Thank you to everyone who responded to our December Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
December Quandary: I’ve been working for several weeks with a client who was in a serious car crash that left her in a deep depression for years. When she recounts her story, I find myself unusually affected, as if I’m reliving the event with her. At the end of our sessions, I feel exhausted and stressed. I’ve heard a little bit about vicarious trauma but don’t know much about how to deal with it. I plan to work through this with my supervisor, but in the meantime, are there some good, practical ways to protect myself that still allow me to be fully present and empathetic with my client?
1) Slow Things Down
The idea that it’s necessary for the client to relive the traumatic event and for the therapist to empathically “go there” with the client is an old premise dating back to the 1990s. It was an idea inspired by Freud’s “talking cure” but actually has no scientific basis. Worse yet, telling and retelling the story can retraumatize the client by repeatedly and unnecessarily activating his or her trauma responses as well as yours. If this therapist is feeling stressed and overwhelmed, then his client is experiencing even more stress. His exhaustion is an empathic reaction, telling him that it’s too much for both of them.
Some things to consider: Is she anxious about reliving the accident? If she is, I’d recommend slowing her down. I’d ask her to share a little, then have her pause to notice how activating it is. Next, I’d ask her to take a breath or two and let the activation settle before having her share a little more. I’d help her notice the experience of being witnessed rather than assume that my empathy is accomplishing this. If she insists on telling her story in full, I’d have her start by going back to the moment she first realized she’d survived. This is the goal of all memory reprocessing techniques: to evoke the sense of an ending, of having survived, of the traumatic event being over.
If she’s resistant to reliving the story, then I’d applaud her sense of having a choice to not go there. I always say, “You had no choice over what happened, but you can choose whether and how you talk about it.”
Janina Fisher, PhD
2) Be Careful Not to Grab Someone Else’s Luggage
I’ve spent more than eight years doing crisis and trauma work, and I clearly remember my supervisors and professors at the beginning of my career mentioning vicarious trauma and its impact on the clinician’s well-being. At the time, I understood what vicarious trauma was, but had not yet experienced it. Like many clinicians, I embarked upon my professional journey intending to assist those in need, but I didn’t really understand my own emotional, physical, and spiritual needs yet.
When I first encountered vicarious trauma, I was quick to nip it in the bud. I became aware of Dan Siegel’s Healthy Mind Platter, which breaks down the seven daily essential mental activities to optimize well-being: sleep time, physical time, focus time, time-in, downtime, playtime, and connecting time. Being aware of the importance of these activities has made me much calmer when I work with trauma.
Today, I’ve fine-tuned a mindfulness approach that helps me greatly when it comes to working with trauma. Although it’s still in its infancy, it keeps me grounded in the present. Mostly, it involves being aware of what’s mine and what’s the client’s. Look at it this way: when you’re at the airport retrieving your luggage from the moving console, it’s easy to mistake someone else’s bag for our own. However, if we create a system for identifying which bag is ours—say, attaching a red ribbon to the handle—we can confidently grab our own bag, then assist others in retrieving theirs.
Other strategies I use include cultivating human connection at work, and in my family and community. I believe that having strong, caring, and compassionate bonds with your clinical team, supervisors, and community can help us process difficult moments in our work. I also go for walks during the day, whenever possible, and when there’s a small gap between sessions, I jump rope so I can engage my body, moving the trauma-induced sensations out of it. By engaging in a regulating movement, I acknowledge that I’ve been triggered rather than ignoring or denying the effect on me. Last, and most importantly, I go to therapy in order to understand what triggers me.
Norma Alicia Moreno, LCSW
3) Roll with the Punches
In my work with trauma survivors, I’ve developed five strategies that help me minimize transference while still holding space for the client and empowering them.
First, I like to schedule these clients early in the day and week, such as a Tuesday at 11 a.m. instead of, say, a Friday at 3 p.m. This way, I’m reducing any unconscious negative anticipation about the session. I also find I have more energy earlier in the week. Second, when I feel as though a session has triggered me, I address my emotional needs as soon as I can with self-care, like a clinical debrief with a colleague or a walk so I can calm down and self-reflect.
When I anticipate that a session may be triggering, I spend a few minutes beforehand doing a little deep breathing to relax my mind and body. I create a specific intention for myself, such as “I will actively listen with an open heart.” I make this mantra relevant, personal, and simple. I also practice self-compassion in sessions when I find myself affected, silently reminding myself to wish the client well and put more trust in our shared process.
Last, I work to develop clients’ self-regulation skills to create a safe container for both of us. This might involve a five-minute body check-in at the start of a session, followed by 5 to 10 minutes of evaluating what strategies worked (or didn’t work) for them, then skill-building exercises involving expressive arts, worksheets, or a grounding practice. To solidify our work together, I also make sure clients know how to do these exercises at home.
Thanks to these strategies, I find that when I work with clients who may trigger me, I’m more prepared, less attached to their pain, and, together, we’re more resilient.
Tiffany Caicco, MA, RP, DVATI
4) Helping Ourselves Helps Our Clients
As an EMDR specialist, I believe the path we take our clients on to explore a troubling memory starts with the question, “What image or picture represents the worst of it?” When we hold a distressing image in our mind, our body starts to react by activating our stress response system. We may experience emotions, such as fear or sadness, as well as physical reactions, like tight muscles or shortness of breath.
Not long into my work, after many stressful sessions that left me feeling emotionally and physically exhausted, I realized that I often visualized the events my clients described to me, and it was taking a toll. To remedy this, I learned to catch myself when I’d start visualizing, and instead, I’d take a deep breath and try to relax the muscles in my body, while continuing to pay attention to the client in front of me. I’d follow their words to understand what happened, while looking for signs that their nervous system was getting activated, such as tight fists or shaking legs. When I’m present for my clients by regulating my own nervous system, I’m helping regulate theirs, too.
If I happen to miss an opportunity to stay fully regulated and find the impact of the stories I hear is affecting me at the end of the day, I often use a brief version of self-care EMDR, developed by Marilyn Luber. It’s helped me manage general stress from this work and prevent burnout. I learned from practicing this method that EMDR almost always ends with acceptance and resourcefulness.
I think this client could greatly benefit from EMDR. I might help her accept that while the accident was horrific, she ultimately found safety because she got help and took steps to heal from it. I believe the drive to heal and discover resources is natural and inherent, meaning that with the right support, we all can walk the path to recovery.
Kyungah Kim, LPC
Greenwood Village, Colorado
5) Get Your Body Moving
Meditation is the royal road to dealing with the vicarious trauma this therapist describes, as
well as the client’s symptoms.
Our body’s response to trauma—both this client’s car crash and her therapist’s reaction to sessions—includes two basic physiological responses, fight-or-flight and freeze. The fight-or-flight and freeze responses can be life-saving and are meant to be quickly turned on and off. Problems come when they persist, as they have with this client after her car crash, and as they do in this therapist after sessions with her. Fight-or-flight is manifesting as the anxiety, the distress described, while freeze is a likely source of the therapist’s exhaustion.
You don’t need to “protect” yourself from your client’s trauma but, rather, free yourself from it. Let it go. Slow, deep breathing for 5 to 10 minutes, in through your nose and out through your mouth, with your belly soft and relaxed, is the antidote to the fight-or-flight response. It will help you let go of the stressful, therapeutic hour and the thoughts and feelings that go with it, and bring you, more relaxed, into the present moment.
Shaking and dancing is another remedy. Standing up and shaking from your knees through your hips, shoulders, and head, then relaxing for a minute or two, then allowing your body to move freely to music that inspires you will energize your frozen, exhausted body and help you release painful feelings
about your session.
As this therapist does soft belly breathing and shakes and dances, he’ll be acting on his own behalf to resolve his vicarious trauma, and this experience will likely make him want to use these techniques in his work with his client.
In addition to counteracting the physiological effects of trauma, these two meditation techniques—soft belly is a “concentrative” meditation and shaking and dancing an “expressive” one—can give the client a much needed, more relaxed perspective on the traumatic memories that may continue to disturb her. They also provide the physiological balance which will make it easier for her to connect with her therapist, and others who may be helpful.
You can learn more about these and other trauma-healing techniques—and check out the scientific evidence for them—in my most recent book, The Transformation: Discovering Wholeness and Healing After Trauma.
James Gordon, MD