you have any questions about this topic or anything else for that matter, do please get in touch, because we’re always happy to help!
– written by Dr Kate Beaven-Marks