The ethical considerations of Counselling ...

Theoretical Paper

The ethical considerations of counselling psychologists working with trauma: Is there a risk of vicarious traumatisation? Amirah Iqbal Content & Focus: This paper will discuss the importance of professional and ethical guidelines for both Qualified Counselling Psychologists and Counselling Psychologists in Training when working in the field of trauma. It will also explore some of the challenges therapists may face when taking these guidelines into account. This paper will present a case vignette on how vicarious traumatisation may present, as well as how it may affect therapists before moving on to discussing how for some people trauma can lead to vicarious resilience. This paper questions if it should be compulsory to introduce trauma awareness courses prior to psychologists working with trauma survivors or within professional training programmes and concludes with suggestions of how therapists may prevent and/or manage vicarious trauma including the importance of self-care. Keywords: Vicarious traumatisation; therapists; counselling psychologists; ethics; trauma; vicarious resilience; self-care. ItHIN tHeRaPy a number of issues may lead to unethical practice. Research has demonstrated that there are salient issues within trauma therapy which have the potential to cause harm to both clients and therapists. some of these issues may include boundaries, countertransference and vicarious traumatisation (Pearlman, 2012). this paper will predominantly focus on vicarious traumatisation and explore some of the BPs and HCPC regulations within this context.

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Background of psychological ethics ethics may be seen as the standards that are used to judge or propose the morality (right or wrong) of an action (Francis, 1999; shillito-Clarke, 2010). the purpose of ethics is to advise towards high professional standards (shillito-Clarke, 2010). to ensure psychologists meet such standards, a structure should be in place to resolve problems should they arise (Francis, 1999). many countries such as China, america and Canada have their own relevant professional 44

bodies which monitor and offer a framework for psychologists to abide to. such published statements may change over time (shillitoClarke, 2010) and it is important to note that the ethical dilemmas in one branch of practice (for example, counselling psychology) will be different from another (such as, forensic psychology). Common to all branches of psychological practice are the key ethical principles that underlie all professional work (BPs, 2009; Francis, 1999). British psychologists are not only regulated by the British Psychological society (BPs), but along with fellow allied health professionals, they are also bound to abide by standards set by the Health and Care Professions Council (HCPC, 2012). the HCPC code of professional conduct (HCPC, 2012) and the BPs’s ethical framework (BPs, 2009) are in place to set a standard of behaviour, principles and attitudes for psychologists. the HCPC standards of conduct, performance and ethics supersede the BPs code of ethics and conduct (BPs,

Counselling Psychology Review, Vol. 30, No. 1, March 2015 © The British Psychological Society – ISSN 0269-6975

The ethical considerations of Counselling Psychologists working with trauma 2009) although Psychologists may use both to act as a framework (HCPC, 2012). In addition, the Division of Counselling Psychology professional practice guidelines (DCoP, 2009) are supplementary, proposing what counselling psychologists should do in pursuit of best practice. ethics may serve as a risk-management strategy (Francis, 1999) informing how psychologists work with their colleagues, clients and members of the general public as ultimately the purpose of the HCPC and BPs is to protect members of the public, clients and psychologists themselves (BPs, 2009; HCPC, 2012). the author will explore whether there are psychological consequences that arise for therapists1 who work with traumatised clients, and if so, what effect does this have on adhering to the BPs and HCPC ethical framework. moreover, do psychologists find regulatory bodies such as the HCPC and BPs restrictive when working with trauma survivors? If so, how do they work within these regulations yet remain ethically minded?

Vicarious traumatisation and the effect on therapists traumatic events include natural disasters such as earthquakes, atrocities like war, or personal events such as sexual or physical assaults/abuse (DSM-5, 2013). this can result in psychological difficulties for people directly affected by these traumatic events. the term post-traumatic stress disorder (PtsD) is used to explain the psychological sequelae (shapiro, 1995) people who have been directly affected by trauma may exhibit. People who may not have been directly affected by a trauma, but have actively worked with survivors experiencing PtsD (and additional forms of psychological distress as a result of trauma) may also be affected. Psychologists are trained to maintain personal and professional boundaries necessary for ethical practice. However, this 1

does not insulate from the effects of emotional content (Pearlman & mac Ian, 1996). therefore, psychologists can be affected by the traumatic experiences of their clients, which at times may lead to vicarious traumatisation (which is referred to in the literature as secondary trauma or compassion fatigue; Zimering, munroe & gulliver, 2003). Vicarious trauma is the experience of a clinician who develops a trauma reaction, secondary to the client’s traumatic experience (trippany, Kress & Wilcoxon, 2004). It has been suggested to involve ‘profound changes in the core aspect of the therapist’s self’ (Pearlman & saakvitne, 1995). this implies a shift or change in the therapist’s perception of experiencing the self, others and the world. If this affects the therapist’s relationships with others and their inner world this may have implications on the therapist’s ethical and professional practice (Pearlman & saakvitne, 1995; Pross, 2006; steed & Downing, 1998; Zimering et al., 2003). Vicarious trauma is conceptually based in constructivist self-development theory (CsDt). Here an individual’s unique personal history is shaped based on their experience of traumatic events. CsDt offers a framework for the assessment and treatment of the self that is affected by trauma. this includes the ability to tolerate strong affect, beliefs about the self and others in regards to frame of reference as well as safety, trust and intimacy (see mcCann & Pearlman, 1990; mcCann & Pearlman, 1992; Pearlman & saakvitne, 1995, for an in-depth explanation on CsDt). literature on vicarious trauma has provided an outline of the signs and symptoms for therapists to be aware of. these symptoms may take the form of changes in personal identity and world view, social withdrawal, lack of trust in others, feelings of helplessness, becoming easily emotionally overwhelmed, numbing of atypical feelings

the term therapist, psychologist and practitioner will be used interchangeably implying a clinician who works with trauma survivors.

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towards people and events, loss of connectedness to others and the self, hypervigilance and a difficulty to connect with joy (mcCann & Pearlman, 1990; Pearlman & saakvitne, 1995; Pross, 2006; steed & Downing, 1998). therapists may not experience all of these symptoms but they may manifest gradually and become pervasive over time, leading to the practical (and ethical) issue of competence (shillito-Clarke, 2010), the blurring of boundaries and not taking care of the self (mcCann & Pearlman, 1990; Pearlman, 2012; Pross, 2006). these issues constitute a problem for the therapist who thinks they are responding to clients in a professional and ethical manner. the degree to which a therapist may experience these symptoms may be based on factors such as their personal experience to trauma, their coping styles and professional circumstances (Pearlman & mac Ian, 1995). Conditions which may contribute to the phenomenon of vicarious traumatisation may include therapists who are new to trauma work and therapists who have experienced personal trauma. these experiences may lead to therapists reporting the most psychological difficulties and more negative effects compared to those without a personal trauma history (Pearlman & saatvikne, 1995). although some research suggests an association between personal history of trauma and the experience of vicarious traumatisation; schauben and Frazer (1995) found the symptoms of vicarious traumatisation was not related to a personal history of trauma (including the experience of assault). this is further supported by research which explored 259 mental health professionals working with clients who had experienced trauma. Personal histories of adult or childhood trauma in mental health professionals was not associated with vicarious trauma. moreover individuals who may have experienced unresolved personal histories were likely to seek the appropriate support through personal therapy (Bober & Regher, 2006). Findings have also indicated that therapists not receiving frequent supervision 46

report an increase of negative symptoms (of directly being affected by their trauma work; Pearlman & mac Ian, 1995). other factors contributing to vicarious traumatisation include the nature of the work, whether or not the therapist accesses personal therapy as a preventative and interventive purpose, the organisational structure, and the background and current training available to the therapist (Pross; 2006; saakvitne & Pearlman, 1996). these factors may evoke ethical concerns for therapists working in the field of trauma.

Ethical and professional framework and vicarious traumatisation (a case study) Neglecting the effect that trauma work has on oneself can be harmful to clients. Both the HCPC and BPs are committed to prevent harm to clients (BPs, 2009; HCPC, 2012). Pearlman and saakvitne (1995) postulated that unaddressed vicarious trauma may lead to therapists blurring boundaries in the therapeutic relationships which can be a foundational element of misconduct among trauma therapists. For example, therapists may avoid exploring trauma or they may mishandle therapy relationships (Dalenberg, 2000; Pearlman & saakvitne, 1995). these behaviours have the potential to re-injure the client. If clients do not benefit from therapy, is it because therapists do not abide to standards such as ‘you must act in the best interests of service users’ or ‘Within the limits of your knowledge, skills and experience?’ as set out by the HCPC (HCPC, 2012, p.3). some of the issues that arise in vicarious traumatisation have been illustrated in the following case vignette which is based on a composite of cases (see Figure 1). Jenna is unaware that she is experiencing vicarious traumatisation. Research shows that there is a need for therapists to be educated on what vicarious traumatisation is (Pearlman & saakvitne, 1995; Pearlman & mac Ian, 1995; steed & Downing, 1998; trippany et al., 2004). although the BPs notes psychologists are responsible ‘to be mindful of


The ethical considerations of Counselling Psychologists working with trauma

Figure 1: Case vignette: Jenna. Jenna is a 31 year old therapist. She has been qualified for just under a year and has not previously worked with clients who have experienced trauma. She does have a personal experience of trauma which occurred in her adolescence. She has received personal therapy to discuss her feelings and issues surrounding her experience (of sexual assault). Jenna chose not to share her personal experience of trauma with her current supervisor due to thinking that it was resolved and not wanting to bring it up. During the last nine months Jenna has been working for a trauma charity. There has been a shift in her perception of herself and others. During the last month she has noted that she is withdrawing from her peers and her partner. Jenna struggles to be intimate with her partner, and also feels that the world is unsafe. She is also struggling to sleep, and experiences somatic symptoms of stomach pains and backache. While listening to client’s trauma experiences Jenna has began to feel emotional and other times she has detached herself. As a result she is struggling to empathise with clients within the appropriate boundaries. There have been occasions where Jenna would prefer not to explore the trauma experiences. Jenna is aware that during the last month she has not been feeling her ‘normal’ self. She ponders going to her supervisor but thinks she needs to deal with this on her own as it may subside. During her psychology training Jenna did not attend any course on trauma or vicarious trauma. She presumed she would attend the relevant courses when she started her new job, but these courses were not discussed or offered to her and now she is unsure what to do.

any potential risks to themselves’ whilst also ‘avoid harming clients’ (BPs, 2009, p.18), how responsible can they be if they are unaware of their ailments? additionally if Jenna and other therapists are unaware of the signs and symptoms of vicarious traumatisation due to a lack of teaching, they may be unaware that they are not meeting the HCPC and BPs’s standards. therefore who should take responsibility to meet these standards? should course providers or organisation structures take responsibility to offer the appropriate training and knowledge? this causes concern because both sets of standards necessitate practitioners to undertake the appropriate knowledge and training which would deem them competent. For example, the HCPC adds ‘you must keep your professional knowledge and skills up to date’ and ‘you must act within the limits of your knowledge, skills and experience and, if necessary, refer the matter to another practitioner’ (HCPC, 2012, p.3). the HCPC standards also state ‘we do not dictate how you should meet our standards’ (HCPC, 2012, p.5) and, therefore, although Jenna is ‘struggling to empathise with clients’, it is not clear whether she should refer her client case to a colleague because it may be questioned, how does one assess harm? How does a therapist know that their practise puts a client in harm, and at what point should the individual/colleague intervene? Using the (BPs) ethical principles in trying to find an answer may benefit individuals. this ethical dilemma is further highlighted with the suggestion psychologists should ‘weigh… the potential harm caused by alternative courses of action or inaction’ (BPs, 2009, p.18). as discussed if Jenna has not received appropriate training in trauma she may not be aware of the effects of trauma work. also, she may not be aware of the higher levels of vicarious traumatisation in therapists who have a personal experience of trauma (mcCann & Pearlman, 1990; Pearlman & saakvitne, 1995; Pross, 2006; steed & Downing, 1998), and who are less


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experienced. Francis (1999) suggests recently qualified psychologists should be mentored by experienced psychologists when it comes to ethical and moral practice. therefore, should the ethical concerns discussed fall upon her supervisor who should abide to the HCPC standard ‘you must effectively supervise tasks you have asked other people to carry out?’ (HCPC, 2012, p.12). Contrastingly according to saakvitne and Pearlman (1996) each trauma worker is responsible for self-care and should also be responsible to engage in frequent and regular supervision. although psychologists ‘have a responsibility to be mindful of any potential risks to themselves’ (BPs, 2009, p.18) they may not be aware of the support available when experiencing vicarious traumatisation. Bober and Regher (2006) analysed 259 questionnaires of mental health professionals working with people who had experienced trauma and found an individual’s coping strategies can individualise a problem leading to the individual feeling that the feelings of vicarious trauma is their fault. the authors suggest it should be seen as a normal and expected reaction when experiencing repeated exposure to material of a traumatic nature. and therefore it might also be noted that the normalcy of encountering feelings associated with vicarious trauma are ones which are incorporated in training to alleviate distress and worry. When reflecting on Jenna’s case, would it be ethical for her to carry on practising if she was aware of experiencing vicarious traumatisation? the literature in this field suggests she could still practise as long as she seeks support, supervision and engages in ‘selfcare’. However, the HCPC tells registrants ‘you must limit your work or stop practising if your performance or judgement is affected by your health’ (HCPC, 2012, p.14). this is an indication of the potential struggle for therapists to work according to evidence and practice, yet try and abide to the standards and ethical guidelines of regulatory bodies. Pearlman (2012) notes that the ability to empathise is critical for therapists working 48

within the field of trauma. However, symptoms of vicarious traumatisation can include ‘a lack of empathy and trust towards others’ (Pearlman & saakvitne, 1995), therefore, if Jenna is struggling to empathise, is she adhering to the BPs’s ethical principle and the HCPC standard of working competently? the ethical and code of conduct and professional standards do not offer insight on how therapists can manage distressing emotions such as a lack of empathy and trust. Pearlman and saakvitne (1995) note that countertransference can occur in the context of trauma work. effective clinical work requires self-awareness on the part of the therapist (Pearlman & Caringi, 2009). the ability to reflect on practice promotes self-awareness (Pearman, 2012) but also, within counselling psychology training, trainees are encouraged to reflect on their practise. therefore, counselling psychologists may be better adjusted to work within the trauma field, and distinguish the feelings which belong to themselves and their clients. another advantage of the counselling psychology doctorate (and psychotherapy training) is a requirement for trainees to attend to personal therapy. this offers a safe space to discuss issues and focus on personal development. However, once qualified, therapists are not required to engage in personal therapy. Findings have suggested therapists who experienced vicarious traumatisation utilised their personal therapy to discuss the impact of their trauma work (Pearlman & mac Ian, 1996). this supported them in meeting their client’s needs and indicates a commitment to professional and ethical practice. Hence, if personal therapy can support ethical and professional practice trauma therapists should consider personal therapy. In addition Bober and Regher (2006) conclude it is clear further research is required exploring workplace conditions and the expectations of working with clients who experience trauma. the authors suggest the research of individuals strategies that may prevent, identify and reduce various trauma responses is needed and as a result of



this organisations should take some responsibility of the training and emotional wellbeing of their employees.

Vicarious resilience Resilience is frequently described as a defence mechanism that supports people to thrive when confronted by adversity. Vicarious resilience is a fairly new concept based on research with psychotherapists who have treated victims of political violence (developed by Hernandez, gengsei & engstrom, 2007). People who have experienced trauma are able to survive when relying on adaptive processes and using strategies to cope (engstrom, gernandez & gangsei, 2008; Hernandez et al., 2007). similar to vicarious trauma, vicarious resilience is also seen as a natural and normal process which can occur in professionals who work in the field of trauma. similarly, psychologists working with a trauma survivor may learn about overcoming adversity. this may result in empowering trauma therapists through their empathic engagement and therapeutic ‘meeting’ with the narrative of trauma (and resilience) of their clients. similar to vicarious traumatisation where therapists are empathically attuned with clients, vicarious resilience may offer a positive re-evaluating and revaluing of work, and lead individuals in a positive healing direction (engstrom et al., 2008). the factors which appear to contribute to vicarious resilience in therapists involve not only the nature and extent of which the therapist connects with the clients pain by being empathically attuned with their client by it also involves core empathic capabilities (engstrom et al., 2008; Hernandez et al., 2007). the ability to engage in self-care notably acknowledges that therapists are taking responsibility for themselves, and by taking responsibility, they may be aware of their clients’ needs. therefore, it is worthy to note vicarious resilience may support therapists in working ethically and professionally with clients.

Prevention and intervention of vicarious trauma although not all practitioners that work with trauma will develop vicarious traumatisation, all are potentially at risk. Vicarious trauma can be prevented, addressed and overcome. therapists experiencing vicarious traumatisation can work through their symptoms and difficulties, leading to an achievement of vicarious transformation. efforts to prevent and intervene when experiencing vicarious trauma should occur across wellness, organisational, education and supervision dimensions (Helm, 2010). this may have benefits when it comes to therapists’ professional and ethical practice. Wellness should be defined on an individual basis for each therapist. However, it may include psychological, physical, behavioural and interpersonal/spiritual dimensions. Wellness may be perceived as self-care. For example, the HCPC requires practitioners to ‘limit your work or stop practising if your performance or judgement is affected by your health’ (HCPC, 2012, p.14). this highlights the importance of psychological well-being. Being committed to self-care may support therapist’s being attuned to their individual needs and may enhance self-awareness, which in turn will aid competent practice. at the organisational level, organisations can greatly influence the type of support employees receive. although the HCPC and the BPs’s ethical and professional codes do not directly explore the support organisations can give, there are standards which call for the need to ‘effectively supervise tasks that you have asked people to carry out’ (HCPC, 2012, p.3). therefore, this suggests that supervisors also have some responsibility in the tasks (and clients) they ask supervisees to work with. It is incumbent upon the practising psychologist to engage in continuing professional development (CPD), and part of the CPD should involve an ethical component (Francis, 1999; shillito-Clarke, 2010). Psychologists should also engage in frequent peer supervision. the work culture should


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actively support and promote employees to speak of their struggles and seek help. this will support psychologists such as Jenna. It has also been suggested psychologists should remain within their area of expertise (Francis, 1999). Both the HCPC (HCPC, 2012) and the BPs ethical code (BPs, 2009) actively state psychologists would work within their competencies. However one may argue we only become experts through mentoring, study and experience. With regards to education and supervision, being educated on vicarious traumatisation may enable trauma professionals to identify symptoms which may lead to the ability to seek support earlier. supervision may be a safe environment where therapists can receive the support required. It should be utilised to prevent vicarious trauma from occurring (through the ability to explore issues, feelings, thoughts, etc.) and if it has occurred, to intervene in a supportive and timely manner (mcCann & Pearlman, 1990; Pearlman & saakvitne, 1995; Pross, 2006). therefore, should it be compulsory to introduce trauma awareness courses prior to psychologists working with trauma victims or within professional training? the research thus far would suggest an awareness of trauma and the symptoms leading to vicarious traumatisation should be explored with trauma therapists (mcCann & Pearlman, 1990, 1992; Pearlman & saakvitne, 1995; steed & Downing, 1998; trippany et al. 2004). this also poses the question, should supervisors give trainees a caseload of working with trauma survivors? are trainees better suited for trauma work as they receive more supervision, or are they more susceptible to vicarious traumatisation? there is a lack of research exploring these questions,

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and although the BPs ethical guidelines (BPs, 2009) and HCPC code of conduct (HCPC, 2012) has not offered any regulations or suggestions of working with trauma, these guidelines should act as a framework for psychologists to decide. this leads to considering the principle of ethics and the topic of decision making; is there manoeuvrability according to the context surrounding an ethical dilemma? Francis (1999) asks ‘can one make an ethical decision without reference to the social context?’ It does seem that although ethical principles are for the long term, therapist’s decisions will vary according to their experiences, views and context of situations. as discussed, vicarious traumatisation can affect therapist’s professional and ethical practice. the advantages of working within an ethical and professional framework can enable therapists to work competently. But also, having more knowledge in the field of practise (for example, trauma) will support therapists in making informed decisions to keep both themselves and their clients safe, but the guidelines suggest therapists should have knowledge in order to perform competently. this means, when experiencing difficulties such as vicarious trauma, therapists are honest with themselves, clients and colleagues and take responsibility for their wellbeing through the use of self-care.

About the Author Amirah Iqbal is a Counselling Psychologist in training at the University of Wolverhampton.

Correspondence Amirah Iqbal email: [email protected]



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