In the field of clinical and health psychology there are situations in which the suffering experienced by patients can have an impact on the mental health of psychotherapists. A line of research dedicated to this field of knowledge focuses on the study of the therapeutic process of trauma cases and the resonant symptomatology in the professionals who attend to these cases (Merriman & Joseph, 2018). Trauma is defined according to the "APA Dictionary of Psychology" as:

Any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning. Traumatic events include those caused by human behavior (e.g., rape, war, industrial accidents) as well as by nature (e.g., earthquakes) and often challenge an individual’s view of the world as a just, safe, and predictable place (American Psychological Association, 2018).

In this regard, the scientific literature identifies vicarious trauma (VT) and secondary traumatic stress (STS) as two of the most important processes that can affect psychotherapists intervening in trauma (Crivatu et al., 2023; Leung et al., 2022). However, because of their similarity, these terms are often confused with each other and are often used interchangeably (Bell et al., 2003; Merriman & Joseph, 2018; Molnar et al., 2017; Leung et al., 2022; Sutton et al., 2022), despite there being important differences between them. VT comprises those negative cumulative changes arising from the therapist-patient interaction, especially when the therapist experiences intense empathy (Branson, 2019; McCann & Pearlman, 1990). Likewise, it has been found that this phenomenon is more frequent in cases where the patient relates traumatic experiences in a detailed and graphic way, producing psychopathological changes in the therapist that can affect their self-perception, their perception of others, their relationships with the environment, and their way of perceiving the world (Branson, 2019). STS, on the other hand, manifests itself through symptoms similar to those of the patient who has suffered the trauma, characterized by intrusive imagery, arousal, avoidance behaviors, and negative changes in cognitions (Figley, 1995; Michalchuk & Martin, 2019). According to a study by Bercier and Maynard (2015), between 5 and 15% of psychotherapists working in this setting suffer from clinical severity levels of VT and STS. Moreover, a high coexistence of and comorbidity between VT and STS has been found in most cases (Bercier & Maynard, 2015; MacKay, 2017; Sutton et al., 2022). Also related to VT is burnout syndrome, characterized by a combination of exhaustion, depersonalization, and feelings of ineffectiveness at work, due to an unfavorable work environment and high occupational stress (Freudenberger, 1974; Maslach, 1976; Roberts et al, 2022). The difference with VT is that burnout does not require indirect exposure to trauma, whereas it is an essential condition for the development of VT (Quitangon, 2019; Roberts et al., 2022). It is important to note that burnout, despite being more related to work stress, is posited as a possible predecessor of STS (MacKay, 2017).

When analyzing the factors related to VT and STS in psychotherapists, the study by Kilpatrick et al. (2013) reveals, in terms of sex/gender, that the prevalence of STS is higher in women than in men and that it increases with a higher level of exposure to traumatic details. Corroborating this finding, the review by Sutton et al. (2022), which does not distinguish between VT and STS, found that symptoms of both disorders occur more frequently in young, single women with limited training and experience. This study also demonstrates that vulnerability factors involving the absence of effective coping strategies and the presence of high levels of stress and personal distress increase the probability of experiencing symptoms associated with these disorders. With regard to the effective protective factors, Yuma et al. (2019) identify as individual predictors of vicarious resilience, the acceptance of suffering, continuous training in stress management, not blaming oneself, and the assumption of manageable workloads. From a group perspective, the protective factors identified include social, family, and work support, as well as actively seeking supervision in the work environment.

The multifactorial structure underlying VT and STS, and their interrelation, constitutes a complex area of research, since most investigations do not explicitly differentiate between the two phenomena. Sabin-Farrell and Turpin (2003) even concluded in their review that VT and STS describe the same phenomenon. The scientific literature consists of reviews focused on the study of protective factors against VT in the case of healthcare workers, firefighters, and other professionals who provide assistance to accident victims (Molnar et al., 2017). However, to the best of the authors' knowledge, there have been no reviews focused exclusively on studying the protective and predisposing factors influencing these processes in psychotherapists in the last decade. While there is evidence of the impact of certain specific factors on VT and STS (Sutton et al., 2022; Yuma et al., 2019), there is a need for more comprehensive research that addresses the holistic set of factors impacting psychotherapists (Branson, 2019; Leung et al., 2022). In this regard, the primary objective of the present review is to determine what are the predisposing factors and the protective factors in relation to VT in the last decade, taking into account its marked comorbidity with STS, specifically in the population of psychotherapists.

Method

An exhaustive exploration was carried out in the Proquest, Web of Science, Scopus, and Pubmed databases, using a search equation integrated by the descriptors "vicarious trauma," "therapist," and "factors" in March 2023. In order to guarantee the suitability of the studies considered, the following inclusion criteria were established: 1. The document had to correspond to a peer-reviewed empirical article. 2. The publication of the paper had to have taken place during the last decade (2013-2023). The language of the article had to be English or Spanish. 4. VT had to be the main variable of the study. 5. STS was considered a subtopic of interest, both because of its high comorbidity with VT and because of the usual indistinguishability between the two in previous literature.

Of the 202 papers identified in the databases consulted, 98 were eliminated due to being duplicates. After a preliminary assessment based on the titles of the papers, 47 papers were discarded due to not adhering to the inclusion criteria. The remaining 57 abstracts were then examined in depth, leading to the exclusion of 27 additional articles. The screening process described above resulted in a total of 30 papers for further review, which culminated in the selection of the 22 papers that make up the present review (see Figure 1).

Figure 1
Flowchart of the Search Process

Results

The total sample of the 22 studies analyzed included 4,064 psychotherapists in the area of clinical and health psychology, with sample sizes ranging from a minimum of 6 (Sui & Padmanabhanunni, 2016) to a maximum of 931 participants (Wozencroft et al., 2019). The mean age of the population, obtained from the sample means specified in 12 of the studies analyzed, was 41.39 years (Aafjes-van Doorn et al., 2022; Barrington & Shakespeare, 2014; Cieslak et al., 2013; Cummings et al., 2021; Diehm et al., 2019; Foreman, 2018; Halevi & Idisis, 2018; Lakioti et al., 2020; Litam et al., 2021; Makadia et al., 2017; Martin-Cuellar et al., 2019; Padmanabhanunni & Gqomfa, 2022). The age ranged from 20 to 79 years, both extremes being found in the Wozencroft et al. (2019) study. The minimum number of years of experience for psychotherapists was 1 year (Cummings et al., 2021; Skar et al., 2022), and the maximum number of years of experience was 30 (Hernandez-Wolfe et al., 2015). All selected articles included mixed samples of men and women, except in two of them where the sample consisted only of women (Padmanabhanunni & Gqomfa, 2022; Wang & Park-Taylor, 2021). A single study did not differentiate by sex (Skar et al., 2022). Seventy percent of the total sample consisted of females and 30% of males. Furthermore, only the study by Melaki and Stavrou (2023) differentiated between public and private psychotherapists, while the others did not differentiate with respect to work setting. Regarding study design, 21 of the 22 studies included in the review adopted a cross-sectional design. The exception was a longitudinal study that performed measurements at different time points throughout the Covid-19 pandemic (Aafjes-van Doorn et al., 2022). The main characteristics of the set of studies reviewed are summarized in Table 1, and the specific details of each included study can be found at the following link: https://zenodo.org/record/8311529.

Table 1

Characteristics of the Studies Included in the Review

Regarding the assessment instruments used in the studies under review, it is worth highlighting that six of these used semi-structured interviews to explore experiences related to trauma cases, specifically, VT and/or STS (Barrington & Shakespeare, 2014; Hernandez-Wolfe et al., 2015; Melaki & Stavrou, 2023; Padmanabhanunni & Gqomfa, 2022; Sui & Padmanabhanunni, 2016; Wang & Park-Taylor, 2021). Regarding the assessment of VT and STS, the Vicarious Trauma Scale (Bride et al., 2004; Aguiar-Fernandez et al., 2022) was applied in four studies (Aafjes-van Doorn et al., 2022; Cummings et al., 2021; Kounenou et al., 2023; Strosky et al., 2018) and the Secondary Traumatic Stress Scale (Jacobs et al., 2019) was implemented in four other investigations (Cieslak et al., 2013; Cummings et al., 2021; Diehm et al., 2019; Makadia et al., 2017). Professional quality of life was a variable included in eight of the articles analyzed (Cummings et al., 2021; Hou & Skovholt, 2020; Lakioti et al., 2020; Litam et al., 2021; Martin-Cuellar et al., 2019; Skar et al., 2022; Sodeke-Gregson et al., 2013; Wozencroft et al., 2019), assessed using the Professional Quality of Life Scale, Version 5 (ProQOL-5). The study by Strosky et al. (2018) analyzed the impact of religious and spiritual beliefs evaluated through the Religious Commitment Inventory (RCI-10) and the Religious and Spiritual Struggles Scale (RSS), and their relationship with mood was assessed through the Brief Measure of Positive and Negative Affect Scale (PANAS).

In the set of studies reviewed, no quantitative data was provided on the prevalence of VT. However, with respect to STS, Cieslak et al. (2013) reported a prevalence of 19.2% in their study with 224 psychotherapists. For their part, Sodeke-Gregson et al. (2013) found that of the total of 253 psychotherapists working with trauma and other issues, 70% were at risk for STS. In five of the selected studies, it is indicated that all or the vast majority of psychotherapists suffered from VT and STS symptoms (Barrington & Shakespeare, 2014; Hernandez-Wolfe et al., 2015; Padmanabhanunni & Gqomfa, 2022; Sui & Padmanabhanunni, 2016; Wang & Park-Taylor, 2021). Furthermore, as noted by Cummings et al. (2021) and Kounenou et al. (2023), burnout was predictive of VT and STS, and both ended up coexisting whenever one appeared (Cummings et al., 2021).

Regarding the analysis of predisposing factors affecting psychotherapists (See Table 2a), three studies found that psychotherapists who have experienced personal trauma show a significantly higher propensity to suffer VT and STS (Cieslak et al., 2013; Diehm et al., 2019; Sodeke-Gregson et al., 2013), while Martin-Cuellar et al. (2019) found no such evidence. On the other hand, four studies found that attending a high number of trauma cases, and increased exposure to these, constitutes a predisposing factor for the occurrence of VT and STS (Cieslak et al., 2013; Diehm et al., 2019; Makadia et al., 2017; Sodeke-Gregson et al., 2013). Likewise, another prominent finding in four of the reviewed studies was that professionals with fewer years of experience have a higher risk of experiencing VT and STS (Foreman, 2018; Sodeke-Gregson et al., 2013; Wang & Park-Taylor, 2021; Wozencroft et al., 2019). Specifically, Wang and Park-Taylor (2021) identified a U-shaped impact curve in relation to professional experience and the presence of VT. This implies that novice psychotherapists presented fewer VT symptoms as they were less stressed due to their inexperience, whereas those with a medium level of experience had difficulty managing trauma cases and presented more VT symptoms. In contrast, veteran therapists have consolidated effective coping strategies, thus mitigating the incidence of VT. However, one of the studies indicated that years of experience was not a significant predictor of these phenomena (Kounenou et al., 2023). In the same vein, being younger in age was related to an increased risk of VT and/or STS in two studies (Halevi & Idisis, 2018; Sodeke-Gregson et al., 2013). Notably, the study by Melaki and Stavrou (2023), differentiating between private and public psychotherapy practice, revealed that only therapists in the private setting had VT symptoms. Furthermore, Halevi and Idisis (2018) and Lakioti et al. (2020) found that therapists with both a poorly elaborated sense of self and life meaning have an increased likelihood of VT, STS, and burnout. Strosky et al. (2018) indicated that psychotherapists experienced more negative affect and internal religious and spiritual crises than the rest of the population because of their clinical work. Finally, the study by Wozencroft et al. (2019) reported that both men and women exhibit the same level of burnout, but that men did not suffer from STS symptoms to the same extent as women.

Table 2a

Predisposing Factors for Vicarious Trauma Identified in the Review

In relation to protective factors (See Table 2b), several investigations have identified that adaptive coping strategies (e.g. self-care, physical activity) are associated with a lower probability of suffering VT and STS (Barrington & Shakespeare, 2014; Litam et al., 2021; Melaki & Stavrou, 2023). However, in contrast to these findings, the study by Sodeke-Gregson et al. (2013) observed a positive correlation between self-care, clinical supervision, and STS. Within this framework of protective factors, five investigations indicate that perceived social support, companionship behaviors-such as talking to and maintaining good relationships with professional colleagues-and a good work environment, especially in public-sector psychotherapists, are associated with a lower likelihood of developing burnout and STS (Diehm et al., 2019; Hernandez-Wolfe et al., 2015; Lakioti et al., 2020; Melaki & Stavrou, 2023; Sodekeke-Gregson et al., 2013). On the other hand, certain attributes of psychotherapists, such as high resilience, a strong value framework, and an extensive social network, have been found to be related to a lower prevalence of VT (Hou & Skovholt, 2020; Litam et al., 2021). Additionally, variables such as empathy, self-efficacy, and adaptability to online therapies were associated with a lower risk of VT (Aafjes-van Doorn et al., 2022; Kounenou et al., 2023; Lakioti et al., 2020). Subjective perception of vitality and energy is inversely related to the likelihood of VT and burnout, according to the study by Martin-Cuellar et al. (2019). In relation to case supervision and psychotherapist-directed therapy, three studies analyzed indicated a reduction in the probability of presenting VT (Hernandez-Wolfe et al., 2015; Kounenou et al., 2023; Skar et al., 2022).

Table 2b

Protective Factors for Vicarious Trauma Identified in the Review

Discussion

The present review aims to analyze the emerging evidence in the last decade on predisposing and protective factors of VT and STS in psychotherapists in the field of clinical and health psychology. It is important to highlight the absence of an informed estimate of the prevalence of VT in the studies reviewed. On the other hand, it is noted that there are significant discrepancies in the prevalence reported for STS, while Cieslak et al. (2013) identify a prevalence of 19.2%, Sodeke-Gregson et al. (2013) raise this risk to 70%, which contrasts with previous evidence reported by Bercier and Maynard (2015), who offer a more conservative prevalence estimate, placing it between 5% and 15% even considering STS and VT together. It is more significant to attest that five studies established that the majority of psychotherapists manifested combined symptoms of VT and STS (Barrington & Shakespeare, 2014; Hernandez-Wolfe et al., 2015; Padmanabhanunni & Gqomfa, 2022; Sui & Padmanabhanunni, 2016; Wang & Park-Taylor, 2021).

The results suggest that burnout could be a precursor of VT and STS, consistent with what was previously posited by MacKay (2017). Moreover, a high comorbidity between VT and STS was identified, congruent with previous research highlighting the complexity and interconnectedness of these phenomena in trauma psychotherapy (Bercier & Maynard, 2015; MacKay, 2017; Sutton et al., 2022). The coexistence of these disorders allows us to put forward three hypotheses: firstly, the correlation between independent disorders; secondly, that indeed, as pointed out by Sabin-Farrell and Turpin (2003) and Melaki and Stavrou (2023), the two disorders constitute the same problem, and; thirdly, that their high comorbidity can be explained on a continuum of psychopathological severity following indirect exposure to trauma. If this approach is correct, it would be relevant to determine which disorder precedes the other. In this sense, it is possible that therapists first experience the patient's trauma symptoms, and subsequently, a more profound change occurs progressively in their own perception of themselves and their surrounding world. While these hypotheses are relevant, it is crucial to note that the precise relationship between VT and STS remains undetermined, which highlights the need for further rigorous research to establish more robust conclusions. To the above must be added the frequent indistinctness and interchangeability of terms shown in the previous literature, an issue that is also corroborated in this review. In fact, by including STS as a subtopic of interest in VT, the present review ensures greater precision by including the relevant studies. Based on the above, to assess these constructs it is proposed to use the Vicarious Trauma Scale (Bride et al., 2004; Aguiar-Fernández et al., 2022) and the Secondary Posttraumatic Stress Scale (Jacobs et al., 2019), and also to create and validate instruments that allow us to assess the comorbidity and temporal evolution of these phenomena accurately.

Regarding the vulnerability or predisposing factors to the development of VT, the following evidence has been identified, in decreasing order of priority. Stress originated by the overload of trauma cases is one of the factors with the highest degree of evidence found in this review (see Table 2a). At the same level of importance are years of psychotherapy experience, which seems to act according to a U-shaped impact model proposed by Wang and Park-Taylor (2021). This is followed by the psychotherapists' personal history of trauma. The inference is that the psychotherapists' own suffering makes them more sensitive to the traumatic events described by their patients, or that these accounts act as a catalyst for the psychotherapists' own trauma, although the interaction of the two factors is also possible. On another note, age may come with more life experience, enhancing coping skills and maturity, with youth being a factor of vulnerability. Next, with the same level of relevance, are low differentiation of self, which makes it difficult to discern between one's own and other people's processes; a less defined meaning of life, which may mean the psychotherapist has difficulty in appreciating what is their personal mission in their private life; as well as religious beliefs that seem to act as an emotional amplifier of dissonances between the trauma and the spiritual-religious dimension. At the same level of importance as the preceding factors is the sex/gender variable. According to previous research, being female, having a personal history of trauma, and being exposed to a high number of traumatic cases increases the risk of STS. This pattern could be related to the high frequency of sexual abuse cases in trauma therapy, and the fact that the majority of victims are female. Moreover, it is plausible that female psychotherapists' identification with feminism as a core value and their solidarity with the victim exacerbate this predisposition (Crivatu et al., 2023; Kilpatrick et al., 2013). In this sense, a relevant line of research would be to analyze whether the characteristics of the patient, or the type of trauma the patient presents, influence the development of VT or STS in the psychotherapist. Finally, working in the private sector has been identified as a predisposing factor for developing VT and STS. This could be attributed to the fact that psychotherapists in the public sector tend to interact more with colleagues and have the opportunity to vent between sessions. In contrast, psychotherapists in the private sector often work alone, which may make it more difficult to manage the stress of vicarious exposure to trauma. This area requires further research, as has already been highlighted by Sutton et al. (2022).

The studies reviewed not only show the psychological cost of caregiving, but also highlight the existence of protective or resilience factors capable of producing secondary post-traumatic growth. Among them, perceived social support occupies a primordial place. This finding highlights the human dimension of psychotherapists, emphasizing that, like any other person, they are social by nature and need to feel support from significant others in the face of the arduous and sometimes overwhelming professional work. Secondly, coping strategies also stand out. At the individual level, the benefits of self-care through physical activity, mindfulness, and attending therapy are identified, as well as the establishing of clear boundaries between work and personal life, among other aspects. At the organizational level, support from peers and professional associations, a healthy work environment, and opportunities for professional development constitute preventive strategies. Clinical supervision has also been identified as a relevant factor. Aspects such as learning, subjective detachment from the cases treated, validation by another professional, the formulation of realistic goals, and emotional ventilation may be mediating variables that explain its efficacy. The protective factors identified in this review constitute possible practical applications that the therapist can implement to prevent or alleviate the negative effects of trauma exposure. Importantly, some egosyntonic factors linked to the psychotherapist's personality, such as resilience, empathy, self-efficacy, and subjective vitality, may buffer and even promote secondary posttraumatic growth.

This review has the following limitations: the term "psychotherapist" encompasses different official training for the same profession, varying according to the countries considered in this review and, therefore, it may involve differences in the psychotherapists’ levels of training. The number of studies included is moderate and the conclusions should be considered preliminary. More noteworthy is the limitation of the construct analyzed, since although it is clear that trauma affects psychotherapists, we cannot state with precision that the pathological manifestation corresponds to VT, STS, or both. Among the strengths, it should be noted that this review is a pioneer in the specific field of psychotherapy, and that it contributes to the development of a relevant line of research in the mental health of trauma psychotherapy professionals.

In short, the results of the present study show that the mental health of professionals responsible for providing wellness to others, especially psychotherapists working in trauma, is not immune to the suffering of others. Therapeutic work, while rewarding, is not without costs. The findings reflect the paradox of caring for the caregiver, underscoring the need for specific support networks for these professionals and the importance of mental health associations and organizations implementing prevention, training, and intervention programs. It is also necessary to carry out more research on this topic and to translate the evidence into clinical practice. The quality and efficacy of psychotherapy depends, to a large extent, on the well-being of psychotherapists, so it is imperative to pay special attention and focus resources on the psychotherapists who dedicate their lives to healing the traumatic wounds of others.

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Author notes

Correspondence: jmguiote@ugr.es

Conflict of interest declaration