Vicarious Trauma, Compassion Fatigue, and Burnout: What causes them and how do we prevent them?

Gianni Pirelli, Pirelli Clinical and Forensic Psychology, LLC
Dana L. Formon, Colorado Department of Human Services
Kelsey Maloney, Texas Tech University

In this article, we address the concepts of vicarious trauma (VT), compassion fatigue (CF), and burnout (BO) within the context of forensic mental health. These are related, albeit distinct, concepts that have been used to describe patterns of negative emotional outcomes in various employment contexts. We begin with a general review and delineation of VT, CF, and BO before discussing these outcomes across professions. Then, we discuss these concepts in the specific context of forensic mental health to include how such issues can impact students, trainees, early career professionals (ECPs), supervisors and instructors, and practitioners. We then use the subfield of forensic psychology as exemplar, whereby we outline relevant research and address VT, CF, and BO within the context of criminal, civil, and administrative matters as well as treatment, teaching, and research contexts. Subsequently, we outline four areas of consideration for those working in the forensic arena, specifically, (a) identifying potential risk factors; (b) recognizing, developing, and strengthening protective factors; (c) overcoming self-care and treatment barriers; and (d) identifying and engaging in therapeutic interventions. Lastly, we set forth a formal call for research, which we believe is essential to the development of a more meaningful understanding of the connection between VT, CF, and BO in forensic mental health.

vicarious trauma, compassion fatigue, burnout, forensic mental health, forensic psychology

“Individuals working in the helping professions often evidence higher levels of empathy and compassion, placing them at risk for negative outcomes. Namely, over 40 years ago, Pines and Maslach (1978) found that increased patient contact time, greater patient-to-provider ratios, and more years spent in higher education obtaining a degree was associated with providers being less likely to feel fulfilled in their work, more likely to seek other employment, and also more likely to describe themselves as more tense and distant toward others both in and out of the workplace. Consistent with this, Figley (2002) noted that higher expressions of empathy in the workplace (specifically toward feelings of hurt, fear, anger, and other “negative” emotions) resulted in the depletion of empathy, leading to overall poorer mental-health-related outcomes for both therapist and client.”

“Professionals who routinely interface with trauma and violence— such as those working in corrections, the legal system, medicine, nursing, and mental health—can develop symptoms related to what is referred to as vicarious trauma (VT), compassion fatigue (CF), or burnout (BO). Those working in the forensic subfields of psychology, psychiatry, social work, and nursing may be even more susceptible to developing problems associated with VT, CF, and BO given the intensive nature of their work. As Abellanoza, Provenzano-Hass, and Gatchel (2018) noted, BO is particularly problematic among emergency room nurses. Nevertheless, although the overarching literature associated with VT, CF, and BO spans several large fields, empirical research is lacking in the forensic subfields, especially when compared with other related areas such as police stress. In addition, and of particular importance, there are limitations in the empirical literature regarding work-related stress, particularly with respect to the ways in which the construct has been operationalized.”

“There is virtually no forensic-specific research base of published empirical studies from which to draw when setting forth considerations to prevent the development of VT, CF, and BO within this overarching arena. Although we set forth a formal call for research in this regard in the following section because the need is clear, such is likely to take many years to develop. Therefore, we first provide four sets of considerations for forensic mental health practitioners, academicians, researchers, and students and trainees based on what we currently know about the development of these problems among helping professionals. The four areas are (a) identifying potential risk factors; (b) recognizing, developing, and strengthening protective factors; (c) overcoming self-care and treatment barriers; and (d) identifying and engaging in therapeutic interventions.”

Identifying Potential Risk Factors
“Some risk factors may be more specific to the development of one particular type of problem— either VT, CF, or BO. For instance, with respect to developing VT, risk factors include exposure to disturbing information, stimuli, and particular clinical presentations (e.g., Cluster B personality disorders); engaging in forensic work generally, but especially working with traumatized groups and on violence, suicide, sex offense matters; and having less training and exposure in these areas. Risk factors that may be more specific to the development of CF can include a high desire to eliminate others’ suffering; the person’s own unresolved trauma history; working with traumatized children, and particularly vulnerable groups; and having high amounts of natural empathy. As for developing BO-related problems, risk factors include having a high caseload and limited resources; lacking professional sup- port from supervisors and coworkers; as well as a lack of systemic support from employers, including, but not limited to, issues related to accruing compensatory time, receiving additional training, having paid leave options, and overtime-related requirements. Moreover, as we noted earlier in the article, it is for these reasons that practitioners working in independent practice settings may also be at risk for developing BO— particularly given the inherent challenges related to securing regular, professional peer support and having fewer safeguards available to avoid working long hours and on weekends and having to take work home.”

Recognizing, Developing, and Strengthening Protective Factors
“The VT, CF, and BO literature includes various protective factors—in terms of professionals’ own characteristics and self-care practices. For instance, self-compassion has been noted to be associated with reduced CF and BO as well as the relevance of increased emotional intelligence and emotion management-related abilities. In addition, Collins and Long (2003) indicated that compassion satisfaction—the perception of benefits rather than costs from working with clients and/or their traumatic symptoms—is also a protective factor in this context, as it is the opposite of CF and is positively correlated with mindfulness skills. Moreover, CF-related effects may be minimized by setting firm professional boundaries with clients to prevent being inundated by others’ distress outside of set working hours, along with engaging in additional training, consultation, and supervision with experienced professionals. Moreover, adaptive, problem-focused coping strategies are thought to be much better to employ in this context as opposed those that are avoidance-based. In addition, organizational job support as well as supervisory and professional consultation models are lauded as ways of increasing practitioner and student/trainee support and reducing VT. Furthermore, practitioners may find meaning and feel satisfaction from seeing their clients improve.”

Overcoming Self-Care and Treatment Barriers
“Mental health providers, including forensic practitioners, can face barriers when seeking help to prevent or reduce the effects of VT, CF, and BO. Although trainees and psychologists often engage in psychotherapy and may view such positively, at least some would likely acknowledge that ‘there was a time when they may have benefited from psychotherapy but did not seek it out.’ Risk factors for developing CF and BO, specific to treatment providers, may include increased levels of self-criticalness, self-judgment, and measuring self-worth in the successes or failures to help others. More general barriers to pursuing psychotherapy include issues related to time, money, work–life balance, social stigma, and concerns about treatment and self-disclosure. Mental health providers may face even greater hurdles than the general public when seeking therapeutic interventions. For example, they may need to travel greater distances to receive treatment to maintain confidentiality, have concerns about being reported to regulatory boards for engaging in certain (potentially unethical) behaviors, and believe they can treat their own symptoms and problems.”

Identifying and Engaging in Therapeutic Interventions
“The VT treatment literature is relatively sparse. However, there is promise in third-wave cognitive– behavioral therapy (CBT) stress management interventions for medical students and other health care providers, such as mindfulness-based stress reduction, compassionate mind training, mindfulness-based cognitive therapy, and acceptance and commitment therapy. One promising intervention for reducing CF and VT, in particular, is the components for enhancing clinician engagement and reducing trauma (CE-CERT) model. This model rejects the notion that radical self-care can treat VT and proposes practitioners and supervisors develop concrete emotion regulation skills. The five components of this model are (a) experiential engagement, (b) reducing rumination, (c) conscious narrative,
(d) reducing emotional labor, and (e) parasympathetic recovery. Although this is a promising intervention, its authors acknowledge that the next steps related to defining fidelity and empirical testing have not yet been addressed.”

“Nevertheless, many organizations and training programs tend to emphasize brief staff trainings or group sessions and work- shops over more formal and in-depth CBT-based interventions. Although organizational- and team-level interventions have certainly been considered to be important components of initiatives focused on reducing BO and the like, individual-level interventions remain an important part of such as well. Indeed, Cramer and colleagues (2019) have recommended empowering health care workforces and implementing a multilevel approach to facilitating coping and well-being.”

“Research on VT, CF, and BO is not particularly new per se, but it simply has not extended into the forensic mental health arenas, including, but not limited to, the subarea of forensic psychology. As noted, we found no published studies on VT, CF, or BO specifically addressing these phenomena in forensic psychologists and only one unpublished study in this regard, which was presented in two conference presentations. Moreover, the extant research related to other forensic clinician groups is limited for various reasons, such as small sample sizes, the sole use of survey methods, the sole use of qualitative methods, and the use of convenience sampling. Of course, these studies have been important, their limitations notwithstanding, because they have set the foundation for future research in this area.

Our aspiration is that this article will serve as a formal call for research in this regard, and the following areas of study are important to pursue:

(i) Identifying the prevalence and incidence of VT, CF, and BO among forensic mental health professionals, including practitioners, academics, researchers, students, and trainees.

(ii) In addition, as Brovko and Foote (2011) aptly pointed out, it would be important to gather data from those who left the forensic arena because of their adverse reactions to such work, generally, or as a result of VT, CF, and BO-related issues, specifically.

(iii) Identifying the correlates of VT, CF, and BO in relation to the presence of risk and protective factors in the aforementioned subgroups. This area of inquiry should include investigation into the specific attributes of the forensic mental health subgroups in question (i.e., practitioners, academics, researchers, students, trainees) as well as environmental and case-specific factors (e.g., working with perpetrators vs. victims; engaging in defense vs. plaintiff’s work in the civil arena; the potential effects of factors related to adversarial allegiance as well as cognitive bias vis-a`-vis clinical-forensic decision making). In addition, investigating both the use and potential role specific coping mechanisms may have in mitigating the development of VT, CF, and BO-related problems, such as ‘gallows humor.’

(iv) It would also be useful to survey forensic medical and mental health educational and training programs through-out the country to ascertain if and how the prevention of VT, CF, and BO is incorporated in their curricula. Although experimental methods, such as those employed by Vera et al. (2019) in their investigation of forensic evaluator empathy, may not be possible in the study of VT, CF, and BO, their recognition of the importance of field research is well-taken. Although generally more difficult to conduct than survey studies, field studies are often more informative and, therefore, useful. As such, it would be beneficial for researchers to conduct field studies on VT, CF, and BO among forensic mental health professionals.

(v) Investigating the potential (moderating) impact transferential issues may have on the development of VT, CF, and BO-related problems among both treating and evaluating forensic clinicians.”

“More research on VT, CF, and BO in forensic mental health is desperately needed. At least ostensibly, those working in this arena may be quite vulnerable to developing such problems; therefore, we need to gain a better understanding on the specific prevention measures that can be taken by practitioners, academics, researchers, students, and trainees in forensic mental health. Once we have a better understanding of the actual inci- dence and prevalence of these problems across forensic subgroups, we can begin to develop a more nuanced perspective on the particular factors that are distinctly associated with VT, CF, and BO in the forensic arena.”

As always, please join the discussion below if you have thoughts or comments to add!