Vicarious resilience (VR) draws on a synthesis of four areas of clinical theory, research and practice. The first relates to the vicarious impact of trauma survivors’ stories and experiences on the professionals who work with them. This phenomenon has been analyzed primarily through the concepts of vicarious traumatization (VT), secondary traumatic stress, empathic stress, and compassion fatigue (Figley and Kiser 2013). The second relates to resilience, exploring the way in which trauma survivors access adaptive processes and coping mechanisms to survive and even thrive in the face of adversity (Masten and Coatsworth 1998; Walsh 2016). The third relates to politically motivated violence, including kidnapping, disappearance, assassination, torture and other forms of persecution (Gangoli 2006). The fourth relates to issues of equity, culture and international trauma work. This area refers to the ways in which class, gender identity, race, sexual orientation, (dis)ability, and religious identity shape the access to and opportunity for recovery, and the meaning therapists, clients, professional communities and societies assign to traumatic experiences and paths for resilience. These areas were integrated into the qualitative and quantitative studies conducted in the U.S. and in Colombia.
International qualitative research studies have documented the presence of VR in mental health professionals, teachers and community leaders working with survivors of severe trauma and family members dealing with the consequences of politically motivated violence, including torture, kidnapping, disappearance, displacement, and young victims of interpersonal violence (Acevedo and Hernandez-Wolfe 2014; 2017; Engstrom Hernández, and Gangsei 2008; Edelkott, Hernandez-Wolfe, and Gangsei 2016; Hernandez, Gangsei and Engstrom 2007; Puvimanasinghe et al. 2015; Silveira and Boyer 2015). This article offers a comprehensive summary of VR, including its origins, its relationship with vicarious trauma (VT), resilience and the contexts that articulated and gave meaning to such experiences, namely, the torture survivors’ movement in the U.S. and the socio-political upheaval that Colombia experienced in the 1990’s and 2000’s. In addition, it discusses the research on VR conducted thus far with educators and community leaders in Cali, Colombia.
The origins of VR
Hernandez, Engstrom and Gangsei (2007) had the opportunity to observe the complexity of the psychotherapeutic process through their participation in programs for and contact with professionals dealing with the treatment of the survivors of torture and political violence. Their work at the “Survivors of Torture International” organization in San Diego, USA, Hernandez’s work in Colombia with human rights activists (2002) and displaced populations, and Gangsei (2004) and Engstrom’s (2004) work with torture survivors provided the background for this focus on the recognition and management of VT in professional staff who come into contact with stories about torture in the course of their activities. They noticed that among the psychotherapists working with torture survivors, some made specific reference to the inspiration and strength they drew from working with clients whom they sometimes described as “heroes.” They developed an interest in integrating vicarious learning and resilience into their theory and practice by proposing the concept of VR. The concept was first tested by interviewing mental health providers who spoke of their positive experiences while working with survivors of torture (Engstrom 2004). This led them to speculate that work with trauma survivors had the potential to affect and transform therapists in a unique and positive manner. The following sections review the torture survivors movement in the U.S. and the Colombian context that supported the VR research, leading to the development of its conceptualization and application.
The movement for the rehabilitation of torture survivors in the U.S.
According to Quiroga and Jaranson (2005), the torture treatment movement began in Latin America in the late 1970s and spread to North America and Europe in the early 1980s. Today, about 350 centers or programs operate throughout the world, and 143 of them are members of the International Rehabilitation Council of Torture Victims (IRCT), the world’s largest membership-based civil society organization supporting the prevention of torture and the rehabilitation of torture survivors. Collectively, these centers serve thousands of torture survivors each year from all parts of the globe. Although their programs differ, these centers usually provide some combination of the following services: physical and mental health care (medical services, counseling, psychotherapy, and psychiatry), and a wide range of direct or indirect services (the latter through referrals) to meet the basic survival needs of the victims, such as food, housing, transportation, financial assistance, legal assistance (in coordination with pro-bono attorneys and paralegal aides), a documentation of the medical and psychological effects of torture for immigration proceedings, and the provision of attorneys, interpreters and cultural brokers for them (Quiroga and Jaranson 2005).
A comprehensive and categorical statistical assessment of the global scale of torture is impossible because torture takes place in the shadows. According to Amnesty International (2015), governments often invest more effort in denying or covering up torture than in undertaking effective and transparent investigations of accusations of torture and prosecuting the perpetrators. In addition, in many countries torture is probably under-reported. However, Amnesty International has reported on torture and other abuses in at least three quarters of the world’s countries. Between January 2009 and May 2013, Amnesty International received reports of torture and similar abuses committed by State officials in 141 countries in every region of the world.
The survivors that trauma therapists serve at specialized centers in the U.S. suffered severe physical, psychological and/or sexual torture and have fled their home countries to protect their lives and well-being. In addition to the mental and physical consequences of torture, they suffered severe and pervasive losses as a result of forced migration —the break-up of their families, harms to their health, poverty and separation from their culture, homes and countries. They faced extreme hardships when they resettled in the U.S., their country of refuge. Some were held in immigration detention facilities for months or years while their applications for asylum were being adjudicated. Those living in various cities in the U.S. were often ineligible for work permits while they were seeking asylum and faced economic, social, cultural and language difficulties as they struggled to acculturate and rebuild their lives (Engstrom and Okamura 2004).
The development of VR research in Colombia
Due to her academic interests and personal and professional links with Colombia, the author was responsible for the second qualitative study of VR ever undertaken in Colombia. This study explained and drew attention to this concept and launched a series of studies in collaboration with the ones carried out by Dr. Victoria Acevedo in Cali (Acevedo and Hernandez-Wolfe 2014; 2017).
The landmark study on VR was published in 2007 (Hernandez, Engstrom, and Gangsei 2007): it was based on the investigations of a group of clinicians who worked with a wide variety of families and individuals who had suffered traumatic events such as kidnapping, torture, and/or assaults in the context of the country’s armed conflict. Colombia offered an opportunity to explore the concept because of the mass killings and retaliatory violence that caused more than 4,000 politically motivated deaths per year in the 1990’s and early 2000’s (International Crisis Group 2002) and the manner in which the long-lasting armed conflict was aggravated by the involvement of armed groups of subversives, extortionists and narcotics-traffickers. At that time, reports by the Office of the UN High Commissioner for Human Rights in Colombia stated that Colombia was in a “Humanitarian Emergency.” As is well known, civilians were often caught in the cross-fire between paramilitary and guerrilla groups who were fighting to dominate the regions they lived in.
One of their gravest crimes was the constant kidnapping of civilians for ransom or political motives, a clear violation of human rights and international humanitarian law. Between 2002 and 2005, the number of victims steadily decreased (Fondelibertad 2005). They were also responsible for other serious crimes against the civilian population (massacres, the forced seizure of lands and the forced recruitment of minors, among others).
Due to its complexity and very diverse settings, the socio-political situation in Colombia offered a rich setting for a creative exploration of how therapists were affected by the survivors they treated. For decades, Colombian mental health professionals were faced with the challenge of finding solutions to multiple levels of complex traumas. They were uniquely positioned to reflect on their work and the positive and negative impact of it on their lives. In addition, the author conducted a study on trauma and resilience processes in the lives of human rights activists in Colombia a few years before the present one. It uncovered layers of resilience which called for further investigations in a clinical context (Hernandez 2002).
VR is embedded in resilience theory as the vicarious learning process which allows for the impact of clients whose positive adaptation stems from their ability to cope with adversity. According to Walsh (2016), resilience is the ability to withstand and rebound from disruptive life challenges: it involves dynamic processes which foster a positive adaptation in the context of a significant adversity. Beyond coping and adaptation, these strengths and resources enable the victim to recover and positively grow. Masten and Coatsworth (1998) view resilience as a dynamic process in which individuals display positive adaptation despite experiences of adversity in the past or in the present.
Resilience stems from usual and normal human adaptive abilities (Hernandez,Gangsei and Engstrom 2007). There are multiple pathways to resilience. For example, Bonanno (2004) mentions “hardiness” as a factor that helps to buffer a person’s exposure to extreme stress and to minimize the experience of distress. In addition to hardiness, he considers “self-enhancement,” “repressive coping,” and “positive emotion and laughter” as “distinct dimensions suggestive of different types or pathways of resilience to loss and trauma” (Bonanno 2004, 25).
Recent developments in the field have added that resilience is a dynamic concept linked to emotional regulation through multiple psychological mechanisms such as habituation, changes in attitudes and thoughts, self-reflection, future planning and changes in self-efficacy as well. These changes lead to an increased ability to cope with and adapt to stressful situations (Nuttman-Shwartz 2014).
VR identifies in a concrete fashion how clients may influence therapists in ways that enhance growth. A focus on how reciprocity occurs in the therapeutic relationship opens up the possibility of appreciating, attending to, and making sense of the process whereby therapists themselves may learn from, and change with their clients. Therapists and clients have a relationship in which they mutually influence each other and construct meaning; therapists are a part of, or participate in, the therapeutic relationship (Anderson 2007). This relationship is framed within layers of contexts (organizational, familial, communal, social) and includes dimensions of power inherent in the therapeutic relationship and structured by the parties’ social positions (Almeida, Hernandez-Wolfe, and Tubbs 2011).
Equity, culture and international trauma work
A key dimension in VR involves making the treatment of trauma meaningful by attending to the therapists’ and clients’ multiple identities in a social context. Brown asserts that “[a] psychotherapist’s ability to understand how a trauma survivor’s multiple identities and social contexts lend meaning to the experience of trauma and the process of recovery comprises the central factor of culturally competent trauma therapy” (2007, 3). Equally central is the therapist’s ability to recognize her or his own multiple identities and the interaction of these identities with the client’s in therapy. As Brown explains, “It also requires the psychotherapist’s awareness of her or his own identities, biases, and membership in cultural hierarchies of power and privilege, powerlessness and disadvantage, as well as personal experiences of trauma” (2007, 4).
It is important to encourage therapists to attend to their own development in multiple contexts of marginalization or privilege by virtue of their class, ethnicity, sexual orientation, age, gender identity, ability, and religion. Often, failing to examine the areas in which therapists hold unearned privileges by virtue of these dimensions hinders their ability to truly appreciate the changes the clients are going through and understand how they can learn from them. VR requires therapists to be voluntarily influenced by their clients. A conscious decision to do so means that therapists acknowledge how their experiences with privilege or marginalization shape their ability to listen, empathize and voluntarily learn from their clients’ ability to cope with adversity.
The vicarious impact of trauma survivors’ stories and experiences on trauma therapists
The transformative impact of socio-political traumas on the lives of clinicians who work with the victims may be positive or negative and is related to the clinicians’ own development and history, clinical skills and ability to cope with vicarious trauma.
Vicarious trauma (VT) describes and explains the negative effects of working with traumatized individuals, families and systems. Pearlman and Saakvitne use the term VT to refer to “a transformation in the therapist (or other trauma worker’s) inner experience, resulting in empathetic engagement with the client’s trauma material” (1995, 31). This concept describes how the cumulative effect of working with traumatized clients may affect the therapists’ feelings, cognitive schemas, memories, self-esteem, and/or sense of safety. It is a unique and inevitable consequence of trauma therapy and it is not an indication of psychopathology in the therapist or his or her client (Pearlman and Mac Ian 1995, 558). VT highlights the presence of a cumulative stress which slowly develops over time as a result of witnessing the client’s suffering and is a natural and inner experience of therapists; secondary traumatic stress and compassion fatigue often cause symptoms parallel to those of PSTD.
Hernandez-Wolfe, Killian, Engstrom and Gangsei (2014) examined the connection between vicarious traumatization and vicarious resilience, and the coexistence of both concepts. They concluded that “trauma therapists can be potentially transformed by their clients’ traumas and resilience in ways that are positive, even if not pain-free” (Hernandez-Wolfe et al. 2014 166). VT and VR processes occur naturally and may co-occur in therapists who treat survivors of political violence, since they, as empathic listeners, are confronted with stories of powerlessness and disruption as well as resourcefulness and adaptation. Both types affect therapists; the degree to which they do so is influenced by factors that may include the length and intensity of the stories, the therapists’ own resources and the context in which the therapy takes place.
In short, VR is not the sum total of all the positive experiences that therapists remember, nor is it a generic term for everything that motivates the therapist. There is a complex array of elements which lead to the empowerment of therapists through their interaction with their clients’ stories of resilience. The following elements were singled out in qualitative studies of the subject (Hernandez, Engstrom, Gangsei 2007; Engstrom, Hernandez, and Gangsei 2008; Hernandez-Wolfe et al. 2014) and later used as the indicators on the Vicarious Resilience Scale, VRS (Killian et al. 2017): changes in life goals and perspectives, client-inspired hopes, an increased self-awareness, self-care practices, an increased capacity for resourcefulness, an increased recognition of the clients’ spirituality as a therapeutic resource, an awareness of how the power and privilege of the therapist are related to the client’s social status and an increased capacity, on the part of the therapist, for being attentive to the victim’s narratives.
Dimensions of Vicarious Resilience
The following factors were tested to develop the VRS. A brief explanation of each factor follows.
Changes in life goals and perspectives
Posttraumatic growth (PTG) refers to a phenomenon of stress which leads to a positive transformation of the self. A traumatic or harmful event may disrupt the victim’s assumptions and narratives about his or her life and change the victim’s perception of day to day events (Tedeschi and Calhoun 2004). Trauma survivors report positive changes in their philosophy of life, reassess what really matters to them, feel more compassion for others and place a higher value on their relationships with their friends and family. The qualitative research on vicarious resilience has shown that helpful professionals who are empathetic towards trauma survivors and their harrowing accounts experience a vicarious PTG which causes changes in their philosophy of life, goals, and perspectives (Hernandez, Engstrom, and Gangsei 2007).
Can clients inspire hope in their therapists and if so, how? O’Loughlin (2006) states that clients influence therapists in positive ways and that therapists can experience personal growth as a result of their work. Using the concept of reasonable hope, Weingarten (2010) posited that the hopefulness of the therapists may emerge when they are willing to be influenced by the hopefulness of their patients in the course of the therapeutic process.
In the past, studies of the subject focused on how the victims use hope as a mechanism to cope with their traumas. In a qualitative study of therapists’ experiences of compassion satisfaction and vicarious traumatization, Hunter (2012) found four characteristics: the empathic resonance of the therapist, the client’s emotional investment in the process of therapy, the sense of mutual affirmation between them, and the satisfactions and risks of working with trauma. A mutual affirmation is important in vicarious resilience as it points to the positive, reciprocal influence of the therapy. Hunter notes that the therapists he studied actively affirmed their clients and felt affirmed by the therapeutic encounter in turn: “The client’s level of role investment and the therapist’s identification with the client appeared to add to the satisfaction and personal affirmation that the therapist experienced” (2012, 222).
Increased recognition of the clients’ spirituality as a therapeutic resource
Confronting and finding a meaning for suffering is a major task of religion and spirituality. People often seek answers to the challenges of life via their faith and/or spirituality (O’Grady, Kari and Jeremy 2012). Wang et al. (2014) evaluated the efficacy of tai chi as a therapy for a variety of health problems through a meta-analysis of 37 randomized controlled trials and 5 quasi-experimental studies published in English and Chinese. They found that the practice of tai chi has beneficial effects for various sectors of the population, as measured by a range of psychological well-being indicators which include levels of depression and anxiety, general stress management and the effectiveness of exercise.
In a mixed-methods study of the influence of meditation on mindfulness in 40 psychotherapists and its effect on their work, Keane (2013) highlighted several factors, such as an enhanced attentiveness to their clients and more awareness of themselves and the need for self-care. Mindfulness practices can enhance skills which are crucial for a therapist, such as attentiveness and empathy, and have a positive influence on the therapeutic relationship. In addition, religious practices and beliefs may improve mental health, strengthen psychological well-being and have a beneficial effect on distress and anxiety disorders, like depression (Ellison et al. 2001). Affirmative religious practices are associated with positive effects (Hebert et al. 2009).
Increased self-awareness and self-care practices
Studies of vicarious trauma (VT), compassion fatigue (CF) and burnout (Barnett et al. 2007; Smith and Moss 2009) have confirmed the vital role of self-care in the well-being of therapists. This body of research points to the need to balance a healthy mind and body to prevent irritability, insufficient or unsatisfactory sleep, doubts about one’s own therapeutic effectiveness, concerns about the size and severity of their caseload and episodes of anxiety or depression. Common behavioral patterns that signify impairment include social isolation, neglecting meal breaks, and putting clients’ needs first. Impairment can lead to poor clinical judgment, an increased risk of ethical breaches, boundary violations, and an inappropriate emotional involvement with clients. Samios, Abel and Rodzik (2013) suggest that a therapist’s ability to recognize the benefits and risks of trauma therapy may depend on an emotional self-awareness which allows her or him to deal with the therapy process in a healthy manner. In addition, Killian (2008) found that a higher emotional self-awareness helped to reduce stress and burnout in professionals who work with trauma survivors. Other authors have come up with specific self-care strategies for such professionals (Mathieu 2011; Regehr and Bober 2005).
Increased consciousness about power relative to social location
Constantine (2001; 2002) defines multicultural competence as a counselors’ ability to reach appropriate levels of self-awareness, knowledge and skills in working with people from diverse cultural backgrounds, including an awareness of cultural values and the socio-political importance of privilege or discrimination and oppression. Constantine found that trainee counselors from racial and ethnic minorities were rated as more multiculturally competent than their European or American peers and that prior multicultural training was a predictor of observer-rated MCCs but not of self-reported MCCs, a difference which was greater than the one reported by previous ratings.
Increased capacity for resourcefulness
Helpful professionals and educators reported a greater sense of personal and professional resourcefulness and self-efficacy as a result of their work with trauma survivors (Hernandez-Wolfe et al. 2014). A central feature of this change was that they attained a stronger sense of their own resilience in the light of their clients’ capacity to recover from terrible experiences. Rossi, Mortimer and Rossi (2011) argue that the therapist’s resourcefulness is a two-way dynamic in which both the therapist and client help to strengthen each other’s resilience. Further, in a qualitative study of psychotherapy undertaken in Brazil, Vandenberghe, Silvestre and Silva (2014) found that the therapist’s positive emotions can improve the therapeutic process by strengthening her or his resourcefulness and providing clues for honing the therapist’s professional skills. A positive attitude leads to compassion and closeness to the patient and may spill over into the therapist’s personal life.
An increased capacity for attentiveness to the patients’ narratives of trauma
According to Colosimo and Pos (2015), psychology defines therapeutic attentiveness as a suitable contact with three aspects of the perception and/or phenomenological awareness of reality: embodied experience, the environment external to the body and interpersonal relationships. They believe that a full engagement with each of these aspects is crucial for the success of the therapeutic process and involves three types of professional conduct: “being in the here and now”, “being open,” and “being with-and-for the client.” They further list some of the factors which may interfere with the therapist’s attentiveness: hyper-intellectualization, fear, fatigue, over-reacting (interpersonal or intrapersonal) and distraction. These errors are more likely to occur when the patient is suffering from extreme forms of traumatic stress. However, they also found that when therapists focus on the resilience and growth of their clients, they can strengthen their attentiveness.
The specific applications of VR to Colombian victims of trauma
Two qualitative studies undertaken in Cali focused on vicarious resilience in relationships which do not involve professional therapists (Acevedo and Hernandez-Wolfe 2014; 2017, with the support of the Corficolombiana NGO). The first studied vicarious resilience in children at middle schools who suffered dislocation and adversity and the effect of their stories on their teachers. Semi-structured interviews were held with teachers who worked in Accelerated Learning programs in Cali to determine their perceptions of their students’ manner of coping with trauma. The second study focused on early childhood and the way in which mothers from low-income families who cared for children from the same background in Hogares Comunitarios Bienestar (community homes run by the Colombian Family Welfare Institute) reacted to the resilience of the traumatized children they dealt with.
VR and teachers in an accelerated learning program
Vicarious resilience in the lives of teachers involves a complex array of factors which help to empower them through their interaction with students who have overcome adversity. These aspects include the regulation of affect as a relational skill, the broadening of relational skills, an echoing of their own adversities, changes in interpersonal relationships, a reassessment of one’s own problems, recognizing the impact of trauma, constructive educational strategies, gaining a perspective on such problems and being flexible about them, an acknowledgment of racial and gender diversity, raising one’s critical awareness and advocacy, and compassion fatigue.
Teachers allowed the influence of their students’ resilience to go beyond the classroom and significantly shape their perception of themselves, their relationships and their environment. They also learned about the relationship between vicarious resilience and the professional, social, and political contexts from which it emerged by observing how their clients actually acted in the face of larger forces and structures, which in turn gave them a better understanding of their own skills and sense of effectiveness in negotiations with those structures.
Community mothers and vicarious resilience
Community mothers working for the Colombian Family Welfare Institute (ICBF 2016) in Cali and its surroundings help to better their relationships with their communities and the families they serve. They have the potential to influence those families and communities by learning about child development, connecting with families and extending their networks of connections. These community mothers reported multiple ways in which helping those children and their families had a positive impact on their own lives and relationships with their families. Their participation in the process of change involved providing a home environment for the children in their care, which fostered their understanding of child development, the regulation of affect, the attainment of a perspective on the problems, empathy, a reassessment of one’s own problems, the strengthening of hope and relational skills, changes in interpersonal relationships and solidarity. They established connections which enabled them to extend their help beyond their immediate relationship with the children and influenced their personal stories and interpersonal relationships outside the community home. In this case, change can be seen as the attainment of a new emotional bonding between the community mothers and the children/families in their care.
There are important differences between the vicarious resilience processes of therapists, teachers and community mothers. While these three groups assist others, their training, the scope of their skills and their practices are vastly different. However, they are all in a position to help others, which often requires them to go beyond traditional expectations of how to deal with victims of trauma who have varied and complex needs, with the aid of specialized consultants. In the case of teachers and community mothers, the emotional links they establish with the children they care for requires them to be emotionally flexible and close to the children.
Therefore, in this case, change can be seen as the attainment of a new emotional bond between the teachers and students. In therapy, by contrast, the therapists must establish clear boundaries between themselves and their clients, deal with issues of influence, transference and counter-transference and have a keen awareness of professional ethics. Clinical studies have found that spirituality is a useful tool in treating victims of trauma. Teachers and community mothers in Colombia used their religious beliefs to strengthen their hope for the children and their own persistence and motivation. They previously had a very strong faith, so that spirituality was not something which only emerged as a result of the changes they witnessed in the children and their families. Finally, these community mothers did not show much awareness of factors of discrimination related to class, race, gender and sexual orientation, which contrasted with the orientation of the therapists and teachers.
VR is a useful tool to counteract deeply fatiguing processes in which helpers may feel that they are the “victims” of those with whom they work. Being attentive to both compassion fatigue and VR helps to strengthen the physical and mental health of those who work in contexts where suffering is present. Acknowledging the importance of VR for the well-being of helpers may lead them to make proactive decisions about balancing their work and life and taking a better care of themselves. This may, in turn, foster more positive emotions (e.g., gratitude, greater self-compassion) and heighten the awareness professionals have about their privileged social position.
Incorporating VR into the training of trauma therapists, teachers who work with children affected by violence and community mothers has the potential to heighten their awareness of the traumas of those they help and bring them benefits which go beyond the work setting. Such training will teach helpers to habitually expand their view of help to include positive emotions and beliefs about the reciprocal benefits of their work with the victims. Silveira and Boyer (2015) note that professionals who are familiar with vicarious resilience can look for it in the people they work with, share their findings with their individual and client families and expand their own opportunities for vicarious resilience and a strengthened optimism.
Areas of future research
In my view, future quantitative and qualitative studies of this subject should continue to focus on bodies of local knowledge of vicarious resilience that may play a key role in specific communities and point to the need for new areas of intervention. For example, research on the role of cultural factors and acculturation in places in Colombia where displaced persons have resettled would shed light on how helpers may strengthen vicarious resilience in their work. In addition, the impact of trauma may differ depending on whether those who experience it come from a collectivist rather than an individualistic culture (Johnson and OKearney 2008). For example, comparing the experience of helpers working with Indigenous, Afro-Colombians and Mestizos would help our understanding of how collectivism plays a role in their overcoming adversity. Furthermore, there is no research to date on how VR may develop in groups and communities. This is an area that merits more investigation in communities who have shown resilience to extreme violence in Colombia.
Another area of study would focus on how helpers are affected by the discrimination their clients suffered due to their race, gender, age, sexual orientation or previous membership of an armed subversive group. Such discrimination may affect the way in which displaced and reinserted groups build new social networks with members of their own groups and the dominant cultural ones. This, in turn, may teach helpers how to shape their relationship with their clients, integrate advocacy into their work and deal with issues of equity.
Finally, VRS can be translated into other therapeutic languages and used as a tool for assessment and intervention by other kinds of clinicians and helpers and help them to focus on changes in their clients and their own ability to be attentive to such changes. Mixed qualitative and quantitative methodologies can be used to gauge broader effects, give more depth to narratives and study the pathways which increase the likelihood of VRS occurring in first responders, mental health professionals, teachers, community leaders and other helpers.