Therapists, complex trauma, and the medical model: making meaning of vicarious distress and limitations to intervention with complex trauma in the inpatient setting

Scope: Complex narratives of childhood maltreatment are common in adult mental health inpatients and are associated with an increased risk of lifetime diagnoses of multiple psychiatric disorders (Chen, Murad, Paras, Colbenson et al., 2010; Edwards, Holden, Felitti, & Anda, 2003). In the aftermath of such experiences, many trauma survivors require the psychiatric and psychological support offered by inpatient mental health services. Inpatient therapists who are vicariously exposed to such trauma narratives face risk to their own physical and psychological wellbeing. Encouragingly, a small body of research suggests vicarious exposure may offer the opportunity for positive personal growth in therapists. However, what is unknown is how therapists make sense of their thoughts, feelings, and responses following exposure to difficult and complex narratives when limited by an inpatient medical model of intervention. Purpose: This phenomenological investigation sought to understand and describe the “lived” experience of therapists exposed to complex trauma narratives within a mental health inpatient setting. It is particularly interested in both positive and negative interpretations of experiencing such work. Methodology: Four highly trained inpatient trauma therapists were recruited. Each therapist participated in a semi-structured interview exploring the impact of inpatient narratives of trauma on their personal and professional lives. Interviews were transcribed and analysed using Interpretive Phenomenological Analysis (IPA). IPA offers a detailed examination of an individual’s “lived” experience and seeks the insider’s perspective through a process of re-iterative interpretative activity. Results: One superordinate theme: Therapeutic integrity and vicarious growth overarched four subordinate themes: 1) Severity, complexity, and repetition; 2) Personal distress and the medical model; 3) Intrapersonal confrontation; and 4) Growth. The first theme explores how distress becomes an intrusive part of responding to their own vicarious exposure. It provides evidence of their intrinsic conflict over time when working within a structured framework of intervention with complex and challenging inpatient trauma narratives. Participants’ sense of self-doubt, guilt, and failure are seen as erosive in the second theme as they each attempted to impose a western culture medical model of intervention on complex psychosocial traumatic experiences. Theme 3 reflects participants using their distress to question their therapeutic integrity challenging former values of intrapersonal honesty, altruism, and relational connection with patients. The final theme captures psychological wellbeing and growth through reconnection with self-integrity and their professional selves. Conclusions: This study highlights the risks to psychological wellbeing in therapists working with complex trauma in an inpatient setting when limited by a medical model framework of psychological intervention. Promisingly, it provides hope that despite vicarious distress, positive and growthful redefining of therapeutic identity through altruism, honesty, and the relational connection may cultivate psychological growth across domains of compassion, empathy, humility, and gratitude. In essence, when time to develop the therapeutic relational alliance in complex trauma is prioritised, therapeutic integrity, psychological wellbeing, and growth was observed in these participants. Implications of the larger work: These findings highlight the potential benefits of a reciprocal relational approach to psychological intervention when complex trauma challenges both patient and therapist well-being in the inpatient system. Without consideration for the power of the therapeutic relationship, and the necessary time to allow for growth and wellbeing to emerge out of complex trauma, it is likely that brief intervention through a medical model will have little impact on long-term psychopathological complications in trauma inpatients, and risk vicarious trauma responses in therapists.