4

TRAUMA, FAITH, AND CARE
FOR THE COUNSELOR

CYNTHIA B. ERIKSSON,
ASHLEY M. WILKINS, AND
NIKKI FREDERICK

I got into the car and immediately burst into tears.
My husband loved the mid-century modern house that the realtor showed us, but it was built just on the edge of a high ridge of the
San Gabriel Mountains in Southern California. All I could think of was the description of homes sliding down bluffs that I had heard as a counselor in the aftermath of the Northridge earthquake. I could also picture the splintered wooden homes I had seen during disaster response work
I had done in Kobe, Japan, after the earthquake in 1995. I hated disappointing my husband, but there was no way I could feel safe living in that home.
(C. E., psychologist)1

Judith Herman’s 1992 classic book, Trauma and Recovery, offers a simple yet unfortunate truth to consider: “trauma is contagious” (p. 140). That may be why Western society tends to want to put survivors in a type of quarantine; we do not really want to hear the stories, because they remind us of what could happen to us or our loved ones. But choosing the path of caregiver to trauma survivors gives us a front-row seat to the ways that life can unfold as tragedy, violence, and loss. In this chapter we will review the important work by therapists and researchers to understand more deeply the impact of trauma work on the self of the counselor. We will discuss the constructs that have been introduced to “name” the experience, and we will review research that examines factors associated with risk and resilience to the experience of traumatization for the trauma counselor. We will also ask the question of what unique risks or protective factors exist in the life of Christian faith, and we will end with specific practical suggestions that you can begin to implement in your life and work today.

Defining the Constructs

Traumatic events can significantly affect the lives of those who experience them. Individuals may develop difficulties in physical, emotional, and social functioning, as well as psychological disorders such as depression, acute stress disorder, or posttraumatic stress disorder (PTSD). Yet the effects of trauma can also extend to caregivers. In fact, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) defines exposure to traumatic events not only as personal, direct experience of events but also as “experiencing repeated or extreme exposure to aversive details of the traumatic event(s)” (p. 271, emphasis added). Hearing the detailed stories of trauma survivors is a sufficient stressor to create PTSD symptoms. Family, close friends, first responders, physicians, and therapists are at risk to experience symptoms related to their care of traumatized individuals.

Though many types of caregivers may be affected, therapists are in a unique role when working with trauma survivors. Therapeutic treatment often includes exposure techniques in which the trained therapist provides a safe place for clients to work through the emotions, thoughts, and beliefs regarding their traumatic events, and this can include detailed accounts of the events and their aftermath (Pearlman & Saakvitne, 1995). In addition, an important aspect of any therapy work is for the therapist to connect empathically with the client (Figley, 1995; Pearlman, 1995). This coupling of exposure to the details, emotions, and cognitions surrounding the events and an empathic connection and authentic care for clients can be extremely demanding. The Christian counselor may develop nightmares, fears, existential questions, difficulty trusting, cynicism, depression, isolation, agitation, and irritability that mirror the symptoms of their clients (McCormack & Adams, 2015). The terms secondary traumatic stress, vicarious traumatization, and compassion fatigue all have been used to describe such symptoms in individuals who are exposed to trauma through their helping roles.

Secondary traumatic stress. The awareness of trauma’s effects on professionals began more than two decades ago. Charles R. Figley (1995) introduced the term secondary traumatic stress (STS), defining it as “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping or wanting to help a traumatized or suffering person” (p. 7). He noted that individuals secondarily exposed to trauma can suffer from PTSD symptoms such as (a) recurrent distressing dreams of the event or recurrent and intrusive thoughts or images of the event; (b) efforts to avoid places, people, or events that remind one of the traumatic event; and (c) hypervigilance, difficulty concentrating, and sleep difficulties. These STS symptoms may develop quite suddenly and can be the result of hearing about one traumatic incident (Figley, 1995; Jenkins & Baird, 2002). STS symptoms may be confusing for the trauma therapist who cannot see an obvious cause (e.g., “I was not the one who experienced that trauma!”), and this may create a situation where the individual withdraws from his or her support network (Figley, 1995).

Vicarious traumatization. These shifts in relationship and self-understanding have been explored in the concept of vicarious traumatization (VT), introduced by Pearlman and her colleagues in the 1990s (McCann & Pearlman, 1990). VT is based on the constructivist self-development theory, which takes into account both the internal and the external responses to indirect trauma exposure that can affect a person’s identity, worldview, and psychological development. VT is marked by profound changes in the core aspects of the therapist’s self or psychological foundation, including “shifts in the therapist’s identity and worldview; in the ability to manage strong feelings, to maintain a positive sense of self and connect to others; and in spirituality or sense of meaning, expectation, awareness, and connection; as well as in basic needs for and schemata about safety, esteem, trust and dependency, control, and intimacy” (Pearlman & Saakvitne, 1995, p. 152).

These existential changes in cognition and views of the self and others parallel the PTSD symptom criteria introduced in DSM-5 related to persistent negative alterations in cognitions and mood (e.g., negative beliefs about oneself or the world, a restricted range of emotions, or a feeling of detachment from others; American Psychiatric Association, 2013). VT can be understood as a transformational process occurring over time in which the counselor is significantly altered in ways that influence both work life and personal life, even sexual desire (Branson, Weigand, & Keller, 2014). The disruptions of sense of self and others can create limits on the therapist’s ability to self-soothe, to be self-aware, to be empathic and compassionate, and to feel safe (Cohen & Collens, 2013; Maschi & Brown, 2010).

I have provided trauma-focused therapies to numerous veterans over the years. In venturing into the emotional pain, I have encountered a handful of narratives that I have resigned myself to never share with another person. This reluctance to disclose is not because these memories do not burden me at times or because I would not benefit from processing my responses to them with a colleague. Instead, they are so heartbreaking and grotesque that I am deeply ambivalent about alleviating my burden. (J. C., psychologist)

Compassion fatigue. Another common term used in the literature to describe the effects of trauma work on the therapist is compassion fatigue (CF), which was coined by Joinson (1992) when describing burnout experienced by nurses. Figley (1995) used the terms compassion fatigue and secondary traumatic stress interchangeably but felt that CF was more easily understood and less stigmatizing. His conceptualization of CF included burnout-related symptoms that highlighted the chronically stressful nature of the work: lack of energy or fatigue, hopelessness about accomplishing work goals, difficulty maintaining boundaries between work and personal life, and feeling depressed in one’s occupation. In CF the burnout-related symptoms were combined with trauma-specific reactions such as nightmares or unintended thoughts about a client’s trauma story, flashbacks of client material, or intrusive thoughts about a frightening experience while working with a client (Gentry, Baranowsky, & Dunning, 2002).

Relationship between constructs. Researchers have often used the three terms (secondary traumatic stress, vicarious traumatization, and compassion fatigue) interchangeably when describing therapist reactions. However, careful analysis has demonstrated differences and commonalities among the three. STS clarifies the nature of posttraumatic symptoms that might appear quite suddenly and cause great distress. CF acknowledges the ways that trauma material can intrude in the counselor’s life but also emphasizes the ways in which exposure to client traumas can degrade the therapists’ sense of efficacy, energy, hope, and boundaries in their work. Finally, VT provides a framework to understand the deep impacts of vicarious exposure as it influences the therapist’s view of the world, meaning, and key constructs of self and others. STS focuses on the visible symptoms; VT emphasizes the internal experience and trauma theory. VT and CF are conceptualized as the result of an accumulation of experiences and exposures to traumatic material from clients’ stories, whereas STS can result from the experience of one event or story (Jenkins & Baird, 2002).

Certain acute trauma care situations (such as the World Trade Center bombing) may create more trauma-specific (STS) symptoms than the burnout-oriented symptoms of CF, but both components are present and significantly related to emotional distress in caregivers (Adams, Figley, & Boscarino, 2008). In fact, a meta-analysis of 41 studies (including over 8,000 participants) indicated that STS and burnout symptoms are highly correlated (r = .69; Cieslak et al., 2014). However, a longitudinal study of two samples (in the United States and Poland) examined the relationship of STS and burnout symptoms over time. Burnout at Time 1 was a predictor of STS at Time 2, but STS at Time 1 was not related to burnout at Time 2, suggesting that while the dimensions of distress in trauma work are interrelated, the experience of burnout (emphasized in CF) may actually create risk for developing greater PTSD-related symptoms, as measured in STS (Shoji et al., 2015).

Risk and Resilience Factors

Figley (1995) has argued convincingly that all professionals working with trauma survivors will be affected in some way by their work. However, not all will develop severe distress, and some will even experience growth (Miller & Sprang, 2016). Certain demographic factors have been identified as risks, including gender, with women generally demonstrating more STS and VT symptoms (Baum, Rahav, & Sharon, 2014; Cornille & Meyers, 1999; Kassam-Adams, 1995). Younger trauma therapists and novice therapists have also shown to be more at risk for VT (Cerney, 1995; Way, Van Deusen, Martin, Applegate, & Jandle, 2004). Other areas that have been identified as factors of vulnerability or resilience are similar to research findings from other traumatized populations: (1) the characteristics of exposure, (2) the counselor’s own trauma history, (3) the surrounding social and organizational support, and (4) the skills the counselor has to engage the traumatic material.

Characteristics of trauma exposure. The necessary, but not sufficient, cause of traumatic reactions is exposure to traumatic events. This factor has been identified in a variety of trauma-counseling settings with varied results. For example, a higher number of trauma cases on a therapist’s caseload increases symptoms of VT (Brady, Guy, Poelstra, & Browkaw, 1999; Kassam-Adams, 1995; Schauben & Frazier, 1995), and the number of hours a week spent conducting trauma therapy has been significantly associated with STS (Bober & Regehr, 2006). Another study noted that longer service with war and torture survivors was a predictor of more CF in counselors (Kjellenberg, Nilsson, Daukantaité, & Cardeña, 2014). These findings emphasize the importance of the amount or chronicity of exposure to trauma narratives.

The type and severity of trauma narratives therapists are exposed to can contribute to a therapist’s vulnerability to symptoms. In a sample of counselors in the United States, those working with survivors of torture, domestic violence, and sexual assault reported more STS symptoms than those working with other types of trauma (Bober & Regehr, 2006). Schauben and Frazier (1995) found that female mental health professionals who worked with survivors of sexual abuse reported significant changes in their schemata for making meaning in the world; this was especially true for those who listened to the trauma narratives of severe cases, such as repeated ritualistic abuse. When working with children who have suffered extreme hardships and trauma, a therapist may be challenged with questions about innocent suffering and the human capacity for evil (Maschi & Brown, 2010). Judith Herman (1992) writes, “Repeated exposure to stories of human rapacity and cruelty inevitably challenges the therapist’s basic faith. It also heightens her sense of personal vulnerability. She may become more fearful of other people in general and more distrustful even in close relationships” (p. 141). Some narratives and presentations may increase the sense of personal threat to the therapist. Veterans Administration therapists working with veterans returning from service in Afghanistan and Iraq noted heightened clinician distress when clients presented as erratic, aggressive, impulsive, and potentially threatening to the clinician (Voss Horrell, Holohan, Didion, & Vance, 2011).

Counselor’s own trauma history. Some trauma workers have gone through their own traumatic incidents in the past, and this can put them at a heightened risk to develop STS as they work as trauma counselors (Killian, 2008; Nelson-Gardell & Harris, 2003; Slattery & Goodman, 2009). When a therapist who is also a trauma survivor is exposed to the trauma narratives of clients, the images, thoughts, and emotions of past personal experiences can arise. However, research has also demonstrated that even in the midst of STS distress, being motivated to provide trauma care as a result of past trauma experiences is associated with higher levels of altruism and working through personal traumas. Therefore, this risk may also be an inspiration to do deeper personal work leading to the therapist’s growth (Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011).

Social and organizational support. Healthy social interactions can be restorative and are a vital component for preventing VT, CF, and STS. Trauma and VT can often result in a breach of attachment. To combat the symptoms of isolation, mistrust, and negative views of the world, it is vital for the trauma worker to engage in social activities that can “offer feelings of hope, joy, beauty, and playfulness to counteract the more heinous aspects of human nature to which we are exposed in our work” (Yassen, 1995, p. 189). Feeling that you have people in your life you can depend on and who depend upon you and knowing that peers in your work setting are supportive are significantly related to lower STS (Rzeszutek, Partyka, & Gołąb, 2015) and VT (Cohen & Collens, 2013).

In addition, a culture of support and understanding within an organization can be a protective factor. When administrators and supervisors recognize the risks inherent in trauma counseling, they can create policies that affirm appropriate limits and support. This includes reinforcing healthy work boundaries such as taking a full hour for lunch, setting reasonable workload expectations, decreasing the number of trauma clients per day, and taking vacations (Cohen & Collens, 2013; Perry, 2014). An organizational context that allows shared power and choice for the therapist also counteracts the feelings of lack of control and powerlessness that can be part of STS and VT (Slattery & Goodman, 2009; Voss Horrell et al., 2011).

Skills to engage clients’ trauma narratives. Trauma work is unique as a type of psychotherapeutic work; the importance of adequate training and education cannot be overstated. Many studies have found that those with specialized trauma training had fewer symptoms of CF, STS, and VT (Chrestman, 1995; Craig & Sprang, 2010; Hesse, 2002). In addition, Craig and Sprang (2010) found that those with specialized trauma training actually had greater satisfaction in their work than those without this type of training.

It is important for the therapist not only to possess knowledge of trauma-informed interventions but also to practice key intra- and interpersonal skills in the work context. Miller and Sprang (2016) highlight that self-care for VT and STS should not be relegated only to time outside work but that within a session, a day, or a work week, counselors can attend to five key skills to mitigate their symptoms: “experiential engagement, reducing rumination, conscious narrative, reducing emotional labor, and parasympathetic recovery” (p. 2). These skills parallel the skills related to safety, emotion regulation, and cognitive reappraisal that are often the focus of our work with clients.

Miller and Sprang (2016) emphasize the need to engage in an empathic and emotionally connected manner with clients that allows for an honest, full experience of the emotions elicited. Harrison and Westwood (2009) note that “when clinicians maintain clarity about interpersonal boundaries, when they are able to get very close without fusing or confusing the client’s story, experiences, and perspective with their own, this exquisite kind of empathic attunement is nourishing for therapist and client alike” (p. 213). In addition to this healthy empathy, Miller and Sprang encourage attention to the personal narratives the therapist tells himself or herself regarding professional purpose, meaning, skills, and hope in efficacy of treatment. They also emphasize the cognitive practice of recognizing and taking active steps to reduce rumination about client material, and they challenge counselors to regularly take steps to reduce their autonomic arousal through physical activity and mindful presence.

Christian Faith and Care for the Counselor

The psychological literature urges practitioners to take time to develop spirituality and spiritual practice as an aspect of resilience to VT, STS, and CF (Killian, 2008; Maschi & Brown, 2010; Merlino, 2011). Baranowsky, Gentry, and Schultz (2005) state, “Develop your spirituality. . . . Spirituality is your ability to find comfort, support, and meaning from a power greater than yourself” (p. 77). The theology that clinicians hold (consciously or unconsciously) and their faith community can inform the meaning they ascribe to their work, their relationships with trauma survivors, their recognition of evil and suffering in the world, and their rhythm of rest and restoration.

Meaning and purpose. Finding meaning and purpose in one’s work can contribute to resilience to VT (Cohen & Collens, 2013; Voss Horrell et al., 2011). How Christian counselors view their work and professional roles can have significant impact on their response to the demands of trauma work. Lonergan, O’Halloran, and Crane (2004) note a developmental trajectory for the trauma counselor from the “rescuer” or “savior” view to a posture of a “vulnerable human” who recognizes the vulnerability in a positive way (p. 356). A mature counselor prioritizes the care offered to clients while owning and acknowledging his or her own humanness. Christian faith and doctrine offer a framework for that developing identity. We desire to serve, but we recognize the limits of our capacity. The Christian counselor has resources that point to transcendent meaning and hope, even when confronted with human limits and the seeming meaninglessness of violence and tragedy (Cunningham, 2004).

Pearlman and Saakvitne (1995) state, “As trauma therapists and researchers, we carry the hope for the human capacity to heal from the effects of trauma” (p. 158). Our knowledge of empirically supported protocols and confidence in treatment efficacy can offer hope to clients and resilience for ourselves (Miller & Sprang, 2016). When we allow ourselves to be open to the pain and chaos of our clients’ experiences, and we see their change and transformation over time, their growth can contribute to our growth (Cohen & Collens, 2013). Yet we, the authors, would add that the Christian therapist also carries a hope for transformation empowered by God’s grace (Eph 2:4-5), even for the most wounded trauma survivor.

Caring for others with compassion and sacrifice. In many Christian traditions, a follower of Christ has a biblical call to compassionate, sacrificial service to others, to truly care for the brokenhearted. In fact, when asked what is the greatest commandment, Christ answers, “You must love the Lord your God with all your heart, with all your being, with all your strength, and with all your mind, and love your neighbor as yourself” (Luke 10:27 CEB, emphasis added). Living with compassion means being deeply moved by the pain of others, engaging at a true level of human connection, and not shying away from the complexity of pain, doubt, rage, guilt, and relief that trauma survivors can hold. This compassionate empathy can both create the risk for VT and STS and be an avenue for healthy presence (Cohen & Collens, 2013; Miller & Sprang, 2016). For Christian therapists, the source of our compassion needs to be the compassion we ourselves experience from Christ (2 Cor 1:3-7). These verses from 2 Corinthians remind us that it is the comfort we receive and the healing that we pursue that allow us to comfort others.

However, in the midst of compassion, the value of sacrificial service can be a confusing burden for Christian counselors, and a self-sacrificing posture has been associated with higher risk for VT (Adams & Riggs, 2008). There may be times when we are called in obedience to sacrifice our time, energy, or resources. However, in some Christian traditions the deep value of sacrifice creates uncertainty around physical and emotional boundaries. The needs of traumatized individuals and communities are often so great and so consistently pressing that the Christian trauma counselor may feel a sense of guilt or disobedience about saying no to a new trauma client, limiting contact outside the session time, or taking vacations. It is critical to remember that setting appropriate boundaries does have the care of the client at the center, both in terms of modeling healthy boundaries and emotion regulation and in terms of keeping the therapist healthy and whole. Unfortunately, in some situations an organizational theology of sacrifice may reinforce an unhealthy expectation of overwork and self-denial. In these settings, staff members who make choices to care for their own needs might be regarded in negative terms (e.g., lazy, selfish, or less spiritual; Maltzman, 2011). Canning (2011) suggests that the concept of stewardship may be a helpful way to note the importance of the counselor attending to both the “use” and the “preservation” of the self as a resource (p. 72).

The positive side of a theology of sacrifice is an orientation toward the needs of the client. The client benefits from the counselor’s hard work of seeking peer or supervisory support, gaining new knowledge through continuing education, and pursuing expert consultation. A commitment to doing excellent work and giving time and resources to our clients reflects Christ’s compassion.

Witnessing evil and a theology of suffering. Christian counseling with trauma survivors demands that we bear witness to the evil that can be part of human existence. As witnesses, we sacrifice the ability to stay unaware or ignorant of the cruelty and loss that others experience; acting as a witness to the pain of another also challenges the therapist to take a stand by voicing the injustice (Herman, 1992). The theologian Serene Jones (2009) sees this witnessing as a critical component of walking with and caring for a trauma survivor. We are called to walk in the tension of being a voice recognizing what “shouldn’t be” (that is, the fact that God’s ordered world should not include experiences like child abuse, violent assault, etc.) and also a voice of hope for what “will be,” the hope of God’s ultimate justice. Both are necessary.

The details of the stories, words, and images were horrific. But for me the hardest and most powerful part was imagining the emotions of the children—what they must have felt and internalized during those incidents. I had to make space for those, while also being careful not to ruminate on them. I found that countering those human evils took a combination of grieving and simultaneously seeking moments of joy, laughter, and silliness with close others in my life. This work requires me to proactively seek beauty and meaning during times of darkness or despair and to hold tightly onto the belief that evil does not get the final word. (N.F., psychologist)

The Christian trauma counselor also has the resources of theodicy and lament. The faith community is a place where our theology of suffering (theodicy) can become a lived experience. How do we hold onto a God who is all-loving and all-powerful when there is suffering in the world? The faith community has looked to Psalms as a hymnbook of despair, disillusionment, questioning, seeking, and praise for generations. The psalms help the people of God remember what God has done for them; they witness to both the uncertainty and injustice that is in the world and the victory and rescue that God has provided. A particular source of restoration for the Judeo-Christian tradition is the act of lament. The psalms of lament and protest cry out to God that he has not yet followed through on the promises that he made to his people. In protest to God we can shake our fists and raise our voices, stating that things are not as they should be, that innocents suffer, that abuse is an intolerable evil. Our Lord hears these prayers, and we hope in the God who has made a covenant with us (Billings, 2015).

Theology of rest and restoration. The work of engaging with stories of tragedy, violence, and uncertainty can only be sustained and healed within a rhythm of sacrifice and rest. This rhythm can happen in the counseling room by taking breaks to engage the calming, parasympathetic nervous system and by spending time away from work through strategic, restful vacations (Miller & Sprang, 2016). The Christian tradition has also emphasized this rhythm in the ministry of Jesus. Disciplines of prayer, retreat, and quiet have historically provided the renewal needed for compassionate work. Bishop Tutu (2004), in the midst of reconciliation work in South Africa, describes his own rhythm as dependent on a discipline of “stillness” (p. 99). Each day he spends the early morning in quiet “to sit in the presence of the gentle and compassionate and unruffled” God of all creation (p. 100). He also includes quiet days in his weekly schedule and one day a month when he goes to a local convent to pray, read, sleep, and eat. Once a year he takes a retreat for at least three days.

The sabbath is one of the most critical components of this rhythm of rest. It may be tempting to view sabbath as a helpful reminder to take breaks from work, but many Christians seem to not really attend to the fact that keeping the sabbath is one of the Ten Commandments. A theological reflection on the importance of sabbath relates the individual to eternity (Heschel, 1951/2005). All week we are engaged in work that connects us to earthly tasks and earthly space. When we disengage from this attention and turn to sabbath, we enter a divine place: “On the Sabbath it is given us to share in the holiness that is the heart of time. Even when the soul is seared, even when no prayer can come out of our tightened throats, the clean, silent rest of the Sabbath leads us to a realm of endless peace, or to the beginning of an awareness of what eternity means” (Heschel, 1951/2005, p. 101, emphasis added). This taste of peace and eternity reorients us to the reality of who we are in relationship to the divine. We are not God. We are not the Savior. We are walking with others as an expression of God’s love. We depend on God’s comfort as we comfort others (2 Cor 1:3).

Practical Strategies to Address STS, VT, and CF

Reflecting on the nature of trauma counseling and the possible vulnerabilities and resources available for the Christian counselor leads to the question of what to do. The following practical strategies reflect the personal choices for well-being (general self-care), the work-related options (professional care), and the resources of faith (spiritual self-care). The challenge of addressing self-care is that while everyone would agree it is a good thing to pay attention to one’s health and well-being, it proves difficult to enact this belief in day-to-day life. Even in the context of STS and VT, therapists believe that things like self-care, leisure time, and supervision are important, but there is no relationship between the belief in the positive impact of these practices and the time therapists allot to do them (Bober & Regehr, 2006). Remembering that burnout can create risk for more trauma-related distress (Shoji et al., 2015), trauma counselors need to pay attention to day-to-day well-being. These strategies require intentionality and practice.

General self-care. Essential to all aspects of self-care is self-awareness—an honest assessment of personal stress levels, health, and energy. This means paying attention to cues such as tension in certain areas of the body, changes in sleep or concentration, or alterations in mood (Killian, 2008). Without this, it is easy to fool ourselves, pretending that we are without needs. Self-awareness undergirds each of the following strategies.

Prepare, plan, and prioritize. Any discipline requires practice and attention. Plan time each day for intentional time alone, allowing for emotional expression or self-encouragement (Hesse, 2002; Merlino, 2011). Set an uninterrupted time for transition away from the responsibilities of work. It may be a routine of listening to relaxing music during a commute or changing out of work clothes when you arrive home. Establish rituals and routines of care, prioritizing a rhythm of renewal and replenishment.

My rhythms of inspiration are essential. Each day I take off my badge, place it in a particular place in my car, and remind myself that my patients are out of my hands for the day. I relish the long drive home because it is a place where I can watch the sun on the mountains, listen to inspiring things, and remind myself that, in the midst of hearing the very worst that humanity can inflict on each other, there are still vital and beautiful and miraculous things happening. (A. W., psychologist)

Social support. Plan time with loved ones. While the effects of VT, CF, and STS may make it tempting to withdraw or avoid relationships, it is important to prioritize connection with and social support from others (Dass-Brailsford, 2010; Pearlman & Saakvitne, 1995). Connection offers opportunities for disclosure of personal reactions and for restorative emotional support (Baranowsky et al., 2005; Norcross & Guy, 2007).

Personal therapy. Seeking personal therapy is an “explicit acknowledgement of oneself as deserving of care and of one’s needs as valid and important” (Pearlman & Saakvitne, 1995, p. 62). Therapy can help identify one’s unique background, wounds, and triggers in order to deepen one’s capacity to work with trauma survivors. Miller and Sprang (2016) note that some trauma counselors may mistake countertransference for empathy; personal therapy focuses attention on these personal reactions.

Recreation. Clinicians should seek life balance that provides time for play away from professional duties (Hesse, 2002; Merlino, 2011; Pearlman & Saakvitne, 1995; Yassen, 1995). Specifically, recreational activities experienced as enjoyable or healing should be practiced on a regular basis (Killian, 2008). Simply put, taking care of oneself includes engaging in activities that are fun. This could include, but is not limited to, spending time in nature or with animals, creative expression (writing, art, music, etc.), gardening, or doing hobbies (Cunningham, 2004; Maltzman, 2011; Yassen, 1995). This also means being open to humor. Confronting many stories of pain may create a seriousness that can make humor seem distasteful, but joy and laughter is an important part of caring for oneself (Yassen, 1995).

Physical self-care. The body holds stress; imagine tense shoulders and sore muscles after a long day of work. Thus, it is important to both increase body awareness and care for the body (Killian, 2008).

Sleep, “down time” or resting time, and relaxation are essential in aiding recovery from physical and emotional exhaustion (Dass-Brailsford, 2010; Maltzman, 2011; Merlino, 2011). Without sleep, capacities to self soothe, monitor affect, and maintain sense of self are disrupted (Pearlman & Saakvitne, 1995). Diet and proper eating are also important aspects of caring for and “refueling” the body (Hesse, 2002; Maltzman, 2011; Merlino, 2011; Yassen, 1995). Self-care literature also exhorts clinicians to exercise (Norcross & Guy, 2007). Suggestions for (nonstressful) exercise range from taking leisurely walks and doing yoga to engaging in rigorous cardiovascular activity based on personal preference. Exercise can release muscle tension accumulated and increase endurance during work with trauma survivors (Cunningham, 2004; Yassen, 1995).

Professional care. Professional care strategies highlight the necessity of an understanding work atmosphere. The structure of a clinic or office can provide great support in trauma care by creating a culture that recognizes the impact of CF, STS, and VT, and reinforces appropriate work boundaries, supervision, and training. A culture such as this maintains respect for both therapists and clients (Harrison & Westwood, 2009; Pearlman & Saakvitne, 1995). The following strategies are meant to offer guidelines for a healthy approach to work with trauma survivors.

Limits and boundaries. Clinicians must have realistic expectations! Setting professional boundaries and limits, as well as balancing caseload with nontrauma clients is important to avoiding overwork and vicarious traumatization (Killian, 2008; Merlino, 2011; Pearlman & Saakvitne, 1995; Yassen, 1995). Additionally, there will be cases that need to be referred to other professionals. Part of limit-setting is taking breaks, vacations, and clinical sabbaticals to extend periods of rest and recovery (Cunningham, 2004; Hesse, 2002; Norcross & Guy, 2007).

Training. Remember that trauma-specific therapeutic skills are a critical component of resilience to the trauma exposure inherent in the work (Craig & Sprang, 2010; Miller & Sprang, 2016; Voss Horrell et al., 2011). Therefore, be certain to attend trainings and continuing education events designed specifically for trauma treatment. In addition, keep reading and learning about VT, STS, and CF; there are many wonderful books and websites to help counselors reflect on their experiences and normalize the challenges of trauma counseling (Lonergan et al., 2004).

Supervision. It is important to have a nonjudgmental place to process reactions and monitor responses to trauma work. Supervision and consultation can provide space in which to grow, learn, and heal with support (Cerney, 1995; Hesse, 2002; Pearlman, 1995; Yassen, 1995). Ideally, supervision would provide a shame-free space where reactions are considered normal, where clinical success can be celebrated (Cunningham, 2004; Pearlman & Saakvitne, 1995), and where existential issues such as evil and death can be discussed (Kjellenberg et al., 2014).

Teamwork. Professional peers are a primary source of support, including validation, normalizing therapist responses, preventing inappropriate responses, reframing the trauma, clarifying and providing insight, and proposing healthy patterns (Catherall, 1995; Miller & Sprang, 2016). Create policies and schedules that prioritize time for collaborating and consulting with trustworthy colleagues to monitor the effects of working with trauma survivors.

Because everyone on our care team works with people who have been traumatized, we have a practice of debriefing one another after providing care to victims. After walking with a family through the death of their 23-year-old daughter, my teammates reminded me that I would need a debriefing. I would have most likely declined if I had not been so adamant about making it a team policy. We finally set the date for my obligatory debriefing and, reluctantly, I went with very low expectations, not really seeing the need for one. After just a few gentle but pointed questions from my teammates, deep emotions pushed their way through to the surface and I began to cry. They helped me talk through my tears, and I felt an unexpected weight of anger and grief lift. I am so grateful for my teammates. I believe this debriefing practice is what enables me and them to continue giving ourselves over and over again to those who have experienced devastating tragedies. (A. G., missionary psychologist)

Workspace. Make sure that your space is safe, physically and emotionally (Pearlman & Saakvitne, 1995). Keep personally meaningful items, reminders of happiness, beauty, and peace, in your workspace. This may mean decorating your office with pictures of meaningful places or favored pieces of art or poetry (Cunningham, 2004).

Spiritual self-care. McCombs (2010) writes, “For centuries, spiritual symbols, beliefs, and spiritual practices have been used to make sense of and restore wellness after traumatic events” (p. 135). Our personal and communal spiritual formation helps sustain us in this work.

Beliefs. Consider your theology of suffering, your theology of sacrifice, and your theology of caregiving or compassion. Speak with a trusted pastor or wise friends to unravel and reflect on unconscious assumptions of responsibility, sacrifice, and suffering you encounter in order to keep those personal beliefs from limiting your work.

I worked with a woman who survived a brutal, premeditated sexual attack. She was a Christian and consistently spoke of her gratefulness of God’s protection. I found myself interpreting her remarks as denial and tended to devalue her posture of gratefulness. I realized that I was allowing my own question—why would God allow such a thing?—to cloud my ability to truly listen and be present with her narrative. (C. E., psychologist)

Faith community. Community can form the framework for engaging with the existential questions that arise (McCombs, 2010). Participate in religious community through worship services, smaller groups, and celebrations. Look for communities that are open to expressions of lament, doubt, and transformation.

Spiritual formation. Take time to develop specific spiritual disciplines and practices before you begin feeling the effects of your work. Such practices include prayer, participation in community life, rituals such as Communion or Eucharist, and reading Scripture. Throughout history, Christians have developed multiple forms of prayer, including Ignatian prayers and retreats, the Jesus Prayer and other breath prayers, and lectio divina. Do not forget the prayers of lament and protest. Join the psalmist in honestly lamenting the evil and pain you witness. Finally, our formation should also follow the command for sabbath. Practicing sabbath as a period of revival reorients us from viewing God as giving to us in limited and scarce ways to the God who provides enough (Cavanaugh, 2008).

Conclusion

Attending to the effects of Christian counseling with trauma survivors and prioritizing our own personal, professional, and spiritual care is a vital part of flourishing in the work. Symptoms of nightmares, intrusive thoughts, avoidance, or irritability may surprise us, but they can be a natural consequence of engaging in the trauma stories of our clients. Recognizing the symptoms of STS, VT, and CF is the first step; the next step is to honestly reflect on areas of risk or resilience that are present in our lives. Remember the call to compassion in 2 Corinthians 1:3-7; it is through the comfort we receive in our own lives that we are able to offer comfort to others. May your journey as a Christian counselor or psychotherapist for trauma survivors be a part of your own journey toward wholeness.

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