Winter 2024 Issue

Trauma-Informed Care
By Kimberly A. Devine, MSW, LCSW, LMFT
Social Work Today
Vol. 24 No. 1 P. 10

Mitigating Vicarious Trauma in Supervision

According to the National Crime Victimization Survey, in 2020, about 16.4% of Americans aged 12 and older reported being a victim of a violent crime.1 This includes sexual assault, rape, robbery, aggravated assault, and simple assault.1 The Substance Abuse and Mental Health Services Administration has found that more than two-thirds of children in the United States have reported at least one traumatic event by the time they reach the age of 16.2

Many of these trauma survivors will seek mental health counseling, and this will lead to clinicians being exposed to numerous stories of trauma. As helping professionals, we connect and build relationships with our clients by empathizing with them, and this can leave us vulnerable to vicarious trauma (VT).3

There is a high and growing demand for trauma-informed mental health services,4 and a shortage of clinicians qualified to provide these services.5 The literature acknowledges the mounting need for trauma work, and with it comes the emotional and psychological risks of providing direct clinical practice. Finding ways to mitigate VT is much needed in clinical practice, and it can begin with applying a trauma-informed care (TIC) lens in supervision.

Vicarious Trauma
Social workers and other mental health professionals regularly engage with numerous traumatized clients. These clinicians are repeatedly exposed to painful and often detailed accounts of their clients’ traumas. In turn, they themselves can be affected and experience indirect or VT.6-8 VT develops because of the accumulative effect of working with numerous clients who have been impacted by trauma.9 Some literature shows that the higher the percentage of clients affected by trauma in a clinician’s caseload, the higher the risk the clinician is at for developing VT.10

VT is used to describe the negative impact that trauma treatment has on clinicians because of their empathetic engagement with clients who have experienced trauma.11 VT is not the same as countertransference because it involves numerous therapeutic relationships and is cumulative.12 VT is also distinguished from burnout, which is an emotional exhaustion from the demands of the job—not specifically related to working with trauma.13

Listening to clients share repeated stories of acts of cruelty, violence, abuse, violations of trust, and more can cause clinicians to begin to experience their own mental health issues, leading them to become cynical, suspicious of others, and untrusting.14 VT can mirror the symptoms of trauma survivors, and it’s described in the literature as the negative changes or cognitive shifts in schemas that occur to the clinicians’ own sense of self, others, safety, and their world view because of the indirect trauma they experience from their clients.6,9,13 Clinicians may bring this mistrustful perspective into their own personal lives by viewing their relationships with family, friends, colleagues, and others with suspicion or by not feeling safe and becoming hypervigilant.14

Many believe the risks of VT are ‘part of the job’ or an occupational hazard.12,13,15 This hazard can have a profound impact on clinicians, and it speaks to the importance of the need for a trauma-responsive supervision practice to decrease the negative effects of VT on clinicians.

Trauma-Informed Care
The Substance Abuse and Mental Health Services Administration defines trauma as a worldwide public health problem that has no boundaries regarding age, race, gender, socioeconomic status, geography, sexual orientation, or ethnicity.16 Trauma can and will affect anyone. Addressing trauma is now viewed as an important part of providing effective mental health care in a variety of settings.16,17

Providing a TIC approach means that the agency, organization, or system understands and recognizes the impact and complexity of trauma, makes the assumption that anyone could be a trauma survivor, that behavior can manifest because of the trauma, and the principles of TIC (safety, trustworthiness and transparency, peer support, collaboration, empowerment and choice, cultural, historical, and gender issues),16 can be used to reduce retraumatization of clients and staff. Using a TIC lens redirects the attention from focusing on “what’s wrong with you” to “what happened to you?” This shift allows clinicians to consider how behaviors and symptoms may make more sense when the trauma history of the client is considered.16

Supervision
The social work profession has a history of viewing supervision as a part of the professional practice, and it parallels the helping relationship with clients.18 The goals of supervision are to foster learning, increase skills, provide feedback, and develop competence.18,19 There are three main functions of the supervisory role—administrative, educational, and supportive.18 The administrative function involves evaluating and monitoring adherence to policies and procedures. The educational function focuses on teaching about models of practice, special population groups, intervention strategies, and linking all of this to the theoretical frameworks that are learned in social work programs. The supportive function is to provide emotional support and guidance with strategies for coping with practice-related stress and challenges that the supervisee may encounter.18 Supervision has been described as an opportunity that links thinking with doing and doing with thinking.20

Trauma-Informed Supervision
Trauma-informed supervision combines information about trauma with supervision, emphasizing the interrelationships between the trauma, practitioner, helping relationship, and the setting in which the work is provided.21 The principles of TIC that guide practice with clients are applied in supervision. There are limited trauma-informed specific supervision strategies in the literature, but what is consistent is that supervision can be a buffer against VT. It is recommended that clinicians working with trauma survivors need to have a supportive and knowledgeable supervisor who is guided by the principles of TIC and understands the importance of the relational aspects of supervision.16,18,22,23

This can become challenging for clinicians to receive because not all supervisors are going to be trauma-informed18,23 or able to provide the necessary time needed for quality supervision.23 Clinicians may have to make the decision to seek supervision outside of their agencies or organizations to be able to receive the benefits of having a trauma-informed supervisor.

Vicarious Posttraumatic Growth
Vicarious posttraumatic growth (VPG) is the positive growth that can occur from working through the traumatic experience,24 and it’s most often used to describe growth from a client perspective. In VPG there are three categories of growth occurring: self-perception, positive changes in interpersonal relationships, and positive changes in life philosophy.24 VPG can also be applied to the clinician who has experienced VT, and a supervisor who is guided by the principles of TIC can help facilitate this growth with the supervisee.

Integrating the Principles of TIC Into Supervision

Safety
The need for safety can be viewed as a foundation of any therapeutic relationship, and it is essential to trauma-informed supervision.23 In this relationship, there must be emotional and physical safety. To accomplish this, the supervisor can start with the physical environment and assess how safe it feels. What does the décor, sitting arrangement, and overall physical set up say? Does the environment reflect acceptance and predictability?18 The supervisor can then move on to focusing on the emotional safety needs by laying out clear boundaries and expectations of supervision and providing support and education with an open dialogue. Supervision is a reflexive practice that provides a safe place for both the supervisor and supervisee to examine the clinical work being done, explore alternative perspectives, debrief on difficult cases, freely speak one’s mind, and come to conclusions about best practices.18

Another way to increase safety is by completing a VT prevention plan. This plan can help the supervisor and supervisees gain knowledge about VT, increase their ability to assess, reflect, and monitor their own risks of VT. Supervisors who take time to make and go over a prevention plan will help supervisees recognize the importance of this and potentially lead to an increased willingness to seek support when needed.25

By providing safety in supervision, the supervisee will feel accepted and understood, and this can lead to them being able to take on a more active role in their own learning and develop the skills needed.18,23

Trustworthiness and Transparency
The principles of safety and trust go together, and one cannot be present without the other.26 Having trust and transparency allows supervisors to guide the supervisees in exploring how their own beliefs influence how they are engaging in therapeutic relationships with clients.23 In supervision, trust develops when the supervisees view their supervisors as people knowledgeable about trauma and they are willing to be vulnerable with them.23 A trusting relationship needs to be in place to allow the supervisees to be comfortable sharing trauma-related reactions. It’s also important that the supervisors are transparent with the supervisees and are willing to share their own vulnerability about reactions to trauma.23

The supervisors and supervisees need to be become comfortable discussing any countertransference or parallel processing that might be related to specific trauma-affected clients they are seeing.9 When needed, supervisors should encourage personal counseling if the supervisees’ own trauma histories are triggered by clients. The literature suggests that supervisees and supervisors who are willing to be vulnerable in supervision with each other have a decreased risk of developing VT, and the quality of services to clients increases.18,23,27,28

Peer Support
The goal of peer support is to create opportunities for connection with one’s peers. One systematic review found that most counselors viewed peer support as central to their well-being.7 However, it was also found that if peers are viewed as unsupportive, one’s vulnerability to VT is increased.7 Overall, peer support is viewed as beneficial if it is supportive and partnership oriented.

Collaboration and Mutuality/Empowerment, Voice, and Choice
The TIC supervisor will be able to balance the role of teacher with the role of consultant. This balance is important because it allows the supervisor to be viewed not only as the teacher (expert) but also as one who is helping foster independence and autonomy in the supervisee.18 The supervisees are given the choice of which interventions they are going to use, and it is not the decision of the supervisors. This is a mutual relationship, and knowledge as well as skills are shared between the two with open and honest communication.18

Empowerment comes from the supervisees’ ability to practice their skills on their own while still having the support of being monitored by their supervisors. Having a supervisor to share successes and challenges and provide feedback can add to a supervisee’s feeling of being empowered as a clinician.18

Cultural, Historical, and Gender Issues
TIC stresses the importance of services being culturally and gender sensitive for counseling services, and this should also be applied to supervision. The supervisors and supervisees both need to be able to recognize the effects that race, culture, implicit bias, and historical trauma may have and how they may manifest in the supervisory relationship.25

Using and respecting pronouns, avoiding making assumptions, and discussing historical traumas and possible triggers are some ways supervisors can use TIC in supervision.25 The literature suggests that there’s a higher satisfaction rate with supervisors who are willing to explore ethnic, gender, and sexual orientation variables in supervision.29

If difficult conversations are managed well, there can be growth and strength in the supervisory relationship.30 Supervisors can lay the groundwork for these conversations at the beginning of the supervisory relationship by laying out the expected professional behaviors of both supervisor and supervisee; the ways in which diversity, difference, and conflict will be acknowledged and addressed; and an agreement is made on how feedback will be given and received.

Conclusion
Although further research is still needed about supervision, the current literature demonstrates the value that quality supervision has on decreasing the negative effects of VT. Clinicians who are working with clients who have experienced trauma need to feel safe to discuss the personal impact this has on them. A trauma-informed supervisor will understand the impact trauma can have, provide the needed safe space, model vulnerability to speak about the personal impact trauma can have, and help the supervisee mitigate the negative impacts. Addressing VT should be a high priority for all organizations and agencies. Delivering trauma-informed supervision will benefit not only the supervisee and supervisor but also the clients they serve.

— Kimberly A. Devine, MSW, LCSW, LMFT, is a clinical social worker in private practice in Palm Coast, Florida. She works with adolescents and adults affected by trauma and provides clinical supervision for both Master of Social Work and Marriage and Family Therapy students. She’s working on her trauma-informed Doctor of Social Work at Barry University, Miami.

References
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2. U.S. Department of Health and Human Services; Substance Abuse and Mental Health Service Administration. Understanding child trauma. https://www.samhsa.gov/child-trauma/understanding-child-trauma. Updated March 17, 2023.

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4. Kilpatrick DG, Resenick HS, Milanak MF, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26(5):537-547.

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16. US Department of Health and Human Services; Substance Abuse and Mental Health Service Administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://store.samhsa.gov/sites/default/files/sma14-4884.pdf. Published July 2014.

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29. Gatmon D, Jackson D, Koshkarian L, et al. Exploring ethnic, gender, and sexual orientation variables in supervision: do they really matter? J Multicult Couns Devel. 2001;29(2):102-113.

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