Introduction

Hundreds of physicians and other clinicians around the United States conduct medical asylum evaluations, in which they are asked to document evidence of torture and persecution of women, men and children fleeing their home countries. During those evaluations, clinicians take histories and perform physical examinations of individuals who have suffered horrific events prior to arriving in the US. Taking part in these encounters and clinical evaluations may put them at risk for vicarious trauma (VT), also referred to as secondary trauma, occupational stress, burnout or compassion fatigue. McCann and Pearlman [1] developed the construct of VT where they proposed that the therapist’s cognitive world can be altered by verbal exposure to the client’s traumatic material.

Close engagement with traumatized clients or patients can involve the provider being exposed to graphic details, including reenactment of the trauma [2]. The therapist also becomes privy to the fact that humans can be intentionally cruel to each other. A client’s painful images and emotions related to trauma can become incorporated into the therapist’s memory. Symptoms of VT involve “cognitive shifts” of which the most commonly affected are areas where losses or disruptions occur relating to perceived safety, trust, esteem, intimacy and control of self and others. Symptoms of VT can have a negative impact on the clinician’s feelings, relationships, and work life [3].

Researchers argued that vicarious traumatization can affect anyone working empathically with trauma survivors including journalists, police, emergency room personnel, shelter staff, prison guards, clergy, attorneys, and researchers [4]. VT has been described in various healthcare professions: nurses, social workers, sexual assault nurse examiners and therapists. In those who provide sexual abuse treatment, male gender, age and childhood neglect were predictors of disruptive cognitions [5]. In one study, 67 % of sexual assault nurse examiners reported vicarious trauma, emotional demands associated with the job and burnout [6]. Another study looking at social workers who work closely with sexually abused clients described the social workers as experiencing denial, anger, depression, and disruption in their lives [7]. Counselors working with victims of domestic violence, child abuse, child sexual abuse, sexual violence and torture experienced more VT compared to other counselors who were not serving these populations [8]. In a study of child welfare professionals, participants exhibited strong sense of hopelessness, disconnectedness from loved ones, lack of trust of others and increased cynicism [9]. The same participants also experienced many PTSD symptoms including intrusive images, startle response and avoidance of certain places, causing them to leave their jobs due to effects of VT. In a study of violence counselors, VT resulted in lower job satisfaction, increased job turnover, absenteeism and deterioration of client service [3]. Furthermore, volunteer counselors seemed more at risk for these negative effects than paid staff, perhaps due to less access to structural support mechanisms to deal with the negative effects themselves.

Very little research has addressed VT in physicians [10, 11] in general. In one study of inner-city family physicians caring for women using illicit drugs, Woolhouse et al. [11] found emotional stress, isolation and characteristics of VT among participants. Even less is known about VT experienced by those who volunteer their time to conduct asylum evaluations or to work with torture survivors. To our knowledge, no research has been published to date about VT in asylum evaluators.

Methods

A general survey about asylum work was distributed to 449 members of the asylum network of Physicians for Human Rights. They survey was distributed through an email with a link to www.surveymonkey.com. Those on the target population list for the survey were sent an initial announcement and two reminders between May and July 2012. The survey included a personalized greeting, a consent form and a link to the survey. Non-responders were sent up to two follow-up emails encouraging participation. At the time the survey was sent, the PHR asylum network had 449 known members: 286 physicians, 86 psychologists, 38 social workers, and 39 were uncoded [12]. Survey questions were designed by two of the investigators (RM and SK) and were not based on previously published validated surveys.

They survey was approved by the Providence Hospital Internal Review Board, in Washington, DC, USA.

The study focused on responses to the following consecutive questions in the survey: (1) “Do you believe you experienced any form of VT (a stress reaction experienced by therapists, counselors, victim support volunteers and researchers who are exposed to disclosures of traumatic images and materials by clients and research participants, in which the therapists or researchers experience long-term or lasting changes in the manner in which they view self, others, and the world) at any point since you started performing asylum evaluations?” yes or no; (2) if so, did you seek any outside support? Yes or no; (3) If you sought support, who was it from? (Check all that apply): Other asylum providers, Colleagues, Friends, Family members, or Mental health professionals. These questions were followed by an open-ended question: (4) “What kind of support do you think would be most helpful to providers experiencing vicarious trauma?” Of note, these were 4 out of a total of 26 questions that primarily focused on demographics (age, gender, geographical location, specialty training, years in practice), but also on whether and where evaluators trained as asylum evaluators and the reasons they choose to pursue this work as volunteers.

Re-categorizing Variables

For the demographic variables profiling the asylum evaluators, age was re-categorized into 4 groups: 39 or younger, 40–49, 50–59, and 60 or older. Medical specialty was classified into 4 groups: Internal Medicine, Family Medicine, Psychiatry/psychology, and Other; years of practice after residency was collapsed into 3 groups: <5 years, 5–10 years, and more than 10 years.

Statistical Methods

We sought to identify characteristics of asylum evaluators associated with an increased chance of reporting vicarious trauma. The evaluator characteristics analyzed included the gender, age, race, medical specialty, years of practice after residency, and number of asylum exams conducted.

Additionally, we sought to identify characteristics of those asylum evaluators reporting vicarious trauma, who were more likely to seek outside support. Moreover, among those who sought outside support, we sought any associations between the characteristics of evaluators and who they were more likely to seek outside support from. Evaluator characteristics analyzed included the gender, age, medical specialty, and years of practice after residency. Statistical models (Appendix) were created for the responses to the questions, and were adjusted for gender, age, medical specialty, and years of practice after residency.

Results

The survey was sent to 449 individuals. 211 began the study (47 %) and 197 completed it (44 %). The specialty distribution of asylum evaluators who responded to our survey is described in Fig. 1.

Fig. 1
figure 1

Specialty distribution

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Most were affiliated with psychiatric or psychological health professions. There were more women who responded to the survey than men and a greater proportion of younger individuals (39 or younger) were among the responders. An overwhelming majority of responders described themselves as White. The majority of responders were in practice for more than 10 years (Table 1).

Table 1 Descriptive statistics by gender
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Vicarious Trauma

192 individuals of the 211 who completed the survey answered this question (91.0 % response rate) (Table 2).

Table 2 Reporting experience of vicarious trauma
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Overall, more participants reported not having experience VT (65.2 vs. 26.2 %). Upon further investigation of those who reported ‘yes’, females were significantly more likely to report having experienced VT (OR 5.52, CI 1.96–15.57, p value 0.001) than males. Being in the psychiatric healthcare field was also associated with VT reporting (OR 4.59, CI 1.08–19.53, p value 0.040). An additional factor associated with the likelihood of reporting VT was the number of evaluations performed. Those who performed between 20–49 and those who performed more than 50 such evaluations were more likely to report having experienced VT (OR 5.0, CI 1.20–20.89, p value 0.027 and OR 8.44, CI 1.78–39.91, p value 0.007, respectively). We found a dose–response relationship even after adjusting for age, years of practice, and specialty, indicating sensitization (Table 3).

Table 3 Vicarious trauma reporting
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Among those who reported having experienced VT, 56 % (47/84) reported seeking outside support, and 44 % (37/84) reported not seeking outside support (only 84 of 210 answered this question). To the question about where they sought support, respondents 58/210) mentioned colleagues, other asylum providers followed by family members and friends. Mental health professionals came in last (Table 4).

Table 4 Sources of outside support for those reporting VT
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The likelihood of seeking support among those evaluators who reported VT was not significantly associated with any characteristics of the asylum evaluators. Moreover, no significant association between the type of support sought, and characteristics of the asylum evaluators was seen. Participants were then asked an open-ended question about what kind of support would—in their opinion—be most helpful to a provider experiencing VT (Table 5).

Table 5 Recommended type of support
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One hundred and forty-five of 211 answered this question (68.7 %) and they could put as many suggestions in their response. Most respondents (Table 5) recommended the support of colleagues and peers (‘collegial’), followed by professional psychiatric and psychological help and counseling, followed by ‘other’, support groups, preparation and training, and self-care (Yoga, meditation, etc.).

Discussion

To the best of our knowledge this is the first study addressing the perceived experience of VT among clinicians who perform medical and psychological asylum evaluations.

The majority of survey participants deny having experienced vicarious trauma. However, among those who self-identified as experiencing VT being female, being in the psychiatric healthcare field, and performing more evaluations was associated with being more likely to report VT.

Real life responses to VT differed from recommended resources. While the majority of those who identified as having experienced VT reported seeking support primarily colleagues, many sought help from family and friends and the smallest proportion sought help from psychiatric health professionals. But the second-most recommended support resource—after colleagues and peers—was counseling and psychiatric/psychological clinicians. There was hardly any mention of family and friends as being a recommended source of help.

This study suffers from several weaknesses. Firstly and most importantly, we only assessed self-reported VT and did not use any validated diagnostic criteria for VT or symptom-based diagnostic tools and instruments. In light of this, any gender differences in VT reporting (females > males) should be taken with a grain of salt. One previous study on VT among immigration judges found a similar gender difference [13], as did a study of 105 judges who found that “female judges or judges with more than 6 years of experience were more likely to report symptoms”[14]. While a study of lawyers who work with asylum seekers did not find a gender difference, it did find a direct correlation between VT and the hours each week of doing asylum work [15].

The finding that more clinicians in the psychological/psychiatric fields reported VT is likely linked to a higher awareness of the definition and diagnostic criteria, and a better ability—due to training—to reflect on the process.

It is also possible that individuals with higher intrinsic levels of perseverance may self-select into the asylum evaluation process and that their perception of having experienced VT will be very different from that of clinicians who encounter patients and clients with trauma histories randomly. The dose–response findings are not surprising as the process of burnout and compassion fatigue appears to be insidious.

Secondly, we have a rather small sample size. The overall response rate (211 out of 449 46.9 %) is not that unusual in this kind of survey, but many individuals taking the survey did not complete all the answers. These fluctuations in our denominators and in the numerators contribute to the width of our confidence intervals and indicate a lack of precision of this preliminary study. We have no information about the non-responders (both overall, but also for individuals survey questions) so it is impossible to know where there was a significant difference in characteristics between the responders and the non-responders. This study provides exploratory data for a phenomenon that is under-studied among physicians in general and in particular in the sub-group of clinicians and physicians who provide care to torture survivors, asylum seeker and refugees.

Despite the study’s shortcomings there appears to be a perceived need for support among this sub-group of clinical care providers. Organizations, individuals and academic centers that recruit, train and use the services of asylum evaluators should make every effort to address the issue upfront and educate their volunteers about the potential for VT and about means of identifying and managing the symptoms if they emerge. Formal and informal support services and resources should be developed, identified and shared with volunteers.

Finally, while recognizing the existence of the trauma in caregivers is important, organizations and individuals wishing to address these issues may be wise to focus on what is often termed “vicarious resilience” [16]: zeroing in on the amazing resilience exhibited by of the victims. There is much to learn about perseverance, resolve and determination from those who braved unspeakable events but—through their engagement in the asylum seeking process—manifest an incredible will to live and to turn their lives around.