Different ways of approaching and understanding this work and how it shapes our lives
“In the role of witness to acts of violence, the therapist feels, at times, overwhelmed and experiences, to a lesser degree, the same terror, rage and despair as the client.”
– Adapted from (Herman, 2001).
Ethical – Spiritual Pain
“[Is] the discrepancy between what feels respectful, humane, generative, and contexts which call on us to violate the very beliefs and ethics that brought us to therapy and counselling work.”
– Vikki Reynolds,
Professionals working with people who have experienced childhood sexual abuse and/or sexual assault will undoubtedly be personally affected by hearing about these traumatic events, and by witnessing the considerable impact and distress they can cause. Working with people who have experienced profound trauma and injustice is complex. It can be experienced as a privilege, bringing an added sense of connection, value and meaning to our lives. It can also become personally draining, at times overwhelming us.
This page is designed to increase understanding, to provide practical support, and to give an opportunity for critical reflection on addressing vicarious trauma. It is divided into four sections. Some workers will prefer to read the sections in order, and some will skip directly to the sections of most interest to them – maybe even starting at section four.
Section one: Definitions
Some of the commonly used terms (e.g. vicarious trauma, compassion fatigue, burnout) and the various definitions used in the literature on the subject.
Section two: Effects and impacts on workers
Some of the ways trauma can impact on workers’ lives, and some signs to look out for.
Section three: Caring practices
Steps can be taken to prioritise worker well-being and long term commitment in doing such important work.
Section four: Ethical dimensions and pain
An alternative or complementary framework for understanding these responses, which highlights the ethical dimensions of working in the face of injustice. This ‘second’ framework arises out of a concern with a limited individualistic and psychologically focused ‘vicarious trauma’ models, and instead invites workers to understand distress as an ethically founded response to the context of the work and the lives of people we engage with.
We are not suggesting that these are necessarily competing frameworks; simply that they articulate different meanings regarding the ways workers respond to this work. The quotes at the top of this page offer a sense of the different perspectives.
We believe it is helpful to maintain a distinction between the effects of vicarious trauma, and the broader concepts of burnout or compassion fatigue. When workers are experiencing overwhelming, intrusive thoughts about abuse, anxiety, panic attacks, intense distress, are deliberately avoiding trauma-related content in the work, or other difficulties associated with trauma, this requires a trauma informed, supportive response. This is different from assistance to address more general feelings of despair or exhaustion associated with working in the sexual abuse field.
Section one: Definitions
Confronting, understanding and responding to the problem of vicarious trauma can be difficult. It is something that is presented as both ‘normal’ and ‘pathological’. On the one hand, the trauma literature almost universally emphasizes that workers will experience a degree of personal distress and disturbance and that these are expected, inevitable, natural and normal responses to repeated exposure to trauma. On the other hand, the literature is equally replete with the language of symptoms, clinical indicators, diagnosis and references to the DSM IV and V. In approaching the topic, we start from the position of accepting that this work affects people’s lives in profound and challenging ways (not always negatively or harmfully), and have tried to summarize what the literature has to say.
Vicarious trauma, secondary traumatic stress, compassion fatigue, burnout and PTSD 
The deleterious impacts that repeated exposure to details of trauma can have on professionals is sometimes referred to as vicarious trauma, secondary stress disorder, compassion fatigue, burnout or PTSD. These terms are sometimes used inter-changeably, but researchers in this area tend to define them as slightly different phenomena. Adding to the confusion is that different authors can give each of the terms slightly different meanings.
Vicarious traumatisation is commonly understood to refer to the cumulative transformative effect on the helper of working with people who have experienced traumatic life events, both positive and negative ; or the “transformation in the inner experience of the therapist that comes about as a result of empathic engagement with clients’ traumatic material” . The impacts on the workers thoughts, feelings, behaviours and general sense of self can be similar to the difficulties faced by the people we are working with. The term ‘vicarious traumatisation’ is often used specifically to refer to professionals ‘secondary traumatic stress’ or ‘secondary victimisation.’ It is often used more broadly to refer to those in a significant relationship with the person directly affected.
Secondary traumatic stress is defined as the natural, consequent behaviour and emotions that result from knowledge about a traumatizing event experienced by another and the stress resulting from helping or wanting to help a traumatized or suffering person. The term is often used to describe the sub-clinical impacts ; however the criteria and identified symptoms are almost identical to the updated PTSD . Secondary traumatic stress includes symptoms produced in response to exposure to details of traumatic event/s experienced by a significant other (i.e. not necessarily as a result of acting in the role of therapist or helper) .
Compassion stress. Charles Figley coined this term as a non-clinical, non-pathological way to characterize the stress of helping or wanting to help a trauma survivor. Compassion stress is seen as a natural outcome of knowing about trauma experienced by a client, friend, or family member, rather than a pathological process. It can be of sudden onset, and is often experienced as helplessness, confusion, increased isolation, as well as secondary traumatic stress symptoms .
Compassion fatigue. Compassion fatigue, also coined by Figley, is considered a more severe example of cumulative compassion stress. It is defined as “a state of exhaustion and dysfunction, biologically, physiologically, and emotionally, as a result of prolonged exposure to compassion stress”. Charles Figley uses it more or less interchangeably with secondary traumatic stress; compassion fatigue is simply more ‘user friendly’ .
Burnout is sometimes used interchangeably with the above terms . It is defined as a state of prolonged physical and psychological exhaustion, which is perceived as related to the person’s work . However, burnout doesn’t necessarily include a traumatic element or PTSD-like symptoms: accountants, for example, can experience burnout from their work  .
Christine Maslach defines burnout in terms of three key elements: “Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind”.
In sexual assault related work, burnout can refer to the inevitable sense of despair that can arise from knowledge of the apparently overwhelmingly large scale of the problem, repeatedly bearing witness to the devastating impacts on many lives, the frustrations that arise from inadequate responses and outcomes in the justice system, and so on. All of which persist regardless of the workers dedication and efforts. Thus, burnout refers to difficulties that are not necessarily best conceptualised in ‘clinical’ terms or in relation to trauma itself. Burnout can be conceptualised as an ‘ethical or spiritual pain’ .
PTSD (Post Traumatic Stress Disorder)
The DSM V made a significant change to the diagnosis of Post Traumatic Stress Disorder, which may impact on future understanding and responses to the problem of ‘vicarious trauma’. Whereas, previously the pre-requisite for the diagnosis of the PTSD was direct ‘experience of’ traumatic event/s, within the DSM V the definition was broadened to include “repeated or extreme exposure to aversive details of the traumatic event(s)” as a potential trigger that can produce persistent intrusive symptoms, avoidance of stimuli, alterations in cognitions and marked alteration in arousal and reactivity (see diagnostic criteria at the end of this page).
This revised definition means that those who work with people who have been sexually victimised and are significantly personally impacted could now be diagnosed with PTSD. Whilst recognition of the profound and overwhelming impact that this work can have is welcome, it also opens up the possibility of ‘vicarious trauma’ becoming subsumed within the broader diagnostic category, the particularities of the experience of vicarious traumatisation becoming de-contextualised and conceptualised as an individual problem.
Video: The neurobiology of trauma
Section two: Effects and impacts on workers
Signs of vicarious trauma
The indicators of vicarious trauma can be categorised into emotional, behavioural, cognitive, and physical / physiological signs and symptoms. There are also what we will call ‘spiritual impacts’.
Individual experiences of/responses to vicarious trauma can vary. The list below is not exhaustive, but indicates the wide-ranging nature of how trauma may impact on the lives of workers.
Changed sense of humour.
Feeling less safe in the world.
Staying at work longer.
Not being able to separate work from personal life.
Increased alcohol consumption.
Undertaking risky behaviours.
Avoiding people or duties.
Changed eating habits.
Hives or rashes.
|Changed relationship with meaning and hope.
Lack of sense of purpose.
Decreased sense of agency.
Reduced sense of connection to others.
Challenged to maintain a sense of self as viable, worth loving, deserving.
Becoming judgmental of others.
Thinking about clients’ traumas when at home/not at work.
Difficulty thinking clearly, concentrating, and remembering things.
Difficulty making day-to-day decisions.
In addition to the above, working in this field can also raise questions connected to our sense of self and our capacity, ability or suitability for this work- what Christina Maslach calls “reduced personal accomplishment”. We can become personally challenged: “Despite your best intentions or commitment there may be no or little improvement for your client. This may cause you to question your understanding of yourself as a person who is able to help or provide for others”.
It can be useful to consider vicarious trauma as operating on a continuum. At one end of the continuum, when engaging and being present with someone who has been abused, we are going to feel and experience the trauma of sexual abuse without becoming knocked off course professionally or personally. At the other end of the continuum a worker can become personally and professionally overwhelmed by exposure to trauma and begin experiencing trauma symptoms associated with PTSD: avoiding reminders of traumatic material, experiencing intrusive thoughts related to the trauma, negative impacts on cognitive processes and emotional states (including depression, and ‘numbness’ or shutting off), and heightened physiological arousal levels and reactivity. As Van Der Kolk notes:
“What distinguishes people who develop PTSD from people who are merely temporarily stressed is that they start organising their lives around the trauma.” 
Whilst, some degree of vicarious trauma is widely thought to be inevitable for mental health professionals who work with people who have been sexually victimised, if someone becomes personally and professionally overwhelmed it is important to seek assistance, from appropriate mental health professionals who specialise in addressing vicarious trauma.
It is useful to maintain awareness of the signs and symptoms of vicarious trauma and how to look after ourselves and our colleagues in a way that supports practitioners to stay engaged and present supporting people in the long term.
Section three: Caring practices
What can support you in doing this work
The following sections describe ways that workers and organisations can utilise to promote self-care and care-for workers. Christine Maslach’s work on burnout reminds us to look at not just the ‘who’ (the person), but also the ‘what’ (environment) when addressing this issue. Vikki Reynolds warns that “When self-care is prescribed as the antidote for burnout, it puts the burden of working in unjust contexts onto the backs of us as individual workers”. Self-care is not only about individual workers, it is also about organisations and communities.
Self-care, or managing the possibility of vicarious trauma, can be experienced as a list of further obligations for workers to attend to if not handled thoughtfully. Just as services grow and develop in response to feedback and input from those we work with, it is important that agency level processes regarding the care of workers are developed through consultation to ensure they are experienced as supportive.
Similarly, ‘vicarious traumatisation’ can potentially become a kind of stigma in a workplace; e.g. as evidence that a worker is ‘not coping’, or ‘not up to the job’. Charles Figley’s notion of ‘Compassion stress’ focuses on the natural responses to the repeated indirect exposure to traumatic material of others. It is a deliberately non-clinical and non-pathologising approach to understanding and responding to the experience of doing this work.
Therapists in private practice who routinely work with people who have experienced sexual abuse/assault may need to be more proactive in establishing and maintaining a professional support structure. This can include both individual and group/peer supports, as well as planning for time off from the work.
One of the challenges for counsellors and therapists working with people who have been sexually victimized is that in order to do effective work, we need to be emotionally present. Being emotionally and personally present is a pre-requisite for a client to experience empathic understanding and therapeutic support. Hence, it is not a question of not experiencing ‘trauma’, but more developing ways to acknowledge and manage personal/counsellor impacts in ways that ensure the focus is on what the client brings to counseling.
Mental health professionals who work primarily in the trauma field experience a greater risk of vicarious trauma when compared with mental health professionals who work in general or diversified fields. The management of caseloads through limiting the number of clients per week and the number of ‘intensely traumatic’ cases may minimise the potential vicarious effects of working in this field . Have realistic expectations of caseloads. If possible, allow some degree of worker control of, or involvement in, the allocation process.
Regular access to individual supervision is a minimum requirement for workers in the sexual assault field, whether in an agency or in private practice. Many agencies provide this internally (for example, this is often a key role for Senior Counsellors), as well as supporting workers to access to external supervision. There is a strong argument to maintain a clear separation between clinical supervision and line management that focuses on operational supervision (though some advise against a total separation of the two supervisory functions) .
Supervision should provide a forum where workers feel safe to discuss the impacts of the work on themselves, without fear of stigmatisation or questioning of their competence. Supervision should also be a place where concerns about worker or client safety can be raised, discussed and acted upon (addressing clearly inappropriate, unethical or harmful conduct). It is good practice to develop supervision agreements clearly spelling out the purpose of supervision, individual and organisational responsibilities and the boundaries of worker confidentiality.
Private practitioners can be at high risk of becoming isolated in the work. Maintaining regular clinical supervision is important, regardless of how experienced in the work one may be.
One-to-one or group peer supervision are important resources for any mental health professional, but particularly so for those who work in the trauma field. Sharing experiences of how the work is affecting work and personal life offers social support and normalisation of the therapist’s own experience. This assists with addressing troubling thoughts such as ‘I am not cut out for this’, or ‘there must be something wrong with me for me to be feeling this way’. Other benefits include reconnecting with others and sharing potential coping resources . Peer supervision has also been found to decrease feelings of isolation and increase empathy and compassion.
In the workplace
Agencies that employ professionals who work in the sexual assault field have a responsibility to assist their workers decrease the effects or occurrence of vicarious trauma . It is not unreasonable to suggest that vicarious trauma is an OH&S issue for agencies working in the field of sexual abuse.
Workplaces can take an active role in caring for workers in the sexual assault field. Suggestions include
- Ensure adequate, comfortable facilities for lunch and tea breaks, in a space that is separate from the counselling areas.
- Provide opportunities for non-counselling work (e.g. community education, resource development).
- Add nurturing and comforting touches to the work space (e.g. plants, framed pictures).
- Take time to share success stories in the work- this can be incorporated into organisational routines such as group supervision or team meetings.
- Foster a culture of care for workers.
Education and training
Ongoing professional development, education and training is essential for mental health professionals who work in the trauma field as research shows this factor to be imperative to effective coping with difficult work.
Personal coping mechanisms
The impact of vicarious trauma can also be decreased when mental health professionals who work in the trauma field maintain a balance of work, play, and rest . This balance would, ideally, include socialising with friends and family, being involved in creative activities, and being physically active. Participation in these activities may promote preservation of a sense of personal identity. Rest and leisure activities are important in decreasing the effects of vicarious trauma, especially because of their restorative nature. In addition, vicarious trauma may affect the ability of trust and therefore a strong social support network can assist to prevent or soothe its effects. Lastly, participation in activities that increase personal tolerance, such as journaling, counselling, meditation, and emotional support from significant others, allow for a natural reconnection to emotions .
The effects of vicarious trauma are often related to a loss of a sense of meaning, and can influence ways of thinking about self, others and the world. Without a sense of meaning, mental health professionals who work in the trauma field may feel cynical, withdrawn, emotionally numb, hopeless, and outraged, and experience sorrow, confusion and despair.
Intentionally engaging in practices that re-connect you to your professional and personal ethics, beliefs and values is an important part of feeling sustained in the work. This could be through supervision conversations which make space for questions of ethics, purpose and intentions; connecting with colleagues who share similar hopes and values; and engaging in community activism around issues of significance.
There can be a range of reasons why workers don’t always take regular breaks from the work. This is understandable, considering the commitment to be of service to others that often motivates workers in this field. It is not uncommon for this commitment to develop into an unreasonable sense of obligation, having workers struggling with thoughts of being selfish, or fearful that they will be perceived as abandoning their clients if they take holidays and breaks.
Charles Figley suggests that a worker’s sense of humour is one of the best resources she/he has in the face of repeated exposure to trauma stories. Of course, it isn’t possible to suggest or prescribe ways to stay in touch with one’s sense of humour as it is so subjective. It might be as simple as making a conscious choice to watch the funny movie rather than the serious documentary occasionally, or making time to catch up with someone who makes you laugh.
Focus on well-being
Just like our clients, we all benefit from putting time and energy into everyday activities that support and enhance our personal well-being. This emphasis on prioritising personal well-being helps us to establish a solid base by which to support people who have been traumatised in the long term. We invite you to make use of the resources available in the Well-being section of this website, including the following articles:
- Well-being assessment
- Five ways to mental well-being
- Good physical health
- Mindfulness exercises
- Relaxation exercises
Section four: Ethical dimensions of ‘spiritual pain’ 
Vikki Reynolds’ work around the concept of worker burnout focusses on the ethical, as opposed to clinical, challenges of working with trauma, injustice and suffering. It is worth noting that nothing in her work dismisses the importance of the issues we have covered in the previous sections. As she says, workers have “an ethical responsibility to engage with enough self-care to be able to be fully present with clients, keep their [clients] suffering at the center, and bring hope to the work”. Her work is not about denying the experience of vicarious trauma, but more about challenging the “prescriptive and individualised aspects of ‘burnout talk’”, where worker’s distress can be:
- Interpreted as a sign that the worker needs to deal with or process some personal issue that has been triggered for them.
- Regarded as a sign of vicarious trauma, prompting well-intended suggestions about how the worker might engage in better self-care.
- Deemed to be a consequence of the worker’s engagement with a particularly ‘difficult’ client or horrendous story.
In these cases, colleagues and/or supervisors can assist the worker to ‘smooth over’ the distress, normalise their distress as a natural effect of hearing trauma stories, reassure them of their competence, and get them back on track. This support can be helpful, however, if this is the sole response, practices of ‘smoothing over’ distress can miss out on opportunities to articulate and reconnect with the ethics that are important to us in the work.
Distress can be an indication that one’s ethics have been transgressed in some significant way; or more acutely, that we have ourselves in some way acted against our own ethics. This is not referring to gross or blatant violations of a worker’s professional ethical responsibilities with clients (of the kind that would call for managerial intervention or referral to a professional association). It might be more along the lines of realising that we have inadvertently been ‘going along’ with ideas that blame clients for the effects of the abuse, or feeling frustrated with a client for our own failure to understand or appreciate the difficulties they are facing, or of our being limited to individual ‘therapeutic’ interventions when we are aware that someone is living in inadequate housing or facing dire poverty.
Distress could also be in response to particular workplace practices or policies which feel disrespectful to clients, or that conflict with what the worker gives value to in the work. It could also be in relation to larger political decisions such as funding cuts that limit the accessibility of services. Workers in sexual assault services commonly bear witness to stories of unhelpful, unjust and often harmful treatment from criminal justice or mental health institutions. This distress is not only about the client’s stories or the worker per se; they connect to larger patterns of injustice in our communities.
Distress related to injustice and ethical pain can be transformative, individually, organisationally and socially. The Royal Commission into Institutional Responses to Child Sexual Abuse is an example of how naming and sharing accounts of individual acts of abuse and institutional failure has produced distress and ethical pain for those not directly involved, subjecting them to vicarious trauma, which in turn has garnered support for significant social change.
Sue Mann  suggests there are a range of possibilities for understanding and responding to worker distress that prioritise the ethical and collective aspects of working with people who have been subjected to sexual abuse. She outlines the following themes and accompanying questions for workers to consider in relation to distress experienced through the work. While this is not quite the same as Charles Figley’s work on ‘compassion satisfaction’, we think there are parallels in terms of highlighting the life-enhancing and (spiritually, ethically) meaningful aspects of doing this work.
Reflective practice questions
In her article ‘How can you do this work?” Sue Mann has developed some useful questions to prompt reflection and build collaborative practice.
Distress as an opportunity to acknowledge values, wishes and hopes.
- Why was this conversation or series of conversations particularly significant to me?
- Is it possible that some belief, something I value or give importance to, has been transgressed or challenged? Can I name what this is?
- Why are these values significant to me?
- How can I find connection with others around these values in my work and the rest of my life?
- What further action might I be able to take in relation to my work that would fit with these values?
Distress as an opportunity to consider workplace practices.
- What opportunities are available to talk about the many experiences of my work?
- Of the many different stories of work that could be shared, what stories and whose stories are being privileged?
- How are the connections people have to what is important and of value to them shared in the workplace?
- What opportunities are there for celebration in relation to the achievements of the work?
- What opportunities are there to share moments of sadness, moments of beauty, moments of joy?
Distress as an opportunity to reconnect with local knowledge and relationships.
This theme stems from acknowledging that sexual abuse counsellors/therapists are often called upon to occupy an ‘expert’ position in relation to the effects of sexual abuse in peoples’ lives. This invitation to be the expert can create considerable pressure on the worker to know all the answers and provide remedies for clients’ difficulties. Furthermore, this expert position can sideline or obscure the knowledge, skills and expertise of clients/service users themselves: both the person in front of us, and those from whom we have learnt in the past. After all, it is a “hard and often unspoken truth” that “we learn our work on the backs of clients” (Reynolds). These questions are about explicitly acknowledging the skills and expertise of clients and communities who know about surviving and resisting the effects of sexual abuse, without whom we as workers would have very little knowledge at all.
- How is the work valuing and building on the contributions of the community of people that might support those we are meeting?
- Are we finding ways to document, and create an audience for, the skills and knowledge that the people with whom we meet have demonstrated in responding to the effects of abuse in their lives?
Distress as an opportunity to connect with others around the politics of the work
- Who else would most likely to share this sense of distress/outrage?
- How could we come together to take some form of action as an outcome of this distress?
- How can the ideas and understandings gained in conversations inform organisational responses, policy, legislative systems, education of other workers?
- How can what is talked about in one on one conversations connect people with each other around their common experience of life in ways that enable broader social action?
- How are the politics of gender, class, race, age, ability, and heterosexual dominance being named and responded to within the conversations I have and within the organisation more broadly?
“I have become more aware that what makes my work sustainable are practices of collaboration”.
Our hope in developing this page is to expand understanding of vicarious trauma. To clearly outline how working with people who have been subjected to child sexual abuse and adult sexual assault impacts and resonates with us. We note that knowledge of the signs of vicarious trauma and having in place personal, professional and organisational practices that prioritise care are important to ensure appropriate support to clients and workers longevity in the field. In the final section we noted Vikki Reynolds emphasis on supporting workers to connect with the beliefs, values and ethics which draw us to do this work and to consider and understand experiences of distress in this context. Reynolds encourages us to move beyond understanding vicarious trauma and burnout in terms of individual deficit, to consider broader ethical and relational dimensions of the work. Sue Mann’s questions further encourage us to consider individual distress within a relational context and to reflect on how this understanding can contribute to building a community of action and support.
Useful online resources
http://www.aifs.gov.au/acssa/pubs/wrap/w4.html ‘Feeling heavy’: Vicarious trauma and other issues facing those who work in the sexual assault field by Zoë Morrison
References and resources
Catanese, S. (2010). Traumatized by association: The risk of working sex crimes. Federal Probation , 74 (2), 36-38.
Catherall, D. (1995). Coping with secondary traumatic stress: The importance of the therapist’s professional peer group. In B. Stamm, Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 80-94). Lutherville, MD, USA: Sidran.
Devilly, G., Wright, R., & Varker, T. (2009). Vicarious trauma, secondary traumatic stress or simply burnout? Effect of trauma therapy on mental health professionals. Australian and New Zealand Journal of Psychiatry , 43, 373-385.
Figley, C. (2002). Compassion fatigue and the psychotherapist’s chronic lack of self care. Journal of Clinical Psychology , 58 (11), 1433-1441.
Follette, V., Polusny, M., & Milbeck, K. (1994). Mental health and law enforcement professionals: Trauma history, psychological symptoms, and impact of providing services to child sexual abuse survivors. Professional Psychology , 25, 275-282.
Herman, J. (2001). Trauma and recovery: The aftermath of violence – from domestic abuse to political terror (3rd ed.). London, UK: Pandora.
Lyon, E. (1993). Hospital staff reactions to accounts by survivors of childhood abuse. American Journal of Orthopsychiatry , 63, 410-416.
Pearlman, A., & Courtois, C. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress , 18 (5), 449-459.
Pearlman, L. (1995). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. Stamm, Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 51-64). Lutherville, MD, USA: Sidran.
Pearlman, L., & Saakvitne, K. (1995). Trauma and the Therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York, USA: Norton.
Rothschild, B., & Rand, M. (2006). Help for the Helper: The psychophysiology of compassion fatigue and vicarious trauma. New York: Norton.
Trippany, R., Wilcoxon, S., & Satcher, J. (2003). Factors influecing vicarious trauma for therapists of survivors of sexual victimization. Journal of Trauma Practice , 2, 47-60.
Diagnostic and Statistical Manual V: Post Traumatic Stress Disorder (PTSD)
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required)
- Direct exposure.
- Witnessing, in person.
- Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
- Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently re-experienced in the following way(s): (1 required)
- Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
- Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
- Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
- Intense or prolonged distress after exposure to traumatic reminders.
- Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance
Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)
- Trauma-related thoughts or feelings.
- Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)
- Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
- Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous.”).
- Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
- Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
- Markedly diminished interest in (pre-traumatic) significant activities.
- Feeling alienated from others (e.g., detachment or estrangement).
- Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity
Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)
- Irritable or aggressive behavior.
- Self-destructive or reckless behavior.
- Exaggerated startle response.
- Problems in concentration.
- Sleep disturbance.
Criterion F: duration
Persistence of symptoms (in Criteria B, C, D and E) for more than one month.