Autonomy, Connection, and Healing Vicarious Trauma in Direct Support

The field of direct support was born in response to people with intellectual and developmental disabilities (IDD) demanding autonomy over their lives and a connection to their communities. Fostering both these forces in clients’ lives is rewarding work for direct support professionals (DSPs). But this workplace environment also puts DSPs at risk of vicarious trauma while providing direct support.

Vicarious trauma disrupts the balance of autonomy and connection, harming not just DSPs, but also people with IDD and the organizations that support them.

While IDD organizations don’t have the power to prevent all stress or trauma, they do have the ability to address vicarious trauma by helping their staff build resilience. Using principles of trauma-informed care and fostering resilience allows organizations to create more sustainable, healthier work environments — preventing DSP burnout and reducing turnover.

Vicarious trauma in direct support

Direct support is intimate work. It often takes place in someone’s home, in the mundaneness of their everyday life. It requires anticipating the needs of persons served, sometimes without verbal communication. In other words, direct support involves a lot of connectedness.

But it also requires respect for the person’s autonomy in decisions. Holding this duality between autonomy and connection in tension is a common experience in direct support.

When I worked as a DSP, my authentic connection to the people I served and my investment in their autonomy is what kept me coming to work through challenges like low pay and role confusion. I experienced the same awe as my client when they shrieked in joy from riding the elevator. But when they experienced discrimination because of their disability, I felt immense responsibility and sadness too.

Vicarious trauma involves experiencing symptoms of post-traumatic stress disorder from hearing or witnessing others’ trauma. Partly because rates of trauma, violence, and discrimination are so high among people with disabilities, those working in direct support are especially susceptible to vicarious trauma.

The symptoms of vicarious trauma, like those of PTSD itself, impact all spheres of life. For example:

Physical

• Experiencing body aches and pains
• Weakened immune system

Psychological

• Difficulty managing emotions
• Withdrawing from loved ones

Cognitive

• Believing the world is less safe
• Having difficulty planning for the future

DSPs may also be entering the work with an existing history of trauma. One study found that 75% of DSPs have experienced at least one Adverse Childhood Experience.

Trauma, whether primary or secondary, disrupts both autonomy (in the form of feeling safe moving through the world) and connection to others (in the form of trust). This transformed way of relating to the world, in turn, negatively impacts clients.

Cycles of trauma and retraumatization

The vicarious trauma DSPs may face in their direct support work, coupled with burnout, lead to compassion fatigue. Compassion fatigue in helping professions results in individuals who no longer feel they can maintain a healthy and objective view of their work.

The causes of DSP burnout and compassion fatigue are multifold. One cause of burnout and vicarious trauma involves times when DSPs witness or experience violence. They may observe self-injurious behavior and property damage while working with clients. One study found that 25% of DSPs are exposed to aggression nearly every day.

The culture of some IDD organizations can also lead to DSP burnout. Traditional interventions teach people with IDD to communicate verbally and politely. These interventions are problematic because trauma responses and neurodiversity lead people to express emotions in idiosyncratic ways, rather than rationally communicate their needs.

Embedded in such a culture, DSPs may engage in behaviors that don’t respect clients’ autonomy because they are burned out, overworked, or experiencing secondary trauma. Such underlying issues are all too common in the field, especially during the pandemic.

At the same time, DSPs and other professionals who demand that clients communicate a certain way may take on the weight of responsibility for clients’ experiences. This can create a power struggle that could trigger aggression, building a conflictual connection.

In other words, DSPs’ struggle with effectively managing the tension between autonomy and connection in persons served can be both a symptom and a cause of vicarious trauma.

Vicarious trauma’s impact and solution

You’re likely all too familiar with one negative outcome of vicarious trauma in direct support: high turnover. The 2020 annual report The Case for Inclusion found that the annual turnover rate for direct support roles was about 44%. Additionally, in 2019, direct support roles had full-time vacancy rates of 8% and part-time vacancy rates of 17%.

Although vicarious trauma is complex, the solution is clear. A trauma-informed approach honors clients’ autonomy by recognizing their ability to make their own decisions in big picture goals and in moment-to-moment choices. It also supports DSPs in developing a healthy, ethical, and supportive connection with persons served, developing a healthy work environment.

Trauma-informed care also informs us that one of the best ways to combat vicarious trauma in direct support is to foster resilience. Organizations can foster resilience in their DSPs by supporting work-life balance, encouraging self-compassion, and improving collaboration between clients’ service providers.

Developing supportive relationships between staff can also foster resilience. When the person I served experienced harm, the support of colleagues spared me from experiencing vicarious trauma.

Of course, it is critical for people in this network of care to turn to each other in ways that are not disrespectful to the client. Consider creating facilitated spaces like case conferences and Balint groups, as well as opportunities for colleagues to connect over topics unrelated to work.

DSPs have the opportunity to honor the unique ways that the people with IDD move through the world, bringing autonomy and connection back into a healthy balance. But they can’t do this alone. Repairing vicarious trauma by building resilience requires the support of agency supervisors and leaders engaged in trauma-informed care.