Tuesday, May 29, 2012

When Does Vicarious Trauma (VT) Become a Sign of Codependency? – Parts I & II

The other day I launched my inaugural workshop on “Combat Strategies at the Burn-in and Burnout Battlefronts” during a “Loss and Grief” program sponsored by the Psychiatric Institute of Washington, DC. The majority of folks in the audience were social workers and other allied health professionals. An issue from an audience member that resonated with many was the potential for “Vicarious Trauma” (VT). The literature has an international flavor, often speaking to the “humanitarian aid” employee involved with some wide scale, “man-made” or war-torn trauma or disaster, e.g., rape, pillage, “ethnic cleansing,” etc. However, vicarious trauma along with its conceptual and operational cousin, “caregiver burnout,” has a wider interpersonal reach and problematic scope. In addition to fleshing out the VT concept, this essay will examine how certain personality traits and tendencies can fuel the vicarious and vicious exhaustive and erosive “trauma-burnout” cycle.

Who Can Catch VT?

According to the Vicarious Trauma and Headington Institutes, “Vicarious trauma is the process of change that happens because you care about other people who have been hurt, and feel committed or responsible to help them. Vicarious Trauma is what happens to your neurological (or cognitive), physical, psychological, emotional and spiritual health when you listen to traumatic stories day after day or respond to traumatic [or emotionally maddening, discouraging, and disheartening] situations while having to control your reaction. VT is a process that unfolds over time. It is not just your responses to one person, one story, or one situation. It is the cumulative effect of contact with survivors of violence” and disaster. However, I believe Vicarious Trauma is not only the product of horrific drama; VT conditions need to be placed on a spectrum of distress and disruption. Other less sensational yet often no less demanding person-social situation contexts contribute to VT susceptibility, including continuously working with or caring for:

1) stateside military personnel and their caretakers – from VA personnel to spouses and parents – grappling with post-traumatic stress injury or traumatic brain injury and its personal and interpersonal effects; men and women who can’t help but compare their pre- and post-“down range” mind-body state: the lingering mental fog, the depression, the nightmares, the angry flashes, the reduced physical mobility, etc.; and, especially with military personnel or even family members, despite the high command’s systematic efforts to destigmatize mental health issues, the many individuals in a “macho culture” who remain ashamed to acknowledge or to discuss their vulnerable and/or compromised “head case” conditions,

2) people who are struggling with poverty or economic displacement, many warehoused by the criminal justice system, or grappling with environments (e.g., a tight job market or foreclosed housing market) that foster a sense of “learned helplessness,” hopelessness for the future, or angry resignation,

3) the victims of domestic, child abuse, sexual abuse, and bullying or other anti-social and destructive actions; intervening with substance abusers and those engaged in other self-defeating addictions and behaviors, including defiance and denial,

4) people whose disastrous, disruptive, demeaning, and/or self-defeating experience may result in a profound sense of loss of personal control and of trust, often contributing to a wariness with perceived “authority figures” and a resistance to accepting counsel; a clash of divergent cultures or conflicting cultural practices between providers and recipients of aid or service may exacerbate interpersonal contentiousness or distance,

5) the aged and infirmed, or being responsible for individuals struggling with profound physical, neurological, and cognitive-affective illness, disability, and/or dementia; not understanding the nature and limits of the condition may create unrealistic expectations and frustration for both parties,

6) a once strong family member or significant other who has now lost his or her bearings, balance, and/or bladder control; in their new “strong one” role, a caretaker who prematurely buries his or her grief regarding this loss and potential “role reversal” is inviting exhaustion if not drama or trauma,

7) teachers who can’t get through to young, irritated students who come to school hungry, or students from dysfunctional families whose hostile and hurtful patterns of interaction in the kitchen are invariably acted out in the classroom; or when a child’s chronic stress contributes to noticeable underachievement, attention deficit, and learning disabilities, if not a sense of shame and depressive tendencies; alas, hurt and hopelessness can morph into withdrawing inside a hardened protective shell,

8) a parent trying to reach, reason with, and restrain a forever angry or defiant, bingeing, texting or drinking while driving, living on the edge, thinking he or she is invulnerable teenager or young adult.

Clearly the potential for Vicarious Trauma and Caregiver Burnout cuts across a wide swath of essential and everyday roles and relationships. At the same time, depending on your personal sensitivity, ongoing stress levels, and the plight of those with whom you are engaged, “you can [eventually] come to question your deepest beliefs about the way life and the universe work, and the existence and nature of meaning and hope.” Such daunting and draining work may result in “existential angst” – the sense that one is constantly being pushed out of a comfort zone and is forced to question the meaning of events, one’s own and others’ actions and reactions. How could a benevolent “God” allow such atrocities, catastrophes, or unexpected and unfair casualties? Why were this person and these people targeted?

Being the witness, recipient, or active participant in distressing, disheartening, disillusioning, and disempowering life scenarios and stories, “day after day, and year after year” can take a profound toll on one’s mind-body-spirit.

So the numbing or alienating field of VT may not just be thousands of miles away; it may be as close as your professional office, a classroom, your living room, or the home of a family member.

Defining Codependency

Clearly, people who place their mind-body-spirit on the line, helping those fighting for post-traumatic survival or struggling to maintain some sense of economic and/or psychological stability, autonomy, self-worth, and competency in a “survival of the fittest” world rate a Purple Heart for passion and compassion. However, this “Vicarious Trauma” and “Caregiver Burnout” helping context is fraught with both subtle as well as the previously noted more obvious risks. If not sufficiently aware of one’s own psychological patterns and needs that can befog clarity and objectivity, purpose and boundary, the situational hazard may not be the sole or primary cause of the VT Syndrome. One must ask two critical questions: does Vicarious Trauma or Caregiver Burnout ever morph into (or, as likely, finally expose) Professional (or Personal) Codependency? That is, do cognitive beliefs, personality characteristics, and patterns of coping and caregiving increase the likelihood of getting VT? And do organizations or family-cultural systems themselves ever purposefully enable or unwittingly facilitate such trauma or burnout?

According to Wikipedia [and my own editing], Codependency is defined as a psychological condition or a relationship in which a person is:
a) controlled or manipulated by another [or who allows themselves to be controlled or manipulated],
b) is affected by or involved with a partner with a pathological[/medical] condition (as in an addiction to alcohol or heroin) or [caretaking a significant other with a traumatic injury or seriously disabling condition],
c) and in broader terms, it refers to the dependence on, [fear of,] or control of another,
d) it also involves placing a lower priority on one's own needs, while being excessively preoccupied with the needs of [or the well-being, approval, performance, or success of] others, and
e) not surprisingly, codependent natures often attract individuals with narcissistic issues, that is people who feel entitled to the care, admiration, and service of others; [however, a subtle form of narcissism may also be present in this codependent dyad, that is, the self-sacrificing individual may also believe, albeit on a covert level, that the world owes him or her for such unselfish, accommodating, and altruistic attitude and behavior; such “fairness” and “heaven’s reward’ fallacies would invariably heighten susceptibility to Vicarious Trauma, both regarding unrealistic expectations in general with wary recipients of aid in particular].

Codependency can occur in any type of relationship, including family, work, friendship, and also romantic, peer or community relationships. Codependency may also be characterized by denial, low self-esteem, excessive compliance, or control patterns. More specifically, people who are codependent often take on the “martyr role”; they constantly put others' needs before their own and in doing so forget to take care of themselves. [In fact, such individuals often use the role of “rescuer” to distract or lose themselves or deny and project their vulnerable emotions onto others’ problems.] This creates a sense that [there’s a serious issue for which] they are "needed"; they cannot stand the thought of being alone and no one needing them. Codependent people are constantly in search of acceptance. When it comes to arguments, codependent people also tend to set themselves up as the "victim." When they do stand up for themselves, they feel guilty.

Codependency does not refer to all caring behavior and feelings or to normal kinds of self-sacrifice or caretaking, but only those that are excessive to [a dysfunctional] degree. For example parenting is a role that requires a certain amount of self-sacrifice and giving a child's needs a high priority, although a parent could nevertheless still be codependent towards their own children if the caretaking or parental sacrifice reached unhealthy or destructive levels. [Such scenarios might include a child compelled to fulfill the unfulfilled fantasies of a parent, or one frequently parenting the parent, or prematurely and subtly yet fairly literally having to be the “man” or confidant in the household; or when a lonely parent needs to be “best” friends with a teenage son or daughter]. Generally a parent who takes care of their own needs (emotional and physical) in a healthy way will be a better caretaker, whereas a codependent parent may be less effective, or may even do harm to a child. Another way to look at it is that the needs of an infant are necessary but temporary whereas the needs of the codependent are constant.

Part I has examined the realm of Vicarious Trauma and Caregiver Burnout, illustrating its common occurrence among many roles and relations in contemporary society, and how the humanitarian if not heroic efforts of helpers and healers can without sufficient awareness and supervision, become a disguised, draining, and hazardous process of relating. Part II begins to flesh out the bridge between codependency and Vicarious Trauma.

When Does Vicarious Trauma (VT) Become a Sign of Codependency? – Part II

Vicarious Trauma as Type “E” Codependency

Alas, succumbing to this self-defeating pattern and propensity may be all too “E”asy, especially when so many of these qualities seem positive, thereby making it difficult or uncomfortable to acknowledge their polar nature. Let’s itemize Ten Key, Double-Edged Characteristics of that “Everything for Everyone, Everywhere, Every Time, and Invariably Exhausted” Type “E” Personality:

1. Empathy, Experience and Emotional Perspective. Feeling another’s pain (whether of an individual or a social group) and wanting to respond actively and compassionately to aid the struggle is an honorable, valuable, and principled mission. A capacity for empathy, an ability to walk in another’s shoes (and especially to feel their bunions) is perhaps the cardinal virtue of “emotional intelligence.” At the same time, an ability to place the problem or struggle in context, that is, being able to identify and understand the multiple factors contributing to the battle is crucial. One needs to see the positives and negatives, the fears and fantasies on all sides; though these dynamics, along with resources and responsibilities, of course, are not necessarily evenly distributed or weighted.

For example, one social worker spoke of leading an emotional support group for public defender attorneys who frequently show signs of vicarious trauma over time when working with rape victims. One attorney nearly reached his breaking point upon becoming a new father to a baby girl. The intensity of his identification with the problem and the victims, along with a more personal vendetta against the perpetrators, skyrocketed. (Of course, if an attorney – male or female – had been sexually assaulted or abused, some therapy focusing on their traumatic history should be a requisite for working with rape victims.)

Experience and Emotional Perspective

When your experience and emotional perspective generates heightened identification and commitment it is especially important to blend some detached concern along with emotional self-awareness if empathy is to remain a vital and virtuous quality and not fuel a vicarious or vicious cycle.

In fact The Headington Institute [] poses two critical questions bearing on the role of empathy and VT:
a) With what sort of problems or people do you find it especially easy to empathize? and
b) What are some ways that caring about people who have been hurt affects you?

2. Expectations, Egoals, and Early Pain. As the Headington Institute website noted, feeling deeply invested in your work or caretaking with a great sense of professional and/or personal responsibility “can lead to very high (and sometimes unrealistic) expectations of yourself and others….For example, you may take it personally when your work or the work of your organization doesn’t have the impact [or the results] you want. Ironically, your sense of commitment and responsibility can eventually contribute to feeling burdened, overwhelmed, and hopeless in the face of great need and suffering. [You may also] extend yourself beyond what is reasonable for your own well-being or the best long-term interests of beneficiaries, [especially if your self-sacrificing nature believes, albeit unconsciously, people should recognize and respond to your painstaking efforts.]

A kindred issue and a potential stressor inherent in caring work is the notion that your worth is dependent on your “success” rate, that is, your competency as a helping professional depends solely on the performance or outcomes of others. Whether “you did your best” or “all you reasonably could do” is never good enough. And especially when engaging others in the complex, often subjective realm of pain and trauma, psychology, and motivation there may be many intervention and intervening factors beyond a professional’s control, including operational policy and procedure. (For example, when talking VT, an overwhelming “doing more with less” caseload size, insufficient worker input in relevant practice issues and decision-making, quality of supervisory support, as well as organizational productivity “numbers” for both people services and paperwork obligations all need to be objectively evaluated.)

If a caregiver minimizes the uncertainty of this mindscape and landscape, and is quick to perceive a client’s or patient’s limited progress as a personal indictment of provider competence (or of the client’s worthiness), or conversely, believes she should be able to reach and rehabilitate just about everyone on her caseload (or management is quick to use a similar judgmental mindset), then accountability expectations need to be scrutinized.

Egoals and Early Pain

In fact, such expectations may indicate this individual (or organization) is less goal-focused and more egoal-driven, that is, the person’s motivation on some level is not mainly determined by the client or infirmed family member’s needs. What’s troublesome is that the helper’s thoughts, feelings, and actions are often covertly driven by approval, power, and/or status needs and, even more, propelled by punctured pride and a thirst for vindication against previous intimidators or abusers. Actually the motivational foundation is often subconscious (early childhood) wounded pain, shame, and smoldering rage. And this lurking pain can too easily and disingenuously devolve into the rigidly righteous or “heroic” HE MAN or sacrificing or savior-oriented SHE MAN complexes.

Humanitarian work as a profession is often characterized by self-neglect, toughing it out, risk-taking, and denial of personal needs. All of these can contribute to more severe vicarious trauma.

The H stands for “Humiliation” and the E stands for “Emptiness” while the S stands for “Self-Sacrificing.” Some people are attracted to healing work to fill their own emptiness and diminished ego or self-esteem; others over time succumb to feelings of exhaustion and emptiness. Remember, burnout is less a sign of failure and more that you gave yourself away! “Expectation, Egoals, and Early Pain” explain much about this erosive spiral.

3. Enthusiasm and Escapism, Exceptionalism and Exorcism. Fire and fervor can be wonderful qualities to spark and fuel any meaningful endeavor, especially one involving service to others. People may be inspired by your energy and ideals. However, unbounded and unrestrained enthusiasm eventually runs into a brick or burning wall. As was noted in the ‘60s classic The Phantom Tollbooth, “Fantasy and imagination suggest how the world might be. Knowledge and experience limit the possibilities; melding the two yields understanding.”

As we’ll see in Part II, escape as in “R & R” – Rest and Recreation – is one of the strategies for preventing or recovering from VT. And momentary escape or controlled flights of fantasy can prime the imagination and originality pump. But if escape becomes constant flight along with “rationalization and running away,” then trauma or drama will likely be your travel companion.

When enthusiasm cannot grapple with some limited or restrained possibilities and boundaries, then, according to Headington Institute, “Research on stress and coping suggests that VT will be more problematic for people who tend to avoid problems or difficult feelings, cannot ask for support, blame others for their difficulties, shun self-reflecting mind and soul searching as weakness, or withdraw from others when things get hard.”

Exceptionalism and Exorcism

Sometimes “headstrong” enthusiasm may morph into rigid idealism, eventually fomenting a fundamentalist doctrine. Such an extremist: a) knows there’s only a single axiomatic truth or “one right way,” b), is motivated to escape one’s past pain and shame, or becomes blind to the multifaceted nature of “reality” and “truth,” c) escapes taking responsibility for one’s own actions or errors, d) labels non-believers as sinners if not infidels and enemies, and e) sees strict and virtuous behavior as a passport to entitlement and exceptionalism or infallible judgment and retribution. Alas, with such a doctrinaire paradigm “heaven on earth” may well transmute into “there’s hell to pay.”

Speaking of hell brings us to our final “E” – actually an “E” phrase: “Emotional and Existential Exorcism.” When an individual has a history of personal trauma, especially a trauma that matches or has some parallels with the trauma of the person or people he is assisting (for example, someone who was sexually abused as a child working with rape victims, that is, someone with “intense empathy”) personal therapy and/or careful supervision is essential for balancing emotional involvement and detached concern. Guided awareness is necessary to help manage the emotional identification and countertransference – whereby the helper unknowingly projects his prior painful experience onto the client – thereby confusing the emotional boundaries, needs, and realities of this acutely intimate and mutually vulnerable encounter. (Such identity-boundary confusion and the need for “virtuous and vicarious control” is often a hallmark of codependent relating.) And the Headington Institute adds, “This risk factor may be especially relevant for staff (that) have often survived the same events and suffered similar losses as those they are assisting. In addition, those with a personal trauma history who are (consciously or unconsciously) using humanitarian work primarily to seek their own recovery instead of engaging in personal healing processes, may have a harder time with VT.”

My explanation is that the person infusing his or her recovery issues and needs in this so-called healing process is engaging in an “exorcism,” the ceremony that seeks to expel an evil spirit from a person or place ( But the real focus of the exorcism is not the person who recently has undergone trauma. The actual target is the “healer” himself, now engaged in an invariably intense and inverted exorcism, attempting to expel his or her own demons in the guise of purging, purifying, and restoring another. In fact, I have come up with “Three Types of Exorcisms”:
a) emotional exorcism or “emoto-cism”:
ridding oneself of present pain, loss, angst and/or rage, and disorientation while attempting to subjugate one’s “Intimate FOE: Fear of Exposure,”
b) existential exorcism or “exis-cism”: ridding oneself of identity confusion and uncertainty about one’s future competence, worthiness, and direction, and
c) echo exorcism or “echo-cism”: ridding oneself of ever reverberating, painful, accusatory overt/covert voices and memories, including “grief ghosts” (email for my series on “Burnout, Burn-in, and Grief Ghosts”) while attempting to subjugate one’s “Intimate FOE: Fear of Exposure.”

Hopefully, these “Ten Key, Double-Edged Characteristics of that “Everything for Everyone, Everywhere, Every Time, and Invariably Exhausted Type ‘E’ Personality” illuminate potential links between codependency and the propensity for Vicarious Trauma.

Closing Summary

Part I of this series has examined the realm of Vicarious Trauma and Caregiver Burnout, illustrating its common occurrence among many roles and relations in contemporary society, and how the humanitarian if not heroic efforts of helpers and healers can without sufficient awareness and supervision, become a disguised and hazardous process of codependency. Part II more specifically examines some common psychological dynamics between codependency and Vicarious Trauma, especially how “E”asy it can be for an excess of empathy and enthusiasm to transmute into unrealistic expectations, egoals and varieties of inverted exorcism.

Part III will focus on the ways family-cultural systems and organizations foster VT amongst its members and how personal helpers and professional healers as well as organizations can prevent the likelihood of Vicarious Trauma and Caregiver Burnout. Until then…Practice Safe Stress!

Mark Gorkin, MSW, LICSW, "The Stress Doc" ™, a Licensed Clinical Social Worker, is an acclaimed keynote and kickoff speaker as well as "Motivational Humorist & Team Communication Catalyst" known for his interactive, inspiring and FUN programs for both government agencies and major corporations. In addition, the "Doc" is a Team Building and Organizational Development Consultant as well as a Critical Incident/Grief Intervention Expert for Business Health Services, a National EAP/OD Company. He is providing "Stress and Communication, as well as Managing Change, Conflict, and Team Building" programs for the Army Community Services and Family Advocacy Programs at Ft. Meade, MD and Ft. Belvoir, VA as well as Andrews Air Force Base/Behavioral Medicine Services. A former Stress and Violence Prevention Consultant for the US Postal Service, The Stress Doc is the author of Practice Safe Stress and of The Four Faces of Anger. See his award-winning, USA Today Online "HotSite" -- -- called a "workplace resource" by National Public Radio (NPR). For more info on the Doc's "Practice Safe Stress" programs or to receive his free e-newsletter, email or call 301-875-2567.