Clinical TopicsCurrent JournalMental Health

Vicarious trauma

Author(s): Casey S. Hopkins, PhD, APRN, WHNP-BC

I am in my kitchen cooking dinner. My children are playing all around me. My mind wanders to the patients I was with just a few hours ago. A 12-year-old girl sat in my exam room telling me that she had been raped repeatedly by her father since early childhood. In the next room was her 14-year-old sister who told me their father had done the same things to her for as long as she could remember. I am replaying their stories in my mind, picturing them in the situations they recounted to me. I’m so sad. I’m mad. How could he do that? Why did those children have to experience that? Did any of the things I said or did today help those girls at all?

“Mom… Mom… Mommy! Will you help me with my math homework?” My thoughts are interrupted. I shake the thoughts from my head. I have my children to care for and dinner to cook. It’s time to move on. It was just another day at work.

A week later, I’m on a run near my house. The air is crisp, and the leaves are falling. Instead of appreciating the beauty around me, I find myself thinking again about the sisters I met the week before. As I pass by houses on my street, I think about what horrors might be going on behind closed doors. I am overwhelmed by my imagination. It’s hard to turn off the thoughts when I know the stories I hear at work are the realities of girls in my community. If it happened to them, it’s probably happening everywhere. I can’t trust anyone. I can’t let my own daughter out of my sight. A car passes by, interrupting my thoughts. I have to get home to get my children ready for school and get myself ready for work. It’s time for another day.

I was recently listening to a speaker during a course I was taking on caring for individuals who have experienced sexual assault. The speaker had spent many years working with individuals who had experienced trauma. She told a story about being on vacation with her family. They were hiking and came to a lookout over a cliff. The view was beautiful, with everyone enjoying the moment. Instead of commenting on the beauty of their surroundings like the others, she made the comment, “I wonder how many people have jumped?” Her first thought was not about the panoramic view of the mountain but about suicide. She recounted that one of her family members voiced concern about her comment. That moment was significant for her because she realized how the trauma she encountered through the people she was taking care of at work was directly impacting her personal life. She went on to discuss how she learned about vicarious trauma and how she was taking better care of herself now. I was on the edge of my seat. Vicarious trauma: I think that’s what I’m dealing with.

What is vicarious trauma?

As nurse practitioners, we are skilled in building rapport and developing trusting relationships with our patients. Naturally, we empathize with our patients and approach their health concerns holistically. Within these working relationships, there is a risk of exposure to trauma as patients disclose their experiences to us. Healthcare providers who are exposed to trauma by either listening to explicit accounts of the trauma or just having explicit knowledge of a traumatic event (eg, reading an account of the event in the patient’s health record) are at risk for vicarious trauma.

Vicarious trauma was first conceptualized and defined in the 1990s.1,2 Vicarious trauma involves affective and cognitive changes resulting from secondhand exposure to trauma.2 Similar to individuals with direct exposure and resulting post-traumatic stress disorder, vicarious trauma is associated with re-experiencing the details of events, avoidance of traumatic material, and symptoms of depression.3 Specific symptoms may include mood disturbances, impaired self-esteem and self-perception, and decreased motivation and empathy. Vicarious trauma takes time to develop and is related to chronic exposure to trauma. Long-term, repeated exposure to trauma results in shifting cognitive schemas. For example, an individual may begin to view the world as an evil or unsafe place, question innate benevolence, or doubt their self-worth.4 These shifts in the cognitive schemas are characteristic of vicarious trauma and contribute to the long-term sequela of symptoms including disturbances in spirituality, self-identity, worldview, intimacy, and trust.5,6

Sometimes the term vicarious trauma is used interchangeably with other related constructs including secondary traumatic stress (also known as compassion fatigue) and burnout. These constructs can describe the impact of providing trauma care, but they are distinct from one another, each describing a unique phenomenon.

Secondary traumatic stress, or compassion fatigue, is similar to post-traumatic stress disorder and is associated with an acute onset of symptoms after a specific exposure to trauma.5,7 Central to secondary traumatic stress are empathy and exposure. The stress of empathizing with and helping or wanting to help the traumatized individual results in symptoms of helplessness, intrusive thoughts, avoidance, negative affect, and feelings of isolation. Unlike vicarious trauma with chronic symptoms leading to cognitive shifts, the psychological responses associated with secondary traumatic stress can develop suddenly and without warning.

Burnout, on the other hand, develops over time. This is much like the progressive nature of vicarious trauma, except the development of burnout does not require exposure to trauma. Burnout is characterized by exhaustion and is often divided into three stages: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.5 Working with vulnerable populations such as those who have or are experiencing trauma, children, people with disabilities, and those with critical or chronic illnesses can contribute to burnout, but individual and organizational factors also can contribute. For example, interpersonal conflicts in the workplace, maladaptive coping patterns, heavy caseloads, and poor management may all contribute to burnout. Burnout exhaustion can result in low energy, sleep disturbances, and other physical symptoms such as headache, fatigue, and even hypertension.6 Similar to vicarious trauma and secondary traumatic stress, symptoms of burnout may include helplessness and hopelessness, mood disturbances, and impaired relationships.6 Although the constructs of vicarious trauma, secondary traumatic stress, and burnout are distinct, they often coexist.5

Who is at risk for vicarious trauma?

Anyone who is exposed to secondary trauma over time is at risk for developing vicarious trauma, but not everyone who is exposed will experience vicarious trauma. For example, in one study the rate of post-traumatic stress symptoms among frontline trauma physicians working during the height of the Covid-19 pandemic was about 12%.8 Why do some have more lasting effects of trauma exposure while others do not? The answer to that question is complex and not well understood. Some factors linked to a greater risk of vicarious trauma are an individual’s baseline psychological wellbeing, support system, and coping mechanisms. A person with a history of anxiety, depression, or other mental health conditions may have a greater risk for vicarious trauma than someone with stable mental health. Baseline mental health and social resources, or the lack thereof, may contribute to one’s ability to cope effectively with trauma.7,9

Evidence is conflicting on certain predictors such as gender and level of professional experience. Certain studies have indicated women are more likely than men to develop vicarious trauma, while others postulate women may appear to experience vicarious trauma at higher rates due to study bias and the likelihood of admitting or disclosing symptoms when compared to men.7 Regarding the level of professional experience, new clinicians have been shown to have a greater risk for vicarious trauma than more experienced colleagues. Other studies, however, have indicated clinicians with more years of experience are often given more difficult cases, which adds to trauma exposure, and also may have a greater risk for coexisting burnout.7 Personality type and level of empathy have been related to vicarious trauma risk as well. Individuals with neurotic personality types (ie, those more prone to negative effects such as anger, irritability, anxiety, depression) experience vicarious trauma more than those with conscientious personality types (ie, self-disciplined, goal-oriented, efficient, cautious).7 Personality traits may play a role in vicarious trauma risk, but personality alone cannot be separated from other genetic and environmental influences on an individual’s perceptions and reactions to trauma. Each individual’s experience with providing trauma care is unique and complex. More research is needed to better understand predictors of vicarious trauma.

How do you withstand the effects of secondary trauma?

Possibly the most vital strategy to withstand the effects of secondary trauma and prevent vicarious trauma is maintaining a healthy work–life balance. Work–life balance is the state of equilibrium that exists as demands from work and one’s personal life are prioritized.10 There is no perfect balance, however, or no “one-size-fits-all” approach. It is individualized and the balance is achieved over time, not from day to day. Providing holistic, therapeutic care is draining and can become all-encompassing. There will always be more to do at work: more patients to see, more projects, committees, and meetings. Creating a healthy balance requires setting boundaries and making time for self-care.

Here are a few practical examples of self-care: First, having social support minimizes the risk of vicarious trauma. Make time for relationships. Communication with coworkers or significant others about the trauma you have experienced is healing. Debriefing creates designated time to process your experiences, make meaning from those experiences, and reconnect with your purpose as a healthcare provider.11 Collegial support through debriefing is paramount in preventing professional stress that may lead to vicarious trauma and/or burnout. Having an environment in the workplace where traumatic experiences can be shared and heard can help to combat the cumulative negative effects of trauma exposure.11 Second, basic self-care practices, including regular exercise, a healthy diet, and restful sleep, are critical to overall wellbeing. Making time for vacations and hobbies also is part of caring for self. These practices help to improve physical and mental health, cognitive function, self-esteem, and mood, all of which decrease the risk for vicarious trauma. Third, awareness and mindfulness practice help to protect oneself from vicarious trauma. Simply knowing how vicarious trauma occurs along with its signs and symptoms reduces the risk for harm because it gives you an opportunity to change your behaviors and responses. Practicing mindfulness involves being present, calm, and connected so that you can be more aware of your feelings and able to communicate feelings more effectively.12 Mindfulness results in greater physical and mental wellbeing, from decreased blood pressure to less anxiety. Fostering a healthier state of physical and psychological wellbeing through mindfulness reduces the risk for vicarious trauma.

When treatment of vicarious trauma is needed, cognitive behavioral therapy with an emphasis on mindfulness, meditation, and stress reduction is recommended.6 If you believe you have symptoms of vicarious trauma, secondary traumatic stress, burnout, or simply want to talk to someone about the stressors of your job, seek out a counselor in your community or online (eg, or Many employers offer employee assistance programs that provide employees with mental health services including short-term counseling, referrals, and follow-up care. Employee assistance programs are designed to help employees cope with stressors and other issues that may impact their work and morale, so take advantage of those resources. For an extensive compendium of resources designed to support healthcare professionals and others involved in trauma care, the United States Department of Justice Office for Victims of Crime created the Vicarious Trauma Toolkit that is freely accessible to all.13

In conclusion, vicarious trauma is a work-related risk for nurse practitioners. Approaching patient care holistically means asking questions about social determinants of health that include, but are not limited to, living arrangements, home life, occupation, safety, and relationships. Sometimes the risk that comes with asking questions is exposure to trauma. But asking and knowing allows for the therapeutic provision of care. We carry the stories of the girls and women we care for. I encourage you to be mindful in caring for yourself and to support one another to protect from and correct the inner transformation that is vicarious trauma so that we can continue providing quality care to our patients who need us the most.

Casey S. Hopkins is Assistant Professor of Nursing at Clemson University in Clemson, South Carolina, and a women’s health nurse practitioner in the Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, at Prisma Health-Upstate in Greenville, South Carolina. The author has no actual or potential conflicts of interest in relation to the contents of this article.

Womens Healthcare. 2023;11(2):22-25. doi: 10.51256/WHC042322


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