Learning Objectives

This is a beginning-to-intermediate level course. After completing this course, the mental health professional will be able to:

• Discuss three common countertransference errors made by clinicians working with trauma survivors.
• Define Vicarious Traumatization (VT) and describe strategies for reducing it.
• Describe ways in which cultural responsiveness and humility are enhanced by understanding the clinician’s own intersectional identities.

The materials in this course are based on the most accurate information available to the author at the time of writing. The field of trauma psychology grows daily, and new information may emerge that supersedes these course materials. This course material will equip clinicians to have a basic understanding of trauma and its effects, and how to assess those effects across a broad range of presentations of post-traumatic distress. This content may provoke painful feelings for some readers, or bring the reader’s own personal trauma experience to mind.

Outline

• Introduction
• Countertransference and Other Challenging Clinician Emotional Responses
• Common Countertransference Responses to trauma
• Numbing and Avoidance
• Prurient Curiosity
• Attack and Blame
• Guilt and Shame – and the Importance of Self-Compassion
• Trauma Reenactments
• Boundary Challenges with Trauma Survivors
• The Boundaries Are the Relationship Are the Therapy
• Making Use of Non-Harmful Clinician Errors to Deepen Therapy with Trauma Survivors
• Cultural and Emotional Responsivity and Humility – Working with Intersectional Identities in the Context of Trauma
• Introduction
• A Few Words About Language
• Defining Cultural Responsiveness: Etic Versus Emic Epistemologies
• We’re All Biased – We Simply Cannot Carelessly Act it Out
• Aversive Bias
• Understanding Privilege
• Representation: Culturally Mediated Transferential Dynamics
• The ADDRESSING Model
• A Few Experiments for Understanding Your Own Intersectional Identities
• Trauma – Another Component of Intersectional Identity
• Trauma and Identity Development
• Trauma Work in the Real World
• Conclusion
• Clinician Self-Care and Prevention of Problematic Vicarious Traumatization
• The Invisibility of Trauma and Trauma-Clinicians
• VT Symptom Checklist
• Self-Care and Emotional Capacity
• References

Introduction

This is the third of three courses in a series about trauma, a biopsychosocial/spiritual-existential phenomenon whose effects can be seen in the forms of distress and dysfunction on almost every variable of human function. The first course, Becoming a Trauma-Aware Clinician: Definitions and Assessment, covers questions of what constitutes a trauma, and how to assess for its effects in a range of ways. The second course, After the Trauma: Skills and Treatment, introduces an overarching framework for trauma work, and then reviews the large variety of specific ways of assisting traumatized people that are now available. This third course, Cultural Competence and Sensitivity in the Trauma-Aware Clinician explores being sensitive to the survivor's multilayered and intersectional cultural identities when confronting the effects of trauma, as well as that of clinicians working with trauma-exposed people.

Countertransference and Other Challenging Clinician Emotional Responses

Countertransference is a reality in psychotherapy. Whether or not your theoretical orientation has an explicit reference to the construct, what is true is that all mental health work, including that framed as largely about medications, are encounters between human beings who come to those encounters fully loaded with personal histories, feelings, and needs (Bailey, 2023). Thus, clinicians have feelings about the people we work with, some of which are immensely helpful to the endeavor of working with traumatized people, others of which are potentially harmful or even destructive when unexamined and misunderstood by the clinician. Some clinicians are trauma survivors and know it. Others are trauma survivors and do not yet identify their life experience within this rubric. Some clinicians have little to no history of trauma exposure, to their knowledge, although they may have intergenerational trauma to which they are not attuned, for example. All of these aspects of clinicians’ own life stories and personal and cultural heritages factor into how they sit with people who are identified as having been exposed to trauma. It is in the nature of working with trauma survivors that such clinician feelings are often more present, more powerful, and more challenging than may be the case with people who are not so identified, in part because of the intense nature of the material and the dynamics of post-trauma responses.

Encountering these less-than-welcome emotional components of a clinician’s self has a troubled history in the mental health disciplines. Like many psychologists trained in the middle of the 20th century, I was given the message in training and supervision that emotions evoked in me by the people I was working with were a problem – my problem, likely a result of my own unresolved conflicts, and that my job was to confront and work through them in my personal therapy so as not to burden people who I saw with the projections of my own materials. The notion that clinicians could, and ought to be, objective, dominated that discourse and continues to influence my generation of Baby Boomer clinicians, despite the growing body of evidence to the contrary regarding the value of the clinician’s humanity to the therapeutic alliance (Norcross & Wampold, 2019).

Some other clinicians, a number that grows with the expanding of the hegemony of cognitive behavioral methodologies in training programs, insist that they do not experience or need to deal with countertransference because they are not psychodynamically oriented – and similarly assert that there is also no transference in the therapy because they work they do is not focused on exploration of unconscious processes. Some writers have argued that if one is doing a cognitive or behavioral therapy that this, per se, obviates the problem of countertransference. Somehow, these clinicians believe that if their construct does not include attention to less adult emotions or symbolic representations in relationships that these are simply banished from the room. In this, the non-conscious aspects of the relationship between a clinician and the people with whom they work is treated parallel to how trauma has been treated by mental health disciplines; if we don’t talk about it, then it’s not there? Well, not really. Both are there, whether directly addressed or not.

I join with Dalenberg (2000), the foremost scholar of countertransference issues in trauma work, in eschewing both of these viewpoints. After intentionally working with trauma survivors for four decades prior to retiring from clinical practice (and unintentionally doing so for far longer than that, as well as continuing to work as a supervisor and consultant to other trauma clinicians), I would argue that while all of the people we work with are likely to evoke some kind of strong emotions from us at some points, anyone we see who has a history of trauma is more likely than others to do so. Why might this be? The simple answer is that everything about trauma has the potential to evoke some kind of powerful response in other human beings. Whether we turn away, become numb, get emotionally activated or sexually aroused, rescue, judge or blame a victim, we are demonstrating those responses.

As Dalenberg (2000) has cogently noted, “trauma victims (sic) figure prominently in virtually every well-known therapeutic dilemma or disaster associated with strong countertransference reactions.” (p.12) She goes on to say that “psychotherapists often have countertransferential reactions to the fact of trauma…the psychotherapist’s pre-existing thoughts and beliefs about the trauma may affect the course of therapy greatly.” (p. 13, italics in original) Many of these problematic clinician responses to work with trauma survivors reflect the experiences of fear, terror, disgust, shame, and powerlessness felt by the clinician in the face of their survivor’s powerful feelings and apparently unreachably self-destructive behaviors. They are also resonances of survivors’ own feelings about the trauma, and often of their feelings about themselves and their own experiences of trauma exposure.

All of these responses are simply human, not deserving judgment by and of themselves. When I train clinicians to work with trauma, I often share my own experiences of going numb, fighting off sleep, and writing grocery lists in my head when first hearing details of traumas that pushed me beyond my then-capacities to know of the cruelties of the world. I talk about my urges to rescue, the foolish things that I have done when faced with the power of post-traumatic emotions sweeping over a particular survivor with whom I am sitting, and me as well, like some kind of emotional tsunami in the room. Each clinician, no matter how experienced, will feel such things repetitively throughout a career, as our capacities to witness trauma change due to personal life experiences or the very real effects of working with trauma survivors. Most clinicians, upon encountering these responses within themselves, feel ashamed, guilty, or both, adding emotions to the mix that confuse, frighten, or alienate the survivor with whom we are working.

Consequently, a necessary step in using the countertransferential material of trauma work in ways that assist the therapy is to accept its presence, warts and all. In fact, it’s best to embrace its presence, and blend with it as a way of deepening our empathy with what a survivor is struggling to feel. Pope and Tabachnick (1993), in their classic article, “Therapists' Anger, Hate, Fear, and Sexual Feelings,” found that more than 80% of their participants, all practicing psychologists, reported experiencing each of these fears with at least one person with whom they work, and most with many of those people. Clearly such emotions are normative, no matter who is sitting with the clinician. With trauma, however, other emotions emerge as well.

Common Countertransference Responses to Trauma

Numbing and Avoidance

What clinicians working with trauma bear witness to is terrible. Trauma is cruel; it is profoundly random and irrational. It breaks the heart and, with repetition, can harden it. A child goes to school, an earthquake occurs, the roof falls in and crushes her. She survives with the memory of the cries of her dying classmates in her ears, and her own terror of believing that she will never be found. A man goes to work, an angry former co-worker storms in and shoots people in front of him. The sight of blood pooling around his desk and the smell of his own body sweating in fear both haunt him as he returns to work each day, and it is worsened when the person who represents him in Congress speaks out against legislation that might control the kind of weapon that killed his friends and haunts his dreams. A woman marries, her husband beats her bloody for no reason and every reason beginning on their wedding night. A decent law-abiding man and a violent felon are both crew members on a fishing boat, it sinks, and only the violent man survives. A father rapes his daughter repeatedly. A priest molests an altar boy, who for the rest of his life becomes nauseous each time he attempts to take Holy Communion. A young woman joins the military to get money to go to college, her best friend’s brains are blown out all over her when a mine explodes their truck as they deliver supplies to the forward base in Faluja, then her buddy in the motor pool sexually assaults her. And on it goes. Some or all of this material is in a day’s work for clinicians working with trauma survivors. For a clinician to remain stoic in the face of this sort of material would be inhuman, and could be evidence of a neurobiological shut-down that disconnects the clinician somatically from the survivor in ways that will be destructive to the therapeutic alliance.

Readers are likely, at this juncture, to wonder why it was necessary to write things in this most blatant and painful manner. Could I not simply refer to sexual abuse, intimate partner violence, combat trauma – the various covering terms that allow us to communicate to survivors our desire to not necessarily hear or know the details of their lives? This is precisely the point I hope to make here. One of the most common countertransference responses that clinicians have to survivors’ material is the desire not to hear or know the details when a survivor is most in need of sharing them. A problematic set of clinician behaviors emerging from this mirrors the numbing and avoidance engaged by trauma survivors themselves as coping strategies; these responses are toxic to trauma work.

Constance Dalenberg (2000), who has conducted extensive research on survivors’ and clinicians’ experiences of trauma-related countertransference, relates a number of poignant stories of trauma survivors whose clinicians were so numb to their stories that they repeatedly failed to listen, forgot that they had been told painful details by the survivor, or in some instances discouraged survivors from telling their stories. Clinicians frequently couch their avoidant strategies with survivors in terms of attempting to spare the survivor from having to speak of the trauma because this will be “retraumatizing.” This stance steals from the survivor the right and power to decide what will and will not need to be spoken; the one being protected from being traumatized by this kind of statement is often the clinicians. This avoidant stance on the part of clinicians does not help survivors. While forcing survivors to speak of the details of their trauma before they have enough safety and stability, and before they are themselves ready to share that information, is also problematic (and is addressed below). Silencing a survivor who is ready to speak and wishes to be witnessed constitutes a form of retraumatization and empathic failure that usually leads to survivors exiting treatment prematurely because they can tell that the clinician cannot tolerate hearing what the survivor has had to live.

In my own early intentional work with trauma survivors, this theme of being silenced by previous clinicians emerged frequently, with one survivor (Brown, 1986) speaking of how her initial post-combat clinician ignored her burgeoning alcohol abuse, and added benzodiazepines to the mixture so that she became too numb to function, much less talk about her traumatic experiences as a nurse in Vietnam. When she re-entered therapy a decade of addiction later, she not only had to deal with her PTSD – she also had to live through the painful process of recovery from substances, and the added shame that her addiction brought to her. Silencing survivors makes them pay an even greater price for trauma.

Clinicians who are tied to the now well-debunked notion of therapeutic objectivity or neutrality, manifested by the withdrawal of the self of the clinician from the relationship, may be particularly at risk for this kind of trauma-related countertransference. If one is struggling to keep oneself non-responsive in the face of painful material, one is much more likely to avoid that material or become internally numb so as to continue to present a facade of unaffectedness. However, no clinicians, no matter how much their theory values genuineness, are immune. Specific issues can evoke our avoidant strategies. The first time we hear the story of an incest survivor from our own ethnic group where the mythology is that such crimes are not committed by our group; the day that we have received our own diagnosis of a serious illness and someone sitting with us is speaking, once again, of their own diagnosis; the day a survivor who shares some or all of our marginalized intersectional identities and is experiencing the kinds of loss that we thought our life circumstances and privilege protected us against; all of these and more can engender avoidant responses. Context affects our ability to hear and know material.

A sub-theme of the avoidance dynamic is that of disbelief. Some of the things that happen to trauma survivors beg belief; this is especially true when we work with survivors of severe childhood abuse, trafficking, torture, or extreme intimate partner violence. Additionally, because of the nature of a trauma, the developmental stage at the time of its occurrence, and the nature of the interpersonal context while the trauma was happening, many trauma survivors’ stories include improbably bizarre material, which feeds avoidant disbelief.

Imagine this scenario: a survivor tells you that her former husband has hacked her computer and bugged her house and car. You would likely think that she was delusional. This, however, is the actual fact pattern of a forensic case in which I was involved, with every detail corroborated by police reports and forensic evidence including the photos of the phone in situ. Or this: a survivor tells you that she was passed around by her incestuous father to different men, who took photos of her having sex with them and their own children. This story sounds bizarre, until you read the law enforcement case file on the pedophile ring of which her father and his friends were a part, or unless you have worked with enough trafficked people to know that this is a common story of their childhoods. If the Nazis and the Khmer Rouge had not been such meticulous documenters of their genocidal practices, who would credit the stories of the survivors of the Nazi and Cambodian holocausts? In the case of the Khmer Rouge, it was only by luck and happenstance that a handful of people survived the notorious Tuol Sleng torture chambers to tell their story. The Killing Fields of Cambodia and the concentration camps of the 1940s, each of which I have visited, are now often pleasant-looking grassy mounds where birds and butterflies festoon the air; the horrors visited in those now-calm locations seem beyond belief. Women raped by Hamas on October 7th, 2023 had those rapes posted online by the rapists. Those women’s stories were then often subjected, for purely political reasons, to the kind of disbelief that had supposedly ceased to occur when a sexual assault survivor spoke out.

Not only do the details of many trauma survivors’ stories leave us wanting to avoid their experiences via disbelief (or its cousin, minimization – “it couldn’t have been that bad”), trauma clinicians have, in the last three decades, worked within a context of a social movement whose entire goal was to discredit adult survivors of childhood sexual abuse, and to blame clinicians for having suggested such abuse that adult survivors were reporting. Clinicians’ fears of being sued by their adult survivors’ parents escalated during the 1990s due to well-publicized litigation being brought by a few of those parents. While the frequency of these cases has reduced over time, it was as recently as January of 2011 that a jury in Wisconsin found a clinician liable to a survivor’s parents because he had failed to “disabuse” the young adult survivor of her beliefs that she had been incestuously abused. Fortunately, this movement has now disbanded. While some of its adherents remain and do their best to promote this now-discredited narrative, the scientific basis for understanding delayed recall has become too strong to ignore in this, the third decade of this century.

This persistent fear by clinicians that they will be sued for believing, or will create a so-called “false memory” if they do not disbelieve, adds weight to the avoidant pull to not believe. While no clinician is in the position of knowing what truly happened to a survivor, all clinicians are in the position of being able to empathically acknowledge the emotional truth of a survivor’s suffering. When, however, a clinician is avoiding the immensity of pain being expressed by a survivor, the “disbelief” or “disabuse” stance is one that can create distance for the clinician while inflicting damage on the traumatized person. Clinicians should be relieved that the False Memory Syndrome Foundation has ceased to exist, no longer funding a network of attorneys and experts in search of possible cases.

The clinician’s job is not to act as the arbiter of the survivor’s reality; to decide for survivors what is narrative truth, the facts about their lives, is hubris at its worst. But as Dalenberg notes, “It is crucial during this negotiation (between belief and doubt) that the clinician respect the bravery of the client as she or he breaks silence and asks to be believed.” (2000, p. 113). Distancing from the emotional truths of what survivors experienced means that they feel abandoned by the clinician – and not because they have issues with abandonment, but because the clinician will have in fact abandoned them emotionally.

Prurient Curiosity

The rise, in the past two decades, of reality television of all sorts demonstrates how powerful the draw of prurient interest is. We claim not to watch shows on which people’s emotions are laid bare for all to see, but the ratings tell the truth; these shows are immensely popular. Clinicians are no more immune to this than are any other people; in fact, some would argue that our interests in the details of other peoples’ lives lies somewhere in the outer limits of decency. Clinicians are curious about people, and our work gives us license to ask intrusive, embarrassing questions about the most intimate details of peoples’ lives; to know and, we hope, guard their secrets. We may experience some discomfort about this, but for the most part, the degree to which psychotherapy is invasive of survivors’ privacy is taken for granted by clinicians. So long as we contain the material within the bounds of confidentiality, clinicians generally give little thought to the ways in which our work violates typical conventions of interpersonal disclosure. “TMI,” the colloquial term for having shared too intimately with others, is the usual content of the sessions in which trauma work is done.

These disclosures also constitute some of the foundation of the power differentials present in therapy. Survivors tell us these intimate details of their lives. We, for therapeutic, ethical, and personal reasons, tend to tell them little or nothing about our own, which increases power differentials in ways that may feel like some kind of trauma reenactment for the survivor.. While this is not an argument for self-disclosure, which may or may not have a place in any trauma work, it illustrates the difference in vulnerability that is normative in therapy. When clinicians use that structural imbalance in order to satisfy their own curiosity, survivors are not well served.

One of the great secrets of trauma work is that some clinicians find the details of our survivors’ traumas exciting, titillating, or even arousing. The survivor has experienced things that are the stuff of novels and movies, has lived in realities that may be exotic to us, albeit in a horrifying way. The clinician has permission to ask questions, and when prurient curiosity is the motive, instead of inquiring in the service of the survivor’s welfare, we do so to scratch the itch of wanting to know “all the gory details” when the survivor is still not ready or able to be that exposed.

This particular dynamic unveils itself most commonly in a clinician’s definitive assertion that the survivors must tell all details of their trauma story immediately in order to get better, often alluding to the notion that keeping secrets has been part of the traumagenic nature of the experience. The clinician pulls for details, “How did you feel when he did that? What did she say?” when there is no therapeutic rationale for knowing that specific information at that particular point in the work, or perhaps ever. Survivors often comply with these not-too-subtle demands to go into painful details that are activating, not healing, often against their own better judgment or desires, wishing to please the clinician, substituting the clinician’s “expert” judgment for their own intuitive sense that this is a bad idea, and hoping that the intrusive questions will cease if the clinician’s desires for details are satisfied. This itself constitutes a form of trauma reenactment in which the more powerful person violates the emotional boundaries of the one with less power, a mirror of what occurs in the trauma experiences of many survivors.

Leaving aside those clinicians intentionally utilizing Prolonged Exposure (PE), which does require survivors to write out a very detailed narrative of their trauma, most approaches to trauma work do not require this kind of blow-by-blow accounting of the psychic blows suffered by trauma survivors. Survivors describe these kinds of therapeutic encounters as violating, and often experience shame at their difficulties in complying with clinician requests/demands for full disclosure of details when it is not the survivor’s desire to share that information.

This particular countertransference also emerges in the form of violations of confidentiality. The clinician knows details of a titillating story. This person observes the forms in telling it at home or a party; the survivor’s name and occupation are stripped out, but the details remain. Entertainment value is increased when particularly interesting details are available to share. Clinicians who are themselves involved in high-profile cases are also at some risk; the wish to require disclosure of more than is needed therapeutically so as to heighten one’s own narcissistic pleasure at being in the know about the famous or infamous person in our office can be difficult to resist. The risk of being “outed” on social media as the expert in a high-profile case is also now present; if you’re the expert witness about the trauma of a famous person who is suing another famous person, your name and role, and the details of your testimony, will be on the internet and out of your control. But this does not give that forensic clinician license to share that information in their social world, no matter how much it has already been exposed on X (aka Twitter) or Threads.

It is normal and human for a clinician to feel curious, aroused, or excited by a survivor’s trauma story. These feelings may even be helpful to the clinician’s capacities for empathy with the survivor, as survivors themselves may have had such feelings which they then deem inappropriate, and about which they feel shame. Clinicians should always be mindful of the “cui bono” question when asking for further information and details related to the trauma, and consider whether their request will assist the survivor, or serve as a reminder that the survivor, by entering the realm of trauma survivorship, has become a curiosity to others, an exhibit on the stage of reality. Trauma reenactments of this sort undermine the therapeutic alliance, and thus the process of recovery.

Attack and Blame

Trauma survivors threaten the rest of humanity by their very existence. They are a reminder that the just world can and does blow up at any time, of the vulnerability of humans in the face of large natural events, or of the ways in which the person we believed loved and cared for us can betray and harm us. Trauma survivors often challenge their clinicians. They don’t trust us (nor should they at first; we are, after all, total strangers to them); they engage in behaviors that disturb us in the service of affect regulation and self-soothing. They demonstrate their learned helplessness via what appears to be passivity or stuckness. They become “irrationally” angry with us, no matter how much we care and how hard we work, and fail to appreciate our care, concern, and personal sacrifice. In other words, they do all of the things that survivors typically do to manage affects and relationships, the very phenomena that have pushed them in to our offices. Clinicians become frustrated – we feel unappreciated, manipulated, and just plain angry. These feelings are normal, but when enacted, they become problematic.

Sometimes, how a clinician responds to these realities of the difficulty of subject and survivor is via attack and blame. . Because we are clinicians, these countertransference dynamics frequently come cloaked under therapeutic rationales – “confrontation,” “avoiding dependency,” “getting this person to take responsibility for their life,” or “setting firm boundaries.” As I’ll discuss later in this segment, clinicians engaging in these behaviors are often entering into a trauma reenactment with the survivor in which they play the role of a perpetrator. Trauma survivors, because of their hypervigilance, are more likely than most people to notice the clinician’s feelings, even when the clinician denies that they are present. The clinician who is denying being angry when asking survivors “what do you think you could have done differently” when they were being sexually assaulted, or “how long do you think it will take you to finally forgive that drunk driver” to the survivor whose need to use a wheelchair for ambulation for the rest of their life was a result of the accident, is not simply engaging in behaviors that are known to be detrimental to the therapy. They are behaving like traumatized humans. With these types of questions, clinicians are also conveying to the trauma survivor that the survivor is having wrong feelings, wrong reactions, and wrong needs about what has happened. The clinician who says, “Call whenever you need to,” and then becomes short and snappy when the survivor believes and acts on this offer; and does so more frequently than the trauma-naïve clinician could have imagined or anticipated because the survivor is having so much intrusive material disturbing their life, so many suicidal thoughts showing up as the door out of misery; that clinician is communicating that the survivor is too much, often precisely what a trauma survivor often fears to be true.

Again, clinicians frequently hide behind the cloak of neutrality and objectivity when delivering hostile comments. Clinicians may also code their hostile withdrawals in terms of “encouraging autonomy,” this for a person who has struggled mightily to allow themselves to lean, at last, on another human being. Clinicians may also, depending on their own personal dynamics, enact hostility in a passive-aggressive martyred manner, sharing too much personal information about how tired, stressed, or over-worked they are in such a way as to convey to survivors that they are the source of the stress and fatigue. This is not to say that a clinician ought never to disclose being tired or off-center. There are times when a genuine self-disclosure can be incredibly helpful to the course of the trauma work. A clinician can deliver this information in a way that clearly demonstrates care and compassion for the survivor when asked the standard “how are you” question. “You may be picking up that I’m a little tired today, and I am. This isn’t about you, and you don’t need to take care of me. I just didn’t want you wondering if my low energy today was about you, because it’s not.” Contrast this with, “You know, work is pretty stressful. I’m glad I could be available to you when you called last night, but I think I might have stretched myself a little too much; I’m pretty tired today. But don’t worry.”

We will be angry while sitting with our trauma survivors – at the universe, for what happened to them, at the individuals or institutions who harmed them, at a system that has failed them, and at them for how they behave. Such anger can be used in a healing manner, with appropriate consultation and support in its employment in the service of the trauma work. Blaming the trauma survivors we work with for what has happened to them, or for the difficulties they encounter in healing from trauma, may protect clinicians from our own feelings of vulnerability, just as numbing and distance do; but these dynamics will certainly undermine trauma work and make it exponentially more difficult for the survivor to derive benefit from what the clinician is attempting to offer.

Guilt and Shame – and the Importance of Self-Compassion

Clinicians working with trauma survivors feel guilt and shame in our relationships with these suffering people. We feel guilty that we have not suffered as they have, even if we ourselves have a trauma history. We feel guilty that we cannot help them fast enough or more effectively. We feel guilty that even if we have ourselves suffered, our lives now work better while this person continues to struggle and suffer. We then resent the survivors we work with for “making” us feel guilty.
We feel shame that we were angry, aroused, avoidant, or fearful. We then withdraw, distancing from the source of the shame, attack its source (in this case, the survivor with whom we’re working), punish ourselves for feeling shame, or attempt to deny its existence. We feel ashamed for this survivors’ vulnerability, weakness, and fear. We feel ashamed of them. Because, through our work with trauma survivors, clinicians are associated with this stigmatized and marginalized group, we experience referred stigma and marginalization.

Guilt and shame absolutely have their place in a clinician’s emotional lexicon. By and of themselves, they are not problematic. We need not feel guilty about guilt, or ashamed of shame, any more than we benefit from feeling any of the other human responses to survivors’ experiences, distress, and dilemmas. If we are able to radically accept that we are two humans, having feelings, working collaboratively to create a safer world for this suffering person in the omnipresence of structural forms of danger, our guilt or shame are not problematic. So how to manage these, and other affects, without undermining survivors’ sense of safety in their relationship with us?

For these and so many other reasons, compassion for self becomes a necessary ingredient of the work of psychotherapy. First, self-compassion allows clinicians to respond effectively to the range of emotional responses discussed earlier. When we both normalize and radically accept these emotions, and then also observe ourselves mindfully and with compassion for our terrible humanity, we soothe and center ourselves.

We also gain invaluable experience with the power of compassion to heal. Many trauma survivors enter therapy with little-to-no compassion for themselves, embroiled in dynamics of self-blame, self-attack, and self-shame, along with their own avoidance and numbness and/or activated arousal. When we, as clinicians, are unable to experience compassion for our own fears and foibles, the survivors we work with will inevitably sense this, and find all too hollow any of our exhortations that they have compassion for themselves.

Compassion is not, however, license to act out our emotions with our survivors. It is, rather, permission to experience our feelings, have them fully, and inquire into how those inner realities can deepen empathy and inform us about survivors’ experiences.

Trauma Reenactments

As noted in the discussion above, one of the patterns into which all of these common clinician/human responses fit themselves is that of a trauma reenactment with the survivor. Such a reenactment is characterized by four roles; each player in the reenactment can, and will, switch between roles during the course of an extended interaction such as trauma work is likely to be. The job for trauma-informed clinicians is to identify when they and the survivor with whom they are working are engaged in this dynamic, and move to the side of it, while being able to identify it and its role in the trauma-healing work itself.

Trauma reenactments occur repeatedly in the lives of many trauma survivors, particularly those whose trauma has been interpersonal and occurred at younger developmental stages. These reenactments spring from a number of variables. These include the survivor’s comfort with familiar relational dynamics, even when those dynamics are destructive, because such dynamics have a feel of rightness, reflecting the distorted post-traumatic view of self, others, and the world common in many trauma survivors (Brown, 2015). Additionally, they pull on common human responses to trauma survivors, including all of those found in clinicians. As many authors about trauma treatment – including Briere & Scott (2006), Courtois (2009), Dalenberg (2000), and Pearlman & Saakvitne (1995) – have noted, what is surprising in a course of therapy with a trauma survivor is not that a trauma enactment occurs, but rather that clinicians are unprepared to encounter this emerging in the work, and are often filled with guilt and shame about having become a part of this dynamic when they at last notice it occurring.

The roles of a trauma reenactment are the Victim, the Rescuer/Martyr, the Abuser/Perpetrator, and the Helpless Bystander. Some readers will recognize the first three as coming from the Karpman Drama Triangle, which describes non-trauma-related interpersonal dynamics as well. The role of the Helpless Bystander is trauma-specific, and is a sub-category of both the Abuser/Perpetrator, in that in this role the player is neglectful, and a sub-category of the Rescuer in which the Rescuer, exhausted and feeling hopeless, has given up.

Trauma survivors in a reenactment generally start in the role of Victim, which needs to be distinguished from having genuinely been victimized by trauma. Given the reality of victimization, it is relatively easy for the survivor to occupy this role. What distinguishes the role from the traumatic reality can sometimes be subtle and initially difficult to detect. It is most easily seen as a role, as opposed to an experience, through the reciprocal responses of the clinician, and from the way in which the traumatized person shifts into another one of the positions in the reenactment as it progresses.

Clinicians most commonly initially situate in the role of Rescuer. In this position, clinicians may over-extend, offering time and energy that they truly do not have available to give. This, in turn, leads to the inevitable position shifts that characterize a trauma reenactment. If resentful, the clinician moves into the Victim position, putting the survivor into the Perpetrator role. Former Rescuers may experience themselves as martyred, misunderstood, or unappreciated by the survivor, leading to the kind of acting out of hostility described earlier in this course.

The Rescuer clinician can also move into the role of Helpless Bystander, which can be both a passive-aggressive act of hostility against a survivor, or a response to the clinician’s own despair and a growing fear that nothing that the clinician does will ever help. In the former instance, the clinician may fail to make safety plans with a suicidal survivor, “forget” to submit paperwork in a timely fashion so that the survivor loses benefits, or, under the guise of empathy, affirm to the survivor that they are indeed, as they have feared, too broken to be helped. In the case of the former, the clinician may simply cease to behave in an effective manner in sessions, passively allowing things to occur that make the survivor into an Abuser, or failing to intervene with active care when it is appropriate and needed, as is the case with a suicidal person. Clinicians in this position often speak of feeling confused, overwhelmed, and simply not knowing what to do.

One of the interesting behaviors of a Bystander reenactment occurs when a clinician has made an error, and then glibly accepted a survivor’s easy forgiveness of the mistake rather than taking initiative to repair the rupture well. When the people we work with are survivors of developmental and/or interpersonal trauma, they are accustomed to placating people in positions of power and authority, minimizing the ways in which people in those more powerful roles (in this case, the clinician) have been hurtful to them out of fear of activating the powerful person’s narcissistic wounds, which will then lead to further pain, or even abandonment, for the trauma survivor.

As we’ll discuss below, countertransference and other clinician errors can become very helpful to the therapy when the clinician attends to them carefully and uses them to affect a true relational repair. But when clinicians take the part of Bystander to their own trespasses and then collude with the survivor in letting themselves off the hook, survivors begin to sense, sometimes without giving words to it, that they are not emotionally safe and begin to withdraw, sometimes dropping out of the therapy not long after.

This role switch can also occur between the clinician and colleagues or institutions. This most commonly happens when a clinician chronically goes above and beyond the call of duty, and then becomes allied with the survivor as co-victims against other professionals who “just don’t understand,” or a system that fails to adequately support the clinician-survivor dyad because the system, for example an agency, is not trauma-informed or, as was true during the Covid-10 pandemic, overwhelmed and under-resourced.

This is not to say that clinicians are not truly exploited by unjust, underfunded systems, or misunderstood by colleagues who fail to appreciate the vicissitudes of trauma work, any more than trauma survivors are not genuinely victimized by their trauma experiences. These experiences of other-than-supportive treatment in some work settings are as well, as are the traumas experienced by the people with whom the clinicians are working. This is not about how difficult the context might be. Rather, the reenactment dynamic reflects a fundamental flaw in how these clinicians have positioned themselves vis-a-vis their work. This almost always begins with a history of over-extendedness in their work with suffering persons, that is, moving quickly into the Rescuer position.

Finally, clinicians can move directly into the role of Abuser/Perpetrator. As described above in the section on blame and hostility, this role finds clinicians behaving in sadistic ways toward the survivor (see Gold, 2020, for some painful descriptions of this type of behavior by clinicians working with trauma survivors). The clinician who sexually acts out with a survivor is also in this role, in this instance, reenacting being the perpetrator of sexual abuse, frequently incest.

What is essential to understand about trauma reenactments is that almost all trauma-informed clinicians will find themselves beginning to be drawn into the initial stages of these dynamics with trauma survivors. We’re human. We have powerful, well-learned, and sometimes evolutionarily-coded response patterns to wounded and vulnerable people, and the typical demand characteristics of an interpersonal relationship with a trauma survivor will point clinicians to one of these positions. All of the common countertransference responses to trauma occupy one of these roles. Consequently, a full comprehension of those common patterns is extremely helpful in mindfully and compassionately noticing oneself walking through the door of a trauma reenactment and stepping back, repairing the ruptures emerging from any participation in a reenactment, thus offering survivors a different outcome in a potentially harmful situation from what was their trauma-created and difficult relational starting point (Bailey, 2023).

It is also important not to blame the trauma survivor/victim for pulling us into these roles. Doing so is to move into the Abuser/Perpetrator position and to become part of a reenactment. Survivors will often frequently experience the clinician as occupying the Abuser/Perpetrator or Helpless Bystander roles when their non-conscious fears about the clinician are stimulated by events in the therapy. One trauma survivor with whom I worked became enraged when I expressed feeling sad at hearing her experiences, insisting that this was a violation of her right to decide how to feel. She had been forced, among other things, to be her father’s emotional sounding board, and could not distinguish at that point between an empathic expression of genuine feeling for her and a narcissistic hijacking of her time and attention. In that moment, I was the Abuser/Perpetrator, no matter what my intention had been. Had I become angry, done an interpretation from a one-up power position of her anger, withdrawn emotionally, or otherwise not simply responded by working to repair the empathic breach, I would, however, have actually stepped into that role, punishing her for rejecting my offering of care. If I had needed her to accept that care to soothe myself, I would have been in the Rescuer role. Caring, without being attached to whether she liked how I did it, and repairing the rupture that I had created, was being a trauma-informed clinician who interrupted the first stages of a reenactment.

Normalizing this interpersonal dynamic – similar to normalizing the occurrence of trauma-related countertransferences – increases the likelihood that trauma work will only be temporarily affected by such patterns of interaction. One of the manners in which trauma reenactments can be detected is that they frequently involve violations of the boundary and frame of trauma work as done by this particular clinician, a topic we will discuss next. The road out of trauma reenactments will be discussed in the final component of this course segment on making effective use of clinician errors.

Boundary Challenges with Trauma Survivors

“If you really don’t think I’m disgusting, you would have sex with me.” This survivor, a person with dissociative ego states, who had been trafficked from birth to age nine, experiencing repeated sexual and physical abuse, as well as neglect and deprivation, must have made this statement monthly in the first years of our work together. When, several years into that work, she realized, through careful attention to cues, that my long-time committed relationship had dissolved, she reiterated her insistence that now that I was single, I should act like anyone who genuinely cared for her, and comply with her request for a truly intimate, thus sexual, relationship.

My consistent, careful, compassionate refusals of her request were met with episodes of suicidal self-injury, attacks of rage, or long periods of silent, angry withdrawnness. In her childhood, she had made herself safe from beatings and starvation by the adults who were trafficking her by offering herself sexually to those dangerous adults, which often soothed their other violent behaviors. My refusals to accept her offers of sex were experienced as abandonment, betrayal, and willingness to let her be harmed. She employed a number of strategies: telling me that the rules (aka the Ethics Code) were more important to me than she was, that I was simply trying to protect myself, and that, of course, I didn’t care about her. In other words, she experienced me as an Abuser/Perpetrator, even as I was firmly refusing to become one.

Yet it was my steadfast assertion that even though I knew that my refusal was painful for her, I would never intentionally do something that I knew could harm her. That became the touchstone of my role as a consistent, benign figure in her inner world, one that she much later credited for our being able to do the work of integration and trauma resolution. She often commented in the latter part of our work together that she had finally gotten it that genuine care always meant refusing to do something that I knew would harm her, even if that refusal was painful, and that she could finally feel safe in knowing that, not just with me, but in the world.

Many trauma survivors will seem to push on clinicians’ boundaries, intentionally as well as accidentally. Reciprocally, it is common for clinicians working with survivors to violate boundaries in the midst of some kind of reenactment. The work of Pope and his colleagues finds that few clinicians are well trained to deal with boundary issues. Boundaries in therapy are perceived by some clinicians as a result of poor training, as arbitrary rules that must be followed in order to manage risk and stay out of trouble – in other words, boundaries are something to be maintained in a compliant, rather than a genuinely comprehended, manner. Thus, when the situations of the trauma survivor appear to require a violation of the boundaries, the clinician may privilege what appears to be compassion or flexibility over being compliant with rules whose purpose was never well understood by the clinician.

The Boundaries Are the Relationship Are the Therapy

A more effective strategy for understanding boundaries in trauma work has to do with noticing how boundaries are about instituting safety and stability for the survivor. Boundaries are about providing safe-enough relationships, a safe container for the work, the kind of relationships which are the cornerstone of trauma work. Clinicians provide these basic needs to the people we work with by having integrity, being reliable, predictable, and willing to model impulse regulation on behalf of the welfare of survivors and the relationship on which trauma work is founded. Thus, time boundaries of sessions are not in place simply because that is how time is billed. They exist to protect the therapy relationship for this survivor – because the clinician has had ample time to recharge and recycle between sessions – and the next survivor – because that next person knows that their time is also sacred and almost entirely inviolable except in the case of genuine emergencies. The money boundaries are in place so that there is an energetic exchange between the parties; each one gives something to the relationship. Fees are negotiated and waived from time to time to reflect survivors’ financial circumstances. Clinicians, however, do not make a practice of endangering their own financial welfare and safety, as it is very difficult to provide a safe-enough environment to a survivor when one’s own self is unsafe. The boundary about not having social or sexual relationships with the people we work with is not there just because the rules forbid it. It is so the interpersonal space of the therapy, like the time, is also sacred, not infiltrated by the concerns and self-interest that will inevitably emerge between friends or potential lovers. It is also there in service of the clinician’s well-being, to make available spaces in life in which one can be one’s complicated, inconsistent self without the risk of harm to a vulnerable survivor.

In short, the boundaries of therapy are there as expressions of clinicians’ care and respect for survivors, and clinicians’ commitment to safeguard the sacredness of the therapeutic relationship. The Hebrew word for sacred, “Kadosh,” derives from a word root meaning “set apart,” and it is within this epistemic framework that clinicians set the space of therapy apart. When a trauma-informed clinician is able to see how the boundaries of trauma work are themselves therapeutic stances that are there to support the development of safe-enough attachment, rather than rules added on to the “real” work of healing trauma, it becomes immensely easier to not accept invitations to participate in trauma reenactments.

Boundaries of the work done with survivors vary from one theoretical orientation to another. Rigid adherence to a boundary when flexibility or compassion is appropriate is itself a form of boundary violation, a hostile enactment. As Ochberg, one of the founders of modern trauma work pointed out long ago (1988), a clinician working with trauma survivors cannot be neutral, behaviorally or morally, as moral neutrality is the functional equivalent of silently standing against the survivor in the Bystander position. There will be times when a clinician who has a norm of not touching the people they work with may find it the morally non-neutral thing to do to hold on to a survivor’s hand as that person is living through a flashback or sobbing in grief. There will be times when a clinician who always and only works within the 50-minute session framework will book regular double sessions with a survivor whose developmental trauma has shut down Broca’s area, making speech slow and painful. Each one of these “boundary crossings,” as they are referred to, must not be done impulsively, although they may occur spontaneously. The clinician must take the time, however briefly, to consider how this is indeed right, and not rescuing, and then have a discussion of the boundary crossing and its meanings to both parties, as well as with a consultant, at the soonest therapeutically appropriate moment.

Making Use of Non-Harmful Clinician Errors to Deepen Therapy with Trauma Survivors

Clinicians are human beings. We are sleepy, inattentive, ignorant, or just plain make mistakes. We get sick or hurt. Some of us give birth or adopt children. Our relationships end, our parents become ill or die. Trauma survivors, often mired in self-blame, will frequently attribute our errors, whether countertransference enactments or completely accidental, to themselves and their spoiled identities. As noted above, they will too quickly let the clinician off the hook. Conversely, the trauma survivor may move into the Abuser/Perpetrator position and lash out in anger at our failures. Trauma reenactments will emerge.

These are potentially fruitful turning points for trauma work when the clinician can recognize them and step out of the trauma reenactment. This requires the clinician to be competent in mindful self-soothing and compassion for self. It is, after all, not easy to sit across from someone who is blasting you profanely for having made a mistake and still maintain some form of humility and equilibrium, while neither groveling nor defending oneself. It is even harder to sit across from someone in pain over what we have done and not rescue, over-apologize, or gloss over the importance of what we have done.

Stepping out of the trauma reenactment requires self-awareness as well. We need to know what the emotional and embodied markers are of our own forays into the roles of the reenactment. I have found that a certain warmth behind the eyes is a sure-fire precursor to my being about to engage in a rescue, while a particular tone in my voice and a feeling in my vocal chords signals me that I’m on my way to being punitive. Clinicians need to also be able to have insight into how they make their most common errors.

Even when the error was made from a position of care, as was true for the survivor to whom I expressed sadness, I needed to understand what had happened for me to repair that rupture. I realized, and shared with her, that I had not only reenacted her abusive relationship with a parent. I had also stepped in much closer emotionally than she felt safe with me doing, and she needed to push me back, hard and fast, in order to feel safe. I had been insufficiently attuned to the ways in which she was managing distance and closeness, and privileging my sense that we were too distant. This is not a grave error; on the 10-point scale of erroneous clinician behaviors, this was perhaps a 2, for me. Nonetheless, it was on the scale, which is what mattered to me. My taking responsibility, not glossing this over because it was “only” a 2 for me, although something closer to a 10 for her, and soothing myself so that I could fully engage with the repair of the rupture to the point where she deemed the repair to have occurred, stepped both of us out of the chasm of the trauma reenactment that was starting to loom between us.

Engaging in repair with a trauma survivor at these moments of relationship rupture can be a profound and powerful thing for a clinician to do. The work of repair may be long. With this particular person, it was several months before she could accept that I was not intentional in my violation of her space, or angry at or rejecting of her for having pushed me away. With other trauma survivors, the work of repair can occur more rapidly. I find that this transparent, calm, and willing embrace of my own humanity, consistent with the research on the Evidence Based Relationship Variables regarding geuineness in self-disclosure (Wampold, Norcross, & Lambert, 2019) is an effective modeling strategy with survivors who have adopted perfectionism as their defense against further trauma, and thus have little to no compassion for their own human flaws and frailties.

We will next discuss a particular focus for countertransference – that of cultural responsiveness and humility, or, as is sadly often true, an insufficiency of either or both of these. Working with aspects of survivors’ marginalized intersectional identities that are not our own, or that overlap with our own, can evoke countertransference responses that are more shame-inducing and difficult to handle. Cultural responsiveness and humility thus enhance emotional competence, and the ability to know and effectively use countertransferential materials.

Cultural and Emotional Responsivity and Humility – Working with Intersectional Identities in the Context of Trauma

Introduction

Trauma occurs within the psychosocial and political frameworks of external cultural realities, as well as in the internal, intrapsychic representations of those realities. Systemic and structural forms of oppression, what I like to refer to as “social pathologies,” such as misogyny, toxic masculinity, white supremacy, and others, are sources of trauma for many that do not occur once, but are persistently present in our lives. A child who is being repeatedly abused and neglected; an adult trapped in painful and apparently inescapable intimate violence, or held captive and tortured; a man whose legs are blown away by a roadside bomb in Iraq; or a family losing their home to an earthquake, are not generic human beings experiencing these traumata in a social and political vacuum.

They are always people who are unique, and sometimes uniquely targeted for traumatic experiences because of marginalized aspects of their intersectional identities – or aspects that were not marginalized until trauma entered the room. Intersectional identities are those various strands of self that make up each of our sense of who we are in the interpersonal world. These survivors, and we, their clinicians, then experience the distress of the trauma, and attempts to cope with that distress, in the psychosocial realities of a particular time, place, and location in the social and political world. Finally, all clinicians, whether trauma-aware and culturally responsive or not, are themselves also the product of this process of identity development in the context of cultural and social realities. We have our own intersectional identities, some of them marginalized, some not. We represent meanings to trauma survivors that may assist, or undermine, the development of a therapeutic alliance and the conduct of psychotherapy itself.

Responding effectively to these realities in clinical work requires the development of cultural responsiveness and humility by all trauma-aware clinicians. This goal has often seemed daunting largely because of how cultural responsiveness has most commonly been defined. The problematic ways in which this construct has been taught has led many clinicians to distance themselves from work with individuals who they perceive as different in some way that might preclude competent practice. These clinicians are fearful of being “accused” of microaggressions, or of not using “correct” pronouns; in other words, of being challenged for not integrating learning about cultural responsiveness into their work and life.

The notion that responsivity is founded in humility, and is a conscious embrace of a life-long stance of having something new to learn at every moment, can be a difficult yet rewarding perspective to adopt. This stance is not unique to trauma work; such distancing, often accompanied by feelings of guilt, shame, and inadequacy, is as normative among many clinicians when issues of difference become foreground, as distancing from trauma survivors has been for those clinicians to whom post-trauma presentations seemed alien or overpowering. Feeling inadequate, and not wishing to admit to one’s ignorance, can induce shame, along with its distancing effects. A goal of this segment of the course is both to disrupt the common narrative of how a clinician develops cultural responsiveness, as well as to engage clinicians in the project of becoming culturally responsive in their work with all of the people with whom they work, not only those defined as marginalized or oppressed or different from the clinician. The keyword to this entire project is humility; one must be humble in the face of the vastness of ignorance that each one of us, regardless of our particular intersectional identities, brings to bear upon the project of connecting across apparent difference.

I’ll be focusing here on an inclusive paradigm for cultural responsiveness and humility that can, and should, be woven into the fabric of the specific approaches to trauma work addressed earlier in this course. Our focus is on creating heightened awareness of one’s own inevitable biases and distortions, and on developing overarching epistemologies of difference rather than algorithms for working with so-called “special populations,” and models of intersectional identities as they affect both the experience of trauma and the later development both of distress and dysfunction, as well as resilience, hopefulness, and post-traumatic growth.

Why should a trauma-informed clinician be centrally concerned with becoming culturally responsive and humble? Why not simply take the stance of referring the survivor who is a member of group “X” to the specialist in that group, and maintain the self-perception of competence and ethical practice by means of limiting the populations with whom one works? Or see all of the people we work with as simply “human,” and take a stance of “color-blindness,” loudly proclaiming that such intersectional identities are differences that don’t matter? Why not feel satisfied with what we know, rather than embracing the reality of our ignorance and unknowing?

First, this is essential because more than is true for any other form of psychic distress, the very nature of trauma is inherently concerned with culture, context, politics, and identity. Much trauma is interpersonal in nature, and each person comes to the experience of trauma, whether as perpetrator or target, as a human with identities, lived experiences, and social realities that, if denied, can silence the survivor just as surely as denying the trauma itself. Many traumas, particularly complex traumas, are those of enforced intimacy, of abuse and betrayal occurring in shared physical and social realities, and frequently of these violations happening in the contexts of shared or overlapping cultures and epistemic systems. Trauma is flavored and shaped by the psychosocial, contextual, political, and cultural milieus in which it occurs. Ironically – within a subject matter that is itself a voicing of previously silenced realities – culture, identity, and social context have largely been the invisible components of conceptualizations of working with trauma survivors until the early decades of this century, and remain marginalized topics in many spaces of the professional trauma therapy world.

Second, because for those readers who do not live in large metropolitan areas replete with specialists in working with every possible population, the option of making a referral to the imaginary specialist is not an option, and even then not always a good idea. “Referring you out to the specialist” is another way of conveying to a trauma survivor that they are uniquely bad or hard to deal with. This strategy is itself a means of emotional distancing from difference. Finally, this strategy reflects an epistemology of difference that, while revolutionary and highly valuable in its day when first introduced into our professions, is no longer a tenable stance for understanding human difference, nor a foundation for a culturally responsive and humble practice. It “ghettoizes” the experiences of those whose marginalized intersectional identities differ from the dominant cultural norm, or from our own. All of us have every single marker of identity present in ourselves, and to routinely decline to work with people who do not appear to share all of our identity markers and knowable intersectionalities reduces our capacities to thoughtfully and critically interrogate those markers in ourselves, and in survivors who appear to resemble us.

A Few Words About Language

Mental health coursework and textbooks on working with difference have commonly used the term “minority group” to refer to marginalized populations who are defined as “other” from the author. I will not be utilizing that terminology, as it is both numerically inaccurate in many instances, and also carries a meta-message that is experienced by many members of these groups as pejorative, e.g., “less than.” Instead, I will be using the terms “marginalized” and “agent” group. Marginalized groups are defined as those groups in a given cultural and political setting that have been historically, and/or are currently, the targets of systemic discrimination, marginalization, subjugation, violence, and/or prejudice. Agent groups are defined as those groups in a particular cultural and political setting that are defined as the norm, to whom possession of power within the hierarchy and institutions of that setting is unquestioned.

Most people contain some mixture of agent and marginalized experiences within their identities. These group memberships, while they may be founded on biological variables such as sex or melanic phenotypes, are actually socially constructed, and thus differ from context to context. But the sociopolitical context, especially hierarchies of power and dominance, then give meaning and value to these constructs within the specific cultural, social, political, and existential realities in which a person exists. As such, these meanings and values may change as the narrative themes of the culture and its politics transform over time. Trauma survivors constitute one large, diverse marginalized group, “other”ized by the norms of cultures that wish to obscure the realities of trauma, loss, and the unpredictability of life. Aspects of identity intersect within each person; Crenshaw (1989) coined the term “intersectional identities” to refer to the lived experiences that all humans have, be they aware or otherwise of our mix of locations on various social dimensions.

Defining Cultural Responsiveness: Etic Versus Emic Epistemologies

Beginning in the 1960s, literatures emerged in the various mental health disciplines noting that the science and scholarship of those fields were distorted through the lenses of dominant cultures, with almost everything written about human beings reflecting, in reality, only the experience of humans who were male, Christian, Euro American, and middle class – members of the cultural dominant groups of the English-speaking world of the Western Hemisphere. The decades of the 1970s and 1980s were marked by an explosion of scholarship on the psychological experiences and needs of many marginalized groups, with volumes dedicated to women, African-Americans, lesbians and gay men, older adults, people with disabilities, and other similar specific marginalized groups.

This sort of scholarship, which focuses on within-group similarities, as well as differences between marginalized and dominant groups, is referred to as an etic epistemology, deriving from an anthropological perspective for studying culture. Etic strategies for knowledge are those emphasizing allegedly objective collections of information about a group based on categories of analysis developed by an “expert” from outside of the group. In the instance of this “Handbook of psychotherapy with some-marginalized-group-or-another” period of scholarship, the etic knowledge offered about members of marginalized groups referred to how they did or did not fit into dominant culture diagnostic categories, and how they did or did not respond to conventional, dominant culture approaches to psychotherapy. The focus on this narrative was on adapting “standard” approaches to working with people for the specific marginalized group, rather than on questioning the epistemic assumptions on which a particular approach to working with people was founded.

Cultural responsiveness within this etic epistemology of difference required clinicians to acquire large amounts of information about specific groups, developing sets of clinical rules and algorithms for working with people who were marginalized-group members. Humility was never considered a good thing. Etic epistemologies and the scholarship arising from them tended to downplay within-group differences, emphasize the homogeneity of groups, and highlight the differences between marginalized and dominant groups. Assumptions that were implicit in this scholarship included that group membership was always a core and foreground component of an individual’s identity, and that marginalized group memberships were relatively fixed, rather than fluid, categories of experience. Culturally “competent” practitioners in this model would thus have specific limits to their competence; being able, for instance, to work well with one marginalized group only, not with others. Some states even offered certifications for clinicians as specialists in work with a particular marginalized group.

Etic models of cultural responsiveness were important and necessary correctives to the state of the mental health disciplines prior to the last third of the 20th century, an era when all behavioral norms were defined unquestioningly through those of agent groups. They were a valuable and irreplaceable initial step in moving these disciplines and their practitioners toward the capacity to work with people from the full range of human experience, punctuating as they did, the varieties of human experiences and the diversity of idioms of psychological distress and behavioral dysfunction.

However, these etic models were also problematic in some important ways. Problems included unquestioned assumptions about the value of standard diagnostic categories and practices. Etic models simply demonstrated, for the most part, how standard practices applied poorly to members of some marginalized groups, rather than raising more fundamental questions about the inherent value of those diagnoses or therapeutic strategies that might have had implications for working with all people. A sort of conceptual ghetto was created in which the “diverse populations” literature flourished, but spilled out little into the dominant culture of the mental health disciplines.

Etic models also have had another, extremely unfortunate set of unintended consequences. By creating a standard for so-called “competence” that was based upon the acquisition of specific knowledge about a particular marginalized group, many clinicians defined themselves as not competent to work with members of most marginalized groups, and, in an attempt to practice ethically, withdrew from working with such individuals, feeling uncomfortable and, in some instances, ashamed of not knowing the correct information. Humility was penalized, not seen as a foundational value for doing this work.

For these reasons, and because of changes in how the study of difference has been approached since the late 20th Century, emic epistemologies of difference and human diversity have emerged in the mental health disciplines as a different paradigm for culturally competent practice. Emic models do not assume an invariant human behavioral norm or standardized categories of understanding and analyzing human experiences, thus supporting an intersectional paradigm. Nor do they place authority in the hands of the external expert.

Rather, these epistemologies are more qualitative and phenomenological in nature, assuming the presence of within-group differences that are meaningful to individuals in those groups even if they are not easily apparent to outside observers. These models invite the development of categories of analysis of lived experience from within a group, disclaiming the existence of the objective or universal. Emic models create an epistemic framework in which members of marginalized groups are themselves the experts on the realities and meanings of their experiences, and in which the experience of intersectional identities is normative and assumed, rather than denied, as is often the case for members of agent groups who have not yet interrogated their own internal variability.

Additionally, within the mental health disciplines, these models have emphasized the importance for clinicians of understanding and interrogating the meaning of our own intersectional identities and inherent, human biases, as well as the implications of those variables for the accurate observation of the distress of others and the design and implementation of healing strategies. Thus, emic models are not simply about understanding the alien other who is a member of a marginalized group. They are also about understanding being human, and about apprehending the intersubjective meanings for all parties of being a clinician of particular intersectional identities working with a survivor with other or similar intersectional identities. In emic models, both parties are observers, and both parties co-construct the meanings of experiences.

Emic models do not assume a stance of expertise on the part of the clinician, but rather, a stance of curiosity and ignorance, frequently referred to in the literature as “cultural humility” or “cultural responsivity.” This position of humility and responsivity has come to increasingly be recognized as an important foundation for effective practice. Culturally responsive and humble clinicians know and embrace the reality that they are indeed ignorant, lacking in sufficient knowledge of the person of the survivor. They embrace the ambiguity inherent in trauma work, and create space in which to compassionately, and without judgment, experience how they may fail in their understanding of the people with whom they work, both because they, clinicians, are apparently different, as well as because they are apparently similar, to the people we work with. Embracing ambiguity and having humility about phenomena arising from intersectional identities, and sociopolitical realities, with all of the people we work with, trauma survivors or not, is a central component of cultural responsiveness. Deepening these capacities will assist in the implementation of the evidence-based relationship variables underlying trauma work that were discussed earlier.

However, the effects of guilt and shame that are frequently distorting dynamics in relationships between marginalized and agent groups seem to disconnect otherwise emotionally skilled clinicians from their willingness to be uncertain and tentative with survivors who represent the Other to them. Clinicians frequently experience themselves as more different, more deficient, and having less capacities to consider engaging with survivors who visibly differ from them. In trauma-informed work, where the clinician’s own emotional responses are more likely to be carefully scrutinized and interpreted by survivors whose experiences have been dangerous and confusing, the presence of such distortions, and the performance anxieties placed upon themselves by clinicians, can lead to serious, difficult-to-repair ruptures in the therapeutic alliance. Consequently, a step toward the development of emic cultural responsiveness for clinicians is the direct confrontation of, and acceptance for, the realities of one’s own biases.

We’re All Biased – We Simply Cannot Carelessly Act it Out

As people of good will, clinicians tend to see themselves as non-judgmental and lacking in malignant bias. We are, in many instances, trained to become aware of our judgments of others and let them go, and cautioned to maintain neutral, objective stances in relationship to the people we work with. This narrative of the unbiased, non-judgmental clinician is deadly to the humble development of cultural responsiveness, as it presumes a way of being that is difficult, if not impossible, for most human beings to achieve.

Evolutionary biology and psychology indicate that human beings are coded to notice difference. Our limbic systems, which are also implicated in the trauma response, light up and become active when data become available in the interpersonal field informing us that another human differs from us in some way. Our limbic system overpowers our cognitive brain, firing more quickly than our orbital pre-frontal cortex. The notion that a clinician can be unbiased presumes the absence of limbic system input, as well as of any personal life history that has ascribed meaning to difference, either positive or otherwise. No clinician matches these criteria.

By the time that the first person we work with professionally, not to speak of the first trauma survivor, enters the office, the average clinician will have had multiple experiences of classically conditioned associations with the visual, auditory, olfactory, kinesthetic, and other sensory cues presented by that individual. The clinician will have bias simply by virtue of being human. Acknowledging this reality is akin to acknowledging any sort of affects evoked by the people we work with, as discussed in the section on countertransference.

Yet when the survivor is identified as a member of a marginalized group, and the clinician’s identity is largely that of agent group status, these awarenesses of the normative nature of clinician bias and negative affects in therapy are often over-shadowed by clinicians’ feelings of guilt and shame for experiencing those emotions toward the survivor whose group has been marginalized in some way. Clinicians, in the internet and social media age, also fear being cancelled, or having scathing reviews written about them on various client feedback websites, should they fail in achieving the unachievable with regard to continuous non-anxious engagement with difference in trauma work. These affects are components of a larger phenomenon known as “aversive” or “modern” bias (Gaertner & Dovidio, 1986, 2005), an understanding of which is another core aspect of developing cultural responsiveness.

Aversive Bias

Aversive bias refers to non-conscious biases held by individuals who consciously eschew overt expressions of bias. Persons who embrace overt expressions of bias, as has become more common in the public domain in the past decade, may also hold aversive biases, but this discussion largely refers to people for whom overt expression of bias is anathema and a source of personal shame when encountered within oneself.

A split emerges in many individuals between their expressed, conscious beliefs, which are not biased and emphasize the value of diversity, equity, and inclusion, and their well-conditioned, non-conscious, and now ego-dystonic biases, which are consciously aversive and shame-inducing to them. Social psychologists who have studied this phenomenon suggest that around 85% of Euro-American individuals hold aversive bias towards persons of color, for example, even though their consciously held attitudes and behaviors may be devoid of overt bias.

Aversive bias has observable effect on interactions with others. Thus, it is not simply a private affair, but rather an intersubjective phenomenon with specific effects on the interpersonal field. Given the sensitivity of many trauma survivors to a clinician’s own unexplored or denied feelings, it stands to reason that aversive bias can play a large part in undermining therapeutic relationship, and thus effectiveness when marginalization is a foreground component of one or both people’s intersectional identities in the relationship of trauma work.

Aversive bias is supported by the defensive strategies of denial and undoing, and leads to shame, discomfort, and distancing by agent group members from marginalized group members. Members of marginalized groups, who, like trauma survivors, are often highly attuned to cues about bias emanating from members of dominant groups, will commonly experience their interactions with such agent group persons as crazy-making and fraught with inauthenticity, just as the survivor encountering a clinician who claims to have no angry feelings while emitting cues of angry affect feels discounted and crazy-made.

Dovidio and his colleagues, in a series of elegant experiments exploring the effects of aversive bias, have paired African American individuals with Euro American individuals on a problem-solving task. The Euro American participants were assessed on measures of both overt and aversive bias, and divided into three groups: Low aversive/low overt bias, High aversive/low overt bias, and High aversive/high overt bias. They found that African American participants had the most difficult time interacting with the middle group, finding it easier to relate to a person who was consistently high in both conscious and non-conscious bias than to deal with the conflicting psychosocial cues emitted by the individual who was unconscious of his aversive bias. Persons in the middle group tended to behave in ways that were inappropriate for the situation; they were either overly friendly, leading to suspicion regarding motive on the part of the African American participants, or became withdrawn and almost punishing, apparently when their inauthentic attempts to create relationship were unsuccessful. (Readers wishing to assess their own levels of aversive bias on the variables of ethnicity and sex can do so for free, and anonymously, online at understandingprejudice.org).

The implications of these and similar findings for the psychotherapeutic relationship are potentially quite powerful. Clinicians who are unaware or in denial of their aversive bias may, like the participants in Dovidio’s studies, emit interpersonal cues with survivors from marginalized groups that undermine their conscious intentions to do well. Given the heightened importance of the therapeutic alliance for people who have anxious or ambivalent attachment styles, which is true for many survivors of interpersonal violence trauma (Norcross & Lambert, 2005), the presence of such non-conscious and disowned bias in the clinician may be particularly toxic to the alliance in trauma work with this population.

Cultural responsiveness does not rest solely in knowing that, in theory, one has aversive bias. Being culturally responsive requires humility, a willingness to acknowledge this fact about oneself compassionately, without shaming oneself or inducing guilt in oneself, as a step toward greater congruence, humility, and authenticity. As noted above, humans are biologically wired to respond to difference, and psychosocially conditioned to associate difference with negative ascriptions that are inescapable in the familial and cultural contexts, often rife with systemic and structural forms of inequality, in which each clinician has been raised. Since virtually all humans have bias, acknowledging that reality about oneself in a compassionate, shame-free way, enhances the clinician’s capacity to work with all people whose intersectional identities differ visibly from their own and particularly enhances emotional competence in work with trauma survivors.

Shame about bias, however, undermines effectiveness. Nathanson (1992) has argued that humans have four predictable responses to shame: withdrawing or distancing from the source of the shame, attacking the self for being shameful, attacking the source of the shame, or denial. Each of these interpersonal and intrapersonal strategies is counter to psychotherapeutic effectiveness. Compassionate acceptance of the reality of clinician bias allows for approach and relationship between agent and marginalized group members, no matter which one is the clinician and which the survivor, an interpersonal style more consistent with the development of a therapeutic alliance. If I am able to accept the reality of my biases, and make them conscious in a mindful and compassionate manner, I will enact them less, distance less from survivors who evoke these biases because I am experiencing less shame about my own responses, and be more willing to be confronted by a survivor without responding in a defensive manner. Cultural responsiveness and humility about one’s humanity creates therapeutic competence.

Understanding Privilege

When clinicians embrace the reality of their bias without shame, then they are free to take the next step toward cultural responsiveness – the acknowledgement of one’s cultural privilege and disadvantage.

Neither privilege nor disadvantage is earned or deserved, and thus neither are deserving of shame. Similar to the acquisition of bias, the experiences of privilege and disadvantage accrue to people because of the circumstances and realities of their lives, few of which, until adulthood, occur in response to their own desires or actions. While the term privilege has become radioactive in some circles in recent years as conflicts within the larger sociopolitical context have worsened, and the word is at times used as an epithet, intended to shame a person assumed to possess certain types of privilege arising from some non-marginalized component of their intersectionalities. I use this term here in a purely descriptive manner regarding the effects on the interpersonal field of one’s place in social hierarchies, a term to which no judgment accrues. We all have privileges of some kinds. We all have disadvantages of some kinds. In our intersectional identities, one or the other of these may become foreground, and then background, over the course of the lifespan.

What is privilege? Peggy MacIntosh (1990) described it as an “invisible backpack” of safety and positive experiences that is carried by each member of an agent group. It cannot usually be taken off, and it is rarely noticed by the person who carries it. I think of it as a package of goodies delivered to unknowing recipients, tokens of power that may be played without their owner’s knowledge. Privilege can disappear; for instance, the person who was previously temporarily able-bodied experiences the loss of that status, and loses the privilege of that status. More recently, some commentators on Jewish identity have noted that the privileges of whiteness ascribed to Jews in the US is a tenuous one that can be revoked depending on sociopolitical realities (Brown, 2024), just as it was in Hitler’s Germany.
Rather, for most individuals whose intersectional identities constitute more agent than marginalized groups, privilege is simply how life is, the description of “normal.” In many dominant cultures, the absence of privilege in the lives of marginalized group members is explained as deriving from some real or imagined deficiencies in the marginalized group (e.g., people are poor because they don’t work hard enough), thus justifying the denial of privilege, and implying that privilege might be earned, when such is never the case.

Most individuals have some mixtures of privilege and disadvantage due to the mingling of agent and marginalized group status in their identities. Privilege creates ease, safety, and a sense of clarity (whether false or real) about what is happening in the interpersonal field. Having these can create resilience, or give access to resources that speed the healing process.

Acknowledging privilege is, like acknowledging one’s aversive bias, a process that often initially induces shame and guilt. Like aversive bias, privilege should be an occasion for neither; being born with pale skin or a penis in a culture that values these characteristics and gives privilege to those who have them is an accident of fate and genes that one did not choose. Culturally competent and humble psychoclinicians must communicate to themselves that whatever privilege they may have accrued by accident of birth is not their fault, and thus not cause for guilt or shame. It simply is what it is, in the cultural context that ascribes privilege to one’s unearned personal characteristics or life circumstances.

Shame or guilt over privilege, similar to shame about one’s aversive bias, can undermine both effective assessment and treatment in psychotherapy. Most centrally, empathic relating can be undermined when the powerful and sometimes insidious effects of the absence of privilege on well-being and psychological robustness are denied or downplayed; this is one of the ways in which insidious trauma is often missed in diagnostic formulation. A clinician denying privilege can also become numb to the ways in which privilege’s absence shapes life’s realities. To call oneself color-blind is an excellent example of privilege at work; only if the shade of my own skin has not systemically disadvantaged me can I act as if this variable matters little.

Loss of privilege is sometimes a component of trauma. The Syrian physician refugee in the U.S. who cannot pass the language exam to become licensed again to practice medicine, who now drives Lyft for a living, and, as a Muslim and a refugee, is a target of systemic Islamophobia and xenophobia, has not just suffered the trauma of war and refugee status; that person has also lost the privileged locations formerly occupied in their homeland. Those losses are a component of the trauma.

Representation: Culturally-Mediated Transferential Dynamics

When clinicians have been able to mindfully and humbly observe their bias and privilege, then they are better equipped to comprehend the complex phenomenon of representation. The 19th Century African American suffrage activist, Anna Julia Cooper, said, “When and where I enter, then and there the whole race enters with me” (quoted in Giddings, 1996). Cooper’s statement is true for each psychoclinician, and each survivor. When and where we enter the exchange of therapy, into the room come our personal and cultural histories, and our privileges and our biases. We will represent things to our survivors, and they to us. This, I would suggest, is more than simply issues of transference or countertransference, as the things we represent, including our status as a trauma survivor or not, are currently active in the social environments in which we and our survivors live. The dynamics of representation, even when symbolic, are not simply non-conscious representations of personal history; they are the interpersonal and political realities in which therapy takes place.

Culturally competent and humble practice, with trauma survivors or not, requires a heightened awareness of what it is we represent, and what is represented to us by our survivors. This is especially the case when one or the other person represents a component of personal or historical trauma to the other. For cultural responsiveness and humility to be infused into our work, psychoclinicians must consider how both visible and invisible aspects of our intersectional identities may carry meanings to which our survivors are not insensitive. Clinicians may attempt to deny social realities by telling themselves (and sometimes their survivors) that they are inattentive to a survivor’s phenotype, sex, size, or accent; such statements, reflecting experiences of privilege, are experienced as invalidating to survivors from marginalized groups, who are rarely perceived, and treated, outside of the framework of those variables.

Privilege, ironically, confers a lack of awareness that one is a representative because an aspect of privilege is that one is not expected to represent one’s entire group. The divorcing heterosexual individual is, for example not seen as evidence of the failure of that sexual orientation, but simply a person having a bad relationship experience. The divorcing lesbian couple may experience more shame for having somehow “proved” the homophobic meme that same-sex relationships are supposedly short and meaningless. For psychoclinicians whose primary intersectional identities are those of agent groups, and who are thus most likely to be affected by the non-conscious assumptions of privilege, heightened attention to how and what one represents is essential for culturally competent practice and appropriate humility. This interrogation of one’s identities can also deepen empathy, as the agent group psychoclinician begins to appreciate what it means to live as a visible, audible, or palpable symbol of something good, bad, or indifferent, in one’s daily life.

A basic assumption of culturally responsive and humble practice is that we can never assume that survivors trust us, even when we appear to share important aspects of intersectional identities (Gomez, 2020, 2021). This dovetails with what we know about working with trauma. Trauma is itself destructive to trust. When we overtly represent difference in a way that, consciously or not, conveys a message of threat, or if a survivor evokes the same in us, our willingness to bring these dynamics of difference and representation into shared awareness not only increases cultural responsiveness, but also makes steps toward the deepening of empathy, and makes our humility visible to a survivor, which in turn is likely to increase our worthiness of their trust.

When we represent current or historical trauma to survivors, and are aware of it, we increase the possibility of earning trust when we tell the truths about our acceptance of our role as representative of our culture. Acknowledging and validating the presence of dynamics arising from such representations in the therapy office can communicate to survivors that we have the humility and willingness to tell truths that are uncomfortable for us as clinicians, not simply to invite survivors to experience their own discomfort. Power becomes more balanced when we eschew the anonymity of privilege built into clinical roles and foreground our own identities, as marginalized group member survivors must do often in their daily lives.

Thus, simply saying, “I’m wondering what it means for our work together that I’m apparently able-bodied and you’re a person with a visible disability” communicates a clinician’s cultural responsiveness and humility in several ways. First, the clinician is being honest about difference and humble about not pretending to know everything that it means. Second, the clinician is taking responsibility for opening the discussion, something that the more powerful person in a dyad rarely does. Finally, the clinician is acknowledging the awareness that they represent things to the survivor arising from apparent differences in what could be an important strand of intersectionalities. This kind of exchange exemplifies culturally responsive practice, which may engender a modicum more of safety for the trauma survivors, who now know that they are not alone, with a heightened awareness of the meanings of difference in the room.

The ADDRESSING Model

Finally, culturally responsive practice stands on the foundation of the belief that each human being represents the range of aspects of human diversity, and that being culturally responsive requires clinicians’ awareness of their own identities and social locations as well as those of survivors. Human diversity is not about “special populations,” but about the nature of being human. Challenging oppressive norms and structural and systemic forms of oppression is something done not only altruistically, on behalf of traumatized survivors, but also from enlightened self-interest, with the assumption that each person is in some manner harmed by current social structures of hierarchies of value and structural inequalities. Using epistemologies of difference which invite clinicians to consider how to think about and analyze experiences of identity are valuable to support cultural responsiveness because clinicians need not acquire discrete data bits about particular groups. Rather, clinicians learn how to think about what it might mean to have the lived experiences of existing in a survivor’s intersectionalities of identities.

Experts on the development of cultural responsiveness in psychotherapy have proposed a variety of epistemologies of difference. The one I have found helpful is Pamela Hays’ ADDRESSING model (2016), which she utilizes within a framework of cultural responsivity. The acronym stands for a non-exhaustive list of components of intersectionalities, each of which exists to some degree in all persons. ADDRESSING is a starting point, not the end of understanding intersectionalities; it offers an epistemology of intersectionalities that empowers clinicians and survivors alike to identify those aspects of intersectional identities that are foreground or core.

Any of the ADDRESSING variables can become central strands in the development of identities for all individuals; they are:

A: Age-related factors, including chronological age and age cohort
DD: Disability/ability, developmental and acquired, visible and invisible
R: Religion and spirituality
E: Ethnic origins; race/phenotype, culture
S: Social class, current and former
S: Sexual orientation; lesbian, gay, bisexual, heterosexual, questioning, asexual, pansexual, demisexual, aromantic – not an exhaustive list
I: Indigenous heritage/colonization history/colonizer history
N: National origin/immigration status/refugee/offspring of immigrants G: Gender/biological sex (male, female, intersex)/gender identity (masculine, feminine, transgender, cisgender, non-binary, other gender non-conforming).

This model makes explicit that all humans have intersectional identities. Although one aspect may become central phenomenologically or foreground interpersonally, that may also change over time. Each person is the unique intersection of some combination of these strands of self. Identities emerge in the dialectical struggle between individual experiences and temperament, and group and collective experiences and norms. None of these variables will combine in the same manner for any two people, even two members of the same family. Root (1998), in a fascinating study of siblings of mixed heritage, found that rarely did two such siblings have the same racial/ethnic identities, nor did such identities reflect obvious phenomena such as melanic phenotypic (aka “racial”) features.

Trauma was frequently a variable affecting how people identified. For example, in one family of mixed Euro-American and Indigenous heritage in which the Euro-American parent had sexually abused all siblings, all the survivors identified as Indigenous and enrolled members of their indigenous nation, consciously choosing to highlight that aspect of identity not associated with the abusive parent. Some of these individuals had the melanic phenotype associated with indigenous people, but two had blond hair and green eyes like their mother, who was also of mixed Indigenous and Euro-American heritage. This family exemplifies in a stark manner the ways in which trauma woven into a family’s components of marginalized or agent identities then shapes the ways in which people may self-identify.

A Few Experiments for Understanding Your Own Intersectional Identities

An interesting and valuable exercise that a clinician can do in order to better comprehend the ADDRESSING model and its clinical applications is to create a drawing that represents the various aspects of his identities in which each component of identity is given a size commensurate with its perceived influence on one’s sense of self. These pieces are then arranged in the drawing so that their relationship to one another can be seen. These pictures are tremendously Informative; I have seen braids, flowers with petals, Venn diagrams, puzzles, and attempts to represent three-dimensional constructions.

Another interesting experiment that can assist clinicians in comprehending the concepts of multiple and intersecting identities for themselves, which can then improve their capacities to engage in this kind of analysis and awareness with survivors, is to do an identity- and context-informed genogram, if using genograms is something with which the clinician is familiar. In this exercise, I ask people to draw a typical genogram, and then request that they include an ADDRESSING description of each of the people in the genogram. I then request that they draw lines from each of these ADDRESSING variables to historical and contextual factors that influenced these identity components, or were potentially salient to the person because of their identities. So for instance, in the box of a person born in the U.S. in 1926 there might be lines drawn to the Great Depression and WWII. There would also likely be lines drawn to the women’s liberation movement. For a person of Japanese descent, there would be another line drawn to the W W II concentration camps; that line also might exist for a person who grew up in an area from which Japanese-American citizens had been deported.

The combination of filling in ADDRESSING variables and cultural/historical/contextual variables superimposed on a typical genogram format allows certain identity processes to become more transparent, and also begins to explicate cultural and social factors that might have affected those identities. Potential or known traumagenic social phenomena, and their relationship to aspects of intersectional identities, can be clearly seen in this way. After doing this exercise, I will sometimes ask people to go back to their identity drawing and add trauma to that picture if they have not already done so, using the trauma- and culture-informed genogram.

Trauma – Another Component of Intersectional Identity

Trauma is another component of intersectional identities, weaving into its various strands. Some survivors are also children of trauma survivors, living with legacies of intergenerational transmission of trauma experiences (Danieli, 1998). Still others identify with cultures that have been so immersed in trauma, such as Latinx, African-American, Jewish, Khmer, Native American, Native Hawai’I, Armenian, or other colonized indigenous cultures, that the experience of historical trauma has been woven into other aspects of identity by the centrality of historical trauma to that social location (Chavez-Duenas, Adames, Perez-Chavez, & Salas, 2019; Comas-Diaz, 2020, 2022; Comas-Diaz, & Jacobson, 2001; Comas-Diaz, Adames, & Chavez-Duenas, 2024; Fernandez, 2022; Pole, Gone, & Kulkarni, 2008).

Perpetration, or having been in the role of the colonizer, is another facet of many people’s intersectional identities, a variable that fuels some of the shame that leads to denial of bias (Brown, in press). Slave-holders, soldiers who shot women and children in wars, descendants of those who colonized the Western Hemisphere and the Global South, or people who imprisoned or tortured others in the countries from which they both came, all have suffered what Shay calls the “moral injury” of being trauma perpetrators. That moral injury was often traumatic to the family cultures that they created, of which both clinicians and survivors are the inheritors.

Each aspect of intersectional identities in the ADDRESSING model can be linked to the experience of trauma in some manner; this can be due to direct targeting as is the case for hate crimes or gender-based violations such as sexual assaults, or can have occurred more indirectly (for example, with poverty being a risk factor for exposure to violence). A complete discussion of this topic can be found in Brown (2008, in press). Individuals may also attribute, accurately or not, their experiences of victimization to some component of their identities, and struggle with self-hatred for an inescapable fact about themselves that they believe rendered them vulnerable.

There are special issues inherent in this dynamic for complex trauma survivors. Because the perpetrators of complex trauma are so frequently those with whom a survivor was or is emotionally intimate, the survivor’s intersectional identities may overlap with those of their perpetrators. Struggles with knowing who one is, which are commonplace among survivors of complex trauma, may be intensified by the ways in which identification with or loyalty to a marginalized group has become contaminated by shared membership with those who committed the harms. Cultural responsiveness can be enhanced by a clinician’s ability to embrace, and invite survivors to embrace, these painful contradictions and experiences of betrayal, and to see identity development as reflecting multiple social locations, and as fluid, rather than fixed.

Trauma and Identity Development

Root, an identity theorist who has used the experiences of people of mixed melanic phenotype (aka racially mixed) to develop her models (1998, 2000, 2004a, 2004b), has argued that in order to develop an identity theory for persons of mixed social locations, several factors need to be present. First, this model needs to account for within-group bias and oppression, the sort of expression of internalized oppression or horizontal hostility that can occur when marginalized group membership is present.

Second, such a model must see as positive the experience of multiple identities. Root’s model is a useful paradigm for cultural responsiveness in understanding the identity experiences of trauma survivors by construing mixed identities as that to which one aspires, rather than avoids. Her model next notes the importance of the effects of changes in social and political contexts, and social reference groups that are available to a person and which affect their own understanding of who they are.

Finally, the model must acknowledge the interaction of experiences in the person’s social ecology, including family environment, history, political realities, and biological heritage. Root, also an award-winning tile and ceramics artist with a keen visual sensibility, has portrayed her model graphically as a series of nested, interactive, and overlapping boxes in which these various factors are in constant interplay, and in which identity is in a continuous process of development rather than moving toward a fixed and apparently stable state.

Cultural responsiveness and humility in trauma practice is enhanced by this, or similar models of identity formation, because it allows the clinician to conceptualize the survivor’s sense of who they are, not only as a continuously transforming matrix of multiple social locations, but also as not requiring a fixed and stable state in order to be functional or nourishing for that person. Many survivors of trauma exist in a liminal identity state, one in which transition is a constant. What is less obvious, but equally important for the culturally competent trauma-informed clinician to take into account, is the degree to which liminal identities are those emerging as a function of a post-traumatic healing process, in which identity as a trauma survivor becomes integrated in a positive fashion into other aspects of identity.

Trauma Work in the Real World

Finally, each aspect of intersectional identities, each social location informing that identity, and each of the ways in which those variables have become embedded in the experiences of trauma and recovery, are affected by the social and political realities of the world. Cultural responsiveness and humility requires clinicians to remain attuned to the ways in which external events, which may seem distal to the therapy process, are proximal in their capacities to evoke affect, intensify bias, or change the meaning of the relationships between people in that process. For a trauma-informed clinician, this should be familiar territory, as this resembles the ways in which events outside of therapy can be trauma triggers. Many clinicians reported an uptick in trauma-related materials emerging during the 2016 US presidential race, as levels of microaggressions and actual hate crimes, including several involving the mass murders of members of marginalized groups, or the extrajudicial killings by law enforcement officers of people of color, have multiplied, with many of those acts of hatred being committed by the highest officials of the U.S. government. In the intervening years, including the four years in which the leadership of the US engaged in active hate speech on a regular basis, empowering more hate speech by members of the public and legislators then and since 2021 as well, feelings among marginalized people of being concretely less safe in the world have become heightened. Add the realities of the Covid-19 pandemic, in which members of BIPOC communities were at objectively higher risk of dying due to pre-existing health disparities and pre-existing disparities in care, and the world took on a very real life-and-death quality that has not eased much as the height of pandemic deaths has gone down. Taking all of that into account and dealing with it in trauma work has become an important challenge for clinicians moving forward, particularly as many clinicians report being affected by this uptick in hate speech and hate crimes since November, 2016.

Conclusion

Becoming culturally responsive and developing cultural humility as a clinician is a process where one never quite arrives at the conclusion. As one grows in cultural responsiveness, one grows in humility and ignorance, and in the awareness of how one might stretch one’s intellectual, experiential, and emotional edges to better develop empathy with the persons with whom one works. Deepening cultural responsiveness and humility leads one, paradoxically, to make more errors of commission at first. This trend is one that should be familiar to all clinicians working with trauma survivors; deepening of intimacy and relationship, whether in psychotherapy or elsewhere in life, allows sufficient contact that we will make errors because we are stepping out of our comfort zones. Aversive biases will express themselves behaviorally, countertransference evoked by representation will be acted out, and willingness to acknowledge error and listen to distress will be called upon repeatedly. One is never complete in the process of moving toward cultural responsivity; one is always moving in that direction, humbly acknowledging one’s need for continued growth. But like the objects in the mirror, our capacities for responsivity are closer than we think. The parallel processes and skills inherent in working with trauma serve clinicians well on the journey to cultural responsiveness; deepening cultural responsiveness by deepening humility, in turn sharpens the skills of the clinician entering the invisible world of trauma.

The final component of this course focuses on the topic of clinician self-care. To thrive as a trauma clinician, and make the investment of time and energy in the process of learning to do this work yield life-long rewards, self-care is not simply a good idea. It’s a necessity.

Clinician Self-Care and Prevention of Problematic Vicarious Traumatization

“To study psychological trauma means bearing witness to horrible events. When the traumatic events are of human design, those who bear witness are caught in the conflict between the victim and the perpetrator. It is morally impossible to remain neutral in this conflict. The bystander is forced to take sides. It is very tempting to take the side of the perpetrator. All the perpetrator asks is that the bystander do nothing. He (sic) appeals to the universal desire to see, hear, and speak no evil. The victim, on the other hand, asks the bystander to share the burden or pain. The victim demands action, engagement, and remembering.” (Herman, 1992, p. 8).

Not long after the field of trauma began to re-emerge in our professional worlds, clinicians began to speak with one another of the effects on their own well-being of doing trauma work. The concept of “secondary traumatic stress” emerged to describe clinicians’ experiences of having referred symptoms from survivors, including intrusive images of materials heard in therapy sessions. The construct of “compassion fatigue” also became part of the vocabulary of trauma clinicians. Unlike pure burnout, these experiences seemed unique to the reality of sitting in the presence of the horrors of the world described by trauma survivors. While reducing one’s exposure to this material, similar to reducing exposure directly to trauma, seemed to be an effective step for clinicians wanting to reduce such distress, distance neither allowed for continuing practice with trauma survivors, nor ultimately addressed the deeper transformations affected in clinicians by engagement, not simply with the details, but also with the existential disruptions of the world of trauma.

As Herman notes in the quote above, the pull in the trauma dynamic is to become a passive bystander or a perpetrator; becoming engaged as the ally of the traumatized person seems to exact a price while appearing to do nothing seems easy and joining with a perpetrator creates the illusion of power. As discussed in the previous segment on countertransference, many clinicians working with trauma survivors enter into trauma reenactments with specific survivors in which they take on those bystander or perpetrator roles. Even more problematic is when this stance with one survivor begins to become the clinician’s standpoint in relationship to the world and trauma in general.

Thus, no discussion of doing effective trauma-informed work can be complete without a discussion of self-care. It is self-care, and awareness of the ways in which we are affected by working with trauma survivors, that serves as the most effective preventative against falling into bystander and perpetrator roles. Self-care assists the clinician to exit the role of rescuer, which is the other problematic stance of trauma reenactments, and to enter a place of empowerment for self and survivors alike. It is also an investment in being able to do this work well for the long haul.

The Invisibility of Trauma and Trauma Clinicians

Clinicians who work with trauma live in what I have called an “invisible world” (Brown, 2010) where both survivors’ pain and their own empathic and compassionate responses are unseeable and unknowable to those around them. The culture-at-large attempts, with decreasing success in the era of the 24-hour news cycle and omnipresent social media, to bury the realities of trauma; there may be a story or two in the news about a combat veteran with PTSD around Memorial Day, or the occasional tabloid presentation about someone’s horrific victimization by a predator, and then silence falls on the topic. Even after the latest mass shooting, there are a few days of “thoughts and prayers” and then, for the most part, the world goes silent until the next occurrence. The quotidian nature of trauma is hidden behind these stories; the daily suffering of many is unseen and unheard. The rules of confidentiality, which are in place to protect the privacy and safety of the people with whom we work, also create forms of silence for clinicians. Where and how do we speak of our work; we cannot come home and say to a partner, “Oh yes, today I heard about a rape and children being beaten and, oh by the way, that the rapist got off because the person I’m working with was too terrified to testify.” Many clinicians work alone, particularly since the beginning of the Covid-19 pandemic and the shift to the isolating world of telehealth. Even those who do not work from home or in solo practice may not necessarily have colleagues who are trauma-aware and thus both able and willing to hear of the realities of trauma to which the trauma-aware clinician is witness. This isolation and absence of social validation, at work and home alike, can compound the challenges of doing trauma work by creating parallel experiences of being invisible and unheard to those of the survivors with whom we work.

In the mid-1990s, Pearlman and Saakvitne proposed the construct of Vicarious Traumatization (VT) (1995) to explain the emotional and existential changes faced by many clinicians working with trauma survivors. They defined VT as the expectable consequences of engaging empathically with trauma survivors during the course of one’s work as a clinician. They differentiated it from Secondary Traumatic Stress, as well as from burnout, proposing instead a framework for comprehending the deeper, cumulative effects to which long-term work with trauma survivors leads.

VT, unlike STS, does not entail having PTSD-like symptoms arising from exposure to information from survivors about their Criterion A traumatic stressors. Unlike burnout or compassion fatigue, VT does not reflect general stressors in the workplace; in fact, the authors who first described it were part of a trauma-aware, compassionate, collegial workplace that was under the direction of one of them. VT is not about having no control over our work.

VT is, rather, unavoidable, an experience of transformation that can enhance us, or wound us, or both. When understood and dealt with head-on, it is not problematic. In fact, VT has the capacity, when used well, to enhance a trauma-informed clinician’s capacities and to lead to post-traumatic growth for the clinician. Understanding and engaging with one’s own VT is core to self-care for a trauma clinician. Self-care is an ethical necessity for continuing work in this field.

VT is also not the same as countertransference, although it inhabits a similar emotional territory. Pearlman and Saakvitne arrived at the construct through their attempts to explicate the countertransferential experiences that they and the clinicians they worked with encountered in working with trauma survivors, particularly those with complex trauma arising from childhood sexual abuse. As noted in a previous section of this course, countertransference can be extremely powerful in working with trauma survivors because of the intensity of painful emotions that emerge in the work of psychotherapy with this population (Dalenberg, 2000). Countertransference, however, occurs in a specific therapeutic relationship and responds to the particular variables present in the unique encounter between a given clinician and individual survivors or their families.

VT is a more profound, far-reaching, and extensive experience than is countertransference, secondary traumatic stress, or compassion fatigue. It reflects trauma clinicians’ journeys with survivors into that invisible world and becoming a citizen of that planet. It is not simply about a specific survivor-clinician relationship, but rather the cumulative impact on a trauma clinician of that person’s engagement with, and both conscious and non-conscious responses to, the stories and feelings of many different trauma survivors over time.

It also involves the ways in which those stories intersect with the clinician’s own experiences of trauma. Many clinicians are ourselves “wounded healers;” many clinicians working with trauma have chosen this field, consciously or not, because of our personal or cultural trauma histories. VT is not, however, the province only of wounded healers; acknowledging one’s own status as wounded rather than attempting to avoid or deny it will assist a clinician in coming to terms with VT, while VT may be more shocking for clinicians whose trauma work becomes their own just world trauma.

Clinicians’ VT comes with them to every encounter in life, not only those in the therapy office, and is powerful in large part because its effects cannot be compartmentalized within the confines of professional life. VT is the story of how being a trauma clinician changes us. With self-care, it is the story of how we are changed for the better. “There is a crack in everything – that’s how the light gets in” sings the poet Leonard Cohen; approaching those cracks in our own hearts with compassion and self-care does make them conduits for light, not simply places where we or the survivors we have the honor to work with have been broken.

VT develops in almost every clinician who works consistently and intentionally with trauma survivors because these stories of harm and betrayal not only evoke emotions related to a clinician’s own intersectional identities and life experiences, and resonate to our own trauma stories, it also occurs because our experience of witnessing these lives acts on and changes our identities and their meanings forever. VT creates a profound transformation in the clinician’s own consciousness and sense of self as an actor in the world. In that transformative process, through the experience of genuine, open-hearted emotional encounter with other humans who have survived trauma, we experience a change of world-view, identity, and self-view, and find ourselves reevaluating our needs, feelings, and interpersonal relationships. As Pearlman and Saakvitne write, “…we view it [VT] as an occupational hazard, an inevitable effect of trauma work.” (1995, p. 31).

I would add that encountering VT is a spiritual/existential challenge to clinicians who work with trauma. If we rise to and meet that challenge, we grow. Failing to do so, we become distant, disengaged, and emotionally hardened, risking our capacities for ethical and competent work practice.

VT is not a passing experience. If a clinician stays engaged in work with trauma survivors then VT becomes another component of our intersectional identities. This is not necessarily a bad thing; in fact, when VT is acknowledged, and embraced, and integrated into a clinician’s sense of self rather than denied and disowned, it becomes a source of resilience and an inner place from which a clinician can join empathically with trauma survivors in ever more profound ways. If I can become aware of and know how simply witnessing stories of trauma affects me, I have an experiential base that allows me to validate the transformational power of direct trauma exposure in an emotionally truthful manner. My VT, for example, informed my responses to survivors of torture, war, and unexploded ordnance who I met on a trip to SE Asia toward the end of 2016. I was able to be with them empathically, not avoid them or objectify them. It also informed my decision about how and when to retire from direct service as a clinician working with trauma survivors; I was able to assess that I was coming close to having an “empty tank” within the next few years, and decided to retire before I began running on empty, a state in which many clinicians, at the ends of our careers, undo the relational healing we have offered previously.

When survivors hear and feel my responses to their stories, they can hear and feel a resonance that has its roots in VT. Recalling the earlier segment discussing the application of the evidence-based relationship variables to work with trauma survivors, VT can become a component of more authenticity and authentic empathy for clinicians. Looking at VT from this perspective makes it an avenue for the clinician’s own posttraumatic growth, a process of transcendence and increased personal wholeness that emerges from the encounter with the emotional abyss (Tedeschi & Calhoun, 2004). Dealing with VT enhances a clinician’s capacity to maintain emotional competence (Pope & Brown, 1996; Pope, Sonne, & Greene, 2006; Pope & Vazquez, 2010), which supports ethical practice.

Because it can enhance empathy and the capacity for genuine connection between clinicians and trauma survivors, VT can also become a catalyst for enhanced cultural responsiveness and humility in clinicians. This is because, in my experience, the heightened capacities for empathy engendered by successful integration of the VT experience make clinicians more attuned to possible ruptures in the relational field, and thus more willing to have the humility to notice where they may be acting in a culturally other-than-sensitive manner with survivors. Just as, for many trauma survivors, the experience of trauma has given them the coping strategy of heightened awareness of other humans’ subtle emotional cues, so too can VT be a path toward a more nuanced awareness by clinicians of where meaning lies for the people we work with and how to best be fully present in our relationships with them. This sort of deepening of awareness and connection is foundational to an approach to trauma-informed work that goes beyond an intellectual grasp of the value of greater sensitivity to trauma to an embodied, felt, and committed relationship with that sensitivity.

Left unaddressed, however, VT has the potential to undermine a clinician’s capacities because of its potentially numbing and deadening effects on a clinician’s relational and empathic capacities. The risks inherent in VT are similar to those arising from direct trauma exposure. Clinicians who cannot identify or acknowledge their VT may find themselves becoming numbed and distancing themselves from the stories that they hear. They may begin to use a variety of affect-control strategies, such as over-work, substance abuse, or intellectualization, to contain the distress that is an inevitable and normal human response to the work of listening to trauma stories. The us/them split in the field of trauma practice, in which trauma survivors become the disturbed “other” from whom professionals create emotional and cognitive distancing, reflects a profession-wide failure to adequately acknowledge and metabolize our collective VT. The more I need to assert how I am not “one of them,” and the more exotic and different I make the narrative of post-traumatic distress, the more likely it is that I will lose attunement to survivors, ignore or minimize their experiences of pain, and be adversely affected by my own VT.

VT occurs in part because of what clinicians working with trauma survivors witness in our work. Even if clinicians were to restrict themselves only to seeing those trauma survivors who have experienced natural disasters, those clinicians would still be a witness to knowledge of extreme human suffering, loss, and grief, and to the knowledge that life as one knows it can irretrievably be swept away in an instant. There is simply not a trauma known to humankind the realities of which are not threatening to our illusions about the safety and stability of the world.

Clinicians who work with the survivors of interpersonal trauma, combat, genocide, and discrimination will have, in addition to confrontations with the random and chaotic nature of the world, emotionally intimate encounters with the realities of human cruelty. As a specialist in therapy with survivors of childhood maltreatment, I know that during my four decades of the practice of trauma work I sometimes felt as if I was surrounded by evidence of unspeakably horrible things that adults have done to children, behaviors beyond my capacity to have ever imagined until survivors gave me this painful education. It is impossible to work with trauma survivors and remain in a state of naive hopefulness about the world and its human inhabitants. But naive is the important word. Genuine hope occurs with our eyes wide open.

This is because we must be hopeful as trauma-informed clinicians. Hope is a necessary ingredient of therapy, something we both know intuitively, and can demonstrate empirically (Snyder, Michael & Cheavens, 1999). The trauma clinician’s non-naive, grounded hope for survivors’ healing processes and their expectation that what is offered will be of assistance to the survivor are essential ingredients of what we do for the people with whom we work. Ironically, some of the same experience as a clinician that gives one hope, the pleasures of having had the time to watch many people heal from trauma, also exposes clinicians to increased realities of VT as we spend more time in the presence of survivors.

Because VT is a profound and sometimes hidden experience for trauma psychoclinicians, it touches on all aspects of the clinician’s intersectional identities and may aggravate a clinician’s hidden wounds of insidious trauma, betrayal, or cultural experiences of danger. Knowing the meanings of our own intersectional identities as they create both vulnerability and resilience allows us, as trauma clinicians, to more accurately understand what VT is acting on, and how it is likely to manifest.

Although VT involves a transformation of the self of the clinician at a deep level, the signals from within that we are experiencing unaddressed VT commonly emerge both behaviorally and interpersonally, both with survivors and with our emotional and social networks of support. VT is not the problem; failing to acknowledge and address it is. Saakvitne, Gamble, Pearlman, and Lev (2000) have identified a variety of signs and symptoms that are common in clinicians experiencing VT that is not being acknowledged and embraced. These include emotional numbing and withdrawal, feelings of hopelessness and despair, loss of meaning-making and spiritual connection, loss of respect for survivors and one’s own profession, and distancing from intimate relationships. Persons experiencing VT also note that they feel engulfed by their work and unable to escape from it. Feelings of loss of safety and loss of the just world figure heavily in VT for some clinicians, while others may experience a lighting up of previously quiescent insidious traumatization.

I have found it helpful to use the following checklist of common signs of VT to assess one’s own VT load. Take a minute to see where you score on this list. Give an item 0 points if you never feel it; 1 point if seldom, 2 if occasionally, 3 if frequently, 4 if always.

VT Symptom Checklist
VT Symptom	0	1	2	3	4
Increased fatigue
Increased illness
Feelings of alienation from those around you
Inability to play or take down time
Dreading going to work or volunteer setting
Problems with respecting your own boundaries
Increased cynicism
More fear for safety of loved ones
More fear for own safety
No “me” time
Talking about trauma work all the time
Feeling disconnected from friends and family
Feeling invisible outside of work
Less enjoyment of sex
Loss of respect for victim/survivors
Negative world-view
Existential/spiritual emptiness
Feelings of hopelessness
Feelings of despair
Intrusive thoughts
Nightmares
Social withdrawal
Emotional Numbing-“hardened heart”

When you have tallied up your score, you have a reasonably good indication of your VT load. More symptoms and more scores of 3 or 4 are warning signs that you not only are experiencing VT – you’re not dealing with it.

Because VT, like trauma itself, does not happen to a generic clinician, issues of a clinician’s intersectional identities all play out in how VT is experienced and expressed, and in the strategies available to any given clinician to respond to and integrate VT. When specific interventions have been designed to address VT, such as the Risking Connection curriculum, outcome data tend to indicate that an emphasis on clinicians’ own self-care in their training seems to be a central aspect of its effectiveness.

This message about self-care is central for continuing safe and effective trauma-informed practice. Self-care is countercultural for many of the larger cultures informing a clinician’s identities. The social constructions of our identities frequently contain prohibitions on care for self, on seeking support, or on using scarce resources if we are not in dire need. It can, consequently, be useful for clinicians who are struggling to master self-care to frame it in terms of ethics, and our responsibilities to the people with whom we work to show up able to do our jobs.

Self-Care and Emotional Capacity

Maintaining competence (a term with which this author is not entirely comfortable – but it is the word used in our Ethics Codes; I prefer “capacities”) is a core component of ethical practice; for psychologists it is written specifically into the APA Ethical Principles and Code of Conduct (APA, 2002). While generally competence has been defined in terms of acquisition of knowledge and supervised experience, Ken Pope and I (Pope & Brown, 1996) proposed the concept of “emotional competence” when discussing work with sexual abuse survivors as an additional necessary facet of competence, and thus ethical practice, for clinicians working with trauma survivors, and I would now refer to this as “emotional capacities,” eschewing competence as a term that implies that one can achieve completion, rather than as an ever-developing phenomenon.

This construct contains several variables, including the capacity to hold the ambiguity of survivors’ remembering processes, and the ability to remain fully emotionally present with the painful details and strong affects of a survivor’s story. I would now add to that construct that emotional capacity includes the abilities and willingness to mindfully and compassionately observe one’s own responses to those stories, including one’s own VT dynamics, and to mindfully and compassionately observe one’s own transformations in the wake of continuing engagement with trauma survivors.

In order to achieve these goals of emotional capacity, self-care becomes not an option, but rather as much as, or, I would argue, more of a necessity as the acquisition of knowledge of new therapeutic techniques, given what a small percentage of the variance of the outcome of trauma work to which those techniques contribute. That said, self-care is a highly personalized thing. The shapes it takes must be those reflecting the individual clinician’s preferences and capacities. However, there are variables that ought to be present in self-care, no matter what shape it takes.

Self-care should engender hope and undermine despair. The “trance of despair,” as I have previously referred to it (Brown, 2010), is one of the symptoms of VT gone untended; it is the problematic transformation of self, arising from becoming emotionally flooded by empathic connection with trauma survivors’ despair and hopelessness, and also by invitations from structural and systemic forms of oppression in the world around the clinician to see oneself as not being to make a difference in the horrors and crimes occurring at the highest levels. Thus, self-care activities should leave clinicians more hopeful and optimistic about the world, themselves, and their work.

Self-care should assist the clinician in dealing with her or his existential challenges and fears. As Yalom (1980) noted in his foundational work on existential psychotherapy, existential crises are precipitated for us by encounters with the four “existential psychodynamics” – death, freedom, isolation, and meaninglessness. Trauma-informed work means that the clinician will daily encounter these topics in the starkness of their realities. Self-care assists the clinician with integrating these realities into consciousness without becoming trapped in feelings of hopelessness and helplessness. Rather, the converse occurs, even in the presence of knowledge of terrible realities.

Self-care should also lead to joy, or at least its possibility. It should evoke the “homo ludens,” the playful self. It should provide connection and assist the clinician in reducing isolation and invisibility, a particularly important goal in today’s lives of clinicians sitting at our desks staring into screens. Self-care is likely to be more effective if some of it allows the clinician to be more fully embodied, as one of the pernicious signs of VT is increasing dissociation from the clinician’s own body, something that appears to be aggravated when the clinician came into trauma work already struggling with embodiment.

How a clinician constructs self-care to include these ingredients will be variable. While the norm in our profession is to suggest personal psychotherapy and consultation, these are neither the quintessence of self-care, nor the end-all and be-all of this activity. They are, for instance, unlikely to contain the elements of playfulness and embodiment that are central to a well-developed strategy for self-care. But neither can belly-dancing, gardening, or raising chickens substitute for some kind of focused and intentional interaction with colleagues, both peers and elders, about the nature of this work; personal consultation at the very least is necessary. In this age of lives lived online, a face-to-face consultation does not require a community of colleagues who live in physical proximity; geographic isolation no longer necessarily creates interpersonal isolation.

Trauma-aware clinicians must be alert to their own self-talk about self-care, and the ways in which they sacrifice care for self in order to offer care to others; canceling one’s self-care activity to fit in an hour for a survivor in crisis may be fine once, but when this kind of squeezing oneself out becomes a pattern, a clinician may be flirting with allowing VT to go unaddressed. Dealing with our vicarious traumatization is a non-optional, central component to the emotional competence required for working with trauma survivors.

We also need to know how to recognize when we are approaching the end of our capacities to do this work. Assessing our levels of VT, our own numbness or distancing responses, or our own persistent arousal, and seeing these behaviors and/or feelings not responding to our usual shorter-term self-care activities, allows us to decide to take extended time off, in the form of a sabbatical, or to retire. Being a clinician is not a life sentence; while it is challenging for trauma clinicians to leave their work, it is essential to know when to say “when.”

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