What is vicarious trauma and who does it affect?

Vicarious trauma is the psychological harm that accumulates from repeated exposure to other people’s traumatic material. It affects clinicians, social workers, emergency responders, lawyers exposed to distressing material, and others whose roles involve sustained contact with trauma. Research by McCann and Pearlman (1990) and Pearlman and Saakvitne (1995) established that the pattern mirrors direct trauma in important ways.

What is moral injury and how is it different from burnout?

Moral injury is the psychological harm that follows from perpetrating, failing to prevent, or witnessing acts that transgress one’s moral or ethical beliefs (Litz et al., 2009; Shay, 2014). It is distinct from burnout, which is the depleted state that follows from sustained occupational stress. Moral injury responds to a specific therapeutic approach focused on meaning, accountability, and repair, rather than the energy-management interventions typical of burnout treatment.

Why do senior professionals struggle to seek psychological support?

The pattern is well-documented in Australian research, particularly in lawyer wellbeing (Krill et al., 2016) and doctor mental health (Beyond Blue, 2019). Several factors contribute. Professional identity is often heavily invested in capability, so admitting difficulty feels like admitting failure. Confidentiality concerns are higher in small professional communities. And the workload that creates the difficulty also makes seeking support practically harder.

How is therapy for senior professionals different from general therapy?

The clinical work itself draws on the same evidence-based frameworks (CBT, ACT, trauma-focused therapy, schema therapy). What differs is the context. Effective therapy with senior professionals requires contextual fluency with their work, distinguishing organisational problems from personal coping deficits, and appropriate administrative care around confidentiality. The therapeutic stance is one of professional respect rather than instruction.

Being the Professionals' Psychologist: Therapy for professionals in high-stakes roles

Sarah Fischer
4 days ago
8 min read

How Behavioural Edge Psychology supports professionals carrying complex, high-stakes work

Therapy for senior professionals in high-stakes roles addresses several psychologically distinct patterns. Vicarious trauma and cumulative exposure follow repeated contact with other people’s traumatic material (McCann & Pearlman, 1990). Moral injury, the psychological harm from acts that transgress one’s ethical beliefs under constrained conditions (Litz et al., 2009; Shay, 2014), presents differently from anxiety and depression and requires a specific therapeutic approach. The helper’s paradox, in which those trained to support others struggle to seek help themselves, is well-documented in Australian research on lawyer and doctor wellbeing (Krill et al., 2016; Beyond Blue, 2019). Effective therapy with these clients combines evidence-based clinical work with an organisational psychology lens that distinguishes individual coping deficits from structural conditions that exceed sustainable demand.

Healthcare worker in scrubs, accompanying a blog post about therapy for professionals who support others

There is a particular kind of weight that settles on people whose work involves carrying others. The emergency department registrar who has not slept properly in months. The senior lawyer whose calendar has not held an unscheduled hour in years. The CTO who knows precisely which vulnerabilities are still in production and cannot say so to the board. The therapist who has not stopped thinking about a recent client. The CEO who cannot share with anyone in the building what they are actually worried about. They are not failing at their jobs. They are doing demanding work, well, for sustained periods, in systems that often do not adequately support them.

A meaningful proportion of my practice is made up of these clients. Senior professionals, clinicians, lawyers, executives, technical leaders, regulators, people who hold significant responsibility and who are usually the ones helping others. The clinical work I do with them sits at a particular intersection. It draws on evidence-based therapy for the symptoms they are experiencing, on organisational psychology for the systems they are working inside, and on a stance of professional respect that recognises they are not coming for advice on how to do their jobs. They are coming because something is costing them more than it should.

What makes this work psychologically distinct

Several patterns recur with sufficient frequency to be worth naming. Each has a recognised research literature, and recognising them is often the first step in working with them clinically.

Vicarious trauma and cumulative exposure

Repeated exposure to other people’s traumatic material accumulates in ways that mirror direct exposure (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). The emergency department registrar who sees another paediatric resuscitation, the child protection social worker reviewing another file, the criminal lawyer reading another set of interview transcripts, these clinicians and professionals carry material that does not stay neatly inside the working day. The pattern is not limited to direct caregivers. The IT security professional working through the aftermath of a major breach, the engineer reviewing a fatality, and the executive announcing redundancies all hold work that has psychological weight, even where the clinical literature has historically paid them less attention.

Moral injury

Moral injury is the psychological harm that follows from perpetrating, failing to prevent, or witnessing acts that transgress one’s moral or ethical beliefs, particularly under constrained conditions (Litz et al., 2009; Shay, 2014). The clinician who discharges a patient they believe is not yet stable because no inpatient bed is available. The engineer who is overruled when raising a safety concern. The senior leader who must implement a decision they believe is wrong. Moral injury presents differently from anxiety and depression and responds to a different therapeutic approach (Williamson, Murphy, & Greenberg, 2020). Naming it correctly matters.

The weight of consequential decisions

Some professionals live with the knowledge that decisions they make can have far-reaching consequences, including for people they will never meet. The structural engineer signing off on a design, the registrar making a treatment decision under pressure, the CISO weighing how much to disclose about an active incident, the executive whose decision will affect a workforce. These professionals often function well precisely because they take this responsibility seriously. The clinical question is whether they have anywhere safe to process what it costs them.

The competence trap

Many high-functioning professionals are conditioned, both by training and by selection effects, to identify strongly with their capability. When the work begins to cost them more than it returns, the response is often to work harder, deny the depletion, and attempt to outperform the problem. The competence trap is what happens when professional identity becomes load-bearing for personal worth, and when admitting difficulty feels like admitting failure. This is recognised in the burnout literature (Maslach & Leiter, 2016) and is one of the most common patterns I see in early sessions with new professional clients.

Isolation at senior levels

As people move up an organisational hierarchy, the number of people they can talk to candidly tends to shrink. Senior executives, partners in professional firms, and clinical leaders often describe a particular kind of loneliness, surrounded by people who report to them or scrutinise them, and very few who can hear them without consequence. This pattern is well-documented in research on senior leadership, identity, and transitions (Petriglieri, Petriglieri, & Wood, 2018), and it has clinical implications. Therapy can be one of the few places where a senior leader can think out loud without political cost.

Always-on culture

Constant availability erodes recovery. Sonnentag’s (2018) research on recovery from work identifies four pathways, psychological detachment, relaxation, mastery, and control, and shows that all four are degraded by the structural features of always-on roles. The on-call engineer who cannot fully disengage, the partner who is expected to respond to emails on annual leave, the executive whose phone never goes off. The biological cost of this pattern is now well-established, and it shapes what is therapeutically possible. If recovery conditions cannot be created in the role, that has to be addressed alongside the symptoms.

The helper’s paradox

Those trained to support others often struggle to seek or accept help themselves. There is sometimes an internalised expectation that helpers should not need help, and that asking for it represents a failure of professional identity. The Australian research on lawyer wellbeing (Krill, Johnson, & Albert, 2016) and on doctor mental health (Beyond Blue, 2019) consistently shows this pattern. The professionals most likely to need support are often the ones least likely to seek it, and most likely to seek it only when their function is already compromised.

How I work with these clients

The clinical work required for therapy for professionals in high-stakes roles draws on several frameworks. Trauma-focused therapy for vicarious trauma and post-traumatic presentations. Cognitive-behavioural and ACT-based approaches for anxiety, depression, and burnout. Specific moral injury frameworks where indicated (Litz et al., 2009; Williamson et al., 2020). Where the difficulty is shaped by the organisation as much as by the person, organisational psychology informs how we make sense of what is structural and what is individual.

That distinction matters. A common therapeutic error with professional clients is to treat what is in fact an organisational problem as if it were a personal coping deficit. If a role consistently requires more than a person can sustainably give, no amount of mindfulness practice will fix it. Part of what I bring to this work is the capacity to separate the two, and to support clients in deciding what to change in themselves, what to attempt to change in their environment, and what to accept that they may need to leave.

Speaking the language

Contextual fluency is one of the harder things to find as a professional looking for therapy. When a barrister describes a sentencing hearing, when a senior nurse describes a particular type of family meeting, when a cybersecurity professional describes the texture of incident response, the therapist either understands what is being said or has to ask. Both are fine. The cost of the latter is the time spent translating, and the small but persistent friction of being the educator in your own therapy. My background in organisational psychology, my research on trust and psychological safety in workplaces, and the years of work with the Victorian Bar mean that for most professional clients the translation work is reduced rather than eliminated.

What therapy for professionals in high-stakes roles actually looks like

Sessions are structured but not formulaic. Early sessions usually establish what is happening clinically, what is happening organisationally, what the client wants from the work, and what the constraints are. Mid-phase work is the substantive therapeutic content, including trauma processing where indicated, cognitive and behavioural work for anxiety and depression, skills work for emotion regulation, and where relevant, work on the patterns the client carries into work relationships. Later sessions consolidate. Many clients return periodically rather than continuously, which is appropriate for the work.

Confidentiality is absolute within the standard limits applying to all Australian psychologists. For senior professionals with public profiles, additional administrative care can be taken around scheduling, communication, and records.

Getting started

My consulting rooms are in Caulfield South and St Kilda. I offer telehealth across Victoria for clients whose schedules or roles make travel unworkable. Initial appointments include a longer first session to do the assessment work properly, and a follow-up to consolidate the plan before therapeutic work begins.

You can book at behavioural-edge-psychology.au4.cliniko.com/bookings or contact the practice on 03 8771 4315. If you are not sure whether what you are experiencing warrants this kind of work, a brief enquiry is welcome.

References

Beyond Blue. (2019). National Mental Health Survey of Doctors and Medical Students. Melbourne, Beyond Blue.
Krill, P. R., Johnson, R., & Albert, L. (2016). The prevalence of substance use and other mental health concerns among American attorneys. Journal of Addiction Medicine, 10(1), 46 to 52.
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans, a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695 to 706.
Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience, recent research and its implications for psychiatry. World Psychiatry, 15(2), 103 to 111.
McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization, a framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131 to 149.
Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist, countertransference and vicarious traumatization in psychotherapy with incest survivors. New York, W. W. Norton.
Petriglieri, G., Petriglieri, J. L., & Wood, J. D. (2018). Fast tracks and inner journeys, crafting portable selves for contemporary careers. Administrative Science Quarterly, 63(3), 479 to 525.
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182 to 191.
Sonnentag, S. (2018). The recovery paradox, portraying the complex interplay between job stressors, lack of recovery, and poor well-being. Research in Organizational Behavior, 38, 169 to 185.
Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine, 70(5), 317 to 319.

About the author

Dr Sarah Fischer is the Principal Psychologist and CEO of Behavioural Edge Psychology, with consulting rooms in Caulfield South and St Kilda. She holds a PhD in Psychology from Deakin University and is registered with AHPRA, endorsed in organisational psychology. She also serves as the Bar psychologist to the Victorian Bar and holds a casual academic appointment at Deakin University.

Her work sits at the intersection of evidence-based practice, trauma-informed care, and neurodiversity-affirming assessment. Her published research spans psychological safety, organisational trauma, trust and leadership, and has appeared in the Australian Journal of Psychology, Frontiers in Psychology, and the Journal of Healthcare Leadership.

To book an appointment, visit behavioural-edge-psychology.au4.cliniko.com/bookings or contact the practice on 03 8771 4315.

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