Resilience is a dynamic interactive process, describing a relative resistance to environmental risk experiences, and implies better than expected psychological outcomes (Luthar et al, 2000). The term ‘resilience’ has been used to refer to a group of factors that promote positive outcomes in terms of adjustment, competence, good health and development in individuals exposed to threatening conditions, traumatic experiences or severe adversity (Luthar, 2003). Therefore, during times of significance stress, such as the COVID-19 pandemic, it is important to examine the factors that might enhance resilience.
As Mental Health Psychology Practitioners (MHPPs) are classified as key workers, they are likely – now more than ever – to experience stress related to the responsibilities of their role, as it exposes them to others’ traumatic life experiences. Primarily, this is related to the nature of therapy where there is extensive and consecutive exposure to traumatic life events, empathic commitment with clients’ traumatic experiences, and the facilitation of interventions that seek to encourage the healing process (McCann & Pearlman, 1990). The cumulative effect of this work may have a transforming and deleterious impact on therapists, resulting in a phenomenon known as ‘vicarious traumatisation’. Specifically, vicarious trauma describes the emotional and cognitive disruptions faced by therapists as they engage in therapeutic relationships with survivors of traumatic events (McCann & Pearlman, 1990).
Beyond doubt, the wellbeing of MHPPs affects the quality of care and service-user outcomes (Delgadillo et al, 2018); it is therefore critically urgent to capture how MHPPs cope during the pandemic and to explore factors that assist them in developing resilience in a period of unexpectedly high stress. Hence, the aim of this study was to investigate how vicarious traumatisation has affected MHPPs who performed their duties during the COVID-19 pandemic and the factors that enhanced their coping skills and resilient features.
A qualitative, exploratory approach was deemed suitable for the purposes of this research as it allowed unearthing substantial descriptions of participants’ experiences and enabled their voices to be heard. Invitations to participate in the study were sent to professional organisations; nine MHPPs, both males and females, responded and semi-structured interviews, lasting one hour on average, were used to collect data. Participants were based in urban and rural areas in the UK, working in private and governmental institutions, with both new and established clients. Their working experience ranged from three to 25 years and all stated that during the pandemic they were busier than normal.
Interviews ranged across a series of themes and data was analysed using thematic analysis. The emerging themes reflect the reality of participants, including the effects of vicarious traumatisation on their wellbeing and strategies they employ to sustain positive mental health and demonstrate resilience.
The lack of conceptual clarity has characterised research on vicarious traumatisation for the past three decades, mainly because it has been confused with job burnout. Although parallels can be drawn between vicarious trauma and burnout, incidents of burnout are attributed to the circumstances encountered within the working environment (Brady et al, 1999), whereas vicarious traumatisation includes indirect exposure to traumatic materials, post-traumatic stress disorder symptoms, and negative shifts in therapists’ cognitive schema (Cieslak et al, 2013). This means that the therapist may experience feelings and symptoms comparable to those of the client (Pulido, 2007). For example, Bober, Regehr and Zhou (2006) found that therapists who were exposed to victims’ trauma were more likely to report higher levels of traumatic stress symptoms and intrusion. Other studies specifically examining the mental health of psychologists have found elevated rates of depression and stress in this population (Gilroy et al, 2002).
McCann and Pearlman (1990) argued that vicarious trauma may be considered a normal reaction to trauma work; however, more recent studies report that it may result in emotional, cognitive, and physical symptoms that can disrupt a therapist’s personal and professional self. These include intrusive imagery and distressing thoughts, evading, emotional numbing, hyper arousal, and somatisation including headaches, nausea, sleeplessness, anger, sadness and anxiety. According to Creamer and Liddle (2005) these symptoms are exacerbated in disasters that are low in predictability and high in destruction and duration of impact.
As such an example, Pulido (2007) discussed the 9/11 terrorist attacks on New York City. Pulido argued that working with clients who had 9/11-related issues was complicated for the social workers who participated in their study, as they had been exposed to the same disaster as their patients. This collective trauma – defined as the psychological upheaval that is shared by a group of people who all experience an event (Aydin, 2017) - played a major role in heightening the resultant vicarious traumatisation in professionals, some of whom reported relevant symptoms three years after the event.
Drawing parallels with the COVID-19 pandemic, it is important to consider that the unpredictability of COVID-19 has altered the way societies function in a collective way; it has led to huge changes in everyday life, including extended periods of isolation and high levels of uncertainty for everyone. Long-term effects related to the nature of the collective trauma, caused by the pandemic, are likely to increase the demand for mental health care. It is thus important to study the effect of vicarious trauma on MHPPs’ wellbeing and the mechanisms they employ to deal with it and develop resilience.
COVID-19 and vicarious trauma
The MHPPs who participated in this study reported different experiences, based on their role and clients. However, they all raised concerns for groups and individuals they were working with and for the way the pandemic altered their own way of life, both at the professional and personal level. The majority of these professionals reported that anxiety and depression among their clients were ‘worsened by limited access to treatment’. Relationship violence, the effects of unemployment, suicide attempts, loneliness and increased use of alcohol were also discussed by the professionals as trends in mental health they found concerning, especially among patients who had no or limited access to services. According to participants, the unavailability of stress relief strategies that people usually employ, such as going to the gym or taking trips, had rendered their role in supporting their patients more vital than ever.
For many MHPPs this was an extra burden, resulting in distressing thoughts about the wellbeing of their patients. More specifically, some participants expressed feelings of inadequacy and anger as they felt they could not ‘help patients properly’ especially when they, themselves, were trying to process and adjust to a new status quo. This led to many participants questioning their abilities as practitioners and experiencing feelings of helplessness and vulnerability. This was particularly the case with less experienced therapists who reported feeling uncomfortable when discussing with clients the ways the pandemic had affected them. Flashbacks of their clients’ stories and other intrusive symptoms, such as sleeplessness, were also experienced by less experienced MHPPs.
Identification with patients’ fears was one of the key themes this research uncovered. As discussed above, collective traumas pose challenges for MHPPs to practise their profession, as they are exposed to the same disaster as their patients. Pulido (2007) argues that clients’ stories, fears and experiences can interact with the professional’s own stress levels and concerns; most participants in this research found it difficult to help patients when they were struggling to maintain their own emotional balance.
The analysis demonstrated this was predominantly the case for those participants who dealt with patients who unexpectedly lost loved ones because of the pandemic. One of the participants, whose own brother had been diagnosed with COVID-19, but recovered, admitted experiencing intrusive symptoms like distressing thoughts and sleeplessness; this was because she was identifying with patients who had lost loved ones, therefore internalising their pain. ‘I could have been in their position’, she kept repeating during our conversation. Other participants engaged in avoidance, for example minimising the importance of the pandemic or avoiding experiencing positive emotions. One of the therapists, treating patients who were diagnosed with COVID-19, reported hyperarousal symptoms such as constant washing of hands and extensive use of personal protective equipment.
Development of resilience
It is important to consider how MHPPs ‘stay sane’, despite their psychological health continuously being threatened by phenomena such as vicarious traumatisation. Over the past 30 years research has focused on the so-called ‘resilient people’, namely those individuals showing a relatively good psychological outcome despite having suffered experiences that would be expected to bring about serious consequences (Luthar, 2003). As discussed, although a contested concept, resilience, is concerned with the combination of serious risk experiences and a relatively positive psychological outcome despite those experiences (Luthar, 2003).
Researchers in this field have identified several protective factors that can affect someone’s resilience and make a fundamental distinction between them. These protective measures include interpersonal (external) factors, such as relationships among individuals, and intrapersonal (internal) factors, developed from the internal attributes of individuals. The relationship between these protective factors and risk factors has been widely investigated. Rutter (2013) conducted an extensive review on the topic of stress and resilience and suggested that the latter is indeed a personal reaction to adverse circumstances. Rutter (2013) suggested that resilience may be fostered, for instance, by exposure to manageable stressors, experiential learning, social relationships, and mental features such as self-reflection and planning. As MHPPs are routinely and indirectly exposed to crisis and critical events experienced within the therapeutic relationship, the development of resilience is critical for this professional category and is a significant predictor of counsellors' wellbeing (Arnout & Almoied, 2020).
The MHPPs who participated in this study reported several mechanisms they employed to maintain positive wellbeing and develop resilience during these unprecedented times. This happened despite the fact that most of them did not have any prior experience in handling issues that collectively affected society. Most of the participants mentioned they were not trained in disaster mental health counselling and had to rely on their own knowledge, skills, and experiences to deal with patients who were severely affected by the pandemic.
The importance of frequent, systematic supervision sessions was described by most participants as the key factor affecting their wellbeing and helping them set boundaries between their personal and professional lives. Professionals who received regular individual supervision reported higher levels of wellbeing than those who did not; they emphasised that this practice had encouraged them to become more reflective as practitioners by identifying both personal and professional development needs. This is in line with research on resilience and reflection, according to which, adversity has the potential to trigger a conscious process of self-reflection; self-reflection facilitates the capacity to evaluate task orientated coping and problem-solving strategies and is proposed to strengthen resilience (Crane et al, 2018).
Many MHPPs stated it was difficult to set boundaries and avoid identification with patients’ problems, especially during the lockdown. However, practising yoga, meditation and mindfulness were described as useful tactics in building stress resilience, along with taking up new hobbies and avoiding social media, which, as one participant stated, has ‘the tendency to exaggerate’. Having self-awareness and being able to manage their emotions was reported as a key factor in distinguishing among their different roles (as parents, friends and therapists) and helped them in performing their duties. Engaging in self-care was deemed essential by most participants, as it made them feel ‘recharged and ready to deal with a demanding job’.
Seeking social support was also mentioned as another way of developing resilience among those who were interviewed. Lockdown and social distancing affected the quality of social support participants received, but they all mentioned it as a mechanism that could enhance their resilience to stress. Some participants stated that having ‘informal supervisions’ in the form of frequent conversations with colleagues and peers helped them deal with the symptoms of vicarious trauma and set boundaries between their feelings as human beings and their professional role.
The findings of this study suggest a number of interventions that can be implemented in order to reduce the effects of vicarious trauma among MHPPs and develop resilience. As highlighted by the participants, there is a need to train and prepare MHPPs for situations that can be described as collectively traumatic. Acquiring tools that can help them live with the uncertainty of prolonged stress can benefit both the professionals and their patients. Receiving training and support on developing strategies that could assist them in alleviating the symptoms of vicarious traumatisation was also reported as essential. According to participants, continuous professional development activities should focus on promoting positive wellbeing and include self-care strategies, like yoga and meditation. These practices have consistently been associated with decreases in both anxiety and depression as well as with increases in mindfulness (Cahn et al, 2017).
Increasing the frequency of individual supervisions and providing more support to less experienced MHPPs may also reduce the symptoms of vicarious traumatisation among MHPPs who deal with patients affected by disasters. In addition, reflecting on the positive impact of social support on mental health and wellbeing, group therapy sessions with peers should be considered as a way of boosting support for MHPPs. Finally, research has demonstrated that mental health workers may experience symptoms of vicarious traumatisation many months or years after the traumatic event (Pulido, 2007). Therefore, it is essential to organise follow-up care programmes for this group of professionals, focusing on recovery interventions.
This study has identified prospective areas of training that can inform the ways in which MHPPs are supported at critical moments. Future research should address the long-term effects of vicarious traumatisation on MHPPs who performed their duties during the COVID-19 pandemic to capture changes over time. Findings from studies such as this one can support professionals in dealing with any additional stressors their role entails and can potentially contribute to increased motivation, empowerment, and personal fulfilment among MHPPs, eventually leading to more positive outcomes for service users.
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