Bearing Witness to Clients’ Traumatic Experiences in Psychotherapy and Therapist Mental Health

Early 2020 has brought with it a number of unprecedented challenges. These challenges include navigating the coronavirus-19 (COVID-19) pandemic and combating police brutality and racism more broadly while in the midst of that pandemic. For some, experiencing or witnessing actual or threatened harm from COVID-19 may be traumatic (Horesh & Brown, 2020). Further, the deaths of George Floyd, Breonna Taylor, Tony McDade, and countless others sparked discussion and protests about centuries of racism and discrimination in the United States (US). While events like directly or indirectly experiencing threatened or actual harm – such as experiencing or witnessing police brutality – are readily categorized as potentially traumatic events in the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM–5; American Psychiatric Association [APA], 2013), experiencing racism more broadly can also be traumatic (Williams et al., 2018). Taken together, therapists play an important role in supporting clients as they navigate these potentially traumatic events related to COVID-19 and racism in the US. In bearing witness to such traumatic experiences, however, therapists themselves may develop trauma-like symptoms that can negatively affect their well-being and the quality of care they provide (Follette et al., 1994; Penix et al., 2019). Therefore, the purpose of the present article is to review the types of changes therapists may experience after bearing witness to client trauma, risk factors for experiencing those changes, intervention strategies for optimizing therapist mental health, and challenges associated with implementing those strategies.

In practice and research circles, several terms are interchangeably used to describe the consequences of therapists’ indirect exposure to trauma. However, these terms – such as secondary traumatic stress (STS; Figley, 1995), vicarious trauma (McCann & Pearlman, 1990), and compassion fatigue (Figley, 2002) – refer to particular types of changes in the literature. Specifically, STS is used to describe symptoms that mirror those of posttraumatic stress disorder (PTSD; e.g., hypervigilance, negative cognitions) among those who have been indirectly exposed to trauma (Figley, 1995). While the DSM-5 (APA, 2013) categorizes indirect exposure to trauma as a Criterion A event for PTSD, STS is the historical construct used to assess such symptoms among healthcare workers and authors have argued for the retention of the term “STS” in those contexts (for a review, see Penix et al., 2019). Vicarious trauma focuses on a smaller subset of STS symptoms, including changes in cognitions occurring after indirect exposure to trauma (e.g., negative beliefs about the self or the world; McCann & Pearlman, 1990). Last, compassion fatigue consists of two components: STS and burnout (Figley, 2002). Unlike STS and vicarious trauma, burnout does not require indirect exposure to trauma and instead assesses symptoms such as exhaustion and depersonalization (Maslach, 1982). Nevertheless, the development of PTSD-like symptoms after indirect exposure to trauma (hereafter, “STS”) is considered an occupational hazard of providing psychotherapy to traumatized clients (e.g., Adams et al., 2006).

Bride and Figley (2009) proposed a theoretical model explaining the development of STS while providing psychotherapy that is comprised of (1) therapists’ indirect exposure to clients’ traumatic experiences, (2) portraying empathy during client interactions, and (3) accounting for factors linked with STS risk. First, studies examining the role of therapist exposure have yielded mixed results, where some have found that providing care to more traumatized clients was associated with greater STS (e.g., Cieslak et al., 2013; Handran, 2015) and others have not (e.g., Follette et al., 1994; Perron & Hiltz, 2006). Recently, a meta-analysis of 38 studies found a link between having a higher proportion of traumatized clients and reporting more STS symptoms (Hensel et al., 2015). Thus, there is some evidence that exposure to clients’ traumatic experiences increases STS risk in therapists.

Second, relatively fewer studies have examined the role of empathy in STS risk. One study did not find a link between empathy and STS (Badger et al., 2008), but another study found that trauma workers who demonstrated more empathy reported increased levels of STS (MacRitchie & Leibowitz, 2010). However, aspects of empathy may protect against STS, such as self-other awareness and better emotion regulation (Wagaman et al., 2015). Future research precisely identifying the role of empathy in STS risk is imperative given that it is a core component of the therapeutic alliance (Bordin, 1979) and a meta-analytic predictor of better psychotherapy outcomes (Elliott et al., 2018).

Third, studies have explored a range of factors linked to STS. Regarding therapist factors, meta-analytic findings suggest that younger age, less experience, less trauma training, higher levels of work, and less social support were linked with greater STS (Hensel et al., 2015). In contrast, therapist ethnicity, gender, having a similar trauma history as clients, being emotionally involved with clients, experiencing posttraumatic growth, and supervision quality were not meta-analytically linked with STS. Furthermore, stronger beliefs that one can manage their STS symptoms (i.e., coping self-efficacy; Cieslak et al., 2016), less burnout (Cieslak et al., 2014), more positive appraisals of the benefits of one’s therapeutic work (i.e., compassion satisfaction; Avieli et al., 2016), and engaging in self-care (Penix et al., 2019) are associated with less STS. Therapists also endorse fewer STS symptoms when they report that their leadership and organizations promote healthy behaviors (e.g., taking care of one’s mental and physical health; Penix et al., 2019) and support therapists (e.g., Handran, 2015), respectively. Altogether, therapists may be at lower risk of STS if they are older, more experienced, acquire more trauma training, have lighter workloads, more social support, greater coping self-efficacy, less burnout, have higher levels of compassion satisfaction, engage in more self-care, and have supportive leaders and organizations.

The development of interventions targeting these risk factors in order to mitigate therapist STS is somewhat controversial. On the one hand, some have recommended against implementing interventions given that therapists tend to report sub-clinical STS symptoms, and little is known about impairment associated with STS (Elwood et al., 2011). On the other hand, others have argued that it is still important to identify at-risk groups in order to provide interventions that are tailored to those therapists (Hensel et al., 2015). To date, research is still needed to identify STS interventions that are most effective in ameliorating STS among at-risk groups. In their review, Bercier and Maynard (2015) found that no study utilized an experimental or quasi-experimental design to examine whether an intervention reduced STS in therapists. Since then, two studies have reported results from randomized controlled trials of web-based interventions for therapists treating traumatized military populations (Cieslak et al., 2016; Penix et al., 2020). Specifically, Cieslak et al. found that providing educational resources and enhancing perceived self-efficacy in managing STS symptoms resulted in less STS. In contrast, an intervention that targeted protective factors such as providing specialized training for treating PTSD, fostering social support, and promoting self-care resources did not reduce STS (Penix et al., 2020). Whether targeting other risk and protective factors for STS constitutes an effective strategy – such as emotion regulation, health-promoting leadership behaviors, and organizational support – has yet to be tested.

Overall, challenges remain in developing, implementing, and disseminating STS interventions. First, the impact of STS symptoms on therapist impairment, their provision of client services, and the organizations they serve is under-studied. This gap in the literature serves as a barrier for justifying the need to develop, research, and implement STS interventions. Second, therapists often have high workloads that can serve as a barrier to finding time to complete trainings or interventions targeting STS. This barrier can also make it challenging for therapists to participate in research studies about STS. For example, studies examining STS interventions in therapists have reported challenges with therapist retention and optimizing therapist use of available web-based interventions (Cieslak et al., 2016; Penix et al., 2020). Last, little is known about the factors that may promote therapist engagement in STS interventions, which makes it challenging for future researchers to develop and tailor interventions to better meet therapists’ needs and more effectively mitigate STS.

In conclusion, it is important that therapists attune to how their mental health may be affected by bearing witness to clients’ traumatic experiences related to recent events with COVID-19 and racism in the US. Research suggests that attunement may be particularly important among therapists who treat more traumatized clients, are younger, less experienced, have less trauma training, manage higher workloads, and endorse more burnout symptoms. Therapists may mitigate their STS risk by engaging in social support, enhancing their sense of coping self-efficacy, fostering their compassion satisfaction, and engaging in self-care. Additional research examining the impact of STS on therapists and potential intervention strategies can further support therapists’ efforts to optimize their mental health and the quality of client care provided.