Posted: May 12th, 2022

Coping AND Vicarious Trauma

Coping AND Vicarious Trauma
An exploration of child welfare caseworkers’ experience of secondary trauma and strategies for coping.
Authors:
Rienks, Shauna L.. Butler Institute for Families, Graduate School of Social Work, University of Denver, Denver, CO, US, shauna.rienks@du.edu
Address:
Rienks, Shauna L., Butler Institute for Families, Graduate School of Social Work, University of Denver, 2148 S. High St., Denver, CO, US, 80208, shauna.rienks@du.edu
Source:
Child Abuse & Neglect, Vol 110(Part 3), Dec, 2020. ArtID: 104355
NLM Title Abbreviation:
Child Abuse Negl
Publisher:
Netherlands : Elsevier Science
ISSN:
0145-2134 (Print)
1873-7757 (Electronic)
Language:
English
Keywords:
Coping strategies, Secondary traumatic stress, Child welfare, Self-care, Caseworkers
Abstract:
Background: The use of coping strategies can protect against the detrimental effects of many work-related stressors. Given the stressful nature of casework with traumatized children and families, there is a need to better understand how to prevent the experience of secondary trauma. Objective: The goal of this study is to examine child welfare caseworkers’ experience of secondary traumatic stress (STS) and the extent to which coping strategies act as a buffer. Participants and Setting: This study utilizes both cross-sectional (N = 1968 at baseline) and longitudinal (N = 653 at 3-year follow-up) data from child welfare caseworkers in three states. Methods: Participants were recruited as part of a larger workforce study and invited to complete an online survey. Results: Results indicated relatively high levels of secondary trauma, with 29.6 % of caseworkers scoring in the ‘severe’ range. Caseworkers’ experience of STS was positively associated with burnout and negatively associated with organizational support and coping. Those who utilized coping strategies reported fewer symptoms of secondary traumatic stress both concurrently and three years later. Of the 15 coping strategies explored, the more proficient copers were most likely to have a clear self-care plan, participate in activities or hobbies, and have a work-to-home transition plan. Conclusions: Study results point to the importance of developing a self-care plan and having organizational supports that help protect child welfare caseworkers from the negative effects of secondary trauma exposure, both concurrently and over time. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Child Welfare; *Coping Behavior; *Social Workers; *Trauma; *Compassion Fatigue; Organizational Behavior; Self-Care Skills; Social Support; Stress
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Comprehensive Organizational Health Assessment DOI: 10.1037/t53538-000
Organizational Climate Measure DOI: 10.1037/t62894-000
Copenhagen Burnout Inventory DOI: 10.1037/t62096-000
Coping Measure DOI: 10.1037/t05400-000
Grant Sponsorship:
Sponsor: US DHHS, Administration for Children and Families, Children’s Bureau, US
Grant Number: Cooperative Agreement 90CT7002
Other Details: University at Albany’s School of Social Welfare
Recipients: No recipient indicated
Methodology:
Empirical Study; Followup Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jan 14, 2020; Accepted: Jan 3, 2020; Revised: Oct 10, 2019; First Submitted: Jun 13, 2019
Release Date:
20200116
Correction Date:
20210114
Copyright:
All rights reserved.. Elsevier Ltd. 2020
Digital Object Identifier:
http://dx.doi.org/10.1016/j.chiabu.2020.104355
Accession Number:
2020-03527-001
Result List Refine Search PrevResult 1 of 68
Empathy and coping as predictors of professional quality of life in australian registered migration agents (RMAs).
Authors:
Raynor, Danielle, ORCID 0000-0001-7966-0885 . Faculty of Society & Design, Bond University, Gold Coast, QLD, Australia
Hicks, Richard, ORCID 0000-0002-1830-5713 . Faculty of Society & Design, Bond University, Gold Coast, QLD, Australia, rhicks@bond.edu.au
Address:
Hicks, Richard, Faculty of Society & Design, Bond University, Gold Coast, QLD, Australia, 4227, rhicks@bond.edu.au
Source:
Psychiatry, Psychology and Law, Vol 26(4), Aug, 2019. pp. 530-540.
NLM Title Abbreviation:
Psychiatr Psychol Law
Page Count:
11
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
Australia : Australian Academic Press
ISSN:
1321-8719 (Print)
1934-1687 (Electronic)
Language:
English
Keywords:
burnout, compassion satisfaction, coping strategies, empathy, professional quality of life, registered migration agent, secondary traumatic stress
Abstract:
Threats to professional quality of life such as compassion fatigue constitute a risk for those working with trauma-exposed individuals. Research has investigated professional quality of life in first responders, mental health practitioners, and medical personnel, but the impact on Registered Migration Agents (RMAs) who work with trauma-exposed refugee clients has not been evaluated. This study examined the prevalence of secondary traumatic stress, burnout and compassion satisfaction in 188 RMAs, and the roles of empathy and coping strategies. More than one-third of the sample members were potentially at risk of compassion fatigue (under two-thirds indicated compassion satisfaction). Regression results suggested that compassion fatigue was significantly related both to lower empathy and to maladaptive coping; while adaptive coping and high empathy significantly predicted compassion satisfaction. Results indicate a potential occupational hazard for RMAs working with trauma clients; suggesting tailored interventions to reduce the risk of deleterious compassion fatigue on RMAs. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Empathy; *Quality of Work Life; *Sympathy; *Compassion Fatigue; Occupational Stress; Professional Personnel; Satisfaction; Threat; Posttraumatic Stress
PsycInfo Classification:
Personnel Attitudes & Job Satisfaction (3650)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Empathy Assessment Index
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Trauma Exposure Scale
Brief COPE Inventory DOI: 10.1037/t04102-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20181112
Correction Date:
20210527
Copyright:
The Australian and New Zealand Association of Psychiatry, Psychology and Law. 2018
Digital Object Identifier:
http://dx.doi.org/10.1080/13218719.2018.1507846
PMID:
31984094
Accession Number:
2018-57099-001
Number of Citations in Source:
51
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Empathy and coping as predictors of professional quality of life in Australian Registered Migration Agents (RMAs)
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Contents
Professional quality of life
Lawyers and compassion fatigue
Coping
Empathy
Method
Participants
Materials
Demographic questionnaire
Exposure
The brief COPE
The Empathy Assessment Index (EAI; Lietz et al., 2011)
The Professional Quality of Life (ProQOL; Stamm, 2010)
Design & procedure
Results
Hierarchical multiple regression: Predicting burnout
Hierarchical multiple regression: Predicting STS
Hierarchical multiple regression: Predicting compassion satisfaction
Discussion
Limitations and future research
Practical implications
Ethical standards
Declaration of conflicts of interest
Ethical approval
Informed consent
References
Full Text
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Threats to professional quality of life such as compassion fatigue constitute a risk for those working with trauma-exposed individuals. Research has investigated professional quality of life in first responders, mental health practitioners, and medical personnel, but the impact on Registered Migration Agents (RMAs) who work with trauma-exposed refugee clients has not been evaluated. This study examined the prevalence of secondary traumatic stress, burnout and compassion satisfaction in 188 RMAs, and the roles of empathy and coping strategies. More than one-third of the sample members were potentially at risk of compassion fatigue (under two-thirds indicated compassion satisfaction). Regression results suggested that compassion fatigue was significantly related both to lower empathy and to maladaptive coping; while adaptive coping and high empathy significantly predicted compassion satisfaction. Results indicate a potential occupational hazard for RMAs working with trauma clients; suggesting tailored interventions to reduce the risk of deleterious compassion fatigue on RMAs.

Keywords: burnout; compassion satisfaction; coping strategies; empathy; professional quality of life; registered migration agent; secondary traumatic stress

During the first half of 2017, Australian registered migration agents (RMAs) managed 68% of the temporary protection visas and 19% of the permanent protection visas (Office of the Migration Agents Registration Authority, [37]) issued by the Australian Department of Immigration and Border Protection (DIBP). As the process of applying for protection necessarily involves disclosure of applicants’ accounts of persecution, fear, trauma and violence (Smith-Khan, [44]), RMAs working on behalf of clients from initial enquiry through to acceptance or rejection of the visa by the DIBP are exposed to such accounts. These narratives have been shown to evoke emotional responses in the listener (Byrne, Lerias, & Sullivan, [ 6]). Whether these emotional responses impact upon professional quality of life in RMAs is of interest. To our knowledge, investigation into the professional wellbeing of RMAs working with potentially traumatized clients (hereafter referred to as trauma clients) has not been conducted.

Research into other professionals working with trauma clients, including lawyers, social workers and counsellors, first responders, doctors, and nurses, suggests investigation is warranted (Brobst, [ 5]; Levin & Greisberg, [29]). Furthermore, it has been suggested that immigration law and working with refugees constitutes a high risk for secondary traumatic stress (STS; Barrington & Shakespeare-Finch, [ 3]).

Comparisons of the legal industry with other industries provide valuable insights, because RMAs may also practise as lawyers, and work performed by lawyers is very similar to that of RMAs. Comparisons point to substantially higher rates of depression, anxiety and substance abuse and lower overall wellbeing in lawyers (Kelk, Medlow, & Hickie, [24]; Seligman, Verkuil, & Kang, [42]). Examining outcomes of compassion satisfaction, STS and burnout provides a vehicle for appraising the professional quality of life of RMAs who work with trauma clients. Furthermore, protective factors were of interest with a view to mitigating potential risk factors that have been associated with more profound problems (Pearlman & Caringi, [38]; [40]).

Professional quality of life
Professional quality of life, or professional wellbeing, is defined as the feeling tone individuals experience in their working capacity as human service workers engaging closely with others (Stamm, [47]). The response of helpers to emotional material can be explained primarily by compassion fatigue and compassion satisfaction, namely, the negative and positive aspects of helping, respectively (Stamm, [47]).

Literature suggests risk factors such as maladaptive coping strategies may negatively impact professional quality of life (Skeffington, Rees, & Mazzucchelli, [43]). Other research suggests empathy (Wagaman, Geiger, Shockley, & Segal, [50]) and adaptive coping strategies (Jacobson, [21]) are protective factors that may mitigate these risks. The current study aimed to examine the professional quality of life of RMAs through the lens of these variables.

Secondary traumatic stress occurs when helpers experience more negative than positive appraisals from their work ([12]). Vicarious trauma, traumatic stress, traumatic strain, and secondary trauma are frequent synonyms. Symptoms resulting from direct contact with trauma clients include hyperarousal, avoidance, intrusions, trust and intimacy difficulties, depression, changed cognitions about safety, and increased use of substances (Levin & Greisberg, [29]; McCann & Pearlman, [34]). If left unchecked, STS has the potential to escalate into PTSD (Pearlman & Caringi, [38]).

Burnout is characterised by exhaustion, decreased personal accomplishment, and depersonalization of clients ([ 1]), presenting with symptoms such as reduced performance, depression, anxiety, increased addictions, and interpersonal difficulties (Maslach & Leiter, [33]). Burnout can be differentiated from STS as a general stress phenomenon and, further, as a process related to chronicity of work stressors, whereas STS may present transiently without necessarily leading to burnout ([13]; Maslach & Leiter, [33]).

Conversely, when helpers endorse positive feelings and altruistic satisfaction about working with trauma clients, compassion satisfaction is said to result ([14]; Stamm, [47]). Notably, compassion fatigue, which represents a composite of STS and burnout, and compassion satisfaction, are not considered mutually exclusive; helpers may concurrently evidence high levels of both (Stamm, [45]; [46]). It is proposed that whether helpers experience compassion satisfaction or compassion fatigue is in part contingent upon the quality of their empathic response ([31]).

Lawyers and compassion fatigue
As mentioned, the legal industry provides valuable insights into the impact of working with trauma clients. Burnout in lawyers has been attributed to inadequate non-technical training in ‘soft skills’ of how to work closely with and communicate unfavourable news to distressed clients (James, [22]). The risk of secondary traumatization for lawyers was also first identified over 20 years ago (Pearlman & Saakvitne, [39]). Significantly higher levels of vicarious trauma have been identified in criminal lawyers compared to non-criminal lawyers, evidenced by PTSD-like symptoms (Vrklevski & Franklin, [49]). Similarly, compared to mental health practitioners, Australian lawyers exposed to traumatic material at comparable levels showed significantly higher STS scores (Maguire & Byrne, [32]). Their results suggest that organizational factors may have more influence than personality factors on how helpers respond to clients’ traumatic material. Further studies showing similar levels of compassion fatigue when comparing mental health care workers with medical practitioners (e.g., Zeidner, Hadar, Matthews, & Roberts, [51]) imply that some disciplines may pose a greater risk than others.

Finally, Baillot, Cowan, and Munro ([ 2]) found evidence in case managers handling claims for asylum seekers of STS adversely affecting job performance, threatening their clients’ chances of obtaining asylum. Furthermore, case managers used a range of putatively maladaptive coping strategies, such as denial of responsibility and detachment, in a bid to avoid the contagion of distressing client emotions. The relevance of coping strategies to RMA professional quality of life is discussed next.

Coping
Coping refers to the process of using cognitive, emotional and behavioural methods to execute a response to stimuli considered to exceed the threshold an individual is able to handle (Bober, Regehr, & Zhou, [ 4]; Endler & Parker, [11]). Coping strategies have typically been classified according to emotion-focused/problem-focused, or adaptive/maladaptive dichotomies. Coping strategies used by RMAs are of interest to assess whether STS and burnout might be mitigated by differences in situational coping responses. One of the very few studies evaluating coping strategies employed by lawyers reported that perceived stress and physical stress symptoms were mediated via maladaptive coping strategies (Kobasa, [25]).

Adaptive coping strategies used by RMAs who exhibit high levels of compassion satisfaction are also of interest, to inform remediation efforts for those at risk of STS. Jacobson ([21]) assessed coping strategies used by Employee Helpance Program (EAP) professionals. Results indicated that adaptive coping strategies were predictive of compassion satisfaction. It was therefore hypothesized that maladaptive coping strategies would be associated with increased STS and burnout, and adaptive coping strategies would be associated with increased compassion satisfaction. Empathy, another variable that might also influence RMA professional quality of life, is discussed next.

Empathy
A multidimensional process, empathy facilitates insight into another’s emotional state in reference to oneself. It spans extremes of basic concern at another’s distress, through to identification with their plight (Gerdes, [16]). It is considered a direct pathway to STS, on the basis that increases in empathy are proportionate to increases in the potential for personal distress ([31]). Empathy comprises physiological components such as affective response and affective mentalizing, and cognitive components, including self–other awareness, perspective taking, and emotion regulation (Gerdes, Lietz, & Segal, [17]).

Affective response, considered a more basic empathic response, comprises an initial unconscious physiological response (Segal, Gerdes, Lietz, Wagaman, & Geiger, [41]). By contrast, emotion regulation is the capacity to balance subjective reactions to another’s situation to prevent overwhelming emotional arousal from becoming distressed (Segal et al., [41]). Indeed, in addition to personal distress, compassion fatigue and burnout may be the consequence of an affective response without emotion regulation (Decety, Yang, & Cheng, [10]).

Another cognitive component, self–other awareness, is the ability to distinguish between feelings and experiences as belonging either to another person or to the self (Lamm, Bukowski, & Silani, [26]). RMAs in possession of high self–other awareness would evidence strong boundaries and not be at risk of personally absorbing the client’s situation outside their professional obligations to Help. Conversely, if RMAs exhibit an affective response, followed by low self–other awareness, emotional contagion from their client is likely (Hatfield, Rapson, & Le, [19]), since an ability to protect themselves from the transmission of aversive emotion is absent.

Higher empathy has been shown to predict less burnout in physicians (Lamothe, Boujut, Zenasni, & Sultan, [27]) and in mental health practitioners: an ability to connect intimately with clients while maintaining clear interpersonal boundaries has demonstrated protection from STS (Harrison & Westwood, [18]). Furthermore, emotion regulation, affective response, and self–other awareness specifically have been found to influence professional quality of life outcomes in other populations (Wagaman et al., [50]). Accordingly, it was hypothesized that high levels of empathy would be associated with increased compassion satisfaction, and low levels would be associated with STS and burnout.

Based upon the above research within comparable industries, the present study combined these variables, hypothesizing ( 1) that low levels of empathy and maladaptive coping strategies would be associated with aversive professional quality of life outcomes, such as burnout and STS in RMAs, and ( 2) that high levels of empathy and adaptive coping strategies would, conversely, be associated with compassion satisfaction.

Method

Participants
Of the 188 Australian RMAs who participated, 61.2% were female (n = 115) and 35.6% were male (n = 67) 3.2% (n = 6) did not specify their gender. The gender split is not necessarily representative of the industry, which reports 47.9% females and 52.1% males (OMARA, [37]). Participants were primarily 38–47 years old (27.7%); in possession of a Grad Cert or Grad Dip in Migration Law (61.7%) as the highest qualification relevant to their job role, while a further 16% held a Bachelor of Laws; 53.2% were originally from Australia or New Zealand, 36.2% were self-employed on a part-time basis, and 33.0% had been working in the industry for 5–10 years. Regarding exposure to distressed clients, 17.2% of RMAs never worked with trauma clients, 35.0% rarely did, 19.4% sometimes did, 10.0% frequently did, and 18.3% did so very frequently.

Materials
Participants completed an online survey, which comprised questions regarding demographics, frequency of exposure to working with trauma clients, and three self-report questionnaires.

Demographic questionnaire
Information was sought regarding a range of demographic items (e.g., gender, age, and employment status).

Exposure
To ascertain the level of contact with trauma clients, RMAs responded on a 5-point Likert scale, from 1 (never) to 5 (very frequently), to: ‘How frequently do you work with trauma-exposed clients?’ and ‘How frequently do you feel affected by your work with trauma-exposed clients?’

The brief COPE
The Brief COPE (Carver, [ 7]) is a 28-item abridged version of the original 48-item Coping Orientation to Problems Experienced (COPE; Carver et al., [ 8]). Items are designed to measure 14 situational coping responses to recent stressors in relation to RMAs’ work, rather than to yield an overall score of coping. The original 14-factor structure (Carver, [ 7]) has been replicated several times (Monzani et al., [35]; Muller & Spitz, [36]), and sound internal consistency of subscales and similar test–retest reliability established (Cooper, Katona, & Livingston, [ 9]). As the author does not recommend creating total scores or aggregates representing adaptive and maladaptive coping strategies (Carver et al., [ 8]), we conducted a second-order Exploratory Factor Analysis. Two factors comprising 10 items (α = .82) and 11 items (α = .71), which represented adaptive coping and maladaptive coping, respectively, were utilised in the current study.

The Empathy Assessment Index (EAI; Lietz et al., 2011)
The 22-item multidimensional EAI measures empathy from a cognitive neuroscience perspective (Segal et al., [41]). Items include ‘I am good at understanding other people’s emotions’ and ‘I can agree to disagree with other people’.

Adequate confirmatory factor analytic structure has been demonstrated across multiple samples (Inzunza, [20]; Lietz et al., [30]). Excellent internal consistency was established (α = .82; Lietz et al., [30]), and results confirmed the expected 5-factor model with each of the factors demonstrating acceptable to excellent internal consistency ranging from α = .70 to α = .84. Internal consistency in the current study was slightly lower but still acceptable ([48]), ranging from α = .63 to α = .75.

The Professional Quality of Life (ProQOL; Stamm, 2010)
The ProQOL has been used extensively across many different professions to measure professional quality of life (see website: http://www.proqol.org/Bibliography.html). It subsumes three subscales of STS, burnout, and compassion satisfaction. Higher scores on the subscales representing compassion fatigue indicate a higher risk for burnout and STS; higher scores on the compassion satisfaction subscale indicate higher satisfaction related to a RMA’s ability to effectively Help clients. Reliability coefficients within our study were very good for the three subscales: STS (α = .86), burnout (α = .84), and compassion satisfaction (α = .90).

Design & procedure
Our study involved a correlational, cross-sectional one-group survey design using a purposive sampling strategy to target current or previous Australian RMAs. Independent variables were empathy and coping strategies conceptualised as either adaptive or maladaptive. Professional quality of life outcomes measured by STS, burnout, and compassion satisfaction constituted dependent variables.

Data collection via an anonymous voluntary survey occurred over six months. The online survey was advertised on various social media sites and was administered using the PsychData online survey platform. Ethics approval was obtained from the Bond University Human Research Ethics Committee.

Results
An alpha level of.05 was used, and all data were analysed using IBM SPSS Statistics v. 24. Preliminary analysis confirmed no major violations of assumptions, and there were less than 5% missing data. Descriptive statistics based on the author’s combination of cut scores (Stamm, [47]) indicated that 61.2% of the sample fell within ideal or normal-range categories, and 36.7% fell into at-risk/distressed categories. Notably, ProQOl scores were intended for screening rather than diagnostic purposes (Stamm, [47]). Therefore, these results do not definitively categorise RMAs as suffering STS or burnout but, rather, potentially as being at risk of such outcomes.

Hierarchical regressions were conducted to determine the contributions of empathy and coping to professional quality of life, after controlling for demographic factors and exposure frequency.

Hierarchical multiple regression: Predicting burnout
Hypothesis 1, that maladaptive coping and low empathy would predict burnout, was supported. After controlling for the demographic variables, maladaptive coping accounted for 30% of the variance, R2change = .30, Fchange( 1, 170) = 79.46, p < .001. Empathy components of emotion regulation (ß = –.30, p <.001) and self–other awareness (ß = –.27, p < .01) were significantly negatively related to burnout. The total combination of independent variables accounted for 50.4% of the variance in burnout. Table 1 displays unstandardised and standardized regression coefficients of all three models.

Table 1. Multiple regression analyses predicting burnout, compassion satisfaction, and STS.

Model 1 Burnout B (ß) Model 2 Compassion satisfaction B (ß) Model 3 STS B (ß)
Step 1
 Age –1.5 (–0.25**) 1.32 (0.24**) –1.47 (–0.25**)
 Gender –0.46 (–0.04) 0.30 (0.03) –0.79 (–0.08)
 Exposure –0.04 (–0.01) 0.01 (0.00) 0.51 (0.09)
Step 2
 Age –0.54 (–0.09) 1.44 (0.26***) –0.47 (–0.08)
 Gender –0.45 (–0.04) 0.35 (0.04) –0.78 (0.07)
 Exposure –0.31 (–0.06) –0.10 (–0.02) 0.21 (0.04)
 Maladaptive coping 0.76 (0.57***) — 0.81 (0.61***)
 Adaptive coping — 0.25 (0.23**) —
Step 3
 Age 0.04 (–0.06) 0.74 (0.14) –0.09 (–0.02)
 Gender –0.39 (–0.04) 0.44 (0.05) –0.55 (–0.05)
 Exposure –0.36 (–0.06) 0.18 (0.03) 0.16 (0.03)
 Maladaptive coping 0.54 (0.40***) — 0.67 (0.50***)
 Adaptive coping — 0.21 (0.19**) —
 Affective response –0.13 (–0.07) 0.45 (0.25**) 0.37 (0.19**)
 Affective mentalising 0.40 (0.15) –0.13 (–0.05) 0.08 (0.03)
 Self–other awareness –0.70 (–0.27**) 0.76 (0.31**) –0.58 (–0.22*)
 Perspective taking 0.01 (0.00) –0.37 (–0.18) 0.32 (0.15)
 Emotion regulation –0.67 (–0.30***) 0.54 (0.26**) –0.56 (–0.25***)
1 Note. N = 175.

2 *p < .05; **p < .01; ***p < .001.

Hierarchical multiple regression: Predicting STS
The second model assessing STS also aimed to address Hypothesis 1, assessing maladaptive coping and lowered empathy as predictors of STS. Maladaptive coping strategies demonstrated a significant positive association with STS, explaining substantial variance, R2change = .33, Fchange( 1, 170) = 97.36, p < .001, while subsequent inclusion of empathy explained further variance, R2change = .12, Fchange( 5, 165) = 8.13, p < .001. As per the burnout model, self–other awareness (ß = –.22, p = .018) and emotion regulation (ß = –.25, p < .001) were significant predictors, in addition to affective response (ß = .19, p = .007). Collectively, variables explained 53.1% of the variance in STS.

Hierarchical multiple regression: Predicting compassion satisfaction
Hypothesis 2, that high levels of empathy and adaptive coping would predict compassion satisfaction, was supported. After controlling for demographics, the addition of adaptive coping explained significant variance in compassion satisfaction, R2change = .05, Fchange( 1, 170) = 9.87, p = .002, as did the subsequent addition of empathy, R2change = .19, Fchange( 5, 165) = 8.71, p < .001. Self–other awareness (ß = .31, p = .007), emotion regulation (ß = .26, p = .001) and affective response (ß = .25, p = .004) were once again significant positive predictors of compassion satisfaction. All independent variables together explained 29.7% of the variance in compassion satisfaction, R2 = .30.

Discussion
It was hypothesized, first, that increased STS and burnout would be associated with maladaptive coping strategies and low empathy. Regression analyses fully supported this hypothesis, consistent with prior research. Maladaptive coping strategies were similarly found to predict secondary trauma symptomology in Australian emergency service workers (Skeffington et al., [43]), for whom the specific coping strategies of distraction, substance use, venting, and self-blame explained a significant amount of variance. Except for distraction, these were common to the suite of maladaptive coping strategies used by RMAs.

The result of decreased empathy predicting increased STS and burnout mirrored other studies of social workers (Wagaman et al., [50]). However, the addition of a significant positive relationship for STS with affective response in the current study suggests greater utilization of emotional empathy by RMAs when confronted by secondary trauma. The empathy paradox, which suggests empathy’s ability both to harm and to protect ([40]), may be evidenced by affective response positively predicting both compassion fatigue and compassion satisfaction in this sample.

In contrast to the model predicting compassion satisfaction, the models predicting STS and burnout found maladaptive coping to account for greater variance than empathy. This might suggest that RMAs who are low in empathy components of emotion regulation and self–other awareness may have difficulty generating a healthful empathic response when confronted with clients’ traumata. In concert with the consequent use of maladaptive strategies, they may be more vulnerable to compassion fatigue. It is possible that empathy may offer greater protective value than that of coping strategies.

It was hypothesized, second, that compassion satisfaction would be associated with high empathy and adaptive coping strategies. Regression analysis results fully supported this hypothesis, with two aspects of empathy (self–other awareness and emotion regulation), and adaptive coping strategies contributing significantly to compassion satisfaction. In addition, a further component of empathy, affective response, was also implicated in predicting compassion satisfaction. Affective response, the ability to unconsciously mirror clients’ emotional states, precipitates cognitive empathic processing of accounts of trauma (Segal et al., [41]). This result is in agreement with theoretical models that state that empathy constitutes a significant pathway to compassion satisfaction, and lack thereof, to STS ([31]).

The results also support previous studies independently affirming the role of empathy in predicting compassion satisfaction. In social workers Wagaman et al. ([50]) found that 20% of the variance in compassion satisfaction was explained by empathy (compared to 19% in the current study), with close replication of self–other awareness, emotion regulation, and, notably, affective response.

Concurrence with prior studies where adaptive coping also predicted higher potential for compassion satisfaction (Jacobson, [21]) shows promise for recruiting adaptive coping skills as a protective factor against compassion fatigue. This contrasts with some authors who have suggested that because adaptive coping is not efficacious under all conditions (Lazarus & Folkman, [28]), it may not be the panacea to preventing compassion fatigue.

Limitations and future research
Limitations included the use of a cross-sectional design, preventing inferences about causality. Furthermore, although major migration agent industry bodies consented to recruitment of their members, membership is not compulsory, and participants constitute a self-selecting sample. The sample’s representativeness of the population is also questionable on the basis of gender bias. This issue is potentially compounded because empirical evidence has shown that females typically report higher levels of secondary traumatization than do males (Kassam-Adams, [23]). Caution is therefore warranted in interpreting these results, as generalizability may be affected.

Having investigated the impact of empathy and coping strategies on professional quality of life, future research may consider the influence of potential moderators such as detachment, self-care, and social support. Providing training to RMAs at risk of compassion fatigue is only ameliorative to the extent that significant moderators of the exposure-distress relationship are also accounted for. The helper’s personal trauma history is an established predictor of compassion fatigue in other professions ([15]; Kassam-Adams, [23]) that may also warrant investigation in RMAs.

Practical implications
Professional development training may address both STS and burnout, which have the potential to degrade the empathic engagement of RMAs with clients and therefore work performance, as a minimum. More pervasive problems may include absenteeism, attrition, and misconduct complaints, which can result in suspension or cancellation of RMA licenses (OMARA, [37]). Empathy training specifically may ameliorate distress, thereby reducing maladaptive coping strategies.

RMAs are not privy to structured clinical supervision and training afforded mental health practitioners. Therefore, the impetus for implementing measures to safeguard the mental health of these individuals by reducing the effects of and normalising responses to trauma work lies with industry bodies, employers and CPD providers. Other than professional development and training, such measures might also include formalised networks of peer sharing and/or consulting, for example, both online and in-person forums, to facilitate best practice knowledge transfer from more experienced RMAs.

Ethical standards

Declaration of conflicts of interest
Danielle Raynor has declared no conflicts of interest.

Richard Hicks has declared no conflicts of interest.

Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the Bond University Human Research Ethics Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent
Informed consent was obtained from all individual participants included in the study.

References
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Pivotal events: ‘I’m not a normal person anymore’—Understanding the impact of stress among helping professionals.
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Howard, Heather. Florida Atlantic University, Boca Raton, FL, US
Navega, Nicole. Florida Atlantic University, Boca Raton, FL, US
Source:
Best Practices in Mental Health: An International Journal, Vol 14(2), Fal 2018. pp. 32-47.
NLM Title Abbreviation:
Best Pract Ment Health
Page Count:
16
Publisher:
US : The David Follmer Group
Other Publishers:
US : Lyceum Books
ISSN:
1553-555X (Print)
2329-5384 (Electronic)
Language:
English
Keywords:
empowerment, professionals, stress, coping, quality of life, occupational burnout, compassion fatigue
Abstract:
To assess the impact of high-stress work on helping professionals, three major constructs have been employed throughout the past two decades: secondary traumatic stress, compassion fatigue, and occupational burnout. Applied together, these constructs provide powerful tools to recognize the debilitating effects that trauma care can have on helping professionals’ quality of life. The objective of this mixed-methods study was to understand coping strategies that helping professionals use to manage stressful working environments within a transactional stress and coping theoretical framework and structural empowerment model. The two major qualitative themes were systemic oppression on the professional side and intrinsic empathy on the personal side. Participants identified a pivotal event that impacted both their personal and professional lives. The use of this conceptual framework with helping professionals is promising as an emerging practice. Cultural shifts in host environments could create spaces for formal debriefing, wellness trainings, and decreased stigma related to help-seeking behaviors. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Empowerment; *Occupational Stress; *Health Personnel; *Compassion Fatigue; Quality of Life
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Methodology:
Empirical Study; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20190307
Copyright:
The Follmer Group, Best Practices in Mental Health. 2018
Accession Number:
2019-02787-004
Number of Citations in Source:
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From secondary traumatic stress to vicarious posttraumatic growth amid COVID-19 lockdown in Greece: The role of health care workers’ coping strategies.
Authors:
Kalaitzaki, Argyroula, ORCID 0000-0002-6416-9740 . Department of Social Work, Faculty of Health Sciences, Hellenic Mediterranean University, Heraklion, Greece, akalaitzaki@hmu.gr
Tamiolaki, Alexandra. Department of Social Work, Faculty of Health Sciences, Hellenic Mediterranean University, Heraklion, Greece
Tsouvelas, George, ORCID 0000-0001-8123-0091 . Department of Nursing, University of West Attica, Psachna, Greece
Address:
Kalaitzaki, Argyroula, Department of Social Work, Faculty of Health Sciences, Hellenic Mediterranean University, Estavromenos, Heraklion, Greece, 71410, Crete, akalaitzaki@hmu.gr
Source:
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 14(2), Feb, 2022. pp. 273-280.
NLM Title Abbreviation:
Psychol Trauma
Page Count:
8
Publisher:
US : Educational Publishing Foundation
ISSN:
1942-9681 (Print)
1942-969X (Electronic)
Language:
English
Keywords:
vicarious traumatization, vicarious posttraumatic growth, secondary traumatic stress, coping responses, coronavirus disease
Abstract (English):
Objective: Health care workers (HCWs) are at risk for suffering negative psychological consequences of the COVID-19 pandemic, such as secondary traumatic stress symptoms (STS), as they are exposed to this traumatic experience both directly, as community residents, and indirectly, in the care of infected patients. Following vicarious exposure, positive psychological outcomes, such as vicarious posttraumatic growth (VPTG), are also likely, though they are less studied. The present study aims to examine (a) the associations among STS, VPTG, and coping strategies among HCWs during the COVID-19 lockdown and (b) the mediating role of coping strategies in the STS–VPTG relationship. Method: Cross-sectional online data were collected amid the COVID-19 lockdown in Greece (March 23, 2020 through May 3, 2020) from a sample of 647 HCWs (25% men, 75% women). The Secondary Traumatic Stress Scale, the Post Traumatic Growth Inventory, and the Brief Coping Orientation to Problems Experienced Inventory were used to measure STS, VPTG, and coping strategies, respectively. Results: HCWs reported moderate to low levels of STS and VPTG, with the VPTG dimensions of personal strength and appreciation of life being the highest categories. Intrusions mental and both adaptive and maladaptive coping strategies predicted VPTG. Adaptive coping strategies partially mediated the relationship between STS and VPTG, whereas maladaptive coping strategies fully mediated this relationship. Conclusions: Understanding the coping responses during lockdown among HCWs is important for developing tailored prevention and intervention actions to protect the populations at risk from the deleterious impacts of uncontrollable and life-threatening diseases and promote posttraumatic growth. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Impact Statement:
Clinical Impact Statement—Positive and negative psychological outcomes might follow vicarious trauma exposure, with the first being less studied. Using a sample of 675 Greek health care workers (HCWs), we examine vicarious posttraumatic growth (VPTG), its association with secondary traumatic stress (STS), and whether coping responses facilitated posttraumatic growth (PTG) during the COVID-19 lockdown. HCWs demonstrated moderate to low levels of STS and PTG. Interestingly, both mental intrusions and coping strategies (both adaptive and maladaptive) were important predictors of PTG. Adaptive coping partially mediated the STS–VPTG relationship, whereas—unexpectedly—maladaptive coping fully mediated this relationship. Stakeholders could implement these findings to protect HCWs and promote their PTG. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Vicarious Experiences; *Health Personnel; *Posttraumatic Growth; *Posttraumatic Stress; Strategies; Compassion Fatigue; Coronavirus; COVID-19
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Greece
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Brief Coping Orientation to Problems Experienced Inventory
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Posttraumatic Growth Inventory DOI: 10.1037/t03776-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jul 29, 2021; Accepted: Apr 6, 2021; Revised: Apr 2, 2021; First Submitted: Oct 24, 2020
Release Date:
20210729
Correction Date:
20220127
Copyright:
American Psychological Association. 2021
Digital Object Identifier:
http://dx.doi.org/10.1037/tra0001078
PMID:
34323568
Accession Number:
2021-68980-001
Number of Citations in Source:
42
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From Secondary Traumatic Stress to Vicarious Posttraumatic Growth Amid COVID-19 Lockdown in Greece: The Role of Health Care Workers’ Coping Strategies
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Contents
Method
Participants
Instruments and Measures
Procedure
Statistical Analyses
Results
Regression Analyses
Mediation Analyses
Discussion
References
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By: Argyroula Kalaitzaki
Department of Social Work, Faculty of Health Sciences, Hellenic Mediterranean University;
Laboratory of Interdisciplinary Approaches to the Enhancement of Quality of Life, Hellenic Mediterranean University;
Institute of Agri-Food and Life Sciences, Hellenic Mediterranean University Research Centre;
Alexandra Tamiolaki
Department of Social Work, Faculty of Health Sciences, Hellenic Mediterranean University;
Laboratory of Interdisciplinary Approaches to the Enhancement of Quality of Life, Hellenic Mediterranean University
George Tsouvelas
Department of Nursing, University of West Attica
Acknowledgement: The data reported in this article were collected as part of a larger data collection. Findings from the data collection have been reported in MS1 (2021), which focuses on related variables (i.e., resilience, coping strategies, PTSD, and posttraumatic growth). However, that article focuses on the general population, whereas for this article only data from health care workers have been analyzed. The variables and relationships examined in the present article have not been examined in any previously published articles.

On February 11, 2020 the World Health Organization (WHO) announced the official name for the infectious disease that caused the 2019 novel coronavirus outbreak, first identified in Wuhan, China in December 2019. The name of this disease is Coronavirus Disease-2019 (COVID-19). On March 11, 2020, WHO declared the COVID-19 outbreak to be a pandemic. The first case in Greece was reported on February 27, 2019, and 1 month later, the Greek government enforced social distancing measures to constrain virus transmission. Cumulative evidence suggests that the COVID-19 pandemic and the resultant lockdown has detrimental effects on the mental health (e.g., PTSD, confusion, anger, stress, anxiety, and depression) of the general population worldwide (Chew et al., 2020; Rajkumar, 2020). Less is known about the effects of lockdown on the mental health of health care workers (HCWs). HCWs could be considered a high-risk population subgroup as they are both personally—as community residents—and professionally—through the care of infected patients—exposed to the pandemic, not to mention work-related stressful conditions and pressures (Kalaitzaki et al., 2020).

Being at the frontline of this crisis and trying to cope with a life-threatening disease can be an extremely traumatic experience for the HCWs (Jung et al., 2020). Recent studies have shown that HCWs who are involved in the diagnosis, treatment, and care of patients with COVID-19 are at the highest risk of various mental health symptoms, such as secondary traumatic stress (STS; Kang et al., 2020; Lai et al., 2020). STS involves symptoms similar to those of PTSD, the only difference being that STS develops from one’s vicarious (indirect) exposure to the traumatic events experienced by others, through a professional relationship of empathetic engagement with and caring for them (Finklestein et al., 2015; Roden-Foreman et al., 2017).

Overwhelming evidence suggests that traumatic experiences undoubtedly have negative consequences for HCWs; however, some studies have indicated that it is possible to experience a positive reaction to indirect trauma, which has been called vicarious posttraumatic growth (VPTG; Manning-Jones et al., 2015; Ogińska-Bulik & Zadworna-Cieślak, 2018). Tedeschi and Calhoun (2004) have argued that traumas cause psychological pain, which in turn, initiates a process of deliberate cognitive restructuring of the self, others, and the world, such that people acquire wisdom from adversity, strengthen relationships with others, foster acceptance of life’s uncertainties, and facilitate openness to new experiences. Kalaitzaki et al. (2020) were the first to suggest that patient care during the COVID-19 pandemic can be a positive experience for professionals, which they referred to as bouncing forward. Few studies have examined the positive psychosocial impact of infectious diseases, such as the severe acute respiratory syndrome (i.e., SARS) epidemic, but only among the general public (e.g., Cheng et al., 2006). The scarcity of research on VPTG during the COVID-19 pandemic makes any research effort imperative.

Joseph (2011) has suggested that a level of posttraumatic stress is necessary for the process of posttraumatic growth. However, the relationship among the effects, both negative (i.e., STS) and positive (i.e., VPTG), of vicarious traumatic exposure among HCWs has been a topic of intense research debate, and, therefore, the results are still inconclusive (Manning-Jones et al., 2015). Some researchers have suggested that STS and VPTG are uncorrelated (Gibbons et al., 2011), whereas others have suggested that they are positively correlated (Kjellenberg et al., 2014). Moreover, Manning-Jones et al. (2017) indicated that moderate levels of STS among HCWs is associated with higher levels of VPTG; this was true only for psychologists and not for nurses, social workers, or counselors. They argued that posttraumatic stress must be challenging enough to promote VPTG, but not so challenging as to inhibit growth.

Stress-related research has focused on coping strategies, where coping is defined as the cognitive, behavioral, and emotional efforts made by individuals in managing and conceptualizing a stressful event (Lazarus & Folkman, 1984). Traditionally, coping styles have been classified into three groups (Carver, 1997): problem-focused (i.e., active coping, instrumental support, and planning), emotion-focused (i.e., acceptance, emotional social support, humor, positive reframing, and religion), and dysfunctional (i.e., behavioral disengagement, denial, self-distraction, self-blaming, substance use, and venting). Meyer (2001) has suggested a second-order dimension of coping that includes both problem-focused and emotion-focused into the adaptive dimension and dysfunctional coping into the maladaptive dimension. Following vicarious traumatic exposure, coping strategies (adaptive and maladaptive) might protect against symptoms of STS and promote VPTG (Rodríguez-Rey et al., 2017). During the COVID-19 pandemic, maladaptive coping has been associated with greater STS among HCWs, whereas adaptive coping has been found to increase the likelihood of positive trauma outcomes (Babore et al., 2020; Ye et al., 2020). Some studies among HCWs have suggested that adaptive strategies might be beneficial for VPTG (i.e., Hamama-Raz & Minerbi, 2019), whereas others (i.e., Ogińska-Bulik & Zadworna-Cieślak, 2018) have indicated that both adaptive and maladaptive coping can predict VPTG. However, to the authors’ knowledge, no study has examined the relationship between coping and VPTG among HCWs during the COVID-19 pandemic.

Based on inconclusive findings on the relationship between STS and PTG (Manning-Jones et al., 2015) and the inconsistent findings on the types of coping strategies (i.e., adaptive, maladaptive, or both) that predict PTG and decrease stress, this study aims to examine (a) the relationships among STS, VPTG, and coping strategies in a sample of Greek HCWs during the COVID-19 pandemic and (b) whether adaptive, maladaptive, or both types of coping strategies predict VPTG. Furthermore, the mediating role of coping strategies in the relationship between STS and VPTG is examined. We hypothesized that VPTG would be predicted by both STS and coping strategies and that adaptive and maladaptive coping would mediate the relationship between STS and VPTG. To the best of our knowledge, this study is the first to examine the relationships among STS, VPTG, and coping strategies among HCWs during the COVID-19 pandemic. Examining the links among these variables on HCWs is of the utmost importance for promoting positive outcomes.

Method

Participants
After excluding two participants not living in Greece, the final sample included 647 HCWs (41% physicians, 37% nurses, 12% social workers, and 10% psychologists). The respondents ranged in age from 23 to 74 years (M = 43.41, SD = 9.81), were mostly female (n = 503; 75%), married (n = 419; 62%), and without children (n = 249; 37%). Participants had university (n = 309; 46%) or postgraduate education (n = 296; 44%), over 15 years of work experience (n = 150; 22%), and they were mostly residing in southern Greece (n = 311; 46%). The majority reported that they either definitely or most likely had contact in their workplace with patients who had suspected (N = 604; 90%) or confirmed cases of COVID-19 (N = 429; 64%).

Instruments and Measures
The questionnaire booklet collected information on demographics, posed work-related questions (exposure to confirmed or suspected COVID-19 cases), and included instruments to assess the psychological impact of the COVID-19 pandemic. Alpha coefficients and score ranges of the measures are presented in Table 1. Total and subscale scores for each instrument were produced by adding all responses or responses on each subscale, respectively.

tra-14-2-273-tbl1a.gifMeans and Standard Deviations, Coefficient Alphas, and Pearson Correlations Among the Study Variables (N = 675)

The Secondary Traumatic Stress Scale (STSS; Bride et al., 2004) consists of 17 items, allocated in three subscales (Intrusions, Avoidance, and Hyperarousal) measuring the intensity of STS experienced in the last 7 days. Items are scored on a 5-point scale, ranging from 1 (never), to 5 (very often). Example items are “Reminders of my work with clients upset me,” “I wanted to avoid working with some clients,” and “I felt jumpy.” Satisfactory reliability and validity (convergent, discriminant, and factorial) has been reported (Bride et al., 2004).

The Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) consists of 21 items, allocated in five subscales (Relating to Others, New Possibilities, Personal Strength, Spiritual Enhancement, and Appreciation of Life) measuring growth after a traumatic experience. Participants were instructed to respond in terms of the change that occurred following the COVID-19 pandemic, using a 6-point scale, ranging from 0 (I did not experience this change) to 5 (I experienced this change to a very large extent). Example items are “I know better that I can handle difficulties,” “I developed new interest,” and “I can better appreciate every day.” The PTGI has excellent internal and test–retest reliability in Western samples (Tedeschi & Calhoun, 1996).

The Brief Coping Orientation to Problems Experienced Inventory (COPE; Carver, 1997) assesses coping strategies via 28 items, allocated in 14 subscales. Participants were instructed to respond about how often they use each strategy to deal with the COVID-19 pandemic on a 4-point scale ranging from 0 (not at all) to 4 (very much). Example items are “I’ve been taking action to try to make the situation better,” “I’ve been expressing my negative feelings,” and “I’ve been getting emotional support from others.” Satisfactory psychometric properties of COPE have been reported in a sample of adults recovering from a hurricane (Carver, 1997).

Procedure
This cross-sectional survey was conducted online amid the lockdown in Greece (March 23, 2020 through May 3, 2020). Approval of the study was obtained from the Research Ethics Committee of the Hellenic Mediterranean University. Participants were recruited using a convenience and snowball mixed-sampling procedure. The Google forms questionnaire, the first page of which included an informed consent statement, was distributed through social networking sites and webpages and forwarded through email to the authors’ contacts. Participants were also asked to distribute it similarly.

Statistical Analyses
The expectation maximization algorithm was used to estimate missing values. Descriptive statistics were means and standard deviations for continuous data or frequencies and percentages for categorical data. Cronbach’s alpha coefficient assessed the internal consistency of the scales. Bivariate correlation analyses were performed using Pearson product-moment correlation coefficients to examine the relationship among STS, coping strategies, and VPTG. Five hierarchical multiple regression analyses (using a stepwise method) were performed for the prediction of VPTG (i.e., per the Relating to Others, New Possibilities, Personal Strength, Spiritual Change, and Appreciation of Life subscales) by the dimensions of STS and coping strategies. All analyses with p < .05 were considered significant and were performed with IBM SPSS Version 23 (IBM, 2015). Three mediation analyses were conducted as path analysis models with AMOS Version 20 (Arbuckle, 2011), using maximum likelihood estimation to test the mediating effect of the three dimensions of coping (problem-focused, emotion-focused, and dysfunctional) in the relationship between STS and VPTG. Direct effects included the relationship between the latent variables STS and VPTG, whereas indirect effects included the relationship between STS and VPTG accounting for the latent variables of the three coping strategies. Parametric bootstrapping of standard errors across 2,000 samples was used for the estimation of indirect effects. Model fit indices were assessed (Hooper et al., 2008; Hu & Bentler, 1999) and demonstrated by the comparative fit index (CFI), Tucker–Lewis index (TLI), incremental fit index (IFI), root mean square error of approximation (RMSEA), and standardized root-mean-square residual (SRMR).

Results

A high percentage of HCWs (79.3%) reported a cumulative STS score of ≥3 (i.e., experiencing occasionally, or often, or very often at least three symptoms; Bride et al., 2004), which is indicative of at least moderate levels of STS. Women scored significantly higher than did men in STS total and subscales scores. HCWs reported moderate to low levels of VPTG, with personal strength and appreciation of life being the highest categories. They also reported frequent use of a range of coping strategies, with acceptance, planning, and positive reframing being the most highly endorsed, followed by active coping and self-distraction. Gender differences were found with women scoring higher in all VPTG subscales. Age negatively correlated with the VPTG dimensions of Relating to Others, r(673) = –.09, p < .05, and New Possibilities, r(673) = –.12, p < .001. The results are presented in Table 2.

tra-14-2-273-tbl2a.gifCorrelation of Age With Vicarious Posttraumatic Growth (VPTG) and Secondary Traumatic Stress (STS) and Gender Differences

Regression Analyses
All VPTG subscales correlated with the STS subscales and coping strategies (see Table 1), so they were subsequently entered as predictor variables in the regressions. Regression analyses (see Table 3) showed that the VPTG relating to others was predicted by use of instrumental support, religion, intrusion, positive reframing, substance use (inversely), and self-distraction. New possibilities were predicted by positive reframing, religion, self-distraction, use of instrumental support, and substance use (inversely). Personal strength was predicted by positive reframing, religion, acceptance, self-distraction, substance use (inversely), and denial. Spiritual change was predicted by religion, intrusion, positive reframing, use of emotional support (inversely), self-distraction, use of instrumental support, planning (inversely), and substance use (inversely). Appreciation of life was predicted by intrusion, religion, positive reframing, self-distraction, substance use (inversely), and denial.

tra-14-2-273-tbl3a.gifHierarchical Regression Results for Predicting the Dimensions of Posttraumatic Growth by the Dimensions of Secondary Traumatic Stress (STS) and Coping Strategies

Mediation Analyses
The three mediation analyses that examined the mediating effect of the three coping groups in the STS–VPTG relationship demonstrated acceptable model fit (see Figure 1). Both problem-focused and emotion-focused coping strategies partially mediated the STS–VPTG relationship (see Figure 1a and 1b), whereas dysfunctional coping strategies fully mediated this relationship (see Figure 1c).

tra-14-2-273-fig1a.gifFigure 1. Note. The standardized path coefficients are presented. Dotted lines represent indirect effects. * p < .05. ** p < .01. *** p < .001.

Discussion

The aim of this study was to examine the association between STS and VPTG among HCWs and to explore the link between both adaptive and maladaptive coping strategies to STS and VPTG. The overwhelming majority of the HCWs exhibited moderate to low levels of STS symptoms. This is in line with one study that found low and moderate STS scores in HCWs during the first period of COVID-19 pandemic (Zhou et al., 2020). Whereas other findings have shown high levels of STS among HCWs (Reynolds et al., 2008; Vagni et al., 2020), it should be noted that the lockdown in Greece was implemented soon after the first confirmed cases, intubated patients and deaths occurred, and before the health care system became overly burdened (statistics are available at https://commons.wikimedia.org/wiki/Data:COVID-19_cases_in_Greece.tab). It can be assumed that if the STS had been measured at a later point, higher scores could have been obtained because the effects of the traumatic exposure on mental health might appear in the future (Kang et al., 2020; Lai et al., 2020).

The current study also provides the first piece of empirical evidence on VPTG among HCWs who were indirectly exposed to the COVID-19 pandemic through the care of their patients. In agreement with previous findings among HCWs (Beck et al., 2017), the HCWs in our sample, although they reported moderate to low levels of VPTG during the initial period of lockdown, had higher scores in the VPTG domains of personal strength and appreciation of life. It appears that facing the COVID-19 pandemic resulted in awareness of personal capabilities and enhancement of self-confidence. Appreciation of life might be an inevitable consequence of facing life-threatening diseases and death itself. It is not known whether the other three domains (relating to others, new possibilities, and spiritual change) need more time to develop or whether the sample possessed specific characteristics that allowed change to rapidly occur in other domains. It has been shown that professionals initially respond with increased levels of distress which later are replaced by personal growth, suggesting that time is needed for any permanent change to occur (Manning-Jones et al., 2015). Therefore, higher levels of VPTG could be expected and are reasonably likely to occur in the long run. Further, because previous studies among HCWs have found that moderate rates of STS were predictive of VPTG (Kjellenberg et al., 2014; Manning-Jones et al., 2017), and we found that STS predicted VPTG, it seems that STS might likely provide the appropriate platform for VPTG to occur in the future (Joseph, 2011). A longitudinal study might highlight potentially higher levels of VPTG.

In line with other findings (Tominaga et al., 2019) in HCWs, mental intrusions predicted VPTG. It has been argued (Brooks et al., 2020; Tedeschi & Calhoun, 2004) that intrusive thinking is a natural response to a stressful event that might have an impact on the degree of growth in the aftermath of trauma. Our study provides further evidence that mental intrusions might be crucial in posttraumatic processing and might promote VPTG. It seems that a severe negative event, such as the COVID-19 pandemic, immediately initiates a cognitive process through intrusive thoughts, which potentially force HCWs to reexamine the meaning of the threat.

Females had significantly higher STS and VPTG scores than males. Studies have indicated that women are more vulnerable to STS symptoms (Cheng et al., 2006), but they can also achieve higher VPTG than men (Jeon et al., 2017). This tendency can be explained by gender differences in their response to trauma. According to Calhoun and Tedeschi (2006) women are more likely to perceive traumatic experiences as threats, and the more threatening an event is perceived, the more growth might occur. In line with other findings (Sleijpen et al., 2016), we also found age to be negatively correlated with VPTG, suggesting that younger people might be more ready to change their cognitive schemas and make positive meanings from trauma.

Somewhat surprisingly, we found that both adaptive and maladaptive coping strategies predicted VPTG. Whereas adaptive coping strategies (i.e., problem-focused and emotion-focused) partially mediated the relationship between STS and VPTG, the maladaptive or dysfunctional coping strategies fully mediated this relationship. Consistent with the theory by Tedeschi and Calhoun (2004), coping responses seem to be mediators between the pain that the trauma causes and the consequent growth. Furthermore, different coping strategies predicted different dimensions of VPTG (Ogińska-Bulik & Zadworna-Cieślak, 2018). The more they reconsidered the situation (positive reframing) and turned to other activities to avoid thinking about it (self-distraction), the more VPTG they achieved in all five dimensions, whereas the more use of alcohol or other substances (substance use) the less VPTG. Admittedly, positive reframing predicted all five domains of VPTG. Whereas religion and use of instrumental support rather expectedly (Kapsou et al., 2010) predicted four and three domains, respectively, other adaptive coping strategies, such as acceptance, planning, and use of emotional support, predicted only one dimension. Kalaitzaki (2021) has shown that planning might be stressful for the HCWs as it contributed to higher STS. It was surprising though that ‘self-distraction’, a so-called maladaptive coping strategy predicted all five domains of VPTG, and ‘denial’, predicted personal strength and appreciation of life. These findings are consistent with others, suggesting that avoidance and emotionally focused strategies positively correlate with VPTG (Ogińska-Bulik & Zadworna-Cieślak, 2018). It might be that people need time to distance themselves from the threat and/or adversity (self-distraction) and at the same time reconsider the situation positively (positive reframing) in order to develop PTG (Tedeschi & Calhoun, 2004).

Although the use of maladaptive coping strategies to deal with the COVID-19 pandemic is seemingly incongruent, Main et al. (2011) have argued that adaptive strategies are effective in dealing with controllable stressors, whereas maladaptive are more effective in dealing with uncontrollable stressors such as infectious viruses. Ye et al. (2020) have also suggested that when an outbreak is perceived as a severe life-threatening situation, then maladaptive coping strategies might be employed. It seems quite plausible that the COVID-19 pandemic is perceived as an uncontrollable disease of extreme threat and uncertainty, which causes feelings of helplessness and hopelessness. It might be that, not knowing how to cope with this new situation and being required to deal with this urgently, a range of coping strategies are recruited and implemented, regardless of whether they are adaptive or maladaptive (Kalaitzaki, 2021). Maladaptive coping strategies are not an effective way to deal with stress, but they do quickly, directly, and temporarily relieve stress. It is, therefore, suggested that the strict categorization of coping strategies is needless and that any strategy that helps individuals to cope, adapt, and reconceptualize stressful events and adversities should instead be considered successful and beneficial responses to stress.

Terror management theory might also explain why dysfunctional coping strategies fully mediated the relationship between the STS and VPTG. The COVID-19 pandemic might be perceived as a mortality reminder, as thoughts of death are in focal attention and people attempt to remove them from their consciousness through suppression, denial, or minimizing perceptions of the threat, or engaging in behaviors to reduce vulnerability, such as abiding by the measures to avoid infection (Pyszczynski et al., 2021). All these coping strategies, contrary to the typical classification as maladaptive strategies, are adaptive in that they help people cope with the threat of personal death.

There are limitations to this study that should be acknowledged. Findings cannot be generalized due to the cross-sectional nature of the study, the convenience sampling, and the overrepresentation of certain subgroups (e.g., women). Causal relationships cannot be established, and any positive impacts might not have developed yet or might not persist in the long run. It is also unknown whether the current findings can be generalized in all HCWs because most of the participants were physicians, who tend to have greater financial resources than other HCWs. Potential interspecialty differences would have provided diversified findings. The self-reported measures administered online might have resulted in social desirability and selection bias. Because HCWs treat traumatized patients, while being concurrently exposed to the same traumatic events themselves (Finklestein et al., 2015), they might suffer both PTSD and STS; future studies should examine the likelihood of HCWs suffering what we call double traumatization.

These findings contribute to the scant literature on VPTG (and its contributing factors) by revealing the impact of HCWs’ STS and coping strategies on VPTG during the COVID-19 lockdown in Greece. The implications for the psychological rehabilitation of COVID-19 indirect trauma survivors are obvious. Acknowledging the coping strategies that HCWs use to deal with the COVID-19 pandemic could direct the development of timely and tailored prevention and intervention services. Encouraging efficient and effective coping responses to stress could safeguard those at risk and facilitate their VPTG. The present findings could also inspire future researchers to examine the underlying mechanisms of the links among coping strategies and VPTG, whether coping responses change, and whether positive changes persist over time.

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Submitted: October 24, 2020 Revised: April 2, 2021 Accepted: April 6, 2021

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Vicarious traumatisation in telephone counsellors: Internal and external influences.
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Authors:
Dunkley, Jane. School of Psychology, Psychiatry and Psychological Medicine, Faculty of Medicine, Nursing and Health Sciences, Caulfield East, VIC, Australia
Whelan, Thomas A.. School of Psychology, Psychiatry and Psychological Medicine, Faculty of Medicine, Nursing and Health Sciences, Caulfield East, VIC, Australia
Address:
Dunkley, Jane, School of Psychology, Psychiatry and Psychological Medicine, Faculty of Medicine, Nursing and Health Sciences, PO Box 197, Caulfield East, VIC, Australia, 3145
Source:
British Journal of Guidance & Counselling, Vol 34(4), Nov, 2006. pp. 451-469.
NLM Title Abbreviation:
Br J Guid Counc
Page Count:
19
Publisher:
United Kingdom : Taylor & Francis
ISSN:
0306-9885 (Print)
1469-3534 (Electronic)
Language:
English
Keywords:
vicarious traumatization, telephone counsellors, coping style, supervision, personal trauma history
Abstract:
The present study investigated vicarious traumatisation among telephone counsellors. In particular, the influence of coping style, supervision, and personal trauma history on vicarious traumatisation was examined. A total of 62 telephone counsellors from trauma related fields completed a series of self-report measures. Generally, levels of traumatisation (i.e. PTSD symptoms and disruptions in beliefs) were low. Nonetheless, five (8.2%) participants had total scores indicating ‘high average3 to ‘very high’ levels of disruption in beliefs. Also, 15 (25.9%) respondents reported that they experienced at least one PTSD symptom. As expected, non-productive coping was related to disruptions in cognitive beliefs, while dealing with the problem was not. In addition, having a strong supervisory working alliance was associated with lower levels of disruption in beliefs. Contrary to expectations, there were no significant predictors of PTSD symptoms despite a positive correlation with personal trauma history. In conclusion, vicarious traumatisation is of concern for telephone counsellors. Efforts to address its impact should focus on developing effective coping styles and enhancing the quality of supervision. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Counselors; *Emotional Trauma; *Hot Line Services; *Vicarious Experiences; Coping Style
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Trauma Attachment and Belief Scale
Supervisory Working Alliance Inventory-Supervisee Scale
Impact of Event Scale DOI: 10.1037/t00303-000
Coping Scale for Adults DOI: 10.1037/t02051-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20070103
Correction Date:
20200713
Digital Object Identifier:
http://dx.doi.org/10.1080/03069880600942574
Accession Number:
2006-20585-002
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38
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Vicarious traumatisation in telephone counsellors: internal and external influences.
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Contents
Potential impact of vicarious traumatisation
Factors that influence vicarious traumatisation
Trauma clients and telephone counselling
Aim and hypotheses
Method
Participants
Materials
The Trauma Attachment and Belief Scale (TABS)
The Impact of Event Scale-Revised (IES-R)
The Coping Scale for Adults (CSA)
The Supervisee Form from the Supervisory Working Alliance Inventory (SWAI)
Procedure
Results
Descriptive statistics
Telephone counselling organisations
Trauma characteristics
Quality of supervision
Predictors of vicarious traumatisation
Discussion
Coping styles and vicarious traumatisation
Availability of supervision and vicarious traumatisation
Supervisory working alliance and vicarious traumatisation
Personal trauma history and vicarious traumatisation
Recommendations for future research
Conclusion
References
Full Text
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The present study investigated vicarious traumatisation among telephone counsellors. In particular, the influence of coping style, supervision, and personal trauma history on vicarious traumatisation was examined. A total of 62 telephone counsellors from trauma related fields completed a series of self-report measures. Generally, levels of traumatisation (i.e. PTSD symptoms and disruptions in beliefs) were low. Nonetheless, five (8.2%) participants had total scores indicating ‘high average’ to ‘very high’ levels of disruption in beliefs. Also, 15 (25.9%) respondents reported that they experienced at least one PTSD symptom. As expected, non-productive coping was related to disruptions in cognitive beliefs, while dealing with the problem was not. In addition, having a strong supervisory working alliance was associated with lower levels of disruption in beliefs. Contrary to expectations, there were no significant predictors of PTSD symptoms despite a positive correlation with personal trauma history. In conclusion, vicarious traumatisation is of concern for telephone counsellors. Efforts to address its impact should focus on developing effective coping styles and enhancing the quality of supervision.

There has been a growing awareness that psychological counselling can be hazardous for the mental and physical health of professionals (e.g. Figley, [11]; Gentry et al., [14]; O’Halloran & Linton, [24]; Pearlman & Saakvitne, [28]). For example, the literature on burnout (e.g. Arvay & Uhlemann, [ 3]; Astin, [ 4]; Azar, [ 5]) and countertransference (e.g. Blair & Ramones, [ 6]; Neumann & Gamble, [23]; Rosenberger & Hayes, [30]) describes symptoms of impairment such as depression and grief. Moreover, theorists have suggested that trauma counsellors are susceptible to vicarious traumatisation, that is, harmful effects similar to those their clients experience (McCann & Pearlman, [20]).

Potential impact of vicarious traumatisation
The concept of vicarious traumatisation is based on McCann and Pearlman’s (1990) constructivist self-development theory (CSDT). According to the theory, trauma can disrupt the counsellor’s cognitive schemata in one or more of five fundamental need areas: safety (feeling safe from harm by oneself or others), trust/dependency (being able to depend on or trust others and oneself), esteem (feeling valued by others and oneself, as well as valuing others), control (being able to manage one’s own feelings and behaviours, as well as managing others), and intimacy (feeling connected to others or to oneself). Further, counsellors can incorporate their clients’ painful stories into their own memory, which may lead to flashbacks, dreams or intrusive thoughts, symptoms considered central to PTSD. These disruptions can be accompanied by affective states such as anger, sadness, and anxiety, and can lead to short or long term defensive reactions including psychological numbing, denial, and distancing (McCann & Pearlman, [20]).

Despite the potential detrimental effects, there has been relatively little research on vicarious traumatisation (Steed & Downing, [35]). The earliest study was conducted as recently as a decade ago (Gabriel, [13]). This investigation explored the effects on group counsellors who worked with AIDS sufferers. It was found that a high proportion of the counsellors who had experienced the death of a client were manifesting traumatic stress symptoms. Subsequent investigations have further highlighted the relevance of vicarious traumatisation for trauma counsellors. For example, Arvay and Uhlemann ([ 3]) studied the level of stress among 161 counsellors. They found that 14% were experiencing high levels of traumatic stress similar to their clients. Likewise, Steed and Downing ([35]) interviewed therapists who worked with sexual assault/abuse survivors and discovered that their work pervasively impacted their lives.

Not only is vicarious traumatisation of concern for counsellors but also for their clients since effected therapists could be expected to function less effectively and professionally (Arvay & Uhlemann, [ 3]). That is, the counsellor’s empathic abilities, efforts to maintain a therapeutic stance and establishment of boundaries with the client might be disrupted (Muhlberger, [22]; Sexton, [33]). Indeed, the consequences of vicarious traumatisation have been reported to range from occasional distancing from clients to victim blaming (Astin, [ 4]; Neumann & Gamble, [23]).

Factors that influence vicarious traumatisation
Not all counsellors experience vicarious traumatisation. According to CSDT (McCann & Pearlman, [20]), a counsellor’s response to hearing a client’s trauma story will depend on aspects intrinsic to the counsellor and the multiple characteristics of the work. Therefore, vicarious traumatisation involves a complex interplay of both internal and external influences.

In order to determine the key influences, investigators (e.g. Johnson & Hunter, [17]; Mauldin, [19]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [32]) have examined a variety of factors. For example, Pearlman and Mac Ian ([27]) focused on the personal trauma history and level of experience of 188 self-identified trauma therapists. They found that those who had a personal trauma history and were newest to the work showed greater disruptions in cognitive beliefs (i.e. safety, self-trust, other-trust, self-esteem), higher levels of intrusion and avoidance symptoms, as well as more general distress.

Schauben and Frazier ([32]) assessed vicarious traumatisation in terms of the counsellors’ caseload and personal history of victimisation. The participants (N = 220) included members of a women psychologists’ organisation and sexual violence counsellors. Those counsellors who worked with a higher percentage of survivors reported more disrupted beliefs about themselves and others, and more PTSD related symptoms. In contrast to Pearlman and Mac Ian (1995), counsellors with a history of prior victimisation were no more distressed than those without this history. Thus, rather than being a hindrance, personal trauma may help counsellors understand the experience of their clients’ and respond empathetically (Elliot & Guy, [10]). Nevertheless, Schauben and Frazier ([32]) provided a narrow definition of personal trauma; it was restricted to the experience of rape or incest, the trauma the clients were more likely to have encountered.

Several studies have examined the influence of coping mechanisms in combating vicarious traumatisation (e.g. Iliffe, [16]; Johnson & Hunter, [17]; Steed & Downing, [35]). For example, Schauben and Frazier ([32]) found that the most used and adaptive coping strategies were active coping, emotional support, social support, humour, and planning. Alcohol and/or drugs use, denial, and behavioural disengagement were associated with greater distress. Johnson and Hunter ([17]) investigated coping in counsellors who worked in sexual assault, mental health or child and family services. Their results indicated that the therapists who worked with sexual assault survivors used more avoidance coping strategies which were associated with greater emotional exhaustion.

Clearly, counsellors and their clients would benefit from the development of methods to deal with vicarious traumatisation. Typically, investigators have argued that there is a need for specialist training, supervision, and debriefing for trauma counsellors (e.g. Adams et al., [ 1]; Iliffe, [16]; Mauldin, [19]; Sexton, [33]; Sommer, [34]).

Despite such recommendations, Pearlman and Mac Ian ([27]) found that only 64% of trauma therapists received supervision. In addition, the therapists who were not being supervised had higher levels of disrupted beliefs. Arvay and Uhlemann ([ 3]) discovered that only 1% of their sample said they sought supervision for self-care. Further research is required to examine not only the availability of supervision, but also the influence of the quality of that supervision on vicarious traumatisation. Such research would have implications for future training programmes, professional development, and organisational support (Iliffe, [16]).

Trauma clients and telephone counselling
Predominately, studies have investigated the effects of vicarious traumatisation on face-to-face counsellors who work with sexual violence survivors (e.g. Astin, [ 4]; Johnson & Hunter, [17]; Steed & Downing, [35]). Yet, it is likely that counsellors who work in other areas are also susceptible. Arvay and Uhlemann ([ 3]) recruited participants from sexual assault centres, hospices, and hospitals and found that as a group these counsellors were impaired. Consequently, there is a pressing need to study professionals who work with a range of trauma clients (Arvay & Uhlemann, [ 3]; Steed & Downing, [35]).

Counselling via the telephone occupies an important place in the provision of mental health services. Some of the benefits include the immediacy with which callers can receive Helpance, easy access, anonymity, interim support until face-to-face counselling is available, cost savings and a perception of control and empowerment (Coman et al., [ 8]; Reese et al., [29]). Given these benefits, it is not surprising that telephone counselling is available worldwide. For instance, Lifeline is currently represented in 19 countries (Lifeline International, [18]) and within Australia there are over 40 Lifeline call centres (Coman et al., [ 8]). Further, the Samaritans ([31]) have developed a website providing access to a directory of the world’s crisis and suicide helplines, of which there are over 40 countries listed.

Despite the importance and prevalence of telephone counselling services, generally they have been neglected by researchers. A search of the literature identified just one study (Mauldin, [19]) that focused on vicarious traumatisation among telephone counsellors. Mauldin ([19]) studied 98 ‘hotline’ workers in America using self-report measures. She investigated whether there were differences in PTSD symptomatology in relation to amount of clinical experience and educational level, as well as whether there were negative changes in cognitive beliefs. Participants were found to have little overall change in beliefs and PTSD symptomatology was not related to clinical experience or level of education. Even so, Mauldin ([19]) found that the participants were experiencing significant stress due to salient events (defined as the most salient traumatic incident conveyed by a caller in the past year). As a result, she concluded that clients’ specific trauma stories rather than pre-existing counsellor variables (e.g. level of experience) were influential in the development of vicarious traumatisation.

Although valuable, Mauldin’s (2001) examination of vicarious trauma in telephone counsellors has several limitations. The pre-existing counsellor variables examined do not include the counsellors’ personal trauma history or coping styles, key factors identified by previous studies (e.g. Johnson & Hunter, [17]; Pearlman & Mac Ian, [27]). The variables investigated tend not to be amenable to intervention, unlike more psychological factors such as coping styles. Finally, the findings have limited generalisability as only counsellors who worked with sexual assault survivors were included.

Aim and hypotheses
Thus, the current study was designed to explore vicarious traumatisation amongst telephone counsellors who work with a range of trauma clients. The aim was to investigate both intrinsic (i.e. coping styles, personal trauma history) and external (i.e. access to supervision, the supervisory working alliance) influences on vicarious traumatisation. In accordance with previous research (Mauldin, [19]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [32]), vicarious traumatisation was defined by the existence of PTSD symptoms and disruptions in cognitive beliefs.

There were four hypotheses. It was predicted that respondents who used the coping styles dealing independently with the problem, optimism, and sharing would have lower levels of vicarious traumatisation, while participants who reported using non-productive coping would have higher scores on the vicarious traumatisation measures. In addition, it was hypothesised that participants who did not receive supervision would have higher levels of vicarious traumatisation. A further expectation was that respondents who perceived themselves as having a strong working alliance with their supervisor would have lower levels of vicarious traumatisation. Finally, it was hypothesised that telephone counsellors who had a personal trauma history would have higher levels of vicarious traumatisation.

Method

Participants
A total of 64 telephone counsellors from a possible pool of 137 (return rate = 46.7%) completed the measures. Of these two were excluded as they indicated they had worked fewer than six shifts, leaving a final sample of 62. This included seven (11.3%) men and 55 (88.7%) women, aged from 24.7 to 75.2 years (M=45.45 years, SD=11.59 years). Twenty-six (41.9%) participants worked as volunteers and 36 (58.1%) were paid counsellors. On average, the respondents had been telephone counsellors for 3.4 years (SD=3.31).

The counsellors were recruited from nine organisations. These were Sids and Kids (n=7), the Suicide Helpline (n=12), Centre Against Sexual Assault (CASA) (n=6), the Aids, Hepatitis and Sexual Healthline (n=4), Griefline (n=15), the Domestic Violence Crisis Service (n=4), the Domestic Violence Line (n=1), the Anti-Cancer Council (n=10), and Stillborn and Newborn Death Support (SANDS) (n=3).

Materials
The questionnaire package contained five self-report questionnaires: a demographic measure, the Trauma Attachment and Belief Scale (TABS) (Pearlman, [26]), the Impact of Event Scale-Revised (IES-R) (Weiss & Marmar, [38]), the Supervisee Scale from the Supervisory Working Alliance Inventory (SWAI) (Efstation et al., [ 9]), and the general short form of the Coping Scale for Adults (CSA) (Frydenberg & Lewis, [12]).

The Trauma Attachment and Belief Scale (TABS)
The TABS (Pearlman, [26]) is the most recently developed test designed to assess the impact of directly and indirectly experienced trauma. In particular, it measures disruptions in beliefs related to five need areas that are sensitive to the effects of trauma, these being safety, trust, esteem, intimacy, and control. Within each of these need areas, separate sets of items tap into beliefs about oneself and others, yielding 10 subscale scores and a total score. For the purposes of the current study only the total score was used. Higher scores reflect greater disruption in beliefs. The TABS has 84 items that are rated on a 6-point Likert scale (1 = disagree strongly, 6 = agree strongly). Negative items are reverse scored. The TABS has been found to have an internal consistency estimate of 0.96 and a test–retest correlation of 0.75 for the total score (Pearlman, [26]). According to Pearlman ([26]), the TABS has sound face validity, construct validity and criterion validity.

The Impact of Event Scale-Revised (IES-R)
The IES-R assesses subjective distress over the past 7 days related to any specific life event. The IES-R (Weiss & Marmar, [38]) was developed to parallel three of the four criteria for PTSD, hyperarousal, avoidance, and intrusion (American Psychiatric Association, [ 2]). In this study, participants responded to the test in relation to the ‘stressful material related by trauma clients’.

The IES-R has 22 questions that are measured on a 5-point Likert scale (0 = not at all, 4 = extremely). The test produces three subscales scores (i.e. hyperarousal, avoidance, intrusion) and a total score. As subscale scores were not used in this study, a total score was calculated by summing the item scores. There are no ‘cut-off’ points for the IES-R as the measure was designed to give an assessment of ‘symptomatic status’ from exposure to a traumatic event (D.S. Weiss, personal communication, 20 September 2003); however, high scores indicate distress from PTSD symptoms (Weiss & Marmar, [38]). The IES-R’s three subscales have internal consistency coefficients ranging from 0.79 to 0.92 and test–retest reliability coefficients ranging from 0.51 to 0.94 (Weiss & Marmar, [38]). No psychometric properties have been reported for the total score.

The Coping Scale for Adults (CSA)
The CSA (Frydenberg & Lewis, [12]) was used to measure coping styles. The scale is available in both a long and short form. As correlations between these versions have been reported to be high, Frydenberg and Lewis ([12]) consider the short form to be a reliable measure.

The short form was used for the present study and consists of 20 items, two of which are optional. It was decided not to use Question 20, an open-response item. The questions are measured on a 5-point Likert scale (1 = doesn’t apply or don’t do it, 5 = used a great deal) and one item is reverse scored. The test conceptualises coping as four coping styles made up of a range of coping strategies: dealing independently with the problem (e.g. problem solving, working hard, humour), optimism (e.g. focusing on the positive, seeking spiritual support), sharing (i.e. seeking professional help, seeking social support) and non-productive coping (e.g. worry, self-blame, ignoring the problem, keeping to oneself). High scores indicate that participants use a coping style frequently. According to Frydenberg and Lewis ([12]), the short form shows satisfactory discrimination, with non-productive coping and dealing with the problem being the most reliable scales.

The Supervisee Form from the Supervisory Working Alliance Inventory (SWAI)
The SWAI (Efstation et al., [ 9]) assesses a person’s perception of another’s behaviour in the supervisory relationship. In particular, the supervisee form from the SWAI (Efstation et al., [ 9]) measures the supervisee’s perceived working alliance with their supervisor. The scale contains 19 items that are rated on a 7-point Likert scale (1 = almost never, 7 = almost always). The test has two subscales: rapport and client focus. Patton and Kivlighan ([25]) found these subscales to be highly correlated. Thus, in the current study only the total score for the supervisee form was used. A high total score indicates a strong working alliance.

Efstation et al. ([ 9]) claimed that the supervisee form has adequate convergent and divergent validity and reliability. Convergent and discriminant validity was confirmed through significant correlations with the Supervisory Styles Inventory and the Personal Reactions Scale-Revised (Patton & Kivlighan, [25]).

Procedure
Following the receipt of ethics approval, managers of a range of telephone counselling services from three states in Australia (i.e. Victoria, New South Wales, and South Australia) were contacted by letter and telephone to request if their staff could be involved in the study. Both verbal and written consent for counsellors to participate was received from the nine previously identified organisations.

A range of approaches were used to inform potential participants about the research. These included advertising the study in an organisation’s newsletter, conducting oral presentations briefly outlining the research to counsellors, or asking the manager to notify staff and distribute questionnaires. Follow-up contact was made with managers to remind them of the study and request that they invite counsellors to participate.

Questionnaires were counterbalanced to eliminate order effects. To ensure anonymity completed questionnaires were returned using reply paid self-addressed envelopes. The time-frame between distributing the first questionnaires and the last receipt of completed questionnaires was approximately 6 months.

Results
Before conducting the analyses univariate outliers were identified through the examination of z scores. Three cases were found, one on each of the total score for the IES-R, the total score for the TABS, and the dealing independently subscale for the CSA measure. These scores were truncated to the extent that each remained deviant from the sample, but was no longer an outlier. No multivariate outliers were identified through examination of Mahalanobis distance values, p<0.0001. The assumptions of normality, linearity, and homoscedasticity were analysed and were only violated on the IES-R scores. Consequently, a log10 transformation of the IES-R scores was conducted.

Descriptive statistics
Descriptive statistics for the TABS, IES-R, CSA, and the Supervisee Scale from the SWAI are presented in Table 1.

Table 1.  Means and standard deviations for the TABS, IES-R, CSA, and Supervisee Scale from the SWAI

Measure n M SD Observed range Possible range
IES-R total scorea 58 9.21 10.36 0–40 0–84
TABS total score 61 45.28 8.18 27–69 <20– > 80
Dealing with the problem 62 69.66 10.63 38–93 21–105
Non-productive coping 62 48.73 13.65 21–84 21–105
Optimism 62 57.26 14.33 35–100 20–100
Sharing 62 81.77 30.65 0–140 1–140
Supervisee scale 44 113.59 18.75 51–133 0–133
aA substantial amount of missing data on item 4 of the IES-R occurred due to a printing error. Given that the average score per item on this measure was low (0.44), it is unlikely that this had an impact on the total score. Therefore, the item was omitted from all analyses and the remaining 21 items were used to provide the total score.
Based on normative scores (Pearlman, [26]), Table 1 indicates that the mean total score for the TABS was in the average range (45–55), while the respondents mean total score for the IES-R was low given the possible score range of 0–84. The most frequently used coping style was dealing with the problem and non-productive coping was the least commonly used.

Telephone counselling organisations
A one-way ANOVA was conducted to determine whether there were any significant differences between the types of organisations and the measures of vicarious traumatisation (i.e. TABS & IES-R). To increase cell size the organisations were collapsed into five categories according to their client base. Sids and Kids and SANDS; the Aids, Hepatitis and Sexual Healthline and the Anti-Cancer Council; and CASA and the Domestic Violence Services were categorised into three groups, respectively, according to the themes: death of a young child, a serious or life-threatening illness, and violence. The Suicide Helpline and Griefline remained as individual categories. The average total scores for the IES-R and TABS for each organisation are shown in Table 2.

Table 2.  Means and standard deviations for the vicarious traumatisation measures

IES-R TABS
Organisation n M SD n M SD
DVa and CASA 11 6.46 10.69 10 43.80 4.34
SKb and SANDS 9 13.56 8.79 10 46.10 10.38
A-Cc and AHSd 12 8.25 8.72 14 41.86 9.81
SHLe 11 10.27 11.33 12 45.75 8.17
Griefline 15 8.60 11.80 15 48.53 6.16
aDomestic Violence Helplines.
bSids and Kids.
cThe Anti-Cancer Council.
dThe Aids, Hepatitis and Sexual Healthline.
eThe Suicide Helpline.
Table 2 indicates that Sids and Kids and SANDS had the highest mean total score for the IES-R, and the Domestic Violence services and CASA had the lowest. Griefline had the highest mean total score for the TABS, while the Anti-Cancer Council and the Aids, Hepatitis and Sexual Healthline had the lowest score for this measure. Nonetheless, the ANOVA showed no significant difference between organisations on the IES-R total score, F( 4, 53) = 1.16, p=0.34 and the TABS total score, F( 4, 56) = 1.36, p=0.26. Given that there were no differences between organisations the respondents were treated as a single group for the remaining analyses.

Trauma characteristics
Approximately a third (n=19, 30.6%) of the participants identified themselves as trauma counsellors. Of the remaining participants, 41 (66.1%) indicated that they did not see themselves as trauma counsellors and two (3.2%) did not respond. The majority (n=41, 66.1%) of counsellors had heard of vicarious traumatisation; nevertheless, most (n=47, 75.8%) had not been provided with specific training. Over half (n=37, 59.7%) of the counsellors indicated that they did not have a personal trauma history. The remaining participants (n=23, 37.1%) said they had a personal trauma history, while two (3.2%) participants did not respond.

The trauma characteristics of the sample were examined in terms of the two measures of vicarious traumatisation. Means and standard deviations of the trauma characteristics for the TABS and IES-R are presented in Table 3.

Table 3.  Means and standard deviations of the trauma characteristics for the Trauma Attachment and Belief Scale (TABS)a (n=61) and the Impact of Event Scale-Revised (IES-R)b (n=58)

Yes No
Scale Characteristics n M SD n M SD
TABS
Perceived themselves as trauma telephone counsellorsc 18 45.22 8.99 41 45.68 7.69
Had a personal trauma historyc 22 44.46 8.05 37 45.73 8.49
Had heard of vicarious traumatisation 40 45.03 7.09 21 45.76 10.11
Had training to deal specifically with vicarious traumatisation 14 45.21 7.93 47 45.30 8.33
IES-R
Perceived themselves as a trauma telephone counsellorc 18 13.56 11.27 38 7.32 9.62
Had a personal trauma historyc 22 11.91 9.25 34 7.41 11.06
Had heard of vicarious traumatisation 38 8.84 9.76 20 9.90 11.65
Had training to deal specifically with vicarious traumatisation 14 8.71 8.13 44 9.36 11.05
aStandardised scores can range from <20 to >80.
bScores can range from 0 to 84.
cTwo respondents did not answer this question.
Table 3 shows that TABS scores were similar for respondents who answered either ‘yes’ or ‘no’ to the trauma characteristics, apart from participants who indicated that they had a personal trauma history. These respondents had a slightly lower mean total score. Mean total scores for the IES-R were higher for participants who responded ‘yes’ to being a trauma counsellor and to having a personal trauma history. Participants who had not heard of vicarious traumatisation and were not provided training to deal specifically with it had slightly higher mean scores for this measure.

Independent-sample t-tests were used to determine whether there were any differences on the TABS and IES-R total scores in terms of trauma characteristics. No analysis was performed for personal trauma history as this variable was entered into the standard multiple regression analyses. The t-tests for the TABS revealed no significant differences between the respondent groups in terms of perceiving themselves to be trauma counsellors, t(57) = 0.20, p=0.84, having heard of vicarious traumatisation, t(59) = 0.33, p=0.74, and training to deal specifically with vicarious traumatisation, t(59) = 0.03, p=0.97. Similarly, t-tests for the IES-R showed no significant differences with regard to respondents having heard of vicarious traumatisation, t(56) = 0.18, p=0.86, and training to deal specifically with vicarious traumatisation, t(56) = 0.20, p=0.84. However, a significant difference was found for the IES-R between respondents who perceived themselves to be trauma counsellors and those who did not, t(54) = 2.40, p=0.02.

Quality of supervision
It was intended to include quality of supervision in the standard multiple regression analyses. However, almost a third of participants (n=17, 27.9%) indicated that they did not receive supervision. Therefore, two Pearson’s product-moment correlations were used to assess the relationship between the vicarious traumatisation measures (TABS & IES-R) and the total score for the Supervisee Scale. A moderate and significant negative correlation was found between the supervisee total score and the TABS total score, r= − 0.36, n=43, p=0.02, representing a shared variance of 13%. This indicates that the stronger the perceived supervisory working alliance the lower the disruptions in cognitive beliefs. There was no significant correlation between the supervisee score and the IES-R total score, r= − 0.26, n=41, p=0.10.

Predictors of vicarious traumatisation
Prior to conducting the standard multivariate regression analyses, the associations between the variables were examined. Table 4 presents a correlation matrix for the IES-R total score, the TABS total score, and the predictor variables.

Table 4.  Pearson’s correlations assessing the relationships between predictor variables and vicarious traumatisation measures

IES-R Supervision Dealing with the problem Non-productive coping Optimism Sharing Personal trauma history
TABS 0.19 0.16 −0.31* 0.38** −0.11 −0.19 −0.08
IES-R 0.02 0.04 0.23 0.14 −0.04 0.28*
Supervisiona 0.08 0.21 0.07 0.06 −0.25
Dealing with the problem 0.12 0.54** 0.43** −0.08
Non-productive coping 0.42** −0.11 −0.05
Optimism 0.38** −0.00
Sharing −0.17
aWhether or not participants received supervision.
*p<0.05, **p<0.01.
As shown in Table 4, a number of predictor variables were significantly related to the vicarious traumatisation measures (TABS & IES-R). Non-productive coping was positively correlated with the TABS total score, while dealing with the problem was negatively correlated with this measure. Personal trauma history positively correlated with the IES-R total score. Also, a number of predictor variables were significantly correlated to each other but these associations were not sufficient to influence multicollinearity. Finally, there was no significant correlation between the IES-R and TABS.

A standard multiple regression analysis was conducted to determine the predictive value of receiving supervision, coping styles, and personal trauma history for the TABS. Although not all of the predictors showed a significant correlation with the TABS, they were included in the multiple regression analyses to accommodate potential suppressor effects (Tabachnick & Fidell, [36]). Table 5 displays the unstandardised regression coefficients (B), the standard error (SE B), the standardised regression coefficients (β), the t statistic, and the R values.

Table 5.  Standard multiple regression of predictors and Total Trauma Attachment and Belief Scale total scores (TABS) (n=61)

Variables B SE B β t Sig.
Non-productive coping 0.32 0.09 0.52 3.66 0.00**
Dealing with the problem −0.28 0.11 −0.35 −2.41 0.02*
Optimism −0.11 0.09 −0.19 −1.19 0.24
Sharing 0.00 0.04 0.10 0.71 0.48
Personal trauma history 0.00 2.09 −0.00 −0.03 0.98
Supervisiona 2.57 2.30 0.14 1.12 0.27
R=0.57**
R2=0.33
Adj. R2=0.25
aWhether or not participants received supervision.
*p<0.05, **p<0.01.
Table 5 indicates R2 (25% adjusted) was significantly different from zero, F( 6, 51) = 4.10, p=0.00, with 33% of the variance explained. Dealing with the problem was negatively related to the TABS total score, while non-productive coping was positively associated with this measure. This indicates that respondents who dealt with the problem had a lower TABS total score, while participants who used non-productive coping had a higher TABS total score.

The influence of coping styles and personal trauma history on PTSD symptoms (IES-R total score) was also examined using a standard multiple regression. Again, all the predictors were included in the analyses to accommodate potential suppressor effects (Tabachnick & Fidell, [36]). Table 6 displays the unstandardised regression coefficients (B), the standard error (SE B), the standardised regression coefficients (β), the t statistic, and the R values.

Table 6.  Standard multiple regression of predictors and Total Impact of Event Scale-Revised scores (IES-R) (n=58)

Variables B SE B β t Sig.
Non-productive coping 0.00 0.00 0.29 1.77 0.08
Dealing with the problem 0.00 0.00 −0.03 −0.15 0.88
Optimism 0.00 0.00 −0.00 −0.02 0.99
Sharing 0.00 0.00 0.06 0.37 0.71
Personal trauma history 0.13 0.06 0.31 2.21 0.03
Supervisiona 0.00 0.07 0.03 0.22 0.82
R=0.39
R2=0.16
Adj. R2=0.05
aWhether or not participants received supervision.
As shown in Table 6, the regression analysis was not significantly different from zero, F( 6, 48) = 1.47, p=0.21.

Discussion
This research explored vicarious traumatisation amongst telephone counsellors. Based on normative scores, telephone counsellors’ level of disruptions in beliefs was in the average range (Pearlman, [26]). Similarly, Mauldin ([19]) found that ‘hotline’ workers had little overall change in cognitive beliefs. In comparison to Mauldin’s (2001) study, the average total score for PTSD symptoms in the present investigation was low. However, Mauldin ([19]) used the IES and not the IES-R. Unlike the IES-R, the original measure only taps into avoidance and intrusion criteria for PTSD. Therefore, it does not give a complete assessment of the response to traumatic events (Weiss & Marmar, [38]). It is recommended that future investigations continue to use the IES-R.

Nevertheless, Mauldin ([19]) suggested that telephone counsellors exhibit spikes in PTSD symptoms rather than chronic PTSD. Similarly, McCann and Pearlman ([20]) claimed that PTSD symptoms are probably transient in nature. Perhaps, the level of PTSD symptoms in the present sample is underrepresented given that there was a single assessment point. Future investigations could provide a more accurate indication of symptoms by conducting a number of assessments over an extended period.

Despite the low to average range for mean vicarious traumatisation scores, this does not preclude individual telephone counsellors from being traumatised. There were three participants (4.8%) who had total scores in the ‘high average’ range (56–59) and two (3.2%) who scored in the ‘very high’ range (60–69) for disruptions in cognitive beliefs. Due to the modest sample size only total scores for the IES-R and TABS were used in the current study. However, there were 28 (45.9%) participants who had high average (56–59) to extremely high (≥ 70) scores on at least one of the TABS subscales, indicating that subscale scores should be explored in future research. Also, 15 (25.9%) respondents answered 3 (quite a bit) or 4 (extremely) on at least one IES-R question. Therefore, telephone counsellors appear vulnerable to developing vicarious traumatisation.

This study collected data from telephone counsellors who worked with a variety of trauma clients. There were no significant differences in mean scores for either disruptions in cognitive beliefs or PTSD symptoms across organisations. This suggests that all of the respondents were susceptible to vicarious traumatisation despite working with different client bases. Similarly, Neumann and Gamble ([23]) stated that all counsellors are at risk for developing vicarious traumatisation. In contrast, most previous research has been restricted to sexual violence counsellors (Astin, [ 4]; Johnson & Hunter, [17]; Steed & Downing, [35]). Thus, future research should continue to consider vicarious traumatisation amongst a variety of trauma counsellors.

Coping styles and vicarious traumatisation
The hypothesis that coping styles would be associated with vicarious traumatisation was partially supported. Respondents who employed a non-productive coping style had higher levels of disruptions in beliefs, while participants who dealt with the problem had lower scores on this measure. None of the coping styles were related to PTSD symptoms.

Non-productive coping was the least frequently used coping style. In line with previous research findings (Johnson & Hunter, [17]; Schauben & Frazier, [32]; Steed & Downing, [35]), respondents who used this approach had greater disruptions in cognitive beliefs. For example, Steed and Downing ([35]) discovered that sexual violence therapists identified non-productive coping strategies as being associated with episodes of feeling helpless and not confident, while Johnson and Hunter ([17]) discovered that escape–avoidance coping was a negative predictor of disruptions in intimacy beliefs.

Dealing with the problem was the most frequently used coping style. Likewise, Steed and Downing ([35]) found that participants were very aware of the need to be proactive in taking care of themselves. As expected, respondents who dealt with the problem had less disruption in cognitive beliefs. Similarly, Schauben and Frazier ([32]) discovered that coping styles such as active coping were associated with lower levels of vicarious traumatisation. Thus, counsellors who use non-productive coping styles such as denying the problem and self-blame are not actively generating solutions to deal with vicarious traumatisation. Alternatively, counsellors using strategies such as exercising or developing a plan of action are actively taking charge of their situation. In the regression equation dealing with the problem and non-productive coping predicted 33% of the variance in the TABS total score.

In the current research, sharing was the second most frequently used coping strategy. Similarly, Arvay and Uhlemann ([ 3]) found that talking to friends and peers were two of the most common responses for self-care. However, unlike Schauben and Frazier ([32]) who found that seeking emotional support was negatively associated with traumatisation, sharing was not significantly related to the vicarious traumatisation measures in the present study. Also, optimism was not related to vicarious traumatisation. This finding might be related to an overlap in coping styles being measured. Indeed, optimism and sharing were positively correlated with dealing with the problem. Further, optimism was positively associated with non-productive coping. Frydenberg and Lewis ([12]) reported that optimism and sharing are the least reliable scales in the short form of the CSA. Thus, it would be preferable to use the long form in future research.

Availability of supervision and vicarious traumatisation
Approximately one-third (n=17; 27.9%) of the sample reported that they received no supervision. Previous studies (e.g. Arvay & Uhlemann, [ 3]; Pearlman & Mac Ian, [27]) have also reported that a high proportion of therapists do not participate in supervision. However, the prediction that participants not receiving supervision would have higher levels of vicarious traumatisation was not supported. That is, in contrast to the literature (e.g. Mauldin, [19]; Sexton, [33]; Sommer, [34]), receiving supervision was not related to levels of vicarious traumatisation.

The examination of supervision availability in the present study was limited to a single item. However, from the descriptions provided by participants there appeared to be considerable variation in the type of supervision provided. These included differences in the frequency of contact with supervisors, the length of supervision sessions, and whether participants received supervision individually or as a group. It would be valuable for future research to consider the various arrangements when determining the benefits of supervision.

Supervisory working alliance and vicarious traumatisation
The hypothesis that having a strong working alliance would be related to lower levels of vicarious traumatisation was partially supported. Although no relationship was found with PTSD symptoms, participants who perceived themselves as having a strong supervisory working alliance had less disruptions in cognitive beliefs.

Therefore, simply receiving supervision is not sufficient. To effectively reduce disruptions in cognitive beliefs counsellors need to have a positive relationship with their supervisor. Similarly, investigators (e.g. Efstation et al., [ 9]; Holloway, [15]) have argued that a strong supervisory working alliance is fundamental to successful supervision.

Personal trauma history and vicarious traumatisation
The expectation that telephone counsellors who had a personal trauma history would score higher levels of vicarious traumatisation was partially supported. Personal trauma history was positively correlated with PTSD symptoms, although it was not a significant predictor of PTSD symptoms.

Although not a significant predictor, a significant positive correlation indicated that respondents with a personal trauma history had higher levels of PTSD symptoms. Consequently, trauma history appears to play some role. Researchers have indicated that counsellors with a personal trauma history can be more traumatised because they relate to the harmful effects clients experience (Arvay & Uhlemann, [ 3]; Pearlman & Mac Ian, [27]). Thus, it may be valuable for telephone counsellors to receive training in self-awareness so that they are mindful of how their personal experiences affect their reactions to clients’ trauma stories. Even so, the number of participants who indicated that they had a personal trauma history was relatively small (n = 22, 37.3%). Further investigation of the influence of personal trauma history is required before more definitive conclusions can be reached.

Recommendations for future research
Most of the respondents (n=42, 70%) did not perceive themselves to be trauma counsellors despite the literature indicating that their clients were likely to have experienced trauma (Cerney, [ 7]; McCann & Pearlman, [21]). In fact, although previous research has investigated domestic violence counsellors (Iliffe, [16]), this was the only group in the current study in which all participants (n=5) said they were not trauma counsellors. Clearly, not everyone perceives trauma in the same way, regardless of what objectively might be labelled as a traumatic event (Cerney, [ 7]). According to McCann and Pearlman ([20]), the definition of a traumatic event will differ for individuals depending on what is currently salient in their life. The present results revealed a significant difference between respondents who viewed themselves as trauma counsellors and those who did not on PTSD symptoms, but not disruptions in beliefs. The reason for this result is not clear. It would be informative if prospective studies collected qualitative data on counsellors’ definitions of trauma so that a more detailed examination of subjective influences could take place.

This study found that there were deficits in training on vicarious traumatisation. Over a third of the participants had not heard of the term and almost 80% had not been provided with specific training. Nevertheless, there were no significant differences between those who received training and those who did not on the vicarious traumatisation measures. Such a finding needs to be regarded with caution as the Assessment of the effectiveness of training was rudimentary. That is, it was restricted to one item and no distinctions were made in terms of the content or duration of training. Clearly, it is important that future investigations provide a more thorough examination of the outcomes of training programmes.

None of the variables were predictive of the IES-R total score. Therefore, it is recommended that other influences of PTSD be examined. For example, previous research has indicated that counsellors’ caseloads are influential (Schauben & Frazier, [32]). This study requested caseload estimates; however, a high proportion of participants indicated that their caseload varied too much for them to retrospectively state the number of calls they received. Thus, the data were not quantifiable. A more accurate measure of counsellors’ caseload would involve counsellors keeping a diary of calls received.

The results of the present study need to be considered in light of limitations related to the measures of vicarious traumatisation. While the IES-R and the TABS provide indications of the level of vicarious traumatisation they are not conclusive. Both the TABS and IES-R purport to measure ‘first-hand trauma’. Thus, the low to average scores in the current study may indicate that vicarious traumatisation consists of less intense symptoms (Mauldin, [19]). Further, the TABS and IES-R were not correlated indicating that they may be measuring different constructs. Consequently, either a specific multi-item measure for vicarious traumatisation needs to be developed (Schauben & Frazier, [32]) or appropriate norms for vicarious traumatisation should be established for both the IES-R and TABS. Related to this, it is important for investigators to develop a conceptually clearer definition of vicarious traumatisation (Schauben & Frazier, [32]).

The reliance on self-report measures could have influenced the accuracy of the findings as respondents may have minimised their traumatic experiences (Mauldin, [19]). Indeed, Neumann and Gamble ([23]) stated that counsellors can believe that they should be indestructible. Nevertheless, in the present study respondents provided a wide range of scores on both of the vicarious traumatisation measures suggesting some preparedness to admit to weaknesses. A further caution regarding the generalisability of the findings is necessary given the small sample size. Nonetheless, the return rate is comparable to previous studies (Adams et al., [ 1]; Schauben & Frazier, [32]) and the sample represents the largest number of telephone counsellors surveyed in Australia regarding vicarious traumatisation. Other factors related to generalisability include that the majority of the participants were female (88.7%), the number of counsellors from each organisation was small, and there was a broad range of counselling experience. Clearly, these issues need to be addressed in future research.

Finally, future studies could be extended by incorporating assessments of the positive impact of working with trauma clients. While it is important to recognise that telephone counsellors can be traumatised from hearing clients’ stories, a more comprehensive understanding of their experiences would consider potential positive outcomes of this work. For instance, the evidence for posttraumatic growth, which takes into account the positive experiences that can come out of trauma (Tedeschi & Calhoun, [37]), could be investigated.

Conclusion
The current findings have implications for the support of telephone counsellors. Despite low to average scores on the vicarious traumatisation measures, there were individuals who had above average scores for disruptions in cognitive beliefs and PTSD symptoms. Thus, vicarious traumatisation among telephone counsellors needs attention. In particular, efforts to address vicarious traumatisation should focus on developing effective coping styles and enhancing the quality of supervision.

References
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Frydenberg, E. and Lewis, R.1997. Coping Scale for Adults: Administrator’s Manual, Melbourne, , Australia: ACER.

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Holloway, E.L.1987. Developmental models of supervision: is it development?. Professional Psychology: Research and Practice, 18: 209–216.

Iliffe, G.2000. Exploring the counselor’s experience of working with perpetrators and survivors of domestic violence. Journal of Interpersonal Violence, 15: 393–413.

Johnson, C. and Hunter, M.1997. Vicarious traumatisation in counsellors working with New South Wales sexual assault service: an exploratory study. Work and Stress, 11: 319–328.

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Mauldin, A.L. (2001). Vicarious traumatization among sexual assault hotline workers. Unpublished doctoral dissertation, University of Memphis, Tennessee.

McCann, I.L. and Pearlman, L.A.1990. Vicarious traumatization: a framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3: 131–149.

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The hazards of investigating internet crimes against children: Digital evidence handlers’ experiences with vicarious trauma and coping behaviors.
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Authors:
Burruss, George W.. Department of Criminology, Florida Center for Cybersecurity (FC2), University of South Florida, Tampa, FL, US
Holt, Thomas J.. Department of Criminal Justice, Michigan State University, East Lansing, MI, US, holtt@msu.edu
Wall-Parker, April. National White Collar Crime Center (NW3C), Richmond, VA, US
Address:
Holt, Thomas J., Department of Criminal Justice, Michigan State University, East Lansing, MI, US, holtt@msu.edu
Source:
American Journal of Criminal Justice, Vol 43(3), Sep, 2018. pp. 433-447.
NLM Title Abbreviation:
Am J Crim Justice
Page Count:
15
Publisher:
Germany : Springer
Other Publishers:
US : Southern Criminal Justice Assn
ISSN:
1066-2316 (Print)
1936-1351 (Electronic)
Language:
English
Keywords:
Vicarious trauma, Occupational responses, Policing, Digital forensic investigation, Child pornography, Cybercrime
Abstract:
Over the last two decades there has been a substantive increase in the number of cybercrime and digital forensic units in local and state police agencies across the US. There is, however, little research on the occupational responses of individuals serving in specialized roles within criminal justice agencies. Individuals tasked to these units are likely to encounter psychologically harmful materials on a regular basis due to the number of child pornography and sexual exploitation cases they are assigned. As a result, this study examined the experiences of vicarious trauma and coping behaviors of digital forensic examiners in a sample culled from across the country. The findings suggest that exposure to content involving crimes against children directly and indirectly increases the likelihood of trauma and incidence of coping strategies employed. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Crime; *Life Experiences; *Trauma; *Cybercrime; Child Abuse; Pornography
PsycInfo Classification:
Criminal Behavior & Juvenile Delinquency (3236)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Oct 18, 2017; Accepted: Sep 29, 2017; First Submitted: Jul 11, 2017
Release Date:
20171023
Correction Date:
20200713
Copyright:
Southern Criminal Justice Association. 2017
Digital Object Identifier:
http://dx.doi.org/10.1007/s12103-017-9417-3
Accession Number:
2017-47381-001
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The Hazards of Investigating Internet Crimes Against Children: Digital Evidence Handlers’ Experiences with Vicarious Trauma and Coping Behaviors
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Contents
Prior Research on Emotional and Psychological Risks Among Police Officers
Data and Methods
Endogenous Variables
Exogenous Variables
Control Variables
Analysis Plan
Results
Discussion and Conclusions
References
Citations
Full Text
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Over the last two decades there has been a substantive increase in the number of cybercrime and digital forensic units in local and state police agencies across the US. There is, however, little research on the occupational responses of individuals serving in specialized roles within criminal justice agencies. Individuals tasked to these units are likely to encounter psychologically harmful materials on a regular basis due to the number of child pornography and sexual exploitation cases they are assigned. As a result, this study examined the experiences of vicarious trauma and coping behaviors of digital forensic examiners in a sample culled from across the country. The findings suggest that exposure to content involving crimes against children directly and indirectly increases the likelihood of trauma and incidence of coping strategies employed.

Vicarious trauma; Occupational responses; Policing; Digital forensic investigation; Child pornography; Cybercrime

Research on policing demonstrates the stressors officers experience while on the job, including hostile interactions with citizens, emotional encounters with victims of serious offenses, and exposure to experiences with lethal violence and death (Addis & Stephens, [ 1] ; Johnson, [33] ; Violanti, [64] ). These conditions increase the risk of officers’ experiences with emotional burnout (Violanti & Gehrke, [65] ), psychological injury and post-traumatic stress disorder (Huddleston, Stephens, & Paton, [30] ; Robbers & Jenkins, [53] ). Limited evidence also indicates that officers may use fewer positive coping strategies in their private lives, thereby creating tensions in marital and family relationships from alcohol use and other maladaptive coping mechanisms (Ménard & Arter, [43] ; Pasillas, Follette & Perumean-Chaney, [48] ; Swatt, Gibson, & Piquero, [61] ). These negative consequences affect officers’ quality of life, organizational efficacy, and public perceptions of their agency (Newman & Rucker-Reed, [47] ).

Virtually all studies examining police trauma and use of coping experiences focus on line officers who interact with the public every day. Researchers do not typically segment officers by rank or role, yet the policing industry has grown increasingly specialized where different primary work responsibilities shape an individual’s working experiences (Holt, Blevins, & Burruss, [26] ; Rivard, Dietz, Martell, & Widawski, [52] ; Van Patten & Burke, [63] ). As a result, there is a need to understand the unique factors that influence the experience of trauma and use of negative coping strategies employed by officers based on specialized roles within police agencies (see Holt & Blevins, [25] ; Holt, Blevins, & Smith, [27] ; Van Patten & Burke, [63] ).

One particularly under-examined group of police officers are those who work on cases involving digital evidence obtained from computers and mobile devices in support of traditional criminal investigations, as well as cybercrimes (Ferraro & Casey, [19] ; Hinduja, [23] ; Holt, Burruss, & Bossler, [29] ; Krause, [34] ; Stambaugh et al., [57] ). These particular roles have become an important element in many departments over the last two decades. The skills needed to properly seize and handle digital evidence, and the dedicated nature of officers in this role has led to the development of specialized local units and task forces to better deal with these offenses (Hinduja, [24] ; Holt et al., [29] ;Willits & Nowacki, [70] ). There has been a marked increase in the number of specialized cybercrime units among local and state law enforcement agencies, especially in areas with higher population density (Willits & Nowacki, [70] ). Officers working within these units receive specialized technical training and continuing education to use various software suites and conduct undercover on-line investigations. They also tend to be staffed by a small number of officers who experience large caseloads (Krause, [34] ; Perez, Jones, Engler, & Sachau, [49] ), which may increase the stress they experience while on the job (Holt & Blevins, [25] ; Holt et al., [26] ).

Additionally, officers assigned to specialized cybercrime task forces primarily handle cases involving child pornography and sexual exploitation, requiring them to view harmful and disturbing images and video files repeatedly throughout the course of an investigation (Burns, Morley, Bradshaw, & Domene, [10] ; Marcum & Higgins, [40] ; Perez et al., [49] ). It is thought that officers’ exposure to child pornography is linked with a high degree of emotional burnout and work stress (Burns et al., [10] ; Holt et al., [26] ; Krause, [34] ; Perez et al., [49] ). There is limited research on the direct role of exposure to child pornography in predicting trauma and the use of negative coping strategies among specialized officers who act as digital forensic investigators (see Holt et al., [29] ). As a result, it is unclear whether occupational and personal characteristics have a greater impact on negative outcomes associated with their occupational experiences.

To address this gap in the literature, this exploratory study examined a sample of 360 officers who completed cybercrime and digital evidence training provided by the National White Collar Crime Center across the United States. Two regression models were developed to identify the demographic and occupational factors associated with reporting trauma and negative coping strategies. The implications of this study for our knowledge of the working experiences of specialized law enforcement and general trauma are discussed in detail.

Prior Research on Emotional and Psychological Risks Among Police Officers
A great deal of research has discussed the severe physical and emotional risks officers face while on the job from citizen encounters (Newman & Rucker-Reed, [47] ; Tang & Hammontree, [62] ) coupled with the bureaucratic structure of policing generally (e.g. Violanti & Paton, [67] ). Some researchers argue that internalization of police cultural norms, such as sustaining emotional control at all times, may actually increase the potential for officers to report occupational stress (Brown, Fielding, & Grover, [8] ; Dick, [17] ). By restricting the ability to show emotions and remain tough and courageous in all situations, the culture encourages the repression of emotional reactions that may aid in stress reduction. These conditions may also discourage officers from discussing their experiences with family and significant others, as well as mental health professionals (Reiser & Geiger, [51] ; Stephens, Long, & Miller, [58] ). As a result, officers may repress their feelings, leading to poor physical and psychological health over the long term (Stephens et al., [58] ).

Research also demonstrates that police officers tend to employ maladaptive behaviors, such as drinking, to cope with traumatic or stressful experiences, which may further increase stress. The use of positive or effective coping strategies, such as discussing feelings or exercise, can typically minimize feelings of psychological distress, especially when coupled with a strong social support. Problem-focused coping strategies are often employed by officers under stress, and may be less dependent on emotion-based coping strategies that would regulate officer distress (Evans, Coman, Stanley, & Burrows, [18] ). Such strategies include alcohol use, cynicism, emotional detachment, and suspicion of others (Bonifacio, [4] ; Kroes, [36] ; Violanti & Marshall, [66] ). It is thought that individuals are more likely to use emotion-focused coping strategies when dealing with unchangeable events. The use of negative coping strategies is also associated with the development and maintenance of PTSD symptoms in first responder samples (Brown, Mulhern, & Joseph, [9] ; Clohessy & Ehlers, [12] ; Haisch & Meyers, [21] ; Shakespeare-Finch, Gow, & Smith, [55] ).

Most of this research to date has used samples of line officers in police agencies, calling to question how those working in specialized roles may experience trauma or utilize negative coping strategies. Many in specialized roles may have worked as patrol officers, meaning they have had exposure to situations on the street, experienced the larger police culture, and accepted its norms and values (e.g. Herbert, [22] ; Holt et al., [29] ). The unique nature of their current occupational experiences may, however, limit their exposure to physically violent encounters, such as being shot, fighting with suspects or citizens, or examining vehicle crashes.

These issues are notably evident for officers operating as digital forensic examiners in law enforcement agencies. Cybercrime units at the local level are more likely to respond to cases involving cyberstalking, child pornography or sexual exploitation and other sexual offenses (Cunningham & Kendall, [16] ; Holt, Bossler, & Fitzgerald, [28] ; Marcum & Higgins, [40] ; Senjo, [54] ; Wolak, Finkelhor, & Mitchell, [71] ). These cases require substantive exposure to pornographic images and videos, particularly those involving minors, which can cause undue psychological stress after repeated viewings (Burns et al., [10] ; Krause, [34] ; Marcum, Higgins, Freiburger, & Ricketts, [41] ; Perez et al., [49] ; Stevenson, [59] ). Child pornography case examiners report high levels of burnout and exhaustion (Burns et al., [10] ; Perez et al., [49] ; Stevenson, [59] ), as well as commensurate levels of stress as officers in traditional law enforcement jobs (Holt & Blevins, [25] ; Holt et al., [26] ; Holt et al., [29] ). Emotional fatigue has also been correlated with the amount of time examiners were exposed to disturbing images (Perez et al., [49] ). In addition, limited research suggests examiners may apply negative coping strategies in similar patterns to traditional line officers (Holt & Blevins, [25] ; Holt et al., [29] ). Thus, there is a need for more research to understand how exposure to child exploitation evidence and other harmful images may affect examiners’ lives both directly and indirectly.

In addition to the potential impact of the content officers interact with on the job, it is plausible that they may also experience certain occupational responses in keeping with prior research on policing generally. Utilizing this broader empirical literature provides several key hypotheses that merit analysis. Specifically, officers tasked to cybercrime units and digital-forensic investigative roles may have specialized work routines, but also operate within a traditional quasi-military police organization. Their experiences may differ depending on their role within the agency, as those in supervisory positions may spend more time with paperwork and managerial issues compared to those who serve primarily as investigators (e.g. Holt, Blevins, & Smith, [27] ). Individuals principally engaged as examiners may be more likely to report symptoms of trauma from the harmful content they view each day. Those who are supervisors, however, may rely on negative coping strategies because they feel removed from their colleagues who can help them alleviate stress (Holt et al., [27] ). In addition, their responsibilities may generally increase their level of stress and lead to use of negative coping mechanisms.

The bureaucratic nature of most police organizations is also a known source of stress for officers (Coman & Evans, [13] ; Martelli, Waters, & Martelli, [42] ; Spielberger, Westburry, Grier, & Greenfield, [56] ). Similarly, forensic scientists working in local and state crime labs may also experience stress from the difficulties inherent in navigating this administrative environment (Holt et al., [27] ; National Academy of Sciences, [46] ). Individuals who are exposed to difficult content, regardless of the status within the organization, may face the same challenges in emotionally dealing with their experiences. The militarized structure of many policing agencies may also promote the acceptance of police subcultural values, independent of whether they are sworn or unsworn (e.g. Herbert, [22] ).

The size of the agency where the examiner works may also affect the likelihood of coping mechanisms and traumatic stress symptoms. Police officers working in large agencies typically report higher levels of stress than those in smaller agencies (Brooks & Piquero, [7] ; Crank & Caldero, [14] ). This relationship may apply to digital forensic examiners as larger cities may have more established cybercrime units or taskforces, thereby increasing demands on examiners (e.g. Holt & Blevins, [25] ; Willits & Nowacki, [70] ). In addition, large agencies may also increase role conflict and variation in managerial structures that not only affect employee satisfaction and stress, but also isolate specialized officers from other staff (Burns et al., [10] ; Perez et al., [49] ). This finding could also result from the higher levels of reported crime in larger jurisdictions.

Working conditions may affect the risk of stress and PTSD symptoms, such as the absence of social support. Officers in specialized digital forensic roles may face an increased risk of negative experiences at home as a function of their work. Having a family, particularly young children, may make digital examiners more cognizant of the risk of sexual victimization and the prevalence of child pornography (Holt et al., [27] ; Perez et al., [49] ). Thinking about their work while at home may indirectly affect relationships with family members, and potentially increase the risk of PTSD and stress. They may also feel somewhat isolated within the workplace due to the specialized nature of their jobs, making it difficult to commiserate with fellow officers about their tasks or responsibilities (Burns et al., [10] ; Holt et al., [28] ; Perez et al., [49] ).

Officer demographics may also have some tie to the risk of PTSD and stress. Education appears to have a mixed impact on criminal justice employee stress, as Storch and Panzerella ([60] ) found education is not a significant predictor of work reactions. Cullen and associates (Cullen, Lemming, Link, & Wozniak, [15] ), however, found that higher levels of education were related to lower levels of work stress. It is plausible that officers with higher education may have better coping mechanisms to deal with stress (Cullen et al., [15] ). The technical skills needed to effectively perform digital forensic work may also increase job satisfaction for those with college degrees. Female officers also report higher levels of stress than males, especially if they are married and have children (Bowler et al., [5] ; Kurtz, [37] ; Lilly, Pole, Best, Metzler, & Marmar, [39] ). There is also evidence that female officers report PTSD symptoms at a lower prevalence rate than that of the general female population (Lilly et al., [39] ).

Data and Methods
Taken as a whole, there are several potential relationships between working conditions, stress, and PTSD among digital forensic investigators. Our analysis focused on testing three main hypotheses derived from the literature:

Hypothesis one: More exposure to crimes against children (CAC) evidence will increase the experience of trauma.

Hypothesis two: The more examiners are exposed to trauma, the more they will increase coping behaviors.

Hypothesis three: Exposure to CAC evidence will have an indirect effect of increasing coping behaviors through experiencing trauma.

Data were collected in the fall of 2014 to examine these hypotheses using empirical data. Approximately 1200 surveys were distributed to law enforcement personnel who took advanced cybercrime investigation training courses hosted by the National White Collar Crime Center (NW3C) in 38 locations in 23 states across the US. Most classes were held in the Southeast, Northeast, and Midwest. The courses ranged from basic computer crime investigative techniques to more intermediate and advanced material. Content topics included recognizing and preserving electronic evidence, and seizing evidence from specific devices such as GPS, cell phones, and iOS-based products. The final sample consisted of 480 respondents after including only those with cybercrime investigation responsibilities (approximately 40% response rate). After listwise deletion, the final sample n was 360.1 [ 1] Further investigation demonstrated that while variables had cases missing, no more than about 5 % of responses were missing on any one variable. We are therefore assuming that responses were missing at random.

Endogenous Variables
Two variables were used as outcomes in this analysis: trauma and coping. Trauma was measured as a summed index of all 17 items from the Secondary Traumatic Stress Scale (STSS; Bride, Robinson, Yegidis, & Figley, [6] ). The survey begins with the statement: “Below is a list of difficulties people sometimes have after stressful life events. Please … indicate how distressing each difficulty has been for you during the past seven days with respect to your investigative duties.” Respondents were presented with 17 specific items including “I had trouble staying asleep” and “I felt irritable and angry” (all seventeen items for trauma and the items for coping are listed in Appendix). The trauma items were measured on a five-point scale: ( 1) not at all; ( 2) a little bit; ( 3) moderately; (4) quite a bit; and (5) extremely. The index showed a high degree of internal consistency: Cronbach’s alpha was 0.938.2 [ 2]

The coping measure used in this analysis consisted of a summed index comprised of eleven items derived from Jackson and Maslach’s ([32] ) well tested inventory (Burke et al., [11] ; Haarr & Morash, [20] ; Lau et al. [38] ; Pienaar et al., [50] ; Vollrath & Torgersen, [68] ; Wearing & Hart, [69] ). The summed measure showed a reasonable degree of internal consistency (Cronbach’s alpha = 0.734). The coping index items followed this direction: “Please indicate how often you engage in the following coping behaviors.” It included statements such as: “I work harder than usual around the house or on the job”, or “I seek professional help such as a counselor or therapist.” The response scale was arrayed from ( 1) never, ( 2) rarely, ( 3) sometimes, (4) often, and (5) always. The average level of trauma was low on the trauma index, mean = 23.833, as was coping behaviors, mean = 22.583 (note see Table 1 for index scales).

Exogenous Variables
The focal variable for predicting vicarious trauma and coping behaviors was exposure to evidence related to child pornography or exploitation. Four items asked respondents to indicate, “In an average week, how many hours do you spend examining the following materials in support of child pornography/exploitation investigations?” The response scale was (0) none, ( 1) 1-3 h, ( 2) 4-6 h, ( 3) 7-10 h, (4) 11-15 h, (5) 16-20 h, and (6) 21 or more hours. The four items asked about video files, images, e-mail or chat logs, or Internet browser history/caches.

While these items were highly correlated and Cronbach’s alpha indicated a high degree of internal consistency (alpha = 0.962), the measurement scale was not evenly ordered to allow a summation of the items into an index. Instead, we designated a single latent factor called “crimes-again-children (CAC) Exposure.” Using Mplus’ weighted least squares and variance adjusted estimator to account for the ordinal nature of these measures, the latent factor was estimated as a latent underlying continuous measure (Bollen, [ 3] ; Muthén & Muthén, [45] ). The results of the measurement model are reported in the results section.

Control Variables
To account for personal and organizational factors, we included several control dummy variables: female ( 1), had children ( 1), was married ( 1), was a sworn police officer ( 1), and was not currently a supervisor ( 1). We also included level of education (see Table 1), and the approximate size of the agency number of employees (Table 1). The typical respondent was a married male with children. Most were sworn officers (88%), had some college education, was not in a supervisor position (86%), and came from an agency of at least 25 employees.

Analysis Plan
To measure the level of exposure to harmful images and knowledge of crimes against children through digital evidence, we use confirmatory factor analysis to create a latent factor (the individual variable measures are explained below). Two endogenous observed continuous variables, trauma and coping, were regressed on the latent variable and the remaining control variables. Both the measurement model and structural model were evaluated through standard fit indices, including the chi-square test of model fit, the Tucker-Lewis index (TLI), the comparative fit index (CFI), and the root mean square error of approximation (RMSEA). A model that fits the data well will have a non-significant chi-square, TLI and CFI above 0.950, and a RMSEA below 0.050. In addition, the measurement model fit was considered good if the latent factor path loadings were above 0.400. The structural model’s goodness-of-fit for the equations used OLS regression standard metrics, p-values for predictors, and r-square for variance explained by the endogenous variables.

Results
For the multivariate analyses, we first evaluated the measurement model for exposure to harmful evidence in CAC cases. The initial results of the measurement were mixed: chi-square p-value = 0.001; RMSEA = 0.114; CFI = 1.000; and TLI = 0.999. In addition, the factor loadings for all four items were above 0.950. Given that the RMSEA indicated a poor fit yet the CFI and TLI indicated a good fit, we considered whether the ‘video and images’ variables were causing a misfit given these items are closely related. When we correlated these two items’ error terms (r = 0.755, p < 0.000), the fit was good across all indices: chi-square p-value = 0.724; RMSEA = 0.000; CFI = 1.000; and TLI = 1.000.3 [ 3] Given the improvement in fit, we used this second measurement model to assess exposure to harmful evidence.

Next, we evaluated the structural model that had two endogenous variables: coping and trauma. The structural model showed a good fit to the data: chi-square p-value = 0.010; RMSEA = 0.042; CFI = 0.998; and TLI = 0.997. The path estimates, their standard errors, and standardized estimates are reported in Table 2. For secondary trauma, the exposure to CAC evidence was significant and positive (b = 2.042; p < 0.000). This was the only variable that was statistically significant, though having children approached the 0.050 significance cutoff (p = 0.063). This model explained about 7 % of the variation in trauma.

Structural model for predicting coping and secondary trauma among those with digital evidence handling responsibilities (n = 360)

b s.e. β
Trauma
 ICAC evidence exposure 2.042*** 0.509 0.221
 Female 1.551 1.609 0.061
 Kids −2.673 1.438 −0.135
 Married 0.026 1.236 0.001
 Sworn Officer 2.090 1.847 0.076
 Education 0.510 0.494 0.063
 Agency Size 0.059 0.212 0.015
 Not supervisor −0.342 1.344 −0.013
 R2 0.074
Coping
 ICAC evidence exposure 0.189 0.312 0.033
 Trauma 0.246*** 0.031 0.393
 Female 3.064*** 0.922 0.191
 Kids 0.560 0.841 0.045
 Married 0.251 0.706 0.021
 Sworn Officer 1.406 0.821 0.082
 Education 0.075 0.266 0.015
 Agency Size 0.007 0.143 0.003
 Not supervisor 0.251 0.828 0.016
 R2 0.212
For coping, the exposure to ICAC evidence was not significant. Only trauma (b = 0.246; p < 0.000) and being female (b = 3.064; p < 0.000) were significant predictors. The indirect effect of CAC exposure through trauma to coping, however, was positive and statistically significant (b = 0.502; p < 0.001). That is, the effect of CAC exposure increased coping behavior, but only through the trauma experience. This model explained about 21% of the variation in coping.

Discussion and Conclusions
There is a substantive body of research examining the occupational responses of police officers, though few studies consider those of individuals serving in specialized roles. Such examinations are essential to improve our understanding of the contours of police work on officers operating in and out of the public eye. This is particularly true for the increasing number of officers tasked to specialized cybercrime units and digital evidence processing roles at the local level (Willits & Nowacki, [70] ). These officers are more likely to handle cases involving child sexual exploitation and sex offenses generally, which may disproportionately increase their exposure to psychologically harmful materials. Thus, this study examined the levels of secondary trauma and the coping mechanisms employed in a sample of individuals serving as digital evidence investigators in law enforcement agencies across the US.

The main hypotheses examined in this study was supported through statistical analyses: more exposure to materials involving crimes against children (CAC) increased 1) reported levels of secondary trauma and 2) coping behaviors through trauma. It is important to note that the direct effect of trauma to coping behaviors was not significant, and moderated through exposure to CAC. The only demographic variable that was significant was that females were more likely to report the use of more coping mechanisms generally. No prior association between gender and digital forensic examiners’ occupational responses has been observed s(e.g. Holt & Blevins, [25] ; Holt et al., [28] ; Holt et al., 2016). Gender effects have also been mixed in studies of line officers (e.g. Belknap & Shelly, [ 2] ; Krimmell & Gormley, [35] ; Morash et al., [44] ; Zhao et al., [72] ), suggesting more research is needed to refine our understanding of the relationships between demographic factors and working responses generally.

These findings reinforce the general finding that investigators face substantial psychological risks through exposure to sexual content featuring children (e.g. Burns et al., [10] ; Holt et al., [29] ; Krause, [34] ; Perez et al., [49] ; Stevenson, [59] ). To reduce the need for constant exposure to harmful content during an investigation, the policing industry should continue to invest in software and technologies that automate the identification of known images and video of child pornography and sexual exploitation (e.g. Holt et al., [27] ; Stambaugh et al., [57] ). At the same time, there will always be a need for human examination of content to identify new victims and offenders. It is essential that officers and management continuously monitor one another for signs of emotional stress or secondary trauma (Holt & Blevins, [25] : Israel et al., [31] ; Jackson & Maslach, [32] ; Perez et al., [49] ).

These findings also support the value of wellness programs and psychological counseling among digital investigators to help minimize the likelihood of experiencing secondary trauma symptoms and encourage healthy coping strategies. Though many agencies encourage or mandate the use of counseling services after so many hours of exposure to content, the broader culture of policing places little value in these services (see Burns et al., [10] ; Holt & Blevins, [25] ; Holt et al., [27] ; Perez et al., [49] ). Thus, managerial support and validation for officer mental health services may encourage the use of counseling among examiners (Krause, [34] ; Perez et al., [49] ). There is also a need for research to assess the efficacy of such programs, including debriefing protocols, mental health screening processes, and counseling services (see also Holt & Blevins, [25] ; Perez et al., [49] ).

The exploratory nature of this study demonstrates the need for greater research to assess the issue of PTSD and occupational responses among criminal justice system employees. While the sample represents officers involved in CAC investigations, it is limited by the fact it was drawn from trainees receiving instruction in advanced cybercrime investigation. Cybercrime investigators who do not have the resources or logistical means to take the NW3C training are not represented in this study. At the same time, all U.S. law enforcement agencies are eligible to have their employees take the training, and it is brought to jurisdictions across the country. It is likely this sample is fairly representative of CAC investigators, but future research is needed with broader, more inclusive sampling strategies to develop a robust population.

The limitations of this study require further research to ensure the generalizability of the findings to others in the field of cybercrime and digital investigations. This study used empirically validated survey items to assess trauma and coping behaviors (Bride et al., [6] ; Jackson & Maslach, [32] ). The findings suggest that reviewing CAC evidence can have a deleterious effect on law enforcement personnel. The use of generalized measures for trauma and coping suggest future research may benefit from the inclusion of additional measures that relate to crimes against children to see if the effect is more pronounced.

Similarly, future research is needed to disentangle reported trauma and coping as a function of current and past law enforcement experience. In this sample, respondents included detectives, some line officers, and some supervisors. Individuals who reported the use of coping strategies and trauma may have these experiences from their past work in the field, though it may also stem from exposure to CAC content in their current role (see Holt et al., [27] , for further discussion). Thus, additional research is needed to understand the association between current working experiences, prior work experience in the field, and measures of trauma and coping.

Finally, the quantitative methods applied in this study provide direction that may be best examined in further detail through qualitative methodologies. The specialized nature of digital forensic examination coupled with small staff size means this population of criminal justice system actors may be best examined through interviews and field observations to understand their experiences. Interviews and observations can demonstrate not only how they spend their time while on the job but how examiners interact with one another and the extent to which they share or refute the traditional subcultural values of policing (e.g. Herbert, [22] ). Ethnographic research can also expand our knowledge of the organizational dynamics that shape examiner experiences, including bureaucratic impediments, training needs, and technological challenges. Such work is essential to improve our knowledge of the experiences of this growing sector of the criminal justice system (e.g. Willits & Nowacki, [70] ) and improve the ways that officers experience their jobs and serve the public.

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Footnotes
1 The proportion of missing cases across the original variables were between 2% and 6%. The summed index variables had a higher proportion of missing because the missing cases in the original data compounded in the index. Because the proportion of missing cases was around 5% we assume they are missing at random. Furthermore, we used Mplus’s FIML imputation algorithm to replace missing cases, but the results were virtually the same. To keep the descriptive sample the same as the model, we did not use imputation.

2 Even though we used confirmatory factor analysis for the model, some of the items were based on validated indices from the literature. Therefore, following the extant literature, we used the indices rather than create latent factors.

3 Correlating the error terms for observed variables can be problematic as this can improve model fit base solely on chance (i.e., in another sample, the improvement may not occur). Given these two items were similar, we assume the correlated error accounts a real correlation in measurement error. To confirm this, we tested a measurement model with the images variable removed and the model fit remained the same: chi-square p-value = 0.000; RMSEA = 0.000; CFI = 1.000; and TLI = 1.000).

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By George W. Burruss; Thomas J. Holt and April Wall-Parker

George Burrussis Associate Professor of Criminology at the University of South Florida and affiliated with the Florida Center for Cybersecurity (FC2). He received his Ph.D. in criminology and criminal justice from the University of Missouri St. Louis in 2001. His research areas include criminal justice organizations and cybercrime.

April Wall-Parkeris a research associate at the National White Collar Crime Center whose work oversees the implementation and analysis of programs associated with high-tech crimes.

American Journal of Criminal Justice is a copyright of Springer, 2018. All Rights Reserved.

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Coping and work-related stress reactions in protective services workers.
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Authors:
Cummings, Caroline. Department of Clinical Psychology, University of Nevada, Reno, Reno, NV, US, caroline.cummings@nevada.unr.edu
Singer, Jonathan. Department of Clinical Psychology, University of Nevada, Reno, Reno, NV, US
Moody, Sarah A., ORCID 0000-0001-8143-1627 . Department of Interdisciplinary Social Psychology, University of Nevada, Reno, Reno, NV, US
Benuto, Lorraine T.. Department of Clinical Psychology, University of Nevada, Reno, Reno, NV, US
Address:
Cummings, Caroline, Department of Psychology, University of Nevada, Reno, 1664 N. Virginia St., Reno, NV, US, 89557, caroline.cummings@nevada.unr.edu
Source:
British Journal of Social Work, Vol 50(1), Jan, 2020. pp. 62-80.
NLM Title Abbreviation:
Br J Soc Work
Page Count:
19
Publisher:
United Kingdom : Oxford University Press
ISSN:
0045-3102 (Print)
1468-263X (Electronic)
Language:
English
Keywords:
brief COPE, burnout, coping, protective services workers, work-related stress
Abstract:
Burnout, secondary traumatic stress (STS) and vicarious trauma (VT) are three highly prevalent work-related stress reactions experienced in helping professions, but prevalence rates and protective/risk factors of these stress reactions in protective services workers have been understudied. The purpose of the current study was to examine coping mechanisms utilised by protective services workers and their relationship with the experience of burnout, STS and VT. Participants (N = 228) completed online measures of coping strategies and work-related stress reactions. Socially supported coping was the only adaptive coping skill that significantly predicted less burnout in protective service workers and none of the adaptive coping skills were associated with decreased STS or VT symptoms, suggesting that adaptive coping skills may not be effective enough to combat work-related stress reactions in protective services workers. Furthermore, child protective services (CPS) workers reported experiencing significantly more burnout, VT and STS symptoms than adult/elder protective services workers. Given the findings, there is a need for the testing of interventions that target increasing professionals’ protective factors, especially CPS workers, for experiencing work-related stress reactions, rather than focusing solely on teaching and strengthening traditional coping skills, or addressing inconsistent risk factors. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Occupational Stress; *Protective Services; *Stress Reactions; Social Workers; Trauma; Vicarious Experiences; Compassion Fatigue
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Vicarious Trauma Scale DOI: 10.1037/t03119-000
Brief COPE Inventory DOI: 10.1037/t04102-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jun 25, 2019
Release Date:
20210315
Copyright:
Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.. The Author(s). 2019
Digital Object Identifier:
http://dx.doi.org/10.1093/bjsw/bcz082
Accession Number:
2020-17543-005
Images:
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Coping with vicarious trauma in the aftermath of a natural disaster.
Authors:
Smith, Lauren E.. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US, l.smith26@umiami.edu
Bernal, Darren R.. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Schwartz, Billie S.. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Whitt, Courtney L.. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Christman, Seth T.. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Donnelly, Stephanie. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Wheatley, Anna. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Guillaume, Casta. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Nicolas, Guerda. Department of Educational and Psychological Studies, University of Miami, Coral Gables, FL, US
Kish, Jonathan. Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Coral Gables, FL, US
Kobetz, Erin. Department of Epidemiology and Public Health, Miller School of Medicine, University of Miami, Coral Gables, FL, US
Address:
Smith, Lauren E., Department of Educational and Psychological Studies, University of Miami, PO Box 248065, Coral Gables, FL, US, 33146, l.smith26@umiami.edu
Source:
Journal of Multicultural Counseling and Development, Vol 42(1), Jan, 2014. pp. 2-12.
NLM Title Abbreviation:
J Multicult Couns Devel
Page Count:
11
Publisher:
United Kingdom : Wiley-Blackwell Publishing Ltd.
Other Journal Titles:
Journal of Non-White Concerns in Personnel & Guidance
Other Publishers:
US : American Counseling Assn
ISSN:
0883-8534 (Print)
2161-1912 (Electronic)
Language:
English
Keywords:
coping behavior, vicarious trauma, natural disaster, family support, 2010 Haiti earthquake, Haitians living in US
Abstract:
This study documents the vicarious psychological impact of the 2010 earthquake in Haiti on Haitians living in the United States. The role of coping resources—family, religious, and community support—was explored. The results highlight the importance of family and community as coping strategies to manage such trauma. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Natural Disasters; *Trauma; *Vicarious Experiences; Family; Immigration
PsycInfo Classification:
Personality Traits & Processes (3120)
Environmental Issues & Attitudes (4070)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Very Old (85 yrs & older)
Tests & Measures:
Support Seeking Scale
Social Readjustment Rating Scale DOI: 10.1037/t02251-000
PTSD Checklist—Civilian Version DOI: 10.1037/t02622-000
Grant Sponsorship:
Sponsor: American Cancer Society, US
Grant Number: MRSGT-07-159-01-CPHPS
Recipients: No recipient indicated

Sponsor: Jay Weiss Center for Social Medicine and Health Equity
Recipients: No recipient indicated

Sponsor: University of Miami, Miller School of Medicine, Divisions of General Medicine and Epidemiology, US
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Apr 6, 2013; Revised: Aug 9, 2012; First Submitted: Feb 27, 2012
Release Date:
20140210
Copyright:
All rights reserved.. American Counseling Association. 2014
Digital Object Identifier:
http://dx.doi.org/10.1002/j.2161-1912.2014.00040.x
Accession Number:
2014-00117-001
Number of Citations in Source:
25
Result List Refine Search PrevResult 8 of 68 Next
Holding it together: Coping with vicarious trauma in sport.
Authors:
Day, Melissa C.. University of Chichester, Chichester, WSX, United Kingdom, m.day@chi.ac.uk
Bond, Katherine. University of Chichester, Chichester, WSX, United Kingdom, k.bond@chi.ac.uk
Smith, Brett. Loughborough University, Loughborough, United Kingdom, B.M.Smith@lboro.ac.uk
Address:
Day, Melissa C., University of Chichester, College Lane, Chichester, WSX, United Kingdom, PO19 6PE, m.day@chi.ac.uk
Source:
Psychology of Sport and Exercise, Vol 14(1), Jan, 2013. pp. 1-11.
NLM Title Abbreviation:
Psychol Sport Exerc
Page Count:
11
Publisher:
Netherlands : Elsevier Science
ISSN:
1469-0292 (Print)
1878-5476 (Electronic)
Language:
English
Keywords:
coping behavior, vicarious trauma, sport, trampoline coaches, athletic injury
Abstract:
Objectives: Vicarious trauma refers to the negative effects that may be experienced after witnessing trauma (such as actual or threatened injury) in others. This study aims to examine vicarious trauma in sports coaches by drawing on the experiences of two trampoline coaches who have witnessed a serious athletic injury. In particular, this study focuses on how these coaches have responded to and coped with this traumatic event. Design: The study draws on data from thematic, semi-structured, life history interviews that focus on the occurrence of one particular sports accident witnessed by both coaches. Method: Multiple interviews were conducted in which participants were invited to recall the accident, their own responses to the accident, and the coping strategies employed. Interviews were analyzed using a holistic-content analysis in which thematic similarities and differences between the narratives emerged. Results: There were three main themes that emerged, these were the need to make meaning following trauma, re-experiencing trauma, and acceptance and avoidance coping. Participants demonstrated the individual nature of coping with trauma. While one participant avoided the trauma by minimizing the events, blocking her emotions and giving support to others; the second participant showed acceptance of the trauma, was highly emotional, and received support from others. Conclusions: This study demonstrates the difficulties that may be faced by coaches following vicarious trauma. Although each coach presents different experiences and coping strategies they provide some indications of the level and type of support that may be required after witnessing athletic injury. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coaches; *Coping Behavior; *Sports; *Trauma; Injuries; Vicarious Experiences
PsycInfo Classification:
Sports (3720)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Methodology:
Clinical Case Study; Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jun 21, 2012; Accepted: Jun 6, 2012; Revised: Jun 6, 2012; First Submitted: Nov 20, 2009
Release Date:
20130204
Correction Date:
20200723
Copyright:
All rights reserved.. Elsevier Ltd.. 2012
Digital Object Identifier:
http://dx.doi.org/10.1016/j.psychsport.2012.06.001
Accession Number:
2012-31839-002
Number of Citations in Source:
62
Result List Refine Search PrevResult 9 of 68 Next
Predictors of vicarious trauma beliefs among medical staff.
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Authors:
Mǎirean, Cornelia. Faculty of Psychology, Alexandru Ioan Cuza University, Iasi, Romania, amariei.cornelia@yahoo.com
Turliuc, Maria Nicoleta. Faculty of Psychology, Alexandru Ioan Cuza University, Iasi, Romania
Address:
Mǎirean, Cornelia, Ciurchi no 121A, Bl. H1, Sc. B, Et. 7, Ap. 4, 700367, Iasi, Romania, amariei.cornelia@yahoo.com
Source:
Journal of Loss and Trauma, Vol 18(5), Sep, 2013. pp. 414-428.
NLM Title Abbreviation:
J Loss Trauma
Page Count:
15
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Crisis Intervention & Time-Limited Treatment; Journal of Personal and Interpersonal Loss; Stress, Trauma and Crisis: An International Journal
ISSN:
1532-5024 (Print)
1532-5032 (Electronic)
Language:
English
Keywords:
vicarious trauma beliefs, medical staff, personality differences, coping strategies
Abstract:
The purpose of this research was to investigate personality differences in vicarious trauma beliefs and to explore the interaction effects of personality and coping with these beliefs. A total of 131 medical staff completed measures of personality, coping, and trauma beliefs. The regression analysis emphasized the importance of personality traits (extraversion, neuroticism, and conscientiousness) as predictors of dysfunctional beliefs. The results confirm the hypotheses that vicarious traumatization is determined by individual variables and that positive reinterpretation can buffer the impact of work environment when it comes to personal well-being. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Health Personnel Attitudes; *Personality Traits; *Vicarious Experiences; Strategies; Trauma
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Romania
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Trauma Attachment and Belief Scale
NEO Five-Factor Inventory
COPE Inventory DOI: 10.1037/t10027-000
Grant Sponsorship:
Sponsor: European Social Fund in Romania, Romania
Grant Number: POSDRU/CPP 107/DMI 1.5/S/78342
Date: 2007 – 2013
Other Details: Under the responsibility of the Managing Authority for the Sectoral Operational Programme for Human Resources Development
Recipients: Mǎirean, Cornelia
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jul 1, 2012; First Submitted: Jan 31, 2012
Release Date:
20131223
Correction Date:
20190325
Copyright:
Taylor & Francis Group, LLC.
Digital Object Identifier:
http://dx.doi.org/10.1080/15325024.2012.714200
Accession Number:
2013-10184-004
Number of Citations in Source:
40
Images:

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Predictors of Vicarious Trauma Beliefs Among Medical Staff.
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✖
Contents
THE ROLE OF PERSONALITY TRAITS
COPING AS A MODERATOR IN RELATIONS BETWEEN PERSONALITY AND DYSFUNCTIONAL BELIEFS
THE CURRENT STUDY
METHOD
Participants
Instruments
NEO FIVE-FACTOR INVENTORY
COPING ORIENTATIONS TO THE PROBLEMS EXPERIENCED SCALE
TRAUMA ATTACHMENT AND BELIEF SCALE
DEMOGRAPHIC VARIABLES
Procedure
Hypotheses
RESULTS
Hypothesis 1
Hypothesis 2
DISCUSSION
LIMITATIONS AND FUTURE DIRECTIONS
Acknowledgments
REFERENCES
Footnotes
Full Text
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The purpose of this research was to investigate personality differences in vicarious trauma beliefs and to explore the interaction effects of personality and coping with these beliefs. A total of 131 medical staff completed measures of personality, coping, and trauma beliefs. The regression analysis emphasized the importance of personality traits (extraversion, neuroticism, and conscientiousness) as predictors of dysfunctional beliefs. The results confirm the hypotheses that vicarious traumatization is determined by individual variables and that positive reinterpretation can buffer the impact of work environment when it comes to personal well-being.

Keywords: personality; vicarious trauma beliefs; coping

It is commonly accepted that we are all exposed to at least one potentially traumatic event in the course of our lives. However, those who work in the helping professions are more prone to this type of situation because offering support and Helpance to those coping with pain can significantly reduce the emotional energy and coping resources of professionals (Adams & Riggs, [ 1]).

Psychological trauma can result from direct exposure to a traumatic event (whether natural or man-made) or from indirect or secondary exposure, for instance, while Helping traumatized persons. In other words, the pathological mental condition associated with a trauma can therefore be transmitted in a vicarious way from the victim to the rescue worker (Argentero & Setti, [ 3]; Hatcher, Bride, King, & Catrett, [16]). The purpose of this study was to investigate the incidence of secondary traumatisation from a group of medical staff and to explore some of the main predictors of vicarious trauma in order to identify the individual factors that are able to improve the state of well-being of those working in the helping professions.

To describe the unique effect that work with traumatized clients has on trauma therapists, McCann and Pearlman ([24]) proposed the term vicarious trauma. From their point of view, vicarious trauma describes the process and mechanism by which the inner experience of the therapist is profoundly and permanently changed through bonding with the client’s traumatic experiences. Through repeated exposures to clients’ traumas, professionals may experience negative effects in core aspects of themselves, including their perception of themselves, others, and the world (Trippany, White Kress, & Wilcoxon, [38]). Unfortunately, since the introduction of the term vicarious trauma, development in this area has been limited by uncertainty regarding key concepts and a focus on selective groups of trauma therapists. In particular, research on medical staff has been neglected. There are a large number of medical services that include working in difficult situations and exposure to others’ trauma. Hospital emergency room health care workers routinely witness life-threatening situations experienced by their patients and have to deal with physical and verbal aggression directed toward them. Thus, these workers have higher levels of exposure than people in the general population to events that are implicated in the development of trauma-induced anxiety. Despite that exposure, few studies have examined vicarious trauma in this population.

The origins of the construct of vicarious trauma are rooted within constructivist self-development theory (CSDT) (McCann & Pearlman, [24]). Applied to trauma workers, the theory identifies specific ways in which working with trauma clients can disrupt the individual’s imagery system of memory as well as his or her schema about the self and others (McCann & Pearlman, [25]). According to the theory, people construct their reality through the development of cognitive structures, and these cognitions are then used to interpret events (McCann & Pearlman, [24]). McCann and Pearlman ([24]) indicated that trauma can disrupt a person’s cognitive schemas in one or more of five fundamental need areas: safety, trust/dependency, esteem, control, and intimacy. In other words, vicarious traumatization occurs when a person’s beliefs about safety, trust, control, esteem, and intimacy become increasingly negative as a result of being exposed to a client’s traumatic experiences. The disruptions of the individual’s cognitive schemas can create suspicion, doubts about his or her ability to judge and intervene effectively with clients, feelings of inadequacy, withdrawal, avoidance from others, or excessive control (Trippany et al., [38]). The impact of vicarious trauma upon practitioners can create ethical concerns because vicarious trauma increases the potential for clinical error, increases anger toward clients, and increases the risk of compromising therapeutic boundaries (Trippany et al., [38]).

THE ROLE OF PERSONALITY TRAITS
An area that has received some attention is the variety of factors that are thought to affect vicarious traumatization. The literature has confirmed the presence of vicarious trauma but also highlighted that not everyone who is vicariously exposed to a traumatic event develops symptoms (Lerias & Byrne, [22]). Therefore, there are variables that, if presented, may increase an individual’s likelihood of experiencing vicarious traumatization.

McCann and Pearlman (1990) explained that specific areas of disruption will differ for different individuals depending on which area is more or less salient for them as a reflection of their unique life experiences. The nature of the traumatic event, organizational factors, personality dispositions, and coping variables have commonly been investigated as predictors or correlates of posttrauma outcomes (McCammon, [23]).

In addition to its focus on dysfunctional schemas, CSDT emphasizes the importance of ego resources (resources that allow one to connect with others) in understanding vicarious traumatization (McCann & Pearlman, [24]). As for personal resources, we choose to study personality traits, which can protect individuals or can predispose them to vicarious trauma. Costa and McCrae’s five-factor model of personality (FFM) is a comprehensive taxonomy of higher order trait characteristics. The FFM is comprised of neuroticism (N), extraversion (E), openness (O), agreeableness (A), and conscientiousness (C) (Costa & McCrae, [ 9]). Each of these traits accounts for significant variance in scores when investigating positive or negative outcomes following a traumatic event (Tedeschi & Calhoun, [37]). A positive relationship has been demonstrated between extraversion, openness, and conscientiousness and positive posttrauma perceptions (Tedeschi & Calhoun, [37]). Also, it appears that agreeable individuals are less likely to perceive negative changes as a result of experiencing a traumatic event. Neuroticism is the most pervasive dimension of personality in terms of a pathogenic posttrauma outcome correlation (Watson & Hubbard, [40]).

COPING AS A MODERATOR IN RELATIONS BETWEEN PERSONALITY AND DYSFUNCTIONAL BELIEFS
An important area of research has focused on ways to ameliorate the negative effects of traumatic events. Coping is a process by which an individual manages the demands and emotions generated by a situation that is seen to be stressful (Lazarus, [19]). The process involves appraisals as to whether a situation is a threat, a challenge, or a loss, and perceptions of what can be done to minimize the threat. Following the initial appraisal of the situation, coping strategies have been implemented (Lazarus & Folkman, [20]). In particular, studies have examined the coping strategies of those who work with trauma clients, because different people cope in different ways, and some ways of coping are more effective in helping people to adjust to difficult situations and maintain their emotional well-being.

Coping is a transactional process between the person and his or her environment (Folkman & Lazarus, [13]). Personality dispositions are important determinants of coping because they may predispose people to use certain coping strategies (Suls, David, & Harvey, [36]). And these strategies determine the way we evaluate stressful situations and predict direct attempts to change stressful circumstances or avoid maladaptive cognitive distortions. Although not conclusive, studies (Pearlman & MacIan, [31]; Schauben & Frazier, [32]; Steed & Downing, [35]) have found that coping strategies can influence levels of vicarious traumatization and reduce the associated risks. These studies demonstrate the importance of identifying active coping strategies when it comes to dealing with vicarious traumatization.

Some evidence attests to relations between personality and coping (DeLongis & Holtzman, [12]; Lee-Baggley, Preece, & DeLongis, [21]). Coping has also been described as “personality in action under stress” (Bolger, [ 4], p. 525), and this process is influenced by both situation-specific elements and stable dispositional traits (Folkman & Moskowitz, [14]). Watson and Hubbard ([40]) reviewed a sizeable literature that supports this notion. Also, a more recent meta-analysis by Connor-Smith and Flachsbart ([ 7]) focused on the relationship between personality and coping and showed that extraversion and conscientiousness predict problem-focused coping styles, and neuroticism predicts maladaptive coping styles.

Coping has been examined in relation to other personality variables, such as self-efficacy (Schwarzer, Böhmer, Luszczynska, Mohamed, & Knoll, [33]), hardiness (Kobasa, [18]), and self-esteem (Guinn & Vincent, [15]). We focused on one model of personality that provides a useful context for assessing individual differences in coping strategy use: the five-factor model, a broad-based taxonomy of personality dimensions (Costa & McCrae, [ 8]).

THE CURRENT STUDY
The purpose of this study was to investigate vicarious trauma in the context of treating human pain. Through the nature of their work, medical staff have been typically identified as being indirectly and directly exposed to traumatic events more frequently than would normally occur in the general population. They work to rescue individuals and, although they learn to deal with many stressful events, some of them can have lasting effects. Physicians and nurses are exposed to many serious events in the workplace that occur unexpectedly and cannot be controlled. The term vicarious trauma is used to describe events that these persons can encounter during their work and the negative impact they can have. Changes in cognitive schemas are an indicator of vicarious trauma and consist of disruptions in beliefs about the self and others in the five areas of safety, intimacy, trust, control, and esteem.

According to McCann and Pearlman ([24]), a person’s level of vulnerability to vicarious traumatization could depend on the extent to which he or she is able to engage in a process of integrating and transforming the traumatic experiences. Presumably, such a process would diminish the disruption of vicarious traumatization. For this reason, we decided to study the role of coping in the development of dysfunctional beliefs. Also, although not everyone experiences vicarious trauma in the same way, personality differences were considered.

Based on previous research, we expected that (a) there would be differences between emergency and non-emergency staff concerning the presence of vicarious trauma and (b) the interactions between personality traits and coping would predict participants’ beliefs. As a moderating variable, coping can be considered a transactional process between individuals and posttrauma outcomes.

METHOD

Participants
The research took place in several hospitals in the city of Iasi, Romania. The participants in this study were 76 medical workers from the emergency and intensive care units. Also, we included in the study 70 participants from other departments of the hospitals. Participants who provided incomplete data were excluded from the analysis. The final sample of 131 participants consisted of 67.2% nurses, 25.2% physicians, and 7.6% resident physicians. Our sample was largely comprised of women (82.4%). Ages ranged from 24 to 65, with a mean age of 38.25 years (SD = 10.11). Participants had considerable experience in health care in general (M = 12.24 years, SD = 11.17). For some analyses, participants were divided into two groups: medical staff in the emergency section (63 participants; 48.1%) and medical staff from other sections (68 participants; 51.9%). All participants answered a set of questionnaires after signing a confidentiality contract.

Instruments

NEO FIVE-FACTOR INVENTORY
Personality was assessed using the NEO Five-Factor Inventory (NEO-FFI; Costa & McCrae, [ 9]). The NEO-FFI is a 60-item self-report measure of the five major domains of personality: neuroticism, extraversion, openness, agreeableness, and conscientiousness. Participants were self-rated on a 5-point Likert scale ranging from strongly disagree to strongly agree. Neuroticism assesses general mental stability/instability and includes items focusing on anxiety, hostility, depression, and vulnerability. Extraversion involves gregariousness and positive emotions. Openness refers to fantasy and appreciating ideas. Agreeableness refers to trust, altruism, compliance, and tender-mindedness. Conscientiousness includes items related to competence, order, achievement striving, and self-discipline. Cronbach alphas for the current sample ranged between 0.67 and 0.73 for the five scales.

COPING ORIENTATIONS TO THE PROBLEMS EXPERIENCED SCALE
The Coping Orientations to the Problems Experienced Scale (COPE; Carver, Scheier, & Weintraub, [ 5]) is a theoretically based, 53-item self-report measure. Participants are instructed to report what they usually do when they are under stress. Respondents chose their answers on a 4-point scale from not at all ( 1) to a lot ( 4). The COPE scale consists of three main dimensions: (a) problem-focused coping (active coping, planning, suppression of competing activities, restraint coping, seeking social support for instrumental reasons), (b) emotion-focused coping (seeking social support for emotional reasons, positive reinterpretation, denial, acceptance, religion), and (c) dysfunctional coping (venting, behavioral disengagement, mental disengagement). Of the three main dimensions, we choose to study only two: problem-focused and emotion-focused coping. Tests were conducted for internal reliability (Cronbach alpha) for each of the 10 subscales. Of the 10 subscales, five (instrumental support, emotional support, positive reinterpretation, religion, and denial) had Cronbach alphas ranging between.70 and.76. The others five scales that did not form a reliable measure were not analyzed further.

TRAUMA ATTACHMENT AND BELIEF SCALE
The Trauma Attachment and Belief Scale (TABS; Pearlman, [30]) is designed to assess the impact of directly and indirectly experienced trauma. The TABS has 84 items that are rated on a 6-point Likert scale (1 = disagree strongly, 6 = agree strongly). Negative items are reverse scored. In particular, it measures disruptions in beliefs related to five areas of need that are sensitive to the effects of trauma: safety, trust, esteem, intimacy, and control. Within each of these areas, separate sets of items tap into beliefs about oneself and others, yielding subscale scores and a total score. For the purposes of the current study, the total score was used; higher scores represent greater disruption. Although the TABS was originally designed to measure the impact of trauma upon victims (Pearlman, [30]), some researchers have used the instrument to assess the impact of indirectly experienced trauma (Cunningham, [11]; Pearlman & MacIan, [31]; Schauben & Frazier, [32]; VanDeusen & Way, [39]). The Cronbach alpha for the current sample was.92.

DEMOGRAPHIC VARIABLES
Demographic variables were collected via a questionnaire that covered age, gender, occupation, and work experience.

Procedure
Permission was obtained from the heads of the organizations, and informed consent was obtained from all of the participants. Participants were informed that their participation was voluntary, and then they were asked to complete a questionnaire battery on a confidential, take-home basis. Because their workload was very high, the participants completed the questionnaires at home. They were told that the purpose of the research was to obtain information about the way they think concerning various aspect of their life. In addition, they were asked to volunteer to complete the survey. They were also told that participation was not a requirement and that the information would be collected directly by the researchers, would be kept confidential, and would not become part of their Assessment. Participants completed all measures in the following (fixed) order: NEO-FFI, COPE, TABS, and demographic variables. The importance of answering truthfully was emphasized.

Hypotheses
Hypotheses for the study were as follows.

Hypothesis 1: There will be differences between emergency and non-emergency staff concerning the presence of vicarious trauma.

Hypothesis 2: The interactions between personality traits and coping will predict the participants’ beliefs.

RESULTS
Means, standard deviations, and correlation coefficients for all scales are reported in Table 1.

TABLE 1 Descriptive Statistics and Correlations Between Variables.

M SD 1 2 3 4 5 6 7 8 9 10 11 12 13
1. TABS Demographic variables 2.48 1.06 —
2. Age 38.25 10.11 −.19** —
3. Years of service Personality 12.80 11.17 −.17* .88** —
4. Neuroticism 32.36 6.65 .38** −.11 −.10 —
5. Extraversion 40.41 5.56 −.23** −.08 −.03 −.40** —
6. Openness 41.23 5.2 −.07 .20* .19* −.08 .35** —
7. Agreeableness 44.27 4.66 −.13 .23** .24** −.26** .18* .15 —
8. Conscientiousness Coping strategies 48.82 5.65 −.20* .03 .05 −.34** .26** .15 .34** —
9. Instrumental support 13.70 2.68 −.04 −.04 −.00 .12 .16 .24** −.00 −.00 —
10. Emotional support 12.73 2.95 −.02 −.11 −.08 .14 .22** .22** .01 −.04 .64** —
11. Positive reinterpretation 15.92 2.34 −.24** .26** .24** −.29** .36** .27** .35** .33** .16 .15 —
12. Religion 9.37 2.83 .14 .18* .12 .09 −.19* −.03 .008 −.11 .04 .001 .001 —
13. Denial 10.18 2.67 .08 .17* .17* .17* −.01 .21* .01 −.03 .19* .29** .19* .16 —
Hypothesis 1
A t-test analysis was conducted to examine the differences between medical staff who provide services in emergency situations and medical staff from other departments of the hospitals. The results revealed that there were statistically significant differences in the ratings of dysfunctional beliefs, t(129) = 7.11, p < .001, with higher scores among emergency workers (M = 241.03; non-emergency M = 199.70). These results confirm our first hypothesis. Emergency medical personnel experience a significantly higher level of dysfunctional beliefs in comparison to other professionals who do not systematically interact with victims of traumatic events. Further analyses were conducted using data from the entire sample.

Hypothesis 2
In order to examine potential predictors of dysfunctional beliefs, bivariate correlations (as shown in Table 1) were first examined with three sets of variables: demographic variables, personality traits, and coping strategies. A hierarchical multiple regression was then conducted, using only predictors that correlated significantly with the specific criterion variable. Demographic variables (age and years of practice) correlated significantly with higher disruptions in beliefs. Disrupted beliefs about the self and others were also positively related to neuroticism (r = .8) and negatively related to extraversion (r = − .23) and conscientiousness (r = − .20). Openness and agreeableness, however, were not significantly related to dysfunctional beliefs in our sample (r = − .07 and r = − .13, respectively).

Religion, denial, and instrumental and emotional support did not correlate significantly with dysfunctional beliefs and were therefore not used in regressions with this dependent variable. Higher use of positive reinterpretation correlated with lower disruptions in beliefs. We examined positive reinterpretation as a potential moderator when personality was associated with disruption in beliefs.

We conducted a hierarchical multiple regression analysis (Cohen, Cohen, West, & Aiken, [ 6]) of personality traits, positive reinterpretation, and vicarious trauma beliefs, with the Big Five traits main effects entered in the first step, positive reinterpretation’s main effect in the second step, and the personality–positive reinterpretation interaction in the final step. Main and interaction effects were centered to minimize multicollinearity (Aiken & West, [ 2]). Individual variables within a given set were not interpreted unless the set as a whole was significant.

The results, which are summarized in Table 2, showed that neuroticism (β = .31, p < .001), extraversion (β = − .28, p < .001), and conscientiousness (β = − .21, p = .005) were significant predictors of vicarious trauma beliefs. In addition, positive reinterpretation was a significant predictor of vicarious beliefs (β = − .21, p = .005). Standard multiple regression showed that personality traits accounted for 36% of the variance in dysfunctional beliefs, adjusted R2 = .36, F( 3, 130) = 25.92, p < .001, while coping strategies accounted for 39% of the variance in dysfunctional beliefs, adjusted R2 = .41, F( 4, 130) = 22.61, p < .001. Those participants who reported a higher level of neuroticism and a lower level of extraversion, conscientiousness, and positive reinterpretation were more likely to report higher levels of dysfunctional beliefs. We also found significant interactions between conscientiousness and positive reinterpretation when it came to predicting dysfunctional beliefs (Figure 1).

Graph: FIGURE 1 Vicarious trauma beliefs as a function of conscientiousness and positive reinterpretation. Simple effects were represented with conscientiousness and positive reinterpretation scores defined as at least +1 and −1 standard deviations from the mean, respectively. (Color figure available online.).

TABLE 2 Hierarchical Regression Models of Personality Traits and Positive Reinterpretation on Dysfunctional Beliefs.

Variables (outcome: TABS) β T ΔR2 ΔF
Step 1 .36 25.92
Neuroticism .31 3.96
Extraversion −.28 −3.73
Conscientiousness −.21 −2.86
Step 2 .39 22.61
Positive reinterpretation (PR) −.21 −2.87
Step 3 .40 13.79
Neuroticism PR −.001 −.013
Extraversion PR .08 1.018
ConscientiousnessPR −.14 −1.96
DISCUSSION
The results of our study suggest that personality could be a source of variation between individuals in dysfunctional beliefs. These relations largely supported the hypotheses posed. Also, these results replicate and extend findings from previous research. As in previous studies (e.g., Culver, McKinney, & Paradise, [10]; Miller, Flores, & Pitcher, [26]), our results support the claim that vicarious traumatization can lead to changes in cognitive beliefs/schemas. The highest levels of extraversion and conscientiousness predict a lower level of dysfunctional beliefs, whereas a higher level of neuroticism predicts a higher level of dysfunctional beliefs. Our data show that neuroticism is the strongest predictor of vicarious trauma, this result being in accordance with previous research (e.g., Watson & Hubbard, [40]).

In addition, our results reveal that positive reinterpretation interacted only with conscientiousness in predicting vicarious trauma. Specifically, participants with a high level of conscientiousness had higher scores on the dysfunctional beliefs scale when they reported a lower level of positive reinterpretation. At the same time, dysfunctional beliefs scores were higher when participants had a low level of conscientiousness and a high level of positive reinterpretation. In other words, focusing on positive aspects of the profession has a beneficial effect on the individual only when his or her level of conscientiousness is high. Individuals scoring high on conscientiousness tend to be careful, responsible, and organized. When these qualities are not present, positive reinterpretation makes an individual more vulnerable to disruption by exposure from traumatic life experiences. Although people with high conscientiousness scores tend to use more problem-focused coping strategies (Hooker, Frazier, & Monahan, [17]) and engage in less emotion-focused coping (Hooker et al., [17]), positive reinterpretation, as a form of emotional coping, has a positive effect only in interaction with a high level of conscientiousness. This result could lead to the conclusion that conscientiousness is one of the most important traits that help individuals adjust to the demands of their workplace.

Also, based on previous research, higher levels of conscientiousness have been shown to significantly relate to positive changes in the wake of a traumatic event (Tedeschi & Calhoun, [37]) and to posttraumatic growth (Shakespeare-Finch, Gow, & Smith, [34]). Because helping people can lead to professional satisfaction and can help these workers improve their well-being (Ohaeri, [29]), focusing on positive aspects can protect people from vicarious trauma. Coping strategies are more like dispositions, while personality traits are stable factors. Since it is relatively difficult to change the Big Five personality traits, clinicians should focus on coping styles. These findings could be applied to counseling or management of health professionals by encouraging health professionals to change their coping strategies in order to better adjust to the demands of the workplace.

Is well known that the effects of vicarious traumatization can include multiple affective symptoms, changes in cognitive schemas, disruptions in various life areas, and altered perceptions of the self, others, and the world. This research adds to the current body of knowledge regarding potential posttrauma outcomes and provides evidence that personality and coping variables play a role in people’s perceptions of their own posttraumatic outcomes. Through this study, we support the idea that intervention strategies may be more effective if they are organized according to individuals’ underlying personality dispositions, rather than according to the nature of an event itself (Moos, [28]).

In this study, increased age and years of service correlated with decreased disruption in beliefs. These results are in accordance with previous research (Pearlman & MacIan, [31]) but are inconsistent with constructivist self-development theory, which posits that vicarious traumatization results from cumulative exposure to traumatized clients over time. Further research is needed to clarify these aspects.

LIMITATIONS AND FUTURE DIRECTIONS
This study has some limitations. One is related to the fact that all variables were measured using self-reports. Also, this study was cross-sectional and required participants to recall coping efforts they usually used under stress. In this case, reports may be subject to memory biases (Moore, Sherrod, Liu, & Underwood, [27]). Longitudinal prospective research with trauma workers may help elucidate these relationships. Additionally, we suggest the need for a longitudinal study to clarify the cumulative effects of vicarious traumatization.

Another limitation of the present study concerns the generalization of the findings. Because there were a small number of men in our sample, the results of our study are most applicable to women. Further work is needed to replicate these findings in still larger samples, openly addressing both men and women. We also want to specify that we tested some exploratory hypotheses that need replication for greater confidence in these results.

In conclusion, the results converge to suggest that there is a significant relationship between personality, coping, and vicarious trauma, but further examination of the other dimensions of coping and particular types of vicarious trauma beliefs (esteem, safety, control, intimacy, trust) in this population is warranted. The present findings may guide future prospective research on individual differences in physicians’ and nurses’ vulnerability to vicarious trauma over time. Developing a clearer understanding of which personality factors relate to particular coping strategies and how coping dimensions relate to different dysfunctional beliefs may help in the construction of pre-event education and intervention processes. Further research should also take into consideration the possibility that specific personality facets will better predict disruption in beliefs than do broad traits.

Acknowledgments
This work was supported by the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectoral Operational Programme for Human Resources Development 2007–2013 (Grant POSDRU/CPP 107/DMI 1.5/S/78342 awarded to Cornelia Mǎirean).

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Footnotes
Note. TABS = Trauma Attachment and Belief Scale.

*p < .05; **p < .01.

Note.N = 111. TABS = Trauma Attachment and Belief Scale.

*p < .05; **p < .01.

~~~~~~~~

By Cornelia Mǎirean and MariaNicoleta Turliuc

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Enhancing resilience as a self-care strategy in professionals who are vicariously exposed to trauma: A case study of social workers employed by the South African Police Service.
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Authors:
Masson, Francine. Department of Social Work, University of the Witwatersrand, Johannesburg, South Africa, francine.masson@wits.ac.za
Address:
Masson, Francine, Social Work Department, University of the Witwatersrand, Private Bag 3, Johannesburg, South Africa, 2050, francine.masson@wits.ac.za
Source:
Journal of Human Behavior in the Social Environment, Vol 29(1), Jan, 2019. pp. 57-75.
NLM Title Abbreviation:
J Hum Behav Soc Environ
Page Count:
19
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
1091-1359 (Print)
1540-3556 (Electronic)
Language:
English
Keywords:
Resilience, vicarious trauma, coping strategies, self-care, social workers
Abstract:
Social workers employed by the South African Police Service Social workers employed by the South African Police Service in either an occupational or forensic capacity are vulnerable to vicarious trauma. In order to enhance coping it is imperative that social workers develop self-care practices. In the last few decades, the concept of resilience has received significant attention, particularly in relation to coping with trauma. Hence, the aim of the study was to explore resilience levels in a social work population employed in a traumatogenic environment. A mixed methods research design was adopted and 128 social workers participated in the study. From a quantitative perspective, the Resilience Scale was used to explore resilience levels of social workers. Qualitative interviews were then conducted with 30 social workers to further explore the concept of resilience. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were subjected to thematic analysis. The majority of social workers had medium to high levels of resilience. Interview participants predominantly identified how personality characteristics contributed to resilience. Some, however, had a broader understanding of resilience and included cultural and community influences in strengthening resilience. As part of their self-care practices, social workers need to strengthen and build on their own resilience. Individuals and organizations have a responsibility in this regard to help ameliorate the effects of vicarious trauma. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Resilience (Psychological); *Self-Care Skills; *Social Workers; *Trauma; Vicarious Experiences; Self-Care
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
South Africa
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Resilience Scale DOI: 10.1037/t55271-000
Grant Sponsorship:
Sponsor: National Research Foundation of South Africa, South Africa
Grant Number: 92681
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20191118
Correction Date:
20200713
Copyright:
Taylor & Francis Group, LLC. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/10911359.2018.1474159
Accession Number:
2019-01058-007
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Enhancing resilience as a self-care strategy in professionals who are vicariously exposed to trauma: A case study of social workers employed by the South African Police Service
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Contents
Introduction
Understanding vicarious trauma
Understanding resilience
Family and cultural resilience
Resilience and trauma
Aim of the study
Research design and methodology
Research design
Participants and sampling procedure
Research instruments
Demographic information
The resilience scale (RS)
Interview schedule
Procedure
Analysis
Results and discussion
Participants
Resilience levels in the social workers
Vicarious trauma and resilience
Participants’ understandings of their own resilience
Understanding resilience
Vicarious resilience
Conclusions and recommendations
References
Full Text
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Social workers employed by the South African Police Service Social workers employed by the South African Police Service in either an occupational or forensic capacity are vulnerable to vicarious trauma. In order to enhance coping it is imperative that social workers develop self-care practices. In the last few decades, the concept of resilience has received significant attention, particularly in relation to coping with trauma. Hence, the aim of the study was to explore resilience levels in a social work population employed in a traumatogenic environment. A mixed methods research design was adopted and 128 social workers participated in the study. From a quantitative perspective, the Resilience Scale was used to explore resilience levels of social workers. Qualitative interviews were then conducted with 30 social workers to further explore the concept of resilience. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were subjected to thematic analysis. The majority of social workers had medium to high levels of resilience. Interview participants predominantly identified how personality characteristics contributed to resilience. Some, however, had a broader understanding of resilience and included cultural and community influences in strengthening resilience. As part of their self-care practices, social workers need to strengthen and build on their own resilience. Individuals and organizations have a responsibility in this regard to help ameliorate the effects of vicarious trauma.

Keywords: Resilience; vicarious trauma; coping strategies; self-care; social workers

Introduction
South Africa is a particularly violent country that has been characterized by and has experienced much brutality and social division (Higson-Smith, 2008). Following the end of apartheid, the violence changed from political violence and continued in the form of criminal violence (Hamber & Lewis, 1997). Such crime, particularly violent crime, has reached pandemic proportions (Bruce, 2006) and consequently, the extent of trauma with which police officials deal, has increased significantly (Steinberg, 2008). For example, police crime statistics for the period 2015/16 – 2016/17 reveal that South Africans are 13% more likely to be murdered than they were 5 years ago. On average, there are 50 attempted murders and 61 home robberies per day. As many as 136 sexual offenses were committed daily, with 109 being rape cases. Forty-six vehicles were hijacked on a daily basis, and there were 16 aggravated (violent) robberies every hour (Africa Check, 2017). Police stress in South Africa has received much attention from researchers and academics (Bruce, 2007; Dixon, 2012; Steinberg, 2008), however, what about the forgotten population that exists within the South African Police Service (SAPS), the social workers who work alongside detectives or who provide Helpance for these officers? It seems reasonable to assume that the amount of traumatic material to which social workers who counsel the police officers or who Help police with forensic investigations in cases are exposed, is likely to be significantly high.

Social workers may experience secondary traumatic stress and vicarious trauma as they endeavor to Help clients who have experienced traumatic events (Bride, 2007; Killian, 2008). For SAPS occupational social workers this exposure to the traumatic material may occur through listening to the traumatic experiences of police officers, while for the SAPS forensic social workers as a result of conducting forensic investigations into allegations of child abuse. Secondary traumatic stress may negatively impact on social workers at both personal and professional levels and result in poor service delivery to clients. As a result of their work, social workers may also experience vicarious trauma and changes in their worldviews, their views on humanity and their own sense of meaning. Social workers in this population completed the Trauma and Attachment Belief Scale (Pearlman, 2003) which measured vicarious trauma and were found to have a high-average level of vicarious trauma (Masson, 2016). As vicarious trauma levels are a concern, individuals need to ensure that they maintain and nurture their personal selves in order to perform effectively on a professional level. Adopting personal self-care strategies, might at times feel selfish for practitioners who often find caring for others a more natural process than caring for themselves. However, self-care is imperative in order to be an effective and resilient trauma counselor. The questions arise: What are the resilience levels in social workers working for SAPS and can they develop their own resilience as part of their self-care strategies in dealing with vicarious trauma? This study endeavored to answer these questions and contribute to the discourse about resilience.

Understanding vicarious trauma
McCann and Pearlman (1990) explain the concept “vicarious traumatization” to describe a transformation in the therapist’s inner experience occurring from empathic engagement with clients’ trauma material. Pervasive changes can occur within clinicians over time, due to counseling clients who have experienced trauma. Vicarious traumatization therefore refers to alterations in the cognitive schemata of trauma counselors’ identity, memory system and belief systems (Robinson-Keilig, 2014; Trippany, White Kress, & Allen Wilcoxon, 2004). Through their empathic openness therapists are vulnerable to both emotional and spiritual effects of vicarious traumatization, which can be evident in both the therapists’ personal and professional lives (Saakvitne & Pearlman, 1996). These authors state that while there is an overlap between secondary and vicarious trauma, they differ in focus and emphasis (Ortlepp, 1998). Vicarious traumatization occurs as a result of the cumulative effect upon a therapist who counsels trauma victims. “Vicarious traumatization can have an impact on the helper’s sense of self, world view, spirituality, affect tolerance, interpersonal relationships, and imagery system of memory” (Pearlman, 1999, p. 52).

The effects of dealing with the trauma of others can result in the individual questioning former beliefs and perceptions about life. Jerik (2015) referred to vicarious trauma as ‘soul pain’. In her qualitative study with advocates working with survivors of physical and sexual violence, participants spoke about how they felt that they had been spiritually wounded as a result of listening to their clients’ stories of human brutality. Jirek concluded that working with trauma survivors is likely to affect the soul and spirit of those who try to Help survivors. Courtois (2010) posits that vicarious trauma overlaps to some degree with burnout and counter-transference. However, vicarious trauma differs from burnout in that it specifically involves patterns of re-experiencing clients’ trauma, avoidance, numbing, and persistent arousal. Vicarious trauma could be considered a special type of counter-transference; however, there are not necessarily pre-existing characteristics or unresolved psychological conflicts to explain therapists’ reactions (Figley, 1995; Saakvitne & Pearlman, 1996). Trauma researchers in the last few decades appear to have had a specific interest in understanding why individuals differ in their vulnerability to symptom development and the onset of traumatic symptoms, which have resulted in trauma researchers exploring the concept of resilience.

Understanding resilience
There have been many debates and disputes about an exact understanding of what the term ‘resilience’ means. Some authors emphasize ego control, while others refer to self-esteem and self-efficacy; some to hardiness and yet others to internal and external risk and protective processes (Wagnild, 2009). Jacelon (1997, p. 123) defines resilience as “a personality characteristic that moderates the negative effects of stress and promotes adaptation.”

Research into resilience began in the 1970s, when researchers studied children who, despite living in highly stressful environments managed to progress through normal development. From a developmental perspective, Flach (1998) understands resilience to be a cyclical process. It begins with a divergent stress point which disturbs the homeostasis of the individual and which then results in chaos. Resilience, at this point, is initiated leading to reintegration and a new homeostatic structure at a higher level of functioning. Flach’s understanding of resilience has two phases: disintegration and reintegration. Milner and Palmer (1998) maintain that resilience is a combination of an individual’s physiology and personality factors that predispose individuals to different degrees of resilience. The exploration of resilience subsequently had two distinctive discourses, namely the outcome of resilience and the processes that produce resilience (Ungar, 2012). While there appears to be a general understanding and consensus regarding the outcome of resilient behavior, Jacelon (1997) highlights the controversy surrounding the mechanism of resilience. Whereas some theorists identify resilience as a trait inherent in individuals, others view resilience as a process which may be learned (Wagnild, 2009). Recent understandings of resilience have subsequently moved towards a system concept and away from an intrapsychic concept (Van Breda, 2017).

Clark and Clark (2003) believe that there are significant differences in the way people show their resilience. They believe that resilience is formulated from three particular influences, namely, personal characteristics, external support, and the duration of such support. Personal characteristics or inner resources include sociability, problem-solving ability and the development of self-esteem. People with strong resilience appear to have personal qualities and interact with strong external support for a long duration. This classification of resilience should not be regarded as static for an individual because if any of the variables change, so will the complex interaction of all the other variables and functioning change. These authors explain that successful adaptation to adversity strengthens resilience whereas unsuccessful adaption leads to greater vulnerability. Le las Olas & Hombrados-Mendieta (2014) explored the development of resilience in 613 social work students and social work professionals in Spain. Their results showed that there was a positive association between years of social work experience and their acceptance of self and workplace adversity, showing that resilience increases with experience. Spirituality also appears to have an important influence in the development of an individual’s resilience. In a study exploring coping strategies of Mexican American women who had experienced inter-personal violence De La Rosa, Barnett-Queen, Messick, and Gurrola (2016) found that women who score higher on spirituality also reported greater resilient characteristics.

Ungar (2012) describes the social construction aspects of the theory of resilience and views resilience from a post-modern perspective. Adapting Foucault’s understanding of inquiry he explores the notions of power that explain social interactions. Understanding mental health depends on one’s notion of health and ill health and how society perceives and defines acceptable behavior. This perspective shows how the understanding of what constitutes resilience changes over time and in different contexts. While achieving resilience may appear to promote optimal functioning, developing resilience in one domain (e.g., mental health) can be at the expense of resilience in another domain (e.g., physical health). In their study on resilience, Pole, Kulkarni, Bernstein, and Kaufmann (2006) illustrate this understanding by explaining that if police officers repress fear and sadness which they feel as a result of their work, they may experience physical health problems as a result of the emotional suppression, such as high blood pressure. The environmental and personal factors that have been studied and identified as barriers to health and well-being are often referred to as risk factors. Environmental risk factors include low socioeconomic status, sub-optimal academic achievements, poor family functioning as well as chronic and profound stressors. Personal risk factors include constitutional traits like temperament, sensory-motor deficits, unusual sensitivities, inability to bear frustration or maintain relationships, low self-esteem, and feelings of incompetence (Ungar, 2004). Like different sides of the same coin resilience only develops when there is a risk.

Family and cultural resilience
Carlton et al. (2006) explain that resilience indicators have moved beyond focusing only on individual aspects, to include family and community aspects. Family factors that influence well-being include family support, family caring, relationship formation, and maintenance of parental/self-expectations. In addition, Moss (2010) who studied resilience amongst South African social work client families, incorporates family strengths, adaptability, communication processes, belief systems, navigation of family risks, and the protective buffer systems consequently established as important characteristics contributing to family resilience. Community factors that promote resilience include extracurricular activities, peer support, religion, and community involvement. Cultural identity is an important component of resilience in individuals, especially in those from oppressed or minority cultures. In order to have a healthy cultural identity, individuals need to identity with the cultural strengths inherent in that culture. Van Breda (2001) cites HeavyRunner and Morris (1997) who maintain that children develop natural resilience when they are taught cultural values, which are then cherished and nurtured. This resilience emanates from a healthy and respectful cultural identity. In a qualitative study with 14 South African students, Theron and Theron (2013) explored how positive adjustment occurred in these students as a result of their resilience-supporting interactions within their family communities. In particular, these students’ resilience was developed through kinship and the family community’s focus on mutuality.

Resilience and trauma
The individualistic interpretations and the subjective manner in which people experience the nature, intensity, and duration of symptoms are indicative of the complexity of trauma. Harvey (2007) identifies demographic factors (age, race, class, and gender); neurobiological mediators of hardiness and vulnerability; social, cultural and political contexts as well as access to support and professional Helpance as factors that may influence how an individual responds to a traumatic event. In addition, a key issue is why some individuals exposed to trauma are not at risk of symptom development. Some individuals (irrespective of whether they received professional Helpance after the traumatic event) do not develop persistent Post Traumatic Stress Disorder (PTSD). In fact, some appear to thrive in response to trauma. This response has been termed “positive” or “adversarial” growth post-trauma. Nuttman-Schwartz (2014) identifies two competing discourses explaining resilience and post-traumatic growth—one that says post-traumatic growth (PTG) is superior to resilience and another that says resilience is inversely associated with PTG.

In a study of resilience with 87 volunteer Israeli body handlers, Solomon, Berger, and Ginzburg (2007) assessed how coping styles affected resilience. They understood resilience to be an absence of symptoms in the face of traumatic experiences. They found that body handlers who engaged in a repressive coping style reported lower levels of psychiatric symptomology and greater resilience than non-repressors. Repressive coping styles referred to the tendency to avoid negative thoughts and emotions or threatening experiences. Findings showed that repressive coping styles contributed to the reduction of psychiatric symptomology. The fact that these body handlers all had strong religious beliefs, mutual support, and group cohesion were found to be resilience-bolstering factors. What this study highlights is that repressive coping can have positive effects and may be a necessary coping strategy in certain situations, therefore repressive coping can be viewed as having both positive and negative consequences.

Exposure to indirect trauma has the potential to impact every area of the social worker’s life. The effects of a traumatic event are determined not only by the extent of the trauma exposure but also by the coping methods that one utilizes in order to deal with stress and trauma. The coping strategies utilized may ameliorate or further exacerbate the individual’s overall functioning. Effective coping helps to reduce traumatic stress, whereas ineffective coping can exacerbate the trauma response (Davies, 2001; Figley, 1995). Interventions in the treatment of trauma have focused primarily upon primary trauma survivors while not as much attention has been given to ensuring effective treatment for secondary victims. Bercier and Maynard (2015) assert that more outcome research is required to assess effective strategies in the treatment of secondary traumatization. Furthermore, clinicians often acknowledge that their professional training has not adequately prepared them for how to cope with their personal responses that may arise when working with trauma victims (Jacobson, 2012; Salston & Figley, 2003). Van Breda (2011) refers to the ‘pile up’ of events which can increase the vulnerability of an individual. The occurrence of multiple life stressors or traumatic situations that are not dealt with and instead “pile up” can diminish resilience. For social workers who are over-worked, with high caseloads and numerous traumatic cases, this ‘pile up’ can easily occur resulting in them being more susceptible to secondary traumatization. Reflexive practice and increased self-awareness would not only enhance the quality of counseling services offered to clients but could potentially Help practitioners to regulate the negative effects of vicarious trauma and increase work satisfaction.

Aim of the study
Against this theoretical backdrop, the aim of the study was to explore the levels of resilience in social workers who are vicariously exposed to trauma and to determine the characteristics which develop resilience. It was hypothesized that there would be a significant relationship between vicarious trauma and resilience.

Research design and methodology

Research design
The research methodology employed was a hybrid of both quantitative and qualitative paradigms. In recent years there has been an increasing demand and need for researchers in the social sciences to integrate both quantitative and qualitative designs (Barnes, 2012). The predominant strength of a mixed methods design is that it allows for research to develop as comprehensively and completely as possible.

This research could be considered a case study as it involved an in-depth analysis of a bounded system comprising social workers employed at SAPS. As Rossman and Rallis (2003, p. 114) explain, “case studies are in-depth and detailed explorations of single examples (an event, process, organisation, group or individual).” A mixed method approach, using both quantitative and qualitative data, can still be classified as a case study when it covers a bounded system (Payne & Payne, 2004). Henning, van Rensberg and Smit (2004, p. 42) advocate this mixed approach when they explain, “case studies require multiple approaches in order to truly capture the case in some depth.”

Participants and sampling procedure
The survey containing the quantitative research instruments was distributed to the entire population of approximately 200 social workers who worked for SAPS at the time of the study; therefore sampling was not used in this first phase as every member of the population was invited to participate. All social workers working for SAPS throughout South Africa, both occupational and forensic social workers, were invited to participate as long as they were working in an operational capacity and had been employed by the organization for a minimum of 2 years.

Research instruments

Demographic information
A brief demographic questionnaire was designed in order to obtain essential biographical and background information about the participants. This information included participants’ age, gender, race, marital status, educational qualifications as well as their rank within SAPS and length of employment at SAPS, and was requested in order to provide a meaningful interpretation of the results.

The resilience scale (RS)
The Resilience Scale was first developed in 1993 to measure resilience. The developers, using grounded theory research, identified five characteristics of resilience, namely self-reliance, meaning, equanimity, perseverance, and existential aloneness (Wagnild, 2009). The scale has 25 items and comprises five sub-scales reflecting the five characteristics identified above. The total resilience score is obtained by adding the scores from the five sub-scales. Levels of resilience are calculated according to a scoring schedule, with higher scores indicating higher resilience. The Cronbach Alpha coefficients range from 0.84 to 0.94. Internal consistency reliability was strong (r = 0.91) and concurrent reliability also had good results. The validity of this scale has been supported in many published studies and demonstrates excellent validity (Wagnild, 2009).

Interview schedule
During the second phase of the data collection, qualitative interviews were conducted using a structured interview schedule comprising 20 questions. The themes that were explored in the interviews included the participants’ experiences of secondary and vicarious trauma as well as their coping and self-care strategies and understandings of resilience. The average duration of each interview was about 60 minutes.

Procedure
Before commencing with the study, ethical clearance was obtained from the University of the Witwatersrand’s non-medical ethics committee. Efforts were made to adhere to ethical principles of research including, confidentiality, anonymity, non-maleficence, voluntary participation, anonymity, and benevolence. Permission was also obtained from the South African Police Service. The researcher attended various sectional meetings of the social workers where she distributed the questionnaires. In the questionnaire which contained the quantitative research instruments, participants were asked to indicate if they were willing to be interviewed. From those participants who were willing to be interviewed the researcher purposively chose 30 social workers and interviewed them either face-to-face, telephonically or using Skype.

Analysis
Descriptive and inferential statistics were used to analyze the quantitative data using the Statistical Package for Social Sciences (SPSS). In order to ensure that appropriate statistical procedures were applied in this study, a statistician was consulted. Specific statistical procedures utilized involved a combination of Analysis of Variance (ANOVA); correlations, t-tests, chi-squared tests; and regression. Qualitative data were analyzed using Terre Blanche, Durrheim, and Painter (2006) steps in thematic analysis, namely, familiarization and immersion, inducing themes; coding; elaboration; and interpretation and checking.

Results and discussion

Participants
At the time of the study there were significantly more occupational social workers (OSWs) employed at SAPS than forensic social workers (FSWs), which is reflected in the sample of participants as 102 (79.69%) were OSWs and 26 (20.31%) were FSWs. In keeping with the feminization of the social work profession in South Africa (Sithole, 2010), there were considerably more female social workers (115 or 89.84%) than male social workers (13 or 10.17%). OSWs at SAPS Help the police officers whereas FSWs investigate child abuse cases reported to the police (Stutterheim & Weyers, 1999). There were no male forensic social workers as all the male social workers were occupational social workers. The racial distribution of the participants was as follows: the majority (80 or 62.5%) were Black, followed by 28 (21.88%) White, 18 Colored[ 1] (14.06%) and 2 Indian (1.56%). In the national census conducted in 2015, the South African population was made up of 80.5% Black Africans, 8.8% Coloreds, 8.3% Whites and 2.5% Indian/Asian (Statistics South Africa, 2015).[ 2] While the racial breakdown of the study sample was not representative of the South African population it may have been more proportionally reflective of the social workers employed at SAPS as well as the SAPS employee population.

1 Meyer (2014, p. 161) explains that “‘Coloured people’ refer to the descendants of the Malaysian slaves in South Africa (forced migration by the Dutch East India Company) who inter-married with White farmers and local Khoi people.”

2 South African organisations are expected are expected to categorise people according to these racial groups so that the government can monitor transformation.

Resilience levels in the social workers
Figure 1 shows how most participants scored either a medium (64 or 50%) or high (52 or 40.63%) level of resilience and only a few (12 or 9.38%) had low levels of resilience. None of the male participants had low levels of resilience and most females had medium levels of resilience (57 or 44.53%). Although males had higher mean scores (M = 146.71;SE = 3.02) than females (M = 140.62; SE = 1.3) but the difference was not statistically significant (t[16.797] = 1.853; p > 0.05). Recent resilience studies have found that there are gender differences. For example, the study by Stratta et al. (2013), found that male students who experienced an earthquake had higher resilience levels than female students. Stratta et al.’s (2013) study suggests that there is a need for one to adopt a gender-sensitive approach when enhancing resilience in practitioners.

The mean resilience score for superintendents (M = 138.31; SD = 13.2) was lower than for warrant officers (M = 139.92; SD = 14.1) and captains (M = 142.72; SD = 13.23). Lieutenant colonels have greater responsibility and may be more frequently exposed to more of the severely traumatic cases which may increase their vulnerability and account for lower resilience scores. Looking at whether there were racial differences, the resilience mean score for Coloreds (M = 135.78; SD = 16.54) was lower than for Whites (M = 137.54; SD = 13.22) and Blacks (M = 143.36; SD = 12.78), although this result was not significant. Racial differences were also explored through a regression model.

PHOTO (COLOR): Figure 1. Resilience scores of the participants (N = 128).

PHOTO (COLOR): Figure 2. Box chart showing participants’ resilience score and their perceptions of their resilience (N = 106).

The linear regression model explains 9.8% of the differences in the resilience scores. When controlling for other variables, forensic social workers scored an average of 7.93 points lower than occupational social workers, indicating that they were less resilient than occupational social workers. One could attribute this finding to the nature of forensic social work in that these social workers may find it harder to build defenses or become desensitized when investigating children who may have been abused since children represent one of the most vulnerable groups in society. Captains were also found to be more resilient than warrant officers and had an average score of 5.56 higher on the resilience scale. As the entry-level rank for a social worker is a warrant officer, one can assume that the captains had been employed for longer at SAPS than the warrant officers and therefore had developed more resilience over time.

Black social workers’ mean scores did not differ substantially between sub-scales (Range = 28.04-29.5) and were higher than other racial groups. Colored and White social workers had the lowest mean scores for equanimity (M = 25.5; SD = 5.35) and (M = 25.28; SD = 4.88), while self-reliance was the highest mean score for Coloreds (M = 28.44; SD = 2.975) and Whites (M = 28.57; SD = 2.31). This finding suggests that these racial groups may have a less balanced perspective on life and place emphasis on being self-reliant. Indian social workers obtained high results for all the sub-scales, with perseverance being the highest (M = 32.5; SD = 2.12) and equanimity (M = 29.00; SD = 1.44) the lowest. However, as there were only two Indians in the sample, results in respect of this sub-group need to be interpreted with caution.

Vicarious trauma and resilience
The hypothesis stated that there was a significant relationship between vicarious trauma and resilience. The null hypothesis proposed that there was not a significant relationship between these two variables. Results showed that there was a negative and highly significant relationship between vicarious trauma and resilience (r = – 443; p < 0.01). This finding indicated that higher levels of resilience were associated with fewer vicarious trauma symptoms. Both vicarious traumatization and resilience develop over time and occur as a result of exposure to, or experiences of, adversity. Moreover, vicarious trauma and resilience are both constructs that are reflective of or built upon the belief structure of the individual. The process of enhancing the characteristics of resilience is likely to decrease vulnerability and subsequent negative changes in beliefs and thoughts, which are characteristics of vicarious traumatization.

Participants’ understandings of their own resilience
Participants were asked to rate their own levels of resilience on a Likert scale. Most survey participants (102 or 79.69%) indicated that they considered themselves to be resilient. Only 9 or 7.31% felt that they were not resilient, while 17 (13.28%) did not answer this question. Pearson’s product moment correlation coefficient was used to determine if participants’ perceptions of their resilience were correlated with their total resilience levels and the results showed that there was a positive and highly significant relationship (r = 0.485; p < 0.01). These results are displayed in Figure 2. The figure also indicates the outlier scores, showing that a few social workers’ perceptions of their resilience levels were greater than the resilience score that they obtained.

In order to be effective practitioners, social workers need to have appropriate levels of self-awareness, and in particular they need to be aware of their strengths and weaknesses. Resilience and age of participants were also positively correlated and significant (r = 0.206; p < 0.01), indicating that resilience does appear to develop over time and through life experience. Consequently, particular emphasis needs to be placed on Helping younger social workers within SAPS to develop resilience by creating appropriate spaces where the more mature social workers, who are potentially more resilient, can share their experiences and mentor younger social workers.

Contemporary social work practice incorporates a strengths paradigm that does not focus only on the weaknesses of clients but also explores their strengths and opportunities. As Saleeby (2002, p. 4) explains, social workers need to “mobilise client’s strengths (talents, knowledge, capacities, resources) in the service of achieving their goals and visions and the client will have a better quality of life on their own terms”. Strength-based principles compliment the understanding of resilience. The SAPS social work service adopted the strengths based approach as the basis of the occupational social work practice within SAPS (Stutterheim & Weyers, 2004). Considering that this professional approach is adopted with clients, practitioners themselves need to be aware not only of their weaknesses but of their strengths consequently adopting strategies to enhance their own resilience.

Understanding resilience
As resilience can be culturally and context-specific (Truter, Theron, & Fouche, 2014), one needs to determine what factors contribute to resilience in individuals in a particular context. When exploring the construct of resilience, participants were asked how they understood the term resilience and what (if anything) they could identify within themselves, their community or their work environment which contributed to their resilience in coping with the traumatic aspects of their work. Some participants were not familiar with the term resilience and so the researcher provided the explanation that ‘resilience is the ability to bounce back from adverse (difficult) circumstances and enhance well-being’ (Turner, 2001, p. 441). All participants were able to identify specific aspects contributing to their resilience. Some participants could identify these aspects more easily than others, who appeared rather pensive and could not easily identify the factors contributing to their resilience. While the term resilience has been around since the 1800s, it is only since the 1970s that resilience research gained momentum as physiological and psychological domains collaborated in understanding resilience as a construct (Tusaie & Dyer, 2004).

Acknowledging that developing resilience was a process, one participant felt she was resilient but to get to this point had been quite a journey for her “Yes…but it’s been a hard road to travel (to become resilient)” (P22). Another participant elaborated on this discourse when she explained, “I think… for me, like now I can, I can stand some of the things that I couldn’t before. I can face some of the challenges that I was, that I couldn’t face before” (P11). The debate as to whether resilience is a process or occurs as a result of being a character trait has dominated resilience literature, as researchers have tried to create a universal understanding of the construct (Folke, 2006; Van Breda, 2017; Wagnild, 2009). According to Wagnild (2003) resilience, however fluid, is not a process but an enduring personality characteristic. He understands resilience to be an inherent personality trait, which, depending on life’s circumstances, can either be developed or diminished. A nurturing family, education, social involvement, and personal relationships are factors contributing to the process of moving from vulnerability to one of resilience. One participant spoke about how her healthy and secure childhood made her resilient. For others, this resilience came through empowerment or personality attributes they identified. Using Wagnild’s resilience framework, themes that were identified by participants were grouped into the five resilience characteristics and are presented in Figure 3.

However, more than half of the participants predominantly identified aspects within themselves that they felt made them resilient. These aspects of resilience are represented in Figure 3.

PHOTO (COLOR): Figure 3. Participants’ resilience characteristics analyzed through wagnild’s resilience framework.

However, a limitation of Wagnild’s resilience framework (and use of Wagnild’s scale in this research) is that the reciprocal nature of resilience was not incorporated, professional empowerment and community support could not be appropriately included into Wagnild’s framework. Taking this factor into account the researcher tried to explore the construct in the interviews utilizing a systems framework and explored what personality, cultural and community factors participants identified as contributing to their resilience. Eleven interview participants spoke about how being developed and empowered as a professional helped them to be more resilient. Aspects that they mentioned included increasing professional knowledge and skills, understanding the organizational context in which they worked and establishing professional boundaries (Table 1). Developing and maintaining professional boundaries are critical for any social worker. These boundaries help protect both the client and the social worker from unethical behavior. For social workers creating that emotional divide between professional and private lives is an essential skill in order to reduce burnout.

Only eight (16.66%) participants mentioned aspects in their social circles or community (work, religious or cultural) as factors contributing to their resilience (Table 2), while the majority of participants could not identify any aspects in the community that enhanced and promoted their resilience. Only three participants recognized the role that their culture or community played in their resilience and only one identified her religious community as a source of her resilience.

Participants’ views of how personal resilience is developed through professional empowerment (N = 11).

Identified factor contributing to resilience Sub-themes Number of participants mentioning theme Selected Quotations Illustrating themes
Professional Empowerment Professional Knowledge and Skills 4
“The courses, they do have courses here that we usually attend…the in-service training” (P6).

“I think the trainings that is provided for us helps a lot, especially lately we have another training and I think it really helped just to build up on whatever we had and, and it does help” (P13).

Organisational Knowledge 1
“You know I would say the fact that I got to know the organisation better to feel uncertain about the knowledge that I have. So that also helps in terms of I and I just trust myself more in this environment as a social worker” (P21).

Establishing boundaries 7
“Um… the fact that I create emotional distance between myself and the client….the fact that I set boundaries, that I could set boundaries” (P23).

“I don’t know. I think it’s also a positive decision to make. You know this is your work, this work stays at work” (P29).

“I’m trying to leave things here at the office, not taking It home” (P11).

“Try not to take things personally will help you not to be too much involved” (P30).

Participants’ views of different communities which contribute to personal resilience (N = 8).

Identified factor contributing to resilience Sub-themes Number of participants mentioning theme Selected Quotations Illustrating themes
Support from various communities Work community: colleagues 4
“The support I get from my colleagues that is the most one” (P6).

“With the support system that we are giving each other at work, the support that I’m having… as a person, the support system that I’m having, I think they help me to be resilient” (P19).

Religious community 1
“I like church very much, I’m a Christian and I am the kind of person who likes to talk, when I have a problem, I do talk to someone… and pray” (P8).

Socio-CulturalCommunity 4
“They (the community) provide a lot of support for the child which then gives you hope to go back and help the child at the same time” (P13).

“.. you know, it was a social club that I was a member of, and we are all women and we would also recharge. During the holidays we would go to Durban, we go to recharge, we were professional ladies, we teach us lessons, you know, around the location then we move, we talk, we meet at the restaurant, we eat once a month and then at the end of the year, we go for an outing. So we really happy because we talk and we recharge as well” (P19).

As the construct ‘resilience’ has predominantly been understood to be an intra-psychic or individual characteristic (Tusaie & Dyer, 2004), participants may have answered from this viewpoint. This finding could also be attributed to the erosion of societal and cultural support in South African society, due to the increasing adoption of western values of individualization and self-determination. African culture has always promoted a strong sense of community support, through practical and emotional Helpance. Social cohesion and belonging are also established through rituals and traditions where family and community members show support (Patel, Kaseke, & Midgley, 2012).

Polk’s (1997) perception of resilience acknowledges that resilience is a multidimensional phenomenon that incorporates four aspects: physical and psychosocial characteristics, relational patterns (social roles and relationships), situational patterns (how one views the world) and philosophical patterns (one’s beliefs and values). In order to enhance resilience in order to cope with vicarious trauma, all four aspects need to be considered and explored. The relevance of ecological theory and the salience of ecological considerations need to be acknowledged (Harvey, 2007).

Vicarious resilience
Alongside vicarious traumatization, trauma work offers practitioners the unique opportunity to develop vicarious resilience, as they can also learn to overcome adversity and experience positive transformation through witnessing their clients’ healing processes (Hernandez-Wolfe, Killian, Engstrom, & Gangsei, 2015). Although the construct of vicarious resilience was not specifically explored in this research (which is a potential limitation of this study), two participants spoke about how they learned from, and were encouraged by, the ways in which their clients overcame traumatic situations. This process was reflected in the following quotations:

…Yeah, so I think, that, that thing that I want that person to get out of the situation, I want this person… to find a way to get out of this situation, I think it’s what pushed me, what motivates me every day in doing my work and even me (P12).

You find that other clients are having more problems than you can think of, so when you get all those kinds of problems with different people and all that and how they cope I think you can learn that way (P22).

‘Vicarious resilience’ is a recent construct to emerge in the traumatology literature and refers to the resilience processes that occur within therapists as a result of their work (Engstrom, Hernandez, & Gangsei, 2008). Vicarious trauma theory predicts that counselors are likely to be profoundly affected by their work. Pack (2014) found that as a result of experiencing vicarious traumatization and the resultant search for meaning, counselors fostered personal and professional resilience strategies which enhanced their ability to ‘bounce back’. Ironically this growth emanated from the immersion in trauma work, alongside the adoption of effective coping strategies by counselors.

Conclusions and recommendations
This study explored the levels of resilience in social workers who are vicariously exposed to trauma through their work with clients. While most social workers in the study had medium to high levels of resilience they also experienced medium/average levels of vicarious trauma. The results from this study provide support for the proposed hypothesis, as a significant and negative relationship was established between vicarious trauma and resilience. Therefore, in order to reduce the impact of vicarious trauma, it is important that social workers are educated not only about vicarious trauma but also about resilience. Folke (2006) explains that the study of resilience has focused on an individual’s capacity to absorb shock and still function and that more emphasis should be placed upon the process of resilience that concerns the individual’s capacity for renewal, reorganization, and development. In order to effectively ameliorate the effects of vicarious trauma, social workers need to ensure that they have proactive self-care measures and strategies in place so that they can renew, reorganize and develop themselves.

Forensic social workers levels of resilience were lower than occupational social workers, indicating that specific attention should be given to the forensic social workers to help them enhance their levels of resilience. For forensic social workers acknowledging that they have an important role to play in protecting the lives of children, can help to sustain them in what could be experienced as ‘soul destroying’ work. Furthermore, incorporating a systemic conceptualization of resilience, which includes promoting a healthy work environment would help to facilitate opportunities for social workers (both forensic and occupational) to become more resilient. Specific emphasis should be placed on promoting work cohesion, ensuring adequate managerial control and allowing opportunities for innovation. In addition, supervision, individual counseling, and educational workshops would be important mechanisms to facilitate this growth and help social workers to become more resilient.

The results also showed that most social workers were able to appropriately identify their own levels of resilience. This awareness needs to be continually strengthened, so that social workers consciously employ strategies to enhance their resilience. Just as constructs such as post-traumatic stress disorder are continually refined and developed, so the construct of resilience has changed in its meaning over time. In order to understand how resilience can be considered a self-care strategy, social workers need to familiarize themselves with the theoretical explanations of resilience not only for their clients but also in order to enhance their own awareness and growth. For Fosha (2008) this awareness is an ongoing process as she reiterates the need for social workers to consciously promote resilience and self-awareness in their work. Furthermore, some interview participants indicated that they had developed their resilience through vicariously learning from their clients. Vicarious resilience is a relatively new construct in the field of traumatology, but it is a construct that warrants further exploration and research, particularly in South Africa. If practitioners become more aware of the opportunities trauma counseling and engagement with secondary trauma provides, they may be more open to learning from the experience. The education of social workers in this regard is therefore imperative.

Most of the interview participants understood resilience to be a construct that can be developed. They identified the following factors that contribute to resilience: personality characteristics or attributes, spiritual beliefs, professional empowerment, acceptance of self and others, and support from work, religious and cultural communities. Almost a third of the participants spoke about how being empowered as a social worker strengthened their resilience, this occurred as they increased their professional knowledge and skills, learned more about SAPS and developed professional boundaries. However, the majority of the social workers interviewed predominantly understood resilience to refer to their own intra-psychic processes or personality attributes. Less than a third of the social workers interviewed viewed resilience through an ecological framework, acknowledging that resilience could be influenced or strengthened through cultural and community influences. The ecological understanding of resilience should be an important focus of resilience training for social workers.

What is apparent is that strategies to ameliorate the effects of vicarious trauma should be multi-leveled and should not only be left up to the individual. Organizations need to be proactive and recognize their responsibility to provide support and developmental opportunities for their employees who work with traumatized individuals. In order to increase resilience levels within social workers in SAPS, education about resilience is important and should particularly emphasize aspects of equanimity, while Helping and equipping the social workers to have a balanced perspective on life. This approach needs to be reflected in the organizational policies as well. However, these strategies do not minimize the responsibility of practitioners to ensure that their own mental health and development are intact as they navigate the impact trauma has on them. Self-care strategies need to be developed including the awareness and development of resilience. For South African social workers, exposure to secondary trauma is inevitable and therefore the attention needs to shift to enhancing coping strategies and increasing resilience.

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Wellbeing and coping strategies of alcohol and other drug therapeutic community workers: A qualitative study.
Authors:
Butler, Mark. Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
Savic, Michael. Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia, michaels@turningpoint.org.au
Best, David William, ORCID 0000-0002-6792-916X . Department of Law and Criminology, Sheffield Hallam University, Sheffield, United Kingdom
Manning, Victoria. Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
Mills, Katherine L.. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
Lubman, Dan I.. Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
Address:
Savic, Michael, michaels@turningpoint.org.au
Source:
Therapeutic Communities, Vol 39(3), 2018. pp. 118-128.
NLM Title Abbreviation:
Ther Communities
Page Count:
11
Publisher:
United Kingdom : Emerald Publishing
Other Journal Titles:
International Journal of Therapeutic Communities
Other Publishers:
United Kingdom : Assn of Therapeutic Communities
United Kingdom : Emerald Group Publishing Limited
ISSN:
0964-1866 (Print)
2052-4730 (Electronic)
Language:
English
Keywords:
Australia, Qualitative research, Therapeutic communities, Burnout, TC practice, Staff wellbeing
Abstract:
Purpose: The purpose of this paper is to examine the strategies utilised to facilitate the wellbeing of workers of an alcohol and other drug (AOD) therapeutic community (TC) Design/methodology/approach: This paper reports on the findings of a qualitative study that involved in-depth interviews with 11 workers from an Australian AOD TC organisation that provides both a residential TC program and an outreach program. Interviews were analysed using thematic analysis. Findings: Three main interconnected themes emerged through analysis of the data: the challenges of working in an AOD TC organisation, including vicarious trauma, the isolation and safety of outreach workers and a lack of connection between teams; individual strategies for coping and facilitating wellbeing, such as family, friend and partner support and self-care practices; organisational facilitators of worker wellbeing, including staff supervision, employment conditions and the ability to communicate openly about stress. The analysis also revealed cross-cutting themes including the unique challenges and wellbeing support needs of outreach and lived experience workers. Research limitations/implications: Rather than just preventing burnout, AOD TC organisations can also play a role in facilitating worker wellbeing. Practical implications: This paper discusses a number of practical suggestions and indicates that additional strategies targeted at ‘at risk’ teams or groups of workers may be needed alongside organisation-wide strategies. Originality/value: This paper provides a novel and in-depth analysis of strategies to facilitate TC worker wellbeing and has implications for TC staff, managers and researchers. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Therapeutic Community; *Well Being; *Health Personnel; *Substance Use Treatment
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Aug 12, 2018; Revised: Apr 3, 2018; First Submitted: Aug 7, 2017
Release Date:
20200330
Copyright:
Emerald Publishing Limited.
Digital Object Identifier:
http://dx.doi.org/10.1108/TC-08-2017-0024
Accession Number:
2018-53631-002
Result List Refine Search PrevResult 12 of 68 Next
Strategies for reducing secondary or vicarious trauma: Do they work?
Authors:
Bober, Ted. Ontario Medical Association, ON, Canada
Regehr, Cheryl, ORCID 0000-0001-7814-7836 . University of Toronto, Toronto, ON, Canada, cheryl.regehr@utoronto.ca
Address:
Regehr, Cheryl, Centre for Applied Social Research, University of Toronto, 246 Bloor Street West, Toronto, ON, Canada, M5S 1A1, cheryl.regehr@utoronto.ca
Source:
Brief Treatment and Crisis Intervention, Vol 6(1), Feb, 2006. Special Issue: Economic crisis and women’s childbearing motivations: the induced abortion response of women on public Helpance. pp. 1-9.
NLM Title Abbreviation:
Brief Treat Crisis Interv
Page Count:
9
Publisher:
United Kingdom : Oxford University Press
ISSN:
1474-3310 (Print)
1474-3329 (Electronic)
Language:
English
Keywords:
vicarious trauma, secondary trauma, coping strategies, therapists
Abstract:
This cross-sectional design study sought to assess whether therapists believed and engaged in commonly recommended forms of prevention for secondary and vicarious trauma and whether engaging in these activities resulted in lower levels of distress. In this study of 259 therapists, time spent with counseling trauma victims was the best predictor of trauma scores. Although participants generally believed in the usefulness of recommended coping strategies including leisure activities, self-care activities and supervision, these beliefs did not translate into time devoted to engaging in the activities. Most importantly, there was no association between time devoted to coping strategies and traumatic stress scores. Intervention strategies for trauma counselors that focus on education of therapists and augmenting coping skills unduly individualize the problem. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Distress; *Emotional Trauma; *Therapists; *Vicarious Experiences
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Canada
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Traumatic Stress Institute (TSI) Belief Scale
Impact of Event Scale DOI: 10.1037/t00303-000
Coping Strategies Inventory
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20060227
Correction Date:
20190307
Digital Object Identifier:
http://dx.doi.org/10.1093/brief-treatment/mhj001
Accession Number:
2006-01882-001
Number of Citations in Source:
31
Result List Refine Search PrevResult 13 of 68 Next
Vicarious trauma: The impact on solicitors of exposure to traumatic material.
Authors:
Vrklevski, Lila Petar. Department of Psychology, Macquarie University, North Ryde, NSW, Australia, lil.vrklevski@email.cs.nsw.cs.gov.au
Franklin, John. Department of Psychology, Macquarie University, North Ryde, NSW, Australia
Address:
Vrklevski, Lila Petar, 590 Victoria Rd., Ryde, NSW, Australia, lil.vrklevski@email.cs.nsw.cs.gov.au
Source:
Traumatology, Vol 14(1), Mar, 2008. pp. 106-118.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
13
Publisher:
US : Sage Publications
Other Journal Titles:
Traumatology: An International Journal
Other Publishers:
US : Academy of Traumatology
US : Educational Publishing Foundation
US : Green Cross Project
ISSN:
1534-7656 (Print)
1085-9373 (Electronic)
Language:
English
Keywords:
vicarious trauma, solicitors, traumatic material, legal profession, noncriminal law, criminal law, lawyers, attorneys, depression, anxiety, stress, cognitive changes
Abstract:
This study explored vicarious trauma in the legal profession. A random sample of male and female criminal law (n = 50) and noncriminal law (n = 50) solicitors completed a research pack containing the following questionnaires: a demographic questionnaire; Vicarious Trauma Scale; Satisfaction With Work Scale; Depression, Anxiety, and Stress Scales; Impact of Event Scale–Revised; and Trauma and Attachment Belief Scale. Criminal lawyers reported significantly higher levels of subjective distress and vicarious trauma, depression, stress, and cognitive changes in relation to self-safety, other safety, and other intimacy. No significant differences were found between the two groups on measures of satisfaction with work or coping strategies in relation to work-related distress. Multiple trauma history was associated with higher scores on measures of symptomatic distress. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Attorneys; *Coping Behavior; *Criminal Behavior; *School Violence; *Trauma; Criminal Law; Distress; Legal Personnel
PsycInfo Classification:
Health & Mental Health Treatment & Prevention (3300)
Criminal Law & Adjudication (4230)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Demographic Questionnaire
Trauma and Attachment Belief Scale
Satisfaction With Work Scale [Appended] DOI: 10.1037/t17113-000
Depression Anxiety and Stress Scales DOI: 10.1037/t39835-000
Impact of Event Scale–Revised DOI: 10.1037/t12199-000
Vicarious Trauma Scale [Appended] DOI: 10.1037/t03119-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20090921
Correction Date:
20160114
Copyright:
Sage Publications. 2008
Digital Object Identifier:
http://dx.doi.org/10.1177/1534765607309961
Accession Number:
2009-10420-014
Number of Citations in Source:
42
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Vicarious Trauma: The Impact on Solicitors of Exposure to Traumatic Material
This content may contain URLs/links that would redirect you to a non-EBSCO site. EBSCO does not endorse the accuracy or accessibility of these sites, nor of the content therein.
✖
Contents
Review of the Literature
This Study
Method
Participants
Study Design and Method
Measurement
Statistical Analyses
Results
Descriptive Findings
Trauma Findings
Coping Strategy Findings
Personal Trauma History Results
Satisfaction With Work Results
Discussion
Implications and Recommendations
References
APPENDICES
APPENDIX 1: Vicarious Trauma Scale
APPENDIX 2: Satisfaction With Work Scale
APPENDIX 3: Coping Mechanisms
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By: Lila Petar Vrklevski
Department of Psychology, Macquarie University, North Ryde, New South Wales, Australia;
John Franklin
Department of Psychology, Macquarie University, North Ryde, New South Wales, Australia
Acknowledgement:

The term vicarious traumatization is attributed to McCann and Pearlman (1990b) and describes the changes that occur in trauma workers as a result of working with trauma survivors. It is a cumulative process “through which the therapist’s inner experience is negatively transformed through empathic engagement with the clients’ trauma material” (Pearlman & Saakvitne, 1995, p. 280).

Vicarious trauma involves “profound changes in the core aspects of the therapist’s self” (Pearlman & Saakvitne, 1995, p. 152). These changes include disruptions in both self and professional identity, worldview, spirituality, abilities, and cognitive beliefs particularly in the areas of safety, trust, esteem, intimacy, and control (Saakvitne & Pearlman, 1996). Whereas posttraumatic stress disorder (PTSD) refers to the impact on primary victims of trauma, vicarious traumatization refers to the impact on secondary victims of trauma (i.e., those that work with the primary victims of trauma).

Several other terms have also been used to describe the negative effects that result from working with trauma survivors. These include compassion fatigue or secondary traumatic stress, countertransference, and burnout (Stamm, 1997). Figley (1995) used the term compassion fatigue to describe secondary traumatic stress effects. He explained that “compassion is a feeling of deep sympathy or sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the pain or remove its cause” (p. 7). Countertransference refers to a therapist’s unconscious and conscious responses to a particular client’s transference. It is not specific to trauma work (Wilson & Lindy, 1994). Burnout occurs as a result of prolonged work, leading to emotional exhaustion, erosion of idealism, depersonalization, and loss of self-efficacy (Figley, 1989; Pearlman & Saakvitne, 1995; Sexton, 1999). Burnout can occur in all types of work. The distinction between these terms in the empirical literature is often not made clear, with various studies using some of the terms interchangeably. While there are similarities, overlap, and an interactional effect between the concepts of vicarious trauma, compassion fatigue, countertransference, and burnout, there are also discernible differences (Pearlman & Saakvitne, 1995; Sabin-Farrell & Turpin, 2003). The major difference between these other terms and vicarious trauma is that the latter focuses on changes in cognitive schemas while still acknowledging symptomatic distress (McCann & Pearlman, 1990b).

McCann and Pearlman (1990b) suggest that there are unique aspects of working with survivors of sexual abuse that increase the risk of trauma workers developing vicarious trauma. Specifically, they identify empathic engagement with trauma survivors who relate narratives of overwhelming horror and pain as one of the mechanisms involved in the development of vicarious trauma. Another factor said to be involved in this process is a desire to render Helpance.

They argue that vicarious trauma can lead to personal, professional, and social effects, hence it is crucial to the well-being of clients and trauma professionals to recognize and resolve vicarious trauma (Pearlman & Saakvitne, 1995). Unaddressed vicarious trauma can lead to a loss of effective treatment for the client; an inability to discharge professional, social, and personal responsibilities for the trauma worker; detachment and emotional withdrawal from family and friends; depersonalization; and disillusionment with the organization (Pearlman & Saakvitne, 1995).

Research on vicarious trauma, although predominantly focused on therapists treating survivors of sexual victimization, has also addressed other professional groups (McCann & Pearlman, 1990a). Over the past decade researchers have explored the impact of trauma work on nurses and doctors (Alexander & Atcheson, 1998; Carson, Leary, de Villiers, Fagin, & Radmall, 1995; Clark & Gioro, 1998), ambulance officers (Young & Cooper, 1999), jurors (Hafemeister, 1993), mental health staff (Zimmering, Munroe, & Gulliver, 2003), police officers (Follette, Polusny, & Milbeck, 1994), and museum workers preparing the Holocaust Memorial Museum exhibit (McCarroll, Blank, & Hill, 1995).

Criminal lawyers have been identified as a professional group particularly vulnerable to developing vicarious trauma (Saakvitne & Pearlman, 1996). Yet other than anecdotal evidence and a recent study exploring burnout and secondary traumatic stress (Levin & Greisberg, 2003), there is no research on the impact of trauma work on solicitors (Murray & Royer, 2004).

Solicitors, like doctors, nurses, police officers, and therapists, are visually and emotionally confronted by clients who have been injured and traumatized by purposeful violence. They see, hear, and feel the impact of trauma daily. Overwhelming emotions, injustice, despair, rage, self-harm, and other self-destructive behaviors are exposed and reenacted in intricate detail in the hallowed halls of justice. Solicitors experience a veritable kaleidoscope of traumatic material in the course of providing legal and other professional services to their clients (Murray & Royer, 2004).

As a professional group, solicitors are encouraged to remain emotionally detached from the cases they handle. This detachment is supposed to permit them to exercise dispassionate judgment and allow them to give independent advice to clients. However, they are not automatons. They are human beings who experience, understand, and negotiate interpersonal relationships (professional or otherwise) with the same emotions as other humans do (Murray & Royer, 2004).

Solicitors who work in criminal law deal with rape, sexual abuse of children, murder, and manslaughter on a daily basis. They are exposed to horror in graphic detail through witness testimony, court reenactments, witness conferencing, and photographic and forensic evidence. It would be erroneous to assume that professional detachment protects them from being at risk of developing vicarious trauma (Murray & Royer, 2004).

Review of the Literature

Although much has been written about the effects of vicarious trauma, the number of empirical studies in the area remains relatively small. A review of the literature suggests that a number of issues require rigorous attention: first, the difference between vicarious trauma and related concepts requires greater clarification; second, the development of a well-standardized measure that assesses both components of vicarious trauma (i.e., symptomatic distress and cognitive changes) is required; third, greater attention needs to be paid to the survey methodology to ensure more representative samples of trauma workers are recruited to studies; and fourth, the effects of mediating and moderating variables need to be better understood (Sabin-Farrell & Turpin, 2003; Salston & Figley, 2003).

The two earliest studies in the area of vicarious trauma are those of Pearlman and Mac Ian (1995) and Schauben and Frazier (1995). They have been promoted as the main source of evidence for the development of vicarious trauma in professionals who work with trauma survivors. Briefly, both studies found that therapists with less experience had more disrupted beliefs in the areas of safety, control, intimacy, trust, and self-esteem and higher symptom levels than more experienced therapists. They also found differences between therapists who had personal trauma histories and those who did not.

Several other studies have continued to explore the impact on therapists who work with survivors (Brady, Guy, Poelstra, & Browkaw, 1999; Chrestman, 1995; Ghahramanlou & Brodbeck, 2000; Iliffe & Steed, 2000; Kassam-Adams, 1995; Steed & Downing, 1998). The majority of these studies have adopted a quantitative approach, using a variety of instruments to measure symptomatic distress and cognitive changes. Their findings have been criticized as being difficult to interpret and generalize due to (a) concerns regarding the reliability and validity of the instruments used, (b) small sample sizes, and (c) recruiting participants who had self-identified difficulties with vicarious trauma (Sabin-Farrell & Turpin, 2003).

Studies have also compared vicarious trauma in mental health professionals and police officers (Follette et al., 1994), nurses and counselors (Lyon, 1993), and professionals and volunteers (Salston & Figley, 2003) who work with survivors of sexual victimization. All these studies provide further evidence for the concept of vicarious trauma. However, the differences in the study samples (e.g., profession, work setting), variables measured, instruments used, and methodologies have led to inconsistent findings.

Studies have also explored vicarious trauma in therapists who work with sex offenders (Shelby, Stoddart, & Taylor, 2001) and therapists who work with both survivors and offenders (Way, Vandeusen, Martin, Applegate, & Jandle, 2004). The results suggest that both groups experience similar vicarious trauma effects.

Vicarious trauma effects include cognitive changes (Jenkins & Baird, 2002; Levin & Greisberg, 2003; Pearlman & Mac Ian, 1995; Schauben & Frazier, 1995), intrusions (Kassam-Adams, 1995; Pearlman & Mac Ian, 1995; Steed & Downing, 1998; Way et al., 2004), avoidance (Kassam-Adams, 1995; Way et al., 2004), concerns with safety (Jankoski, 2003), hyperarousal (Jankoski, 2003; Levin & Greisberg, 2003), difficulties with trust and intimacy (Knight, 1997; Pearlman & Mac Ian, 1995; Rich, 1997), self-esteem problems (Pearlman & Mac Ian, 1995), depressed mood, and increased substance use (Rich, 1997; Zimmering et al., 2003).

Even though all trauma workers experience some degree of difficulty with the nature of the work, not all develop vicarious trauma. This suggests that certain variables may mediate or moderate the development of vicarious trauma (Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995).

Moderating variables studied include gender (Kassam-Adams, 1995), age (Ghahramanlou & Brodbeck, 2000), amount of exposure to traumatized clients (Kassam-Adams, 1995; Schauben & Frazier, 1995), length of time providing treatment to survivors of trauma (Chrestman, 1995; Pearlman & Mac Ian, 1995; Rich, 1997), personal trauma history (Follette et al., 1994; Ghahramanlou & Brodbeck, 2000; Kassam-Adams, 1995; Pearlman & Mac Ian, 1995), and personality types or characteristics (Woodward, Murrell, & Bettler, 2005). The data overall are largely inconsistent.

Mediating variables studied include access to clinical supervision (Follette et al., 1994; Pearlman & Mac Ian, 1995; Rich, 1997), training (Chrestman, 1995; Follette et al., 1994), self-care, and social support (Chrestman, 1995; Follette et al., 1994, Schauben & Frazier, 1995). Once again, evidence is sparse and inconsistent.

In summary, although the existing empirical literature is sparse and has largely focused on clinicians who treat traumatized clients, there is enough preliminary evidence to suggest that working with traumatized clients can have a negative impact on trauma workers (McCann & Pearlman, 1990).

What about the impact of trauma work on solicitors? Anecdotal evidence scattered within the case law suggests that they experience adverse effects (Murray & Royer, 2004). Additionally, Levin and Greisberg (2003) found higher levels of burnout, avoidance, intrusions, sleep difficulties, and irritability in family law and legal aid attorneys compared with mental health providers and social service workers. Unfortunately, there does not appear to be any published research exploring vicarious trauma within the legal profession.

This Study

This is an exploratory study that aimed to investigate the impact of working with traumatized clients and their traumatic material on members of the legal profession. The study compared solicitors working with traumatized clients (criminal defense lawyers and prosecutors) with solicitors working with nontraumatized clients (conveyancers and academicians) on a number of measures. The study sought to answer the following research questions.

Is there a difference between solicitors working in criminal law and solicitors working in non-criminal law in terms of vicarious trauma effects?
What are the major coping strategies used by solicitors to deal with work-related distress and do they differ between the two groups?
Does personal trauma history increase vulnerability to vicarious trauma effects?
Is there a difference between the two groups regarding satisfaction with work?
The following hypotheses were presented.

Criminal lawyers would report higher scores on measures of symptomatic distress and disruptions to cognitive schemas as measured by the Vicarious Trauma Scale (VTS); Depression, Anxiety, and Stress Scales (DASS); Impact of Event Scale-Revised (IES–R); and Trauma And Attachment Belief Scale (TABS).
A greater number of criminal law solicitors would report using professional Helpance to cope with work-related distress.
Personal trauma history would be associated with higher levels of vicarious trauma.
Criminal law solicitors would report less satisfaction with work.
Method

Participants
Participants in this study were 100 members of the legal profession. Solicitors working in criminal law (n = 50) were recruited from the Office of the Director of Public Prosecutions (ODPP), the Legal Aid Commission of New South Wales (LAC), metropolitan legal centers, and Women’s Legal Services, New South Wales. The solicitors in this group were members of the Law Society, held current practicing certificates, and specialized in criminal law. Solicitors working in noncriminal law (n = 50) were recruited from the College of Law, Continuing Legal Education database, Macquarie University Law Faculty, and UTS Law Faculty. The total sample was 36% males and 64% females, with a mean age of 39.70 years (SD = 11.08). The total age range was between 24 and 64 years. Self-reported ethnicity was 73% Anglo-Saxon, 8% European, 4% Middle Eastern, and 3% Asian (14% not reporting). Educational background included bachelor’s degree or less (75%) and masters or doctoral degree (25%).

Study Design and Method
Designated staff from each participating organization Helped in recruiting subjects for this study. The head of Human Resources in the ODPP and LAC, the head of Continuing Legal Education at the College of Law, the deans of Macquarie University and UTS Law Faculties, and the managers of metropolitan legal centers sent out e-mails to all staff in their organization asking for volunteers to complete a survey package investigating vicarious trauma. Interested participants collected a research pack from a designated location within the organization and returned the completed pack to the same place. E-mails continued to recruit participants until 100 research packs had been completed. The number of times e-mails were sent varied (between 4 and 15) according to the response rate from each organization. Return of the completed questionnaires signified informed consent. This method of recruitment inevitably raises questions about selection bias. However, it is not possible to know whether solicitors who participated in this study differ from those who declined (Sabin-Farrell & Turpin, 2003). It may be that those who are adversely affected by their work are more likely to volunteer and participate in research they view as meaningful and productive. Alternatively, those most affected by their work may see research as another demand on their time and therefore not participate.

Measurement
Closed-ended survey questions were developed for this study to collect demographic data.

The IES–R (Weiss & Marmar, 1997) is a standardized, self-report measure designed to parallel the DSM-IV criteria for PTSD. It measures subjective distress related to an identified traumatic event on three scales: avoidance, intrusions, and hyper-arousal. The instrument has 22 questions rated on a 5-point Likert-type scale, ranging from 0 (not at all) to 4 (extremely). The original IES (Horowitz, Wilner, & Alvarez, 1979) was developed prior to the adoption of PTSD as a recognized diagnosis in the DSM-III and had two scales: intrusion and avoidance. The IES–R therefore is a more comprehensive measure of vicarious trauma effects than the IES. Scores for the IES–R factors range from 0 to 32 (avoidance and intrusions) and 0 to 24 (hyperarousal). The IES–R has adequate psychometric properties with internal consistency of between .87 and .93 (intrusions), .84 and .86 (avoidance), and .79 and .90 (hyperarousal).

Additionally, a VTS (Cronbach’s α = .88) was developed to assess subjective levels of distress associated with working with traumatized clients. The scale consists of 7 items selected to assess how solicitors experience working with distressed clients (see Appendix I). The VTS items are rated on a 7-point Likert-type scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Total scores range from 8 to 56, with a higher score indicating higher levels of distress. A significant correlation (.261) between the VTS and IES–R was found (p < .01).

The SWWS (Cronbach’s α = .73) was used to measure general enjoyment and satisfaction with work (see Appendix II). The SWWS consists of five items on a 7-point Likert-type scale, ranging from 1 (strongly disagree) to 7 (strongly agree). The range is between 5 and 35, with higher scores indicating greater satisfaction with work.

Data from two other standardized instruments were also analyzed for this study. The DASS (Lovibond & Lovibond, 1995) is a 42-item self-report, paper-and-pencil questionnaire, consisting of three scales— depression, anxiety, and stress—each containing 14 items rated on a 4-point severity/frequency scale, where 0 = did not apply to me at all and 3 = applied to me very much or most of the time. The DASS has sound psychometric properties, with internal consistency of depression = .91, anxiety = .84, and stress = .90; good test–retest reliability; and demonstrated content, construct, and concurrent validity (Lovibond & Lovibond, 1995).

The TABS (Pearlman, 2003) was used to measure disruptions to cognitive schemas. The TABS is a self-report measure consisting of 10 scales and a total TABS score. The scales and internal consistency for each scale are as follows: self-safety (.83), other safety (.72), self-trust (.74), other trust (.84), self-esteem (.83), other esteem (.82), self-intimacy (.67), other intimacy (.87), self-control (.73), other control (.76), and total (.96). There are 84 items rated on a 6-point Likert-type scale ranging from 1 (disagree strongly) to 6 (agree strongly). Higher scores on the TABS indicate more cognitive disruption.

Finally, the survey asked respondents to indicate which coping strategies they used (from a list of eight) to deal with work-related distress (see Appendix III). Examples included listening to music, seeking peer support, seeking professional Helpance, and so on. Responses were marked from 1 (never) to 4 (very often). They were also asked to list any other strategies they used that were not included in the list.

Statistical Analyses
Analyses were conducted using SPSS-12 (for Windows 2001). These analyses included the following: (a) t tests, frequencies, and Mann–Whitney nonparametric analyses to compare vicarious trauma effects, coping strategies, and satisfaction with work between the two groups and (b) 2 × 3 analysis of variance to determine the effects of trauma history. A significance level of .025 rather than the conventional .05 was used in this study as the point for a statistical finding. It is acknowledged that this may result in an inflated experiment-wise Type I error rate. However, being an exploratory study the decision to keep this rate was made so as not to make excessive Type II errors.

Results

Descriptive Findings
The respondent groups did not differ in age or ethnicity (see Table 1). Sixty-four percent of respondents were females (78% of the criminal law group and 50% of the noncriminal law group). In terms of education, 40% of the noncriminal law group had a masters or doctorate degree compared with 10% of the criminal law group. In terms of experience, 32% of the noncriminal law group still had experience (<5 years) in criminal law. In terms of a personal trauma history, 30% of respondents reported none, 15% reported one event, and 55% reported multiple events (20% sexual abuse, 23% physical abuse, 15% neglect, 36% emotional abuse). This is consistent with other studies (Schauben & Frazier, 1995). Of those who reported sexual abuse, 17 respondents were females (26%) and 3 (8.0%) were males. This is consistent with research that suggests that 1 of 4 women and 1 of 8 or 10 men is sexually abused as a child (Koss, 1993). Otherwise, differences between the two groups were not significant.

trm-14-1-106-tbl1a.gifDemographic Characteristics

Trauma Findings
There were significant differences (p < .025) between the two groups in vicarious trauma effects, as measured by total scores on the VTS, DASS (depression and stress scales), and TABS (self-safety, other safety, and other intimacy) scales. The two groups did not differ significantly on avoidance, intrusions, and hyperarousal as measured by the IES–R (see Table 2). Mean scores for both groups across all measures and subscales were in the subclinical range. Additionally, there were significant differences between the two groups on each individual item of the VTS (p < .025) except for Item 4 (I find it difficult to deal with the content of my work; p > .025).

trm-14-1-106-tbl2a.gifLevel of Vicarious Trauma

Coping Strategy Findings
Participants were asked to indicate which strategies they had used to cope with job-related distress (see Table 3). There were no significant differences (other than on peer support, p < .025) between the two groups, with criminal lawyers more likely to seek peer support. The most frequently reported strategies were reading, seeking peer support, listening to music, and engaging in sport or exercise. It was interesting to note that the use of alcohol and prescription and nonprescription medication occurred at about the same rate in both groups, with approximately two thirds of the overall sample having used alcohol and one third of the sample having used medication to cope with distress arising from work. Notably, more criminal law solicitors (36%) compared with non-criminal law solicitors (20%) had sought professional Helpance, although this finding was not statistically significant between the groups. Respondents were also asked to list any additional strategies they used to cope with job-related stress. Responses included eating, religion, and family support.

trm-14-1-106-tbl3a.gifCoping Strategies

Personal Trauma History Results
The full factorial meaning and interaction between group and trauma history was tested. Findings were that in no one case was interaction between trauma history and group significant (p< .025). This means that any differences between the groups were consistent across trauma levels. In only two variables (depression and self-safety) did inclusion of trauma history reduce the effect of a previously significant effect of group to nonsignificance. Participants in both groups with a multiple trauma history displayed greater vicarious trauma effects (see Table 4).

trm-14-1-106-tbl4a.gifPersonal Trauma History

Satisfaction With Work Results
No significant differences (p < .025) emerged between the two groups in terms of overall satisfaction with work, with mean scores being 23.34 (SD = 6.15) for the criminal law solicitors and 23.74 (SD = 6.22) for the noncriminal law solicitors.

Discussion

This study explored vicarious trauma in legal professionals, specifically solicitors engaged in criminal law work. It is the first study to explore vicarious trauma within the legal profession. The study also examined variables associated with vicarious trauma such as personal trauma history, personal and professional coping strategies, and satisfaction with work.

The solicitor groups were similar in age, ethnicity, and experience in law. The criminal law group, however, had a higher number of female respondents and a higher number of respondents with a multiple trauma history (particularly sexual abuse and emotional abuse).

The first hypothesis was supported. The level of vicarious trauma was higher in the criminal law solicitors. In particular, criminal law solicitors reported significantly higher levels of subjective distress and self-reported vicarious trauma, depression, stress, and cognitive changes in relation to safety and intimacy. Even though the differences between the two groups on scales of the IES–R were not statistically significant, the criminal law group reported higher levels of avoidance, intrusions, and hyper-arousal. These results support previous findings (Levin & Greisberg, 2003).

The second hypothesis was supported with a greater number of criminal law solicitors seeking professional Helpance in coping with work-related distress. Thirty-six percent of the criminal law solicitors reported having sought professional Helpance compared with 20% of the noncriminal law solicitors. Overall, however, the two groups did not significantly differ in terms of the strategies adopted to cope with work-related distress. It was interesting to note that only half the respondents in both groups considered discussing work-related distress with a supervisor. They were twice as likely to look for peer support. This finding raises questions about organizational dynamics and organizational recognition of and response to employee distress. It may be that professional Helpance from management is difficult to access for some of the participants or, if available, is not used because of perceived lack of confidentiality (Way et al., 2004).

The third hypothesis was supported with a multiple trauma history being associated with higher levels of vicarious trauma. Participants in both groups with a multiple trauma history had higher scores on all measures of symptomatic distress but not cognitive disturbance compared with participants that had either none or a single trauma history. However, differences between the groups were consistent across trauma levels and not significant.

The fourth hypothesis was not supported. Both groups reported similar levels of satisfaction with work. Even though working with traumatized clients and traumatic material can be distressing and difficult, there may also be an element of satisfaction in providing Helpance to and advocating on behalf of these clients, and ensuring that justice is done. Schauben and Frazier (1995) and Steed and Downing (1998) also found that counselors working with trauma survivors reported several enjoyable aspects of the work, such as witnessing the strength and resilience of their clients, being part of the healing process, and feeling that the work was meaningful and worthwhile. Perhaps this type of attitude serves to reduce the risk of developing vicarious trauma and is worthy of further investigation (Sabin-Farrell & Turpin, 2003).

Although this study provided some further evidence for the concept of vicarious trauma, in relation to criminal lawyers, it is also limited in several respects. First, there is the difficulty of self-selection. It is impossible to know how representative this sample is of criminal and noncriminal lawyers. Solicitors who volunteered for this study may be inherently different from those that declined. The results may also be influenced by response biases such as minimization, lack of self-awareness and insight, denial, or concerns with confidentiality (Salston & Figley, 2003; Way et al., 2004).

Second, the assessment of vicarious trauma has been completed using a number of instruments because a single multi-item measure is still to be developed.

Third, whereas previous studies have only assessed the effects of working with sexual violence, this study has included all other types of violence. This might make the results of this study difficult to compare with others in that there was no assessment of the percentage of each type of violence in each criminal lawyer’s practice.

Fourth, although multiple trauma history was found to be associated with greater vicarious trauma effects, it is not clear whether participants’ responses to the questionnaires related to their own (primary) trauma or to the effect of working with traumatized clients (vicarious trauma). Despite clear instructions to respond to the questionnaires in relation to working with traumatized clients, it may be that some participants’ responses reflect their own traumatic experiences. This would explain scores in the clinical range for participants in the noncriminal law group.

Fifth, there is no assessment in the study regarding period of time between last traumatic event experienced by respondents and participation in the study. Participants with a recent history of trauma (within the past year) may have reflected this in their responses.

Finally, the study did not measure the contribution of burnout or other types of occupational stress inherent in legal work (such as the hostile court environment, conflict, heavy caseloads, and the adversarial nature of criminal law; Murray & Royer, 2004).

Despite these limitations, this study also has a number of strengths. First, it is unique in that it explores the impact of vicarious trauma on a little-studied occupational group (solicitors). Second, it provides preliminary evidence that criminal lawyers experience difficulties working with traumatized clients. Third, it highlights the implications for employers; they need to recognize the impact of trauma work on employees and put in place strategies to raise awareness, educate, and Help those employees adversely affected by trauma work. Fourth, it suggests viable coping strategies for intervention in this group (Sabin-Farrell & Turpin, 2003).

Implications and Recommendations

Recommendations include the following.

The use of prospective or longitudinal studies to determine the variables that moderate and mediate the development of vicarious trauma.
More accurate identification and implementation of coping strategies that may reduce the effects of vicarious trauma.
Qualitative studies to provide additional information on what aspects of criminal law work are most distressing for legal personnel.
Exploration of resilience in relation to trauma work because some solicitors, like some therapists, are able to repeatedly hear stories of horror and pain without experiencing deleterious effects.
Additional research to isolate other variables that may protect from and ameliorate the effects of vicarious trauma.
Greater organizational recognition of the need to put in place strategies to Help staff adversely affected by trauma work (Murray & Royer, 2004).
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APPENDICES
APPENDIX 1: Vicarious Trauma Scale
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
Please read the following statements and indicate on a scale of 1 (strongly disagree) to 7 (strongly agree) how much you agree with them.

My job involves exposure to distressing material and experiences.
My job involves exposure to traumatized or distressed clients.
I find myself distressed by listening to my clients’ stories and situations.
I find it difficult to deal with the content of my work.
I find myself thinking about distressing material at home.
Sometimes I feel helpless to Help my clients in the way I would like.
Sometimes I feel overwhelmed by the workload involved in my job.
It is hard to stay positive and optimistic given some of the things I encounter in my work.
APPENDIX 2: Satisfaction With Work Scale
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
Please read the following statements and indicate on a scale of 1 (strongly disagree) to 7 (strongly agree) how much you agree with them.

In most ways my job is close to my ideal.
The conditions of my job are excellent.
I am satisfied with my job.
So far I have achieved the important things I want in my job.
If I could live my life over, I would change almost nothing.
APPENDIX 3: Coping Mechanisms
Coping Mechanisms: In order to cope with your job have you ever used any of the following: Sport / Exercise 1 4 Never Occasionally Often Very Often Reading Never Occasionally Often Very Often Meditation/Yoga Never Occasionally Often Very Often Alcohol Never Occasionally Often Very Often Prescription or Non-Prescription Medication Never Occasionally Often Very Often Music Never Occasionally Often Very Often Supervision Never Occasionally Often Very Often Peer support Never Occasionally Often Very Often Professional Helpance ie psychiatrist or Never Occasionally Often Very Often psychologist Never Occasionally Often Very Often Are there any other methods you may have used to help you cope with your job:
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Source: Traumatology. Vol. 14. (1), Mar, 2008 pp. 106-118)
Accession Number: 2009-10420-014
Digital Object Identifier: 10.1177/1534765607309961

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Staff experiences of working in a Sexual Assault Referral Centre: The impacts and emotional tolls of working with traumatised people.
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Authors:
Massey, Kristina. Law and Criminal Justice Studies, Canterbury Christ Church University, Canterbury, United Kingdom, kristina.massey@canterbury.ac.uk
Horvath, Miranda A. H., ORCID 0000-0003-4363-4575 . Department of Psychology, School of Science and Technology, Middlesex University, London, United Kingdom
Essafi, Shanaz. Manchester Academy, Manchester, United Kingdom
Majeed-Ariss, Rabiya. School of Health Sciences, University of Manchester, Manchester, United Kingdom
Address:
Massey, Kristina, kristina.massey@canterbury.ac.uk
Source:
Journal of Forensic Psychiatry & Psychology, Vol 30(4), Aug, 2019. pp. 686-705.
NLM Title Abbreviation:
J Forens Psychiatry Psychol
Page Count:
20
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Journal of Forensic Psychiatry
ISSN:
1478-9949 (Print)
1478-9957 (Electronic)
Language:
English
Keywords:
vicarious trauma, sexual assault, coping mechanisms, qualitative
Abstract:
This study considers the impacts on staff of supporting people who have reported sexual violence and attend a Sexual Assault Referral Centre (SARC). This paper focuses on the staff’s perspectives of the stresses and emotional tolls they experience including the coping mechanisms they utilise. Semi-structured interviews were conducted with 12 staff, and a focus group was held with a further four staff of a SARC. The data were examined using thematic analysis. Findings indicated that staff experienced positive emotions connected to the meaningfulness of the work and team spirit as well as a range of unpleasant emotions. Staff also reported emotional numbing, in connection to the specificity, volume and sometimes unpredictable nature of the work. Coping mechanisms used by staff focused on the supportive connection to family, nature, and other team members; the value of clinical supervision; and the avoidance of topics related to work. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Health Personnel Attitudes; *Occupational Stress; *Sex Offenses; *Vicarious Experiences; Experiences (Events); Professional Referral; Psychological Stress
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Female
Location:
England
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Focus Group Schedule
Interview Schedule DOI: 10.1037/t20676-000
Grant Sponsorship:
Sponsor: Canterbury Christ Church University, United Kingdom
Recipients: No recipient indicated

Sponsor: Middlesex University, United Kingdom
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Mar 25, 2019; First Submitted: Nov 16, 2018
Release Date:
20190425
Correction Date:
20210902
Copyright:
Informa UK Limited, trading as Taylor & Francis Group. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/14789949.2019.1605615
Accession Number:
2019-23024-001
Number of Citations in Source:
49
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Staff experiences of working in a Sexual Assault Referral Centre: the impacts and emotional tolls of working with traumatised people
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Contents
Introduction
Study aim
Methodology
Participants
Ethical considerations
Procedure
Data analysis
Rigour
Results
The emotional impact of the client-facing work
Negative emotional responses to work
Positive emotional responses to work
The stresses of volume and nature of SARC work
Nature of the work
Volume of the work
Adaptive coping mechanisms
Coping strategies – in work
Coping strategies – out of work
Discussion
Implications
Strengths and limitations
Practice implications
Acknowledgments
Disclosure statement
Supplementary Material
References
Full Text
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This study considers the impacts on staff of supporting people who have reported sexual violence and attend a Sexual Assault Referral Centre (SARC). This paper focuses on the staff’s perspectives of the stresses and emotional tolls they experience including the coping mechanisms they utilise. Semi-structured interviews were conducted with 12 staff, and a focus group was held with a further four staff of a SARC. The data were examined using thematic analysis. Findings indicated that staff experienced positive emotions connected to the meaningfulness of the work and team spirit as well as a range of unpleasant emotions. Staff also reported emotional numbing, in connection to the specificity, volume and sometimes unpredictable nature of the work. Coping mechanisms used by staff focused on the supportive connection to family, nature, and other team members; the value of clinical supervision; and the avoidance of topics related to work.

Keywords: Vicarious trauma; sexual assault; coping mechanisms; qualitative

Introduction
There are 37 Sexual Assault Referral Centres (SARC) in England and a further six in Wales. They offer specialised services to people who have experienced sexual assault or rape regardless of whether they choose to report the offence to the police or not. The oldest and largest SARC in the country is Saint Mary’s in Manchester. Saint Mary’s saw circa 2000 people in 2017/8 of whom 1237 attended for a forensic medical examination. Saint Mary’s SARC has a unique service delivery model whereby it provides a comprehensive and co-ordinated forensic, aftercare and counselling service to children, women and men who have experienced sexual assault or rape. The services on offer at Saint Mary’s include, but are not limited to: a forensic medical examination carried out by a specialist doctor; access to a crisis worker who can offer support and stay with them throughout the process; support in the aftermath from an Independent Sexual Violence Advisor (ISVA); and counselling with a specialist trained counsellor. Staff who work at these centres have passed rigorous recruitment procedures and have received specialist training.

Rape is associated with the highest levels of PTSD when compared to other sources of trauma, such as combat or physical violence (Kessler, [28]). As such SARC staff can see people immediately after one of the most traumatic things that can happen to them. In high volume SARC’s, such as the one in this study, the staff can see client after client for the entirety of their shift. Despite the obvious traumatic effect that this sort of work has on employees, there is little investigation into professional exposure to traumatic incidents (Bender et al., [ 4]). There is some literature that considers work-related trauma for police officers or fire and rescue workers (Anshel, [ 1]; Brown & Campbell, [ 8]; Hart, Wearing, & Headey, [21]; Harvey et al., [22]). There is also a small amount of literature on the traumatic effects of working with victims of sex crimes, mostly from a policing perspective (Catanese, [12]; Cornille & Woodard Meyers, [17]; Krause, [30]) but there is no literature known to the study authors focusing on sexual assault referral workers in the United Kingdom.

The deficit of literature on this topic means that understanding of vicarious trauma when working in the field of supporting victims of sexual assault is drawn from other professions such as the fields of nursing (Bailey, [ 2]), general counselling (Whelan, [18]) and social work (Choi, [13]). This literature has focused on organisations’ desires to reduce or delay burnout in professionals working in emotionally stressful professions (Collins, [16]; Taylor, [45]) rather than on the actual impact of the work for the individual. One of the few pieces of literature with a focus on the impact on professionals of working with victims of violent and sexual crime comes from the USA (Martin, [34]). In her book, Martin outlines that rape work has a huge emotional toll on workers often leaving them feeling discomfort, distress, anger, hurt and powerlessness from what they experience, by the inadequacies of the criminal justice system and the lack of support for victims. However, professionals she interviewed also reported positive emotions such as an emotional uplift from being able to help people in very distressing circumstances and job satisfaction.

Some of the staff at the SARC are involved in both helping the clients with the emotional effects of what has happened to them but also with the legal process, in cases where the individual has chosen to report the crime. There are a variety of roles which bring with them different emotional tolls and stressors. This difference has been identified in previous studies as well such as Cole and Logan ([15]). This study carried out in the USA found that Sexual Assault Nurse Examiners experienced conflict between providing compassionate care, attending to the biopsychosocial needs of the patient, advocating for the patient and the forensic objective of the exam. Although the responses in Cole and Logan’s study found few differences in the objectives of different staff, role differences were reported. The team at St Mary’s is made up of forensic doctors whose role involves documenting and collecting forensic evidence as well as providing medical care and a supportive atmosphere where the client is at ease whilst these examinations take place. Crisis workers support the clients whilst they are having the forensic medical examination – they are not medically trained but provide emotional support. The ISVAs provide immediate follow-up support as needed by the client. In addition, they support clients through the legal process, even attending court when necessary. Finally, counsellors provide a therapeutic relationship and emotional support to the clients. This is constrained by the legal process because if a case is pre-trial, there are restraints on what can be discussed in the therapy process. Both forensic doctors and crisis workers work on-call shifts some working nights and weekends. The correlation between on-call work and emotional distress is well established in other fields such as medicine (Firth-Cozens, [19]).

Previous research found that for people who do forensic work there is a relationship between coping strategies they use and emotional distress they experience, suggesting that people who work in this field require effective coping strategies to be able to carry out their work (Horvath & Massey, [24]). Their roles can be considered particularly challenging as they are required to juggle the demands of – medical and legal – while also managing the psychological and physical consequences of sexual violence on their clients (and the subsequent impacts on themselves and their colleagues).

Coping mechanisms are often used to explain why some people are able to experience extreme situations and come out without demonstrating any severe psychological impact (Henman, [23]; McCrae, [36]; McCrae & Costa, [37]). Some people are able to find ways to deal with the stress they experience in life very effectively (McCrae, [36]). This ability to cope refers to the set of cognitive and behavioural strategies used by an individual to manage themselves and their emotions in stressful situations (Folkman & Moskowitz, [20]). McCrae argues that an individual’s coping mechanisms change little over the life span inferring they are a characteristic of the individual rather than an evolving attribute. This suggests that some people are better at coping than others and as a result, are more suited to stressful work. Although coping mechanisms differ from person to person, not all coping mechanisms are positive in outcome: there are some that have a level of ‘trade-off’ where emotional relief is obtained at a cost, such as use of alcohol, over spending, misuse of prescription drugs or use of illicit street drugs (Carver, [11]). Overuse of alcohol has been identified as a coping mechanism by doctors for the stress they experience at work (Firth-Cozens, [19]) and other professionals such as police officers (Chopko, Palmieri, & Adams, [14]; Swatt, Gibson, & Piquero, [44]; Violanti et al., [46]; Zavala & Kurtz, [48], [49]). However, there is emerging evidence to suggest that, forensic medical professionals rely more often on positive coping mechanisms rather than negative ones (Horvath & Massey, [24]).

Coping mechanisms contribute to resilience. Resilience is a characteristic of an individual and coping mechanisms is another factor that allows some people to withstand traumatic events. A great deal of research exists on the resilience of children and young people, however, there is less literature available on the resilience of adults (Rutter, [41], [42]). Resilience is the ability that an individual has to bounce back from distressing situations and deal with long term, ongoing stressful experiences (Block & Block, [ 6]; Block & Kremen, [ 5]; Lazarus, [31]). Resilience is often used to describe an individual’s ability to function unexpectedly well in adverse or stressful situations (Klohen, [29]). It is suggested that there are both behavioural and personality factors that explain resilience, including self-esteem (Major, Richards, Cooper, Cozzarelli, & Zubek, [33]), flexible adaptation (Lazarus, [31]) and use of coping mechanisms (Salovey, Bedell, Detweiler, & Mayer, [43]). Although resilience undoubtedly has a developmental and personality component to it, it is not static and is influenced by context (Watson, Ritchie, Demer, Bartone, & Pfefferbaum, [47]). It is also believed by some to be an adaptive state and not a personality trait (Luthar & Cicchetti, [32]). The use of coping mechanisms can enhance and increase an individual’s resilience these two factors do not stand alone.

Study aim
This qualitative study explores the experiences of staff working in a high volume SARC in England. The aim was to consider the emotional tolls and impacts of the work the staff do and following on from that, the coping mechanisms they utilise to deal with these impacts. Ultimately, greater understanding of these factors may improve organisations’ ability to support staff that do similar difficult work and in turn, it may help the staff themselves to understand the potential impacts and minimise the possibility of vicarious trauma.

Methodology

Participants
All staff (60 full-time equivalent) at Saint Mary’s SARC, Manchester, England were invited to participate in this research. A presentation was given about a previous, related piece of work at a SARC staff away day which was followed by discussion of the desire to carry on this investigation and staff were asked to contact the researchers if they wanted to be involved in the planned future research. An internal email was also circulated to all staff, inviting them to be involved.

An interview and focus group schedule was designed by the first and second authors for the purpose of this study. The questions were developed based on their previous research with members of the Faculty of Forensic and Legal Medicine (Horvath & Massey, [24]) and in consultation with the managers of St Mary’s before use. This was to ensure that any potential problems were identified before data collection began. Following this consultation, the interview/focus group questions (see Appendix 1) were used to explore the experiences of the participants. All 16 participants of this opportunity sample were female since all the SARC staff at the time of the research were female. Demographic data were collected on role, gender and whether the individual was full or part time. The staff ranged in age and number of years of experience with some staff being new to the service and others about to retire. The participants were made up predominantly by doctors, Crisis Workers and ISVA’s and a few other roles which were unique and would be identifying if named. The participants varied in whether they were full time or part time and whether they worked Monday to Friday or ‘out of hours’. Only one of the doctors worked exclusively at the SARC, all others were also employed elsewhere in the NHS as well.

Ethical considerations
Ethical approval for the study was obtained from Middlesex University and Canterbury Christ Church University ethics committee where the first and second authors are based. Ethics approval was not deemed necessary by the NHS as this research was deemed to be a service review. Participants had an information sheet that contained an assurance of anonymity, information regarding the study, the possibility to withdraw and the voluntary nature of participation. Signed informed consent was obtained prior to participation and the findings presented in a way that no one could be recognised.

Procedure
The semi-structured interviews with the SARC staff lasted up to 45 min and were digitally recorded. All interviews were conducted by telephone by either the first or second author. The focus group was also recorded and took place on hospital property, lasting approximately an hour.

An interview and focus group schedule were designed by the first and second authors for the purpose of this study. This was informed by discussions with the managers of the service to ensure any potential problems were identified early on. Following this consultation, th e interview/focus group questions were used to explore the experiences of the participants.

See Table 1 for the interview questions.

Table 1. Interview/Focus group schedule.

Question
1 What are the major stresses you experience from working in the sexual assault referral centre?
2 What are the main emotional tolls you experience from working in the sexual assault referral centre?
3 What qualities/characteristics do you think should be identified when recruiting new staff for the sexual assault referral centre to ensure they are best able to cope with the work related stresses and emotional tolls?
4 What training do you think should be offered for sexual assault referral centre staff to enable them to cope with the work related stresses and emotional tolls?
5 What support structures and processes do you think should be offered to help staff cope with the work related stresses and emotional tolls?
6 Are there things you and/or your colleagues do outside the workplace to help you cope with the major stresses and emotional tolls?
Data analysis
The interviews and focus group recordings were transcribed verbatim and anonymised. The research team carried out a thematic analysis on the anonymised transcripts. Thematic analysis is a well-established and flexible research tool which allows for rich, detailed analysis (Braun & Clarke, [ 7]). It requires six phases of analysis of the data which extracts the main themes and the subthemes. These phases are familiarising yourself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report. Phases 1–4 were done by all four researchers independently and this was followed by research meetings where there were team discussions and subsequently joint working on the final phases.

Rigour
To increase the confidence in the data in this study line-by-line analysis (coding) was carried out for each transcript, and the content of each account was read several times looking for any themes in the accounts. Clustering of this material led to the development of emergent themes for each case. Once each case was analysed, cross-cutting themes were identified across the accounts. Finally, this data was combined and the overarching themes were identified.

Having practitioners and non-practitioners involved in the analysis, allowed for investigator triangulation (Reeves, Kuper, & Hodges, [40]) increasing the rigour in this study. The range of researcher’s backgrounds allowed for a complex range of perspectives in the analysis and this in turn generated a richer extraction of the data. Despite the researchers coming from different backgrounds and experience, there was a great deal of overlap in the identified themes.

Results
Thematic map 1 what happens to SARC workers

PHOTO (COLOR): 1. The red dotted line is to indicate that this sub-theme occurs in both stresses and impacts – we need to think about whether it needs to be in both or not and what the similarities/differences are between them.

The three themes that emerged were: 1. The emotional impact of the client-facing work at the SARC, 2. The stresses of volume and nature of SARC work and 3. Adaptive coping strategies used by SARC staff. Each theme illustrates an aspect of the participants’ relationship with the work they do. Some themes also reflect aspects of that individual’s personal life or experience.

The themes will now be described in sequence, but it is important to note that the themes interlink, overlap and fluctuate in importance from individual to individual. The experience of the participants is complex and varies based on their individual characteristics, job role and length of service. Some sub-themes are role specific and as such, they relate only to a subset of participants, this is identified in the results when applicable.

The emotional impact of the client-facing work
Throughout the participants’ narratives, there were frequent references to the emotional impact their work had. Among participants, there was a consensus that one cannot do this type of work without being affected in some way. The belief was that the emotional impact of the work on the individual had the capacity to be both negative and positive. There is a lack of balance in many of the themes, especially this one, with more negative responses being reported than positive. This may be as a result of participants using the interviews as an outlet for their emotional struggles or as a result of negativity bias: people typically remember the bad more readily than the good (Baumeister, Bratslavsky, Finkenauer, & Vohs, [ 3]; Ito, Larsen, Smith, & Cacioppo, [25]).

Negative emotional responses to work
There was recognition amongst staff that working at the SARC meant working in a context where emotions ran high. This was as a result of working with and supporting clients who had recently reported a traumatic life event and participants were able to see the effect of the work on themselves and their colleagues:

This is really emotional work and emotional work has an impact… I think that burnout and emotional fatigue are really serious problems in this sort of work. [Interviewee 5, lines 396–397]

So there’s an enormous amount of emotion floating around, much of which we… I think absorb like blotting paper, quite subconsciously – I don’t think we realise what we’re doing, and clearly we deal with it at the time. [Interviewee 1, lines 52–54]

The participants talked about feeling despondent, as a result of the unrelenting nature of the work they did; the volume of clients they saw combined with the severity of what many clients reported. This feeling resulted also from the insight staff had of the chaotic and tragic lives some clients led, with the sexual assault that brought them to the SARC being one component of this life.

…sometimes sadness or despair at what goes on. You know, stuff that you see coming through your door, sometimes, it gets the better of you. You feel like it’s a bit hopeless, um, because it’s sort of a never-ending. [Interviewee 2, lines 99–102]

The ones that really kind of upset me are not the ones where people have had the most horrific injuries or that kind of thing but the ones where people have just had one awful thing after another awful thing after another awful thing. [Interviewee 4, lines 32–34]

As well as sadness, frustration and anger were commonly reported emotions. Staff expressed anger at what clients had experienced, at the unfairness of life and ‘the system’ that made it hard for people to get what they need after a sexual assault.

Probably the thing that I struggle with at the moment is sometimes feeling really angry when I hear what some people have been through. [Interviewee 6, lines 59–61]

There was also reflection by an individual that anger was not an appropriate emotion so it is not discussed in the same way as sadness or stress may be discussed. However, anger was expressed by other participants, as the second quote below illustrates.

I don’t think my colleagues feel angry – I think that’s, I feel like that very much just me, um – I don’t know, I don’t really talk about that side of it, really. [Interviewee 2, lines 109–110]

So the frustration trips over to anger. [Interviewee 9, line 53]

Staff mentioned that a way that they were able to cope with the, at times, distressing nature of their work was by becoming somewhat desensitised to the subject matter. This was noted to be a personal and professional coping mechanism that enabled longevity. There was a feeling expressed that staff who are unable to desensitise, burn out very fast in this line of work.

It has been case after case after case but they are all awful, you have to switch off to keep engaging with that horror or it’s hard to deal with. [Focus Group 6, 177–178]

Despite the ability to desensitise to cope over time, there were still times when particular cases would hit a ‘personal nerve’ and consequently have a greater impact on the member of staff working with them. Other staff stated that personally challenging cases included seeing clients the same age as the participant’s own child.

The particular cases that I found very difficult have been… cases where I’ve seen somebody who has been a similar age to one of my children… Those are the ones that kind of, if you like, get to me. [Interviewee 4, lines 31–36]

I don’t really like seeing children. That’s from my perspective because I’ve got (number removed to maintain participant anonymity) young children. [Interviewee 11, lines 64–65]

Positive emotional responses to work
Despite the obvious challenges experienced in this line of work, the staff spoke warmly of a dedication to the client group that they have chosen to work with. Almost all of the participants talked about positives of their work. Amongst these was the satisfaction from knowing that they provide an important and meaningful service by being able to help someone in need.

It is hugely rewarding, yeah. It’s hugely rewarding. [Interviewee 5, line 201]

Participants also expressed pride at being able to work in a high-quality service and a confidence that they were able to do an important job well.

That shouldn’t take away from the overall picture, which is that, actually, we’re doing a lot of, of… I don’t know whether good’s the right word, but a lot of positive things by helping people at a time of crisis… [Interviewee 1, lines 592–594]

A strong sense of camaraderie and team support also came across from the participants. There was recognition that being part of a highly skilled, caring team made the job possible. They spoke about the emotional support they themselves received from capable colleagues, when dealing with distressing cases.

I found that the quality of the teams is something that’s sustained me through the work because I’ve been here about eight years now. [Focus Group 6, lines 140–141]

I mean, I think that St. Mary’s is a wonderful organisation to work for. I’ve worked for the NHS for many, many years and St. Mary’s, I think, is quite unique in that it’s..there is a caring culture for staff as well as clients. [Interviewee 5, lines 28–30]

The stresses of volume and nature of SARC work
The stresses of the work carried out at the SARC were seen by participants as different from the emotional impact of their work. Work stresses tended to be focused on the volume and nature of the work whereas emotional impact was connected with the client-facing work.

Nature of the work
The work carried out at the SARC is especially specific and skilled. As opposed to general medical work, the staff at the SARC are repeatedly seeing people in a time of crisis for very specific experiences. This specificity was cited as a source of stress.

I understand why we have to do it. But it’s kind of…there’s no…. Even if we’ve had a day with no cases, we’re still constantly hearing about trauma all the time. So whether you’re answering a phone or you’re in a meeting or you’re talking to colleagues, there’s no happy stories that come through. It’s always just trauma, trauma, trauma all the time. [Interviewee 11, lines 89–92]

The stress from the complex work and trauma is further exacerbated by the fact that many of the clients attending the SARC are complex cases with a high level of need.

I didn’t expect before I came to the SARC was how many vulnerable people we get through the door. [Focus Group, 3, lines 72–73]

…seeing vulnerable people and realising that you just see them at the end of maybe a life history that’s brought them to that point. [Focus Group 6, Lines 91–96]

In addition to these general stresses relating to the nature of SARC work, there were also role-specific stresses highlighted by particular groups of staff.

Being part of a team and the formal and informal support provided by other staff members came out very strongly as a protective factor. The out-of-hours crisis workers however, due to the nature of their shift work, are not recipients of this support to the same degree and unsurprisingly experience added difficulties as a result. Whether the out of hours work was in the centre or based at home, the isolated nature of work was felt to be difficult.

Because I think night time working brings its own challenges. From an emotional point of view, it is about taking advantage of the opportunities to chat. [Interviewee 5, lines 335–338]

I think it can be a bit isolating if you only work out of hours. [Interviewee 4, line 272]

Added to the challenges of working out of hours, crisis workers who take calls at home found that they had trouble switching off after the call and experienced a sort of ‘contamination’ of their home from the distress they are exposed to during the calls.

…taking phone calls at home. And I think that’s because it comes into my home and also, it’s isolated working, lone working on your..in as much as..you haven’t got a colleague to either hold the call and say I just need to take five minutes and talk to somebody, get advice or to even debrief afterwards. So, I find that really challenging [Interviewee 5, lines 12–17]

Forensic doctors were another group that related role-specific stresses: this was from being requested to give evidence in court and wanting justice for the client.

One of the biggest stresses really is not knowing what’s going to happen when you get into court. [Interviewee 8, lines 27–28]

Volume of the work
The actual amount of work that is required was highlighted as a stressor for the staff. Staff expressed feeling that the workload was unrelenting.

It can be quite tiring because it’s busy – it’s a busy centre, um, so it’s one case after another. [Interviewee 2, lines 38–39]

Just the constant never getting to the bottom of your to-do list. It’s just always adding to it and never getting anything done. And I can spend ages talking to someone. And then an hour later someone might say to me, ‘Such and such just called for you,’ and I won’t remember their name because my mind’s just too busy. And then I feel like I can’t be giving them the right service. So, it’s just those stresses. [Focus Group 4, lines 63–67]

Staff articulated in their interviews that it is the accumulative effect of working with clients who have experienced trauma – who may also have high levels of individual need – and the volume of work that led to stress:

There’s that workload pressure. And then there’s the fact that everything we deal with is quite often horrific. So, it’s workload that’s a separate pressure. And then there’s the content of what we do which is disturbing, bizarre, horrific. Quite often, we’ll sit in the morning meeting and think, ‘Oh, that’s just awful.’ And then we’ll do another case and then we’ll have like 20 cases and they’re all awful. And it’s hard to get your head around that because we are a high-volume centre. It has been case after case after case but they are all awful, you have to switch off to keep engaging with that horror or it’s hard to deal with. [Focus Group 6, lines 172–178]

Linked to the sheer volume of work required at the SARC is the unpredictability of the nature of the work: the number of cases seen in a day shift, when they may arrive and what they may require, is outside the control of the staff. This acted as an additional source of stress for participants.

Because they kind of don’t know what could happen with the case until we’ve met the person. It’s hard to sort of plan your day out really. [Interviewee 11, lines 26–27]

The staff also recognised how the amount of work they are required to do and the huge amount of need presented by the clients has an impact on the quality of work they are able to deliver, despite their best efforts.

I think they are the kind of volume of referrals and the needs that we kind of face. So there’s a constant kind of pressure on our time. [Interviewee 6, lines 4–5]

The lack of control or predictability can result in the staff forfeiting their own self-care due to work demands. Although this is a choice made by the staff, it is a choice made out of care for the client and recognition of the vulnerability of the people they work with. Despite management encouraging self-care, staff find this hard when faced with clients in acute crisis.

I mean sometimes we get nothing in at all which is quite rare, but it does happen. Last Friday there was nine requests for acute examination. So it’s completely varied as to how big it can be. Or it just could be whatever you see until the end of that day, but there’s always that pressure of who’s going to come in first, who’s going to do what. And the people will say, “Well, make sure you get a lunch break.” But if the cases have been booked in at certain timeslots, you can’t then ring the police and say, “Put it back by half an hour because I want a sandwich.” [Interviewee 11, lines 211–217]

Adaptive coping mechanisms
It is apparent that the client-facing work carried out by staff at the SARC has an emotional impact with additional stresses due to the volume and nature of the workload. The staff spoke of drawing on a wide range of positive coping mechanisms for self-support, both in and out of work, so as to be able to deal appropriately with their work experiences. These will now be detailed in turn.

Coping strategies – in work
Formal supervision was seen as extremely helpful by those who had accessed it. It was suggested that people who do not access supervision, should do so.

The doctors never really access supervision I think that’s the problem. [Interviewee 4, line 349]

When I started in supervision I found it massively helpful [Interviewee 2, lines 246–247]

…they just think they, you know, they don’t need it. But actually, I think we all probably do, um, but I, I think we kind of… I don’t think we’re even realising that we need it sometimes. [Interviewee 2, lines 305–320]

Some staff suggested that group supervision was less helpful for a variety of reasons including: fear of bothering others; fear of discussing things that may offend others; less timely and not enough time to fully explore issues they personally wanted to discuss.

There’s never enough time really is there when you have a group supervision. To say everything that you have got to say. [Focus Group 3, lines 380–381]

In addition to the formal supervision process, there was a great deal of talk about informal supervision or debriefing. This is where staff would discuss the work or a difficult case with colleagues, at the time, rather than waiting for the next supervision session. Most participants highlighted support from their fellow staff as essential to being able to undertake the work they do. Help, support and camaraderie were listed as essential to coping with this type of work.

It’s interesting because there’s the informal chit-chatting with my colleagues before the formal supervision starts and I value both bits. [Interviewee 5, lines 58–59]

Another organised coping strategy by SARC for the staff which was mentioned by many of the participants was an internal system set-up with the aim at helping staff achieve a healthy work–life balance in acknowledgement of the challenging context of the work and in an effort to alleviate some of the emotional impact and work stresses. This project was found to be helpful by many of the participants, not least because it provided an opportunity to let off steam out of work hours. Participants mentioned how the confidentiality of the work meant that it was not possible to really talk to family and friends about the work they do, so the informal time spent with colleagues was one of the few opportunities to talk freely about the effects of the work.

So we’ve started the well-being initiative, the balance work. And I think some of the physical activities that’s coming out with that and discussions have been valuable in making sure the people are a little bit more resilient. [Interviewee 9, lines 89–91]

Coping strategies – out of work
In addition to the support utilised and strategies adopted in the workplace to deal with the stress, staff also described many helpful out of work practices they were personally involved in. The need for time with loved ones was the most frequently mentioned strategy within this sub-theme. Participants noted the importance of spending time with people that are not involved in the work at the SARC and how these people acted as a distraction and support.

I think that one of them [coping strategies] is, is just being with the family… [Interviewee 1, lines 492–493]

Some participants explicitly noted that their personal roles meant that they consciously left the stress of the work so as to engage in other tasks.

Because when I’m coming home from work that’s when I get my children up. I don’t want them to ever sort of absorb any stresses that I’m feeling because of work. [Interviewee 11, lines 231–232]

In addition to human contact being therapeutic for the staff, dogs were also noted highly in the support listed. Walking in the country, dog walking and exercise were all mentioned as activities the staff did to help them unwind, relax and let go of the things experienced in working time.

I have a dog. And so, when I’m not at work, I spend quite a lot of time in the park. And again, I think I really need that. [Interviewee 6, lines 223–224]

I do normal things like going to the gym, [Interviewee 9, line221]

But walking outdoors is great and getting back to nature is absolutely great, grounding yourself and giving you more positive aspects about life itself. [Focus Group 3, lines 522–524]

Other activities participants spoke of as helping them ‘switch off’ to unwind and not think about work included hobbies, especially ones that required concentration:

So mine might be reading, or doing jigsaws, where I can’t think of anything else but what I’m doing. [Interviewee 1, line 77]

Television viewing was also mentioned as a way of relaxing and unwinding and there was interesting reflection on the propensity to change what one views as a result of the type of work done at the SARC. It was widely noted that participant’s wished to avoid serious or distressing topics.

I can’t watch films with any rape scenes or anything like that. Or anything where it’s gritty. I can’t. It goes off. [Focus Group 3, lines 570–571]

Another coping mechanism mentioned by participants was social or light drinking. There was no reference to any maladaptive or heavy levels of drinking.

There are times when I self-medicate. But I’m not an alcoholic (laughter). [Focus Group 3, lines 518–519]

Discussion

Implications
Based on our findings, it is clear that staff who work with people reporting sexual violence experience high levels of stress and the work they do has an emotional impact on them, even if they also feel very positively about their work. Organisations such as SARC’s have a duty of care to ensure that they do all they can to support their staff as effectively as possible. This study provides valuable information about what staff experience, what they need and how they feel during the course of their working day. The staff in this study talked about feeling overwhelmed by the work load; affected by the tragedy that they see regularly; and the awfulness of the impact of rape and sexual violence on victims. This finding is similar to that of Raunick, Lindell, Morris, and Backman ([39]) who found that vicarious trauma from working as a Sexual Assault Nurse Examiner in the USA was associated with levels of cognitive disruption similar to that of having experienced trauma themselves. Raunick et al. ([39]) conclude that organisations that employ Sexual Assault Nurse Examiners should be aware of vicarious trauma and provide support. The participants from St Mary’s described how important their provided support structures are including informal support such as chats and talks with each other and formal support such as supervision. The staff who work out of hours described missing out on some of this informal support and were impacted by this isolation. This is consistent with previous studies which have shown that workers who are on call experience specific stresses (Firth-Cozens, [19]). Martin ([34]) found that workers who support victims of sexual violence experience deep emotional impacts from that work this was replicated in this study where there was a great deal of discussion about how carrying out this stressful and difficult work affects them as people and changes them forever. Family, interests and nature were all relied on to cope with the stresses of this sort of work. This information provides service managers and policymakers with valuable information about what these staff members need to ensure they are able to continue to carry out their work to a high standard, with as little adverse personal and professional impact. Burnout and compassion fatigue are well documented (Jacobson, [26]; Joinson, [27]; Maslach & Leiter, [35]; Moran, [38]) as is vicarious trauma and work-related PTSD in high pressure professions (Brown, Fielding, & Grover, [ 9]; Carlier, Lamberts, & Gersons, [10]; Catanese, [12]). Participants in this study talked about burnout being a possibility in this line of work, if workers are unable to utilise good coping mechanisms or vent the feelings from the work. As such, the financial and human costs of not supporting staff that carry out this difficult and highly skilled work is already established.

Strengths and limitations
This qualitative study involved interviews of staff that work at one SARC. This specialist group carry out valuable and difficult work, and this study attempts to go some way to understand their experiences and needs as there is a deficit of previous research that explores the impact of working with victims of sexual violence. This gap in the literature is, in part, filled by this unique study. Using thematic analysis, the intention of this study was to explore the lived experience of these highly specialist staff using detailed interviews and a focus group and carrying out an in-depth analysis. This provides rich data and detail about the working lives of the participants.

While the exploratory analysis identifies a number of themes from one service, it is important to note that further research is required to capture the full diversity of staff experiences and possible variations in other services. The SARC where this study was carried out may not be representative of other SARC’s or sexual violence work in other forums.

This high-stress work leads to turnover and the time gap between collecting the data for this study and the write up meant that two participants were uncontactable to give permission to use their quotes. So although they were included in the analysis, their quotes could not be used in the final write up. As is best practice, all participants were contacted and asked for explicit permission to use their quotes. All but one of the participants who were contacted gave this permission.

Two of the authors work within the SARC and the focus group took place in the hospital. Although the collection was conducted by the first two authors who are not employed at the SARC, it is possible that the involvement of staff may have impacted upon how open and honest participants felt during the interview process and upon whether they took part or declined to participate after showing initial interest. It is possible the five staff that showed initial interest but did not follow through were put off from participating because they were concerned about the two members of the research team who are staff at the SARC reading their transcripts. It was made clear to all participants that their transcripts would remain confidential, and every attempt was made to anonymise them before analysis took place, but may still have remained.

Although this study provides in-depth information from the participants all of the participants in this study are female. Moreover, the sample size was not large when considering the diversity of staff roles included in the sample. This again, means it is difficult to generalise from these findings to others working in the sexual violence field. However, it provides a useful and important starting point from which other studies can build.

Practice implications
This opportunity sample has identified some protective factors that participants, and perhaps others, could be supported with – through management and self-care approaches which recognise the importance of fostering and bringing attention to the meaningfulness and importance of the job they do. The importance of a team spirit and collegiality was also abundantly clear, when workers were away from or deprived of the team (out of hours crisis work) there was a clear adverse effect.

Risk factors for negative emotions appear to be the volume of work carried out and repetition of witnessing trauma material. These factors indicate that the number of hours of exposure to traumatic material combined with the content and quality of time away from trauma (both in and out of work) affects emotional well-being.

It was important that trauma material did not contaminate or invade other areas of life. This indicates the importance of creating boundaries between spaces and times to stimulate emotions which counterbalance the more unpleasant ones that result from working with victims of trauma. There is an obvious issue with generalisability as this is an opportunity sample from one SARC, but these findings apply to the opportunity sample and may extend to other people who work with trauma too.

It is also crucial to see what can be done to better support people who carry out this stressful and emotionally difficult work, what organisations can do to provide as much support as possible and how that support can be as effective as possible. Further investigation into what qualities make some people able to do this sort of work effectively and resistant to burn out is needed.

Acknowledgments
The authors would like to thank all the staff who participated in the research and the managers of the SARC for allowing us to conduct the research.

Disclosure statement
No potential conflict of interest was reported by the authors.

Supplementary Material
Supplementary material for this article can be accessed https://doi.org/10.1080/14789949.2019.1605615.

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Identifying compassion satisfaction, burnout, & traumatic stress in Children’s Advocacy Centers.
Authors:
Letson, Megan M., ORCID 0000-0001-6689-7015 . Nationwide Children’s Hospital, Columbus, OH, US, megan.letson@nationwidechildrens.org
Davis, Catherine. Nationwide Children’s Hospital, Columbus, OH, US
Sherfield, Jennifer. Nationwide Children’s Hospital, Columbus, OH, US
Beer, Oliver W. J., ORCID 0000-0001-8581-3673 . Ohio State University, College of Social Work, Columbus, OH, US
Phillips, Rebecca, ORCID 0000-0002-2827-1406 . Ohio State University, College of Social Work, Columbus, OH, US
Wolf, Kathryn G.. Nationwide Children’s Hospital, Columbus, OH, US
Address:
Letson, Megan M., Center for Family Safety and Healing, 655 E. Livingston Ave., Columbus, OH, US, 43210, megan.letson@nationwidechildrens.org
Source:
Child Abuse & Neglect, Vol 110(Part 3), Dec, 2020. ArtID: 104240
NLM Title Abbreviation:
Child Abuse Negl
Publisher:
Netherlands : Elsevier Science
ISSN:
0145-2134 (Print)
1873-7757 (Electronic)
Language:
English
Keywords:
Burnout, Secondary traumatic stress, Vicarious trauma, CAC, Compassion fatigue, Child abuse professionals
Abstract:
Background: Little research exists examining burnout related to the multidisciplinary team (MDT) working in a Children’s Advocacy Center (CAC) setting. Objectives: To measure compassion satisfaction, burnout, and secondary traumatic stress (STS) among CAC MDT professionals; identify work and worker characteristics that may impact compassion satisfaction, burnout, and STS; understand professional and personal impacts of occupational stress; and explore coping responses. Participants and setting: A cross sectional survey was sent electronically to child abuse professionals working in CAC settings across the United States. Methods: Demographics and work characteristics were collected. Participants completed the Professional Quality of Life (ProQOL) to evaluate compassion satisfaction, burnout, and STS and answered open-ended questions regarding professional and personal impacts of occupational stress. Upon completion, participants received their ProQOL scores and additional stress management resources. Results: A total of 885 participants completed the ProQOL (mean age = 42.07; 85% female). Overall mean scores were average for compassion satisfaction, high average for burnout, and in the top quartile for STS. All three scales differed significantly by MDT professional role (ps < 0.001 to 0.01) and employment length (ps < 0.001 to 0.003). Child welfare workers had significantly higher burnout scores than all other professions except law enforcement and prosecutors and significantly lower compassion satisfaction scores than most others. Professionals providing on-call services had significantly higher burnout (p < 0.001). Conclusions: These results contribute to our understanding of MDT professions who might be at higher risk for burnout and STS and help inform future interventions to support the MDT. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Child Welfare; *Job Satisfaction; *Occupational Stress; *Sympathy; *Compassion Fatigue; Advocacy; Child Abuse; Satisfaction; Vicarious Experiences
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Professional Quality of Life
Methodology:
Empirical Study; Interview; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Nov 8, 2019; Accepted: Oct 14, 2019; Revised: Aug 9, 2019; First Submitted: May 30, 2019
Release Date:
20191114
Correction Date:
20210111
Copyright:
All rights reserved.. Elsevier Ltd. 2019
Digital Object Identifier:
http://dx.doi.org/10.1016/j.chiabu.2019.104240
Accession Number:
2019-68786-001
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The relationship between exposure to terror through the media, coping strategies and resources, and distress and secondary traumatization.
Authors:
Ben-Zur, Hasida. School of Social Work, University of Haifa, Haifa, Israel, zbz@netvision.net.il
Gil, Sharon. School of Social Work, University of Haifa, Haifa, Israel
Shamshins, Yinon. School of Social Work, University of Haifa, Haifa, Israel
Address:
Ben-Zur, Hasida, School of Social Work, University of Haifa, Mount Carmel, Haifa, Israel, 31905, zbz@netvision.net.il
Source:
International Journal of Stress Management, Vol 19(2), May, 2012. pp. 132-150.
NLM Title Abbreviation:
Int J Stress Manag
Page Count:
19
Publisher:
US : Educational Publishing Foundation
Other Publishers:
Netherlands : Kluwer Academic/Human Sciences Press
ISSN:
1072-5245 (Print)
1573-3424 (Electronic)
Language:
English
Keywords:
coping, distress, media exposure, resources, terror acts, trauma
Abstract:
The study’s main aim was to examine secondary traumatization among Israeli students. A sample of 203 university students in Israel, 41 men (20%) and 162 women (80%), aged 23.9 years on average, completed questionnaires on media exposure during terror attacks, posttraumatic and distress symptoms, coping styles, and personal resources of mastery and dispositional optimism. The main results showed that higher media exposure during terror attacks was related positively to higher levels of distress and posttraumatic symptoms. Higher resource levels were related to lower levels of posttraumatic symptoms, whereas greater use of avoidance coping was related to higher distress. These data suggest that the media, which tends to magnify and reinforce the effects of terror acts, can prompt secondary traumatization, and demonstrate the importance of an awareness of the risks of vicarious exposure to terror and trauma through the media. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Distress; *Mass Media; *Terrorism; *Trauma
PsycInfo Classification:
Neuroses & Anxiety Disorders (3215)
Population:
Human
Male
Female
Location:
Israel
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Post-Traumatic Stress Symptoms-Self-Report
COPE Scale-Hebrew version
Media Exposure Inventory
Pearlin & Schooler (1978) Mastery measure
Exposure to a Terror Act measure
Brief Symptom Inventory DOI: 10.1037/t00789-000
Life Orientation Test DOI: 10.1037/t06287-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Feb 23, 2012; Revised: Feb 21, 2012; First Submitted: Sep 11, 2011
Release Date:
20120514
Correction Date:
20190311
Copyright:
American Psychological Association. 2012
Digital Object Identifier:
http://dx.doi.org/10.1037/a0027864
Accession Number:
2012-12383-003
Number of Citations in Source:
72
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The Relationship Between Exposure to Terror Through the Media, Coping Strategies and Resources, and Distress and Secondary Traumatization
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✖
Contents
Secondary Traumatization and Media Exposure
Coping Strategies, Styles, and Resources
The Israeli Context
Study Aims and Hypotheses
METHOD
Sample and Procedure
Instruments
RESULTS
DISCUSSION
Footnotes
REFERENCES
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By: Hasida Ben–Zur
School of Social Work, University of Haifa, Haifa, Israel;
Sharon Gil
School of Social Work, University of Haifa, Haifa, Israel
Yinon Shamshins
School of Social Work, University of Haifa, Haifa, Israel
Acknowledgement:

Terrorism and related adverse acts became frequent phenomena toward the end of the 20th century and thereafter. Such acts of terrorism reflect violence emanating from political motives, usually aimed at civilians to create fear and coerce others into actions or inactions, and are perpetrated in acts that achieve maximum publicity (Bogen & Jones, 2006). According to a statistical analysis of terrorist acts carried out between 1968 and 2004 based on the databases, the data for which were collected from open source materials, of the RAND Corporation and the Memorial Institute for the Prevention of Terrorism (Bogen & Jones, 2006), 19,828 such events occurred, causing 86,568 injuries, of which 25,408 were fatal. Most of the acts involved the use of bombs and guns.

Terror acts are intended to cause harm, damage, and death among a large number of people, and are less predictable than natural disasters, as they tend to occur in places considered to be “safe” (Dougall, Hayward, & Baum, 2005). As found for natural and man-made disasters, direct exposure to terrorist and other politically violent acts is associated with higher levels of posttraumatic stress disorder (PTSD) and other related distress and anxiety symptoms (e.g., Maguen, Papa, & Litz, 2008; Norris et al., 2002).

Whereas a majority of the world’s population is exposed to at least one traumatic episode during a lifetime (e.g., Bonanno, Galea, Bucciarelli, & Vlahov, 2006; Galea, Nandy, & Vlahov, 2005), and tens of thousands of people are affected by terror acts directly, many more are affected indirectly, namely, family members, friends, rescue workers, or residents living in the vicinity of the terrorist attacks (see Thompson et al., 2006). Another key factor in the spread of the effects of terrorism and political violence is the mass media, which act as conduits in affecting the general public. Terrorists thus attract the attention of the news media, mainly TV and the Internet, and through these media, that of the public and government, both in the target country and around the globe (Nacos, 2007).

Secondary Traumatization and Media Exposure
Various terms have been used to describe the pathological consequences of indirect exposure to trauma, including secondary traumatization, compassion fatigue (Figley, 1995), and vicarious traumatization (McCann & Pearlman, 1990). Although they differ in phenomenology and manifestations, all of these terms essentially describe the negative impact of bonding to a trauma victim and exposure to that victim’s traumatic material (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995).

The symptoms characterizing secondary traumatization include reexperiencing the traumatic event through intrusive thoughts, images, flashbacks, or dreams; avoidance of reminders of the trauma, and general numbing; and psychological and physiological hyper-arousal symptoms, such as alert reactions, general anxiety, and increased heart rates. These symptoms have been found to be similar to those of PTSD, but of a lower intensity. Another indirect effect, in addition to secondary or vicarious trauma caused by proximity to a terror victim, is that prompted by watching and learning about the effects of terror acts and political violence from the mass media (Dougall et al., 2005), which reach millions of people. The mass media include all methods or channels of information transfer and entertainment, namely TV, Internet, radio, cell phones, and newspapers (Wilkinson, 1997; Swenson & Johnson, 2003). Thus, it is highly probable that watching TV or searching the Internet will lead to exposure to the outcomes of terror acts both visually and in terms of verbal information and commentary. Indeed, Schuster et al. (2001) conducted a national survey after the 9/11 terror attacks and reported that 44% of TV viewers developed one or more of the secondary PTSD symptoms, and Swenson and Johnson (2003) found that in an American academic population, 76% of respondents reported one or more symptoms of secondary PTSD, and 32% reported three or more such symptoms. Among students, media exposure (hours spent on TV viewing the 9/11 coverage) was related to PTSD symptoms (Collimore, McCabe, Carleton, & Asmundson, 2008). In sum, the effects of the media are associated with high levels of posttraumatic symptoms, acute distress, and feelings of insecurity and vulnerability (Slone, Shoshani, & Baumgarten-Katz, 2008). The present study aimed to assess coping styles and resources as moderators of the media traumatic effects.

Coping Strategies, Styles, and Resources
Coping represents behavioral and cognitive efforts to deal with stressful encounters (e.g., Lazarus, 1999; Lazarus & Folkman, 1984; Terry, 1994). Lazarus and Folkman (1984) and Lazarus (1999) classified coping modes as either problem-focused or emotion-focused, thereby delineating the function of coping as dealing mainly with the problem, or with its emotional and physiological outcomes, respectively. Another distinction is approach-avoidance, which refers to engaged coping strategies whose goal is to reduce, eliminate, or manage the problem, versus disengaged coping whose goal is to ignore or avoid the problem and its emotional consequences (Skinner, Edge, Altman, & Sherwood, 2003; Nes & Segerstrom, 2006). The coping model adopted for the present research is that of Carver, Scheier, and Weintraub (1989) which is based on the Lazarus cognitive model of stress (e.g., Lazarus & Folkman, 1984) and behavioral self-regulation theory (Carver & Scheier, 2000). This coping framework includes 15 coping strategies classified by three types: problem-focused strategies, which are considered effective and adaptive; and two different kinds of emotion-focused strategies—those considered functional and sometimes helpful in solving the problem, and those considered ineffective and dysfunctional.

Coping is found to be correlated with outcomes in specific contexts: Emotion-focused coping is highly correlated with psychological distress (e.g., Ben–Zur, Gilbar, & Lev, 2001; Carver & Scheier, 1993; Zeidner, 1995, 2007; Zeidner & Ben–Zur, 1993). Problem-focused strategies show either no significant correlations with state-anxiety (e.g., Zeidner & Ben-Zur, 1993), or positive associations (Zeidner, 2007), although they are found to be related to better performance (Baggett, Saab, & Carver, 1996; Zeidner, 1995). A meta-analysis showed that emotion-focused coping is highly related to distress and its variants (e.g., depression), but problem-focused coping associations with distress were much weaker and inconsistent in direction (Penley, Tomaka, & Wiebe, 2002). In contrast, recent research on coping with traumatic events, summarized by Maguen, Papa, and Litz (2008), suggests that the results regarding coping with traumatic events such as terrorism, which is not under the individual’s control, are equivocal. Thus, several studies found emotion-focused coping to be related to higher levels of distress, anxiety, or PTSD following terror attacks (e.g., Gil & Caspi, 2006; Liverant, Hofmann, & Litz, 2004), and other studies in the context of political violence in Israel found problem-focused coping to be related to higher levels of anxiety (e.g., Gidron, Gal, & Zahavi, 1999).

The present study conceptualized coping as a stable cognitive and behavioral characteristic of the individual, following other investigators who used a trait approach in regard to coping (e.g., Carver et al., 1989; Krohne, 1993; Miller, Combs, & Kruus, 1993). Very few studies, however, have dealt with the association of coping styles with distress and PTSD. Ben–Zur and Zeidner (1995) reported the everyday use of emotion-focused coping associations with anxiety following the Gulf War of 1991, and Ben–Zur (2002b) showed positive associations between dispositional problem/accommodation coping and positive affect, as well as between avoidance/disengagement coping and negative affect.

Apart from coping, personal traits have also been recognized as an important determinant of coping and distress when individuals encounter stressful events. Such traits as dispositional optimism and locus of control or mastery are considered to be personal resources that have been accorded a central role in all contemporary models of stress (Hobfoll, 1989, 1991, 2001; Lazarus & Folkman, 1984; Moos & Schaefer, 1993; Pearlin, 1999). Dispositional optimism is often defined as the generalized expectancy that good outcomes will occur when confronting major problems (Scheier & Carver, 1985). This personal quality is considered to be a determinant of sustained efforts to deal with problems, in contrast to turning away and giving up. Most research findings in this area indicate a positive association between optimism and coping with stressful life events such as chronic diseases or disability (e.g., Ben–Zur & Debi, 2005; Epping–Jordan et al., 1999; Scheier & Carver, 1992). Mastery refers to the extent to which a person perceives having control over his or her life events (Pearlin & Schooler, 1978). It is also defined as inner feelings of strength and as the capacity to cope with and overcome obstacles by relying on one’s own efforts (Hobfoll, Jackson, Hobfoll, Pierce, & Young, 2002). Studies have indicated that mastery is strongly associated with lower levels of anger and depressive moods (e.g., Ennis, Hobfoll, & Schroder, 2000), or negative affect (Ben–Zur, 2002b) and with higher levels of positive affect (Ben–Zur, 2002b, 2003). Finally, a composite score of optimism, perceived control, and self-esteem was related to preabortion stress appraisals and predicted positive wellbeing following the abortion (Major, Richards, Cooper, Cozzarelli, & Zubek, 1998); it also predicted positive adjustment to heart disease (Helgeson, 1999), and lower posttraumatic symptoms among uprooted Israeli citizens (Ben–Zur, 2008).

In studies of natural and man-made disasters (Norris et al., 2002), high levels of personal resources were found to be related to lower distress and lower posttraumatic stress, whereas resource loss was found to be related to high posttraumatic stress levels. High postdisaster distress levels were related to lower optimism following a hurricane (Benight, Swift, Sanger, Smith, & Zeppelin, 1999), whereas a study of the effects of personal resources following an earthquake (Sumer, Karanci, Berument, & Gunes, 2005) reported higher levels of optimism and perceived mastery to be related to lower distress and intrusions.

The Israeli Context
Israeli citizens have been living with wars, political violence, and acts of terror since the country’s existence as an independent state. Since 2000 alone, such events have included the second major uprising of the Palestinians living under Israeli occupation—the Al-Aksa Intifada—which started in 2000, which was marked by suicide bombings and terrorist attacks throughout Israel, and which lasted for about five years, with hundreds of Israelis killed and thousands wounded during that period; the systematic bombardment of the town of Sderot and other settlements in southern Israel bordering the Gaza Strip by missiles launched from the strip over a period of seven years; and the second Lebanese war in the summer of 2006, which witnessed a steady bombardment of missiles launched by Hizballah into northern Israel.

Studies conducted in Israel have investigated the psychological outcomes of terror attacks during the intifada (e.g., Gelkopf, Solomon, Berger, & Bleich, 2008), missile attacks on the Israeli Southern settlements (e.g., Gelkopf, Berger, Bleich & Silver, in press), and missile attacks during the second Lebanese war (e.g., Ben–Zur & Almog, in press; Palmieri, Canetti-Nisim, Galea, Johnson, & Hobfoll, 2008). These studies indicate that direct exposure to acts of violence and terror resulted in high levels of PTSD, posttraumatic symptoms, and/or depression and anxiety.

All of these events were covered by the media intensively, especially by TV. Thus, although most of the population in Israel did not experience terror acts directly, almost all experienced these acts vicariously through the media. Several studies conducted in Israel have shown associations between media coverage of terror acts and high levels of anxiety (Slone, 2000; Slone & Shoshani, 2010) or secondary trauma symptoms (Keinan, Sadeh, & Rosen, 2003). One of the important questions in this context is how Israeli people are affected by the media and how they cope with the direct and indirect effects of terror acts.

Study Aims and Hypotheses
The study aimed to assess secondary posttraumatic symptoms among university students, a population that makes extensive use of the media, and especially of Internet news coverage and short message service (SMS) messaging (Teo & Heong Pok, 2003). The study used coping strategies and resources, as well as level of exposure to terror acts directly and through the media, as the main variables that can potentially affect posttraumatic symptoms and distress. The hypotheses were:

H1: High levels of media exposure will be associated with high levels of posttraumatic symptoms and distress.
H2: High levels of emotion-focused coping and avoidance will be associated with high levels of posttraumatic symptoms and distress.
H3: High levels of problem-focused coping will be associated with low levels of posttraumatic symptoms and distress.
H4: High levels of personal resources will be associated with low levels of posttraumatic symptoms and distress.
H5: High levels of direct exposure to terror acts will be associated with high levels of posttraumatic symptoms and distress.
METHOD

Sample and Procedure
The sample consisted of 203 undergraduate students (who agreed to participate out of 241 students approached; 84%) at a university in northern Israel. The sample contained 41 men (20%) and 162 women (80%), mean age 23.9 (SD = 3.86, range 19–42), the majority born in Israel (73.4%), served in the Israeli army (76.8%), were Jewish (85.7%), and secular (77.3%). The mean reported economic status was about average (3.09, SD = 0.95; range 1 = bad; 6 = excellent). The students were approached in classes, and their participation was voluntary. The general aim of the study was described in the instructions, and the questionnaires were completed in class and handed to the authors. The data were coded and analyzed anonymously. The research was approved by the University of Haifa internal review board.

Instruments
Table 1 presents the psychometric properties of the study variables.

str-19-2-132-tbl1a.gifPsychometric Properties of the Research Variables

Demographic Details

These consisted of age, gender, sector (Jewish or Arab), marital status, place of birth, level of religiosity, military service, number of siblings, parents’ education, and economic status as assessed by respondent.

Mastery (Pearlin & Schooler, 1978)

The scale measures perception of personal control over life outcomes (e.g., “I can do just about anything I really set my mind to do”) and contains seven items rated on a 1 (not at all characteristic of me) to 7 (very characteristic of me) scale. The two high-mastery items and the five reverse-coded items are averaged, with a high score indicating a high level of mastery. Hobfoll and Walfisch (1984) reported a test–retest reliability of .85 or above for the scale, with reasonable internal reliability levels (α = .75). The Hebrew form showed satisfactory internal reliability levels in Israeli studies (e.g., Ben–Zur, 2002a, 2002b, 2003; α = .69–.80) and in the present study (α = .80).

Dispositional Optimism (Life Orientation Test LOT; Scheier and Carver, 1985)

This scale assesses stable positive outcome expectancy, and consists of eight items (e.g., “In uncertain times, I usually expect the best”), rated on a 1–5 (1 = disagree to a large extent; 5 = agree to a large extent) scale. The four positively worded and four reverse-coded items are averaged, with a high score indicating an optimistic tendency. The internal reliability and test–retest of the original version were satisfactory (α = .76, test–retest = .79; Scheier & Carver, 1985). The Hebrew version (Zeidner & Ben-Zur, 1994) has been used in various Israeli studies, and showed satisfactory reliabilities (e.g., Ben–Zur & Debi, 2005, α = .76; Ben–Zur, 2003, α = .61–.83; in the present study, α = .81).

COPE Scale (Carver et al., 1989)

The use of coping strategies to deal with stressful events in everyday life was tested by the short Hebrew version of the COPE scale (Zeidner & Ben–Zur, 1994), which contains 15 coping strategies, each represented by the sum of two items. Respondents indicated the extent to which each of the 15 strategies was used in general. Responses were rated on a four-point scale ranging from 0 = not at all to 3 = great extent. The strategies were active coping, planning, seeking instrumental social support, seeking emotional social support, suppression of competing activities, religion, positive reinterpretation and growth, restraint coping, acceptance, ventilation of emotion, denial, mental disengagement, behavioral disengagement, alcohol/drug use, and humor. Following Carver et al.’s (1989) exploratory factor analysis with varimax rotation was applied to the 15 coping-strategy scores yielding five factors. The first three factors were compatible with Carver et al.’s (1989) factor analysis outcomes, and were used in this study to construct three coping subscales: problem-focused coping (including active coping, planning and suppression, accounting for 13% of the common factor variance); two scales of emotion-focused coping: avoidance coping (including behavioral and mental disengagement, denial, and alcohol/drug use; accounting for 12.36% of the variance) and emotion/support coping (including instrumental and emotional support, and ventilation; accounting for 12.18% of the variance). Coping subscales showed modest internal reliability levels, .65, .64 and .58 for problem-focused, emotion/support and avoidance coping, respectively.

Media Exposure Inventory

This instrument was developed for the present study to assess the frequency of use of various media: radio, TV, Internet, SMS, newspapers, and rumors. For each type of media, frequency of use was assessed using a 1–5 (1 = never; 5 = always) scale in three separate conditions: everyday updating, leisure time, and following a terror act in Israel. The content validity of the inventory was assessed by two trauma experts. As shown in Table 1, the internal reliability of the three media exposure types was in the range of .54–.57.

Exposure to a Terror Act

Respondents were asked to cite the terror event occurring in Israel during the preceding four years that affected them the most, from a list of examples of the most widespread types of acts (e.g., major terror acts occurring in restaurants, buses, hotels, etc.). Actual exposure to the terror act was evaluated by the following self-report question: “Please select and mark an item listed below that best describes your involvement in this event.” The items were: (a) I was injured in the terror event; (b) I witnessed the terror event in person, i.e., not through the media; (c) I had significant others (family members or close friends) who were killed during the terror act; (d) I had significant others (family members or close friends) who were injured during the terror act; (e) I had significant others who witnessed the terror event and shared its details with me; and (f) I was not involved in any way in the event. Respondents could mark more than one answer, but it was their first marked category that counted (there were few additional answers).

Posttraumatic Symptoms

The study used the Posttraumatic Symptom Scale-Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993), which is the self-report version of the structured interview. It includes 17 items which directly correspond to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV;APA, 1994) symptoms. Symptom frequency over the preceding two weeks is reported on a 4-point scale (0 = did not occur or occurred only once; 3 = occurred five times or more per week or almost all the time). The respondents were asked to refer to the terror act that most shocked them, and to refer to their feelings one week after that event in rating the symptoms. The inventory contains three subscales: reexperiencing (5 items), avoidance (7 items), and arousal (5 items). Foa et al. (1993) reported an alpha score of .91 and a 1-month test–retest reliability of .74 for the total score. The Hebrew translation (Gil, 2005) showed high reliability levels for the total scale (.88–.91) and in the present study (.91).

Brief Symptom Inventory (BSI)

This self-report symptom scale is designed to assess levels of psychopathology (Derogatis & Melisaratos, 1983).The original scale consists of 53 items describing a variety of problems and complaints (e.g., nervousness, feeling lonely, feeling strain, etc.), originally rated on a 0–3 scale. The alpha coefficients for all nine dimensions of the BSI range from .71–.85. The Hebrew translation (Gilbar & Ben–Zur, 2002a, 2002b) showed high internal reliability for each of these scales (α = .75–.83), and for the total (α = .96). The present study used the anxiety, depression, and somatization scales (18 items; the suicidal thoughts item was deleted) from the BSI. Respondents were instructed to refer to their feelings during the occurrence of a terror act in Israel, and rate them on a 0–4 scale (0 = not at all, 4 = a lot; α = .94), with high score indicating a high level of distress.

RESULTS

The means of the use of media types for everyday updating, leisure time, and following a terror act in Israel are presented in Table 2. As can be seen in the table the medium most frequently used after a terror act was TV. The intercorrelations of the three media frequency measures were in the range of .52–.66 (p < .001; see Table 3).

str-19-2-132-tbl2a.gifMeans of Differential Uses of the Various Media Types

str-19-2-132-tbl3a.gifIntercorrelations of Psychological Variables

The distribution of responses regarding each of the six types of exposure to a terror event was as follows: Three (1.5%) respondents reported being injured, 11 (5.5%) witnessed the incident in person, 25 (12.5%) had significant others who were killed in the event, 8 (4.0%) had significant others who were injured, 21 (10.5%) had significant others who witnessed the event and shared the details with them, and 132 (66%) were not involved in any way. Because the number of respondents in each of the first five categories was small, for the purpose of statistical analysis these five types of exposure were merged into three categories (Gil & Caspi, 2006) based on similar characteristics: personal exposure, defined as being injured in the event or witnessing it in person, reported by 14 participants (7%); significant other’s exposure, defined as having had significant others who were killed or injured in the event, reported by 33 participants (16.5%); and indirect exposure, defined as a report by significant others who witnessed the event and shared its details with the respondent, reported by 21 participants (10.5%). No differences were found between the three categories on the BSI or PSS-SR measures, and they were therefore combined, with subsequent analyses using a dichotomous variable of exposure: exposure (1) and no exposure (0).

Table 3 presents the intercorrelations between the study variables. As can be seen in the table, optimism and mastery were highly correlated, and also showed similar positive associations with problem-focused coping and similar negative associations with avoidance coping and the distress and trauma outcomes (i.e., BSI and PSS-SR scores). An index of resources was therefore created based on the mean of their z-score transformations, following Ben–Zur (2008). The table also shows that media exposure following a terror act was positively correlated with the BSI and PSS-SR outcomes, whereas exposure to the media either to update or for leisure was not correlated with either outcome.

Next, hierarchical regressions were conducted on the PSS-SR and BSI using the demographic variables of gender (0 = men, 1 = women), age, religion (0 = Jewish, 1 = other religions), country of birth (0 = Israel, 1 = other countries), and economic status (1 = bad, 6 = excellent) as control variables, entered at Step 1. Exposure to terror events and resource variables were entered at Step 2, coping subscales at Step 3 and the three media exposure types at Step 4. As can be seen in Table 4, and confirming H1, media exposure to terror is related positively to both PSS-SR and BSI after all study and control variables are entered into the regressions. Of the coping styles, only avoidance coping contributed to higher levels of BSI, with no effects found for emotion/support or problem-focused coping, thus only partially confirming H2, and H3 was not substantiated. Resources led to lower PSS-SR only, thus only partially supporting H4. Lastly, exposure to terror events contributed positively to both PSS-SR and BSI outcomes, as hypothesized in H5. Apart from these outcomes, the contribution of the demographic variables to the PSS-SR was a nonsignificant 5%, but to the BSI, their contribution was more substantial (20%): Women, immigrants and non-Jews were in greater distress. In summary, the study variables contributed 15% and 13% to the PSS-SR and BSI, respectively, with exposure to terror acts and to the media being more prominent and consistent in contributing to outcomes than resources or avoidance coping, which did contribute to either lower BSI, or higher PSS-SR, respectively.

str-19-2-132-tbl4a.gifHierarchical Regression Analyses of PSS-SR and BSI on Demographic and Research Variables

DISCUSSION

The main finding of the study is the positive association observed between frequency of exposure to reports of terror in the media and higher levels of posttraumatic symptoms and distress symptoms, as hypothesized. These results were obtained while controlling for all other variables in the study, namely, coping, resources, demographics, and direct exposure—the last revealing a positive association with both posttraumatic and distress outcomes as well. Thus, exposure to terror, either directly or through the media, was shown to be the most potent variable in the study. Media effects on posttraumatic symptoms are in accord with a variety of studies showing the effects of the exposure to media on PTSD in a range of contexts (e.g., Dougall et al., 2005; Schuster et al., 2001; Slone et al., 2008).

Exposure to terror through the media is in many cases a voluntary act. People usually decide whether or not to watch TV news and special reports on terrorist acts, or to seek specific information about terror acts on the Internet. It should be noted, however, that exposure to terror through the media may also occur involuntarily when changing TV stations randomly or searching the Internet for certain (other than terror) information. Nevertheless, exposure to the media is frequently self-selected, in contrast to the accidental presence in the vicinity where a terrorist act occurs. Moreover, of the various media formats (i.e., radio, TV, Internet, SMS, and newspapers), TV was rated as the most extensively used medium for acquiring information about terror acts, even in this study sample which was composed of a young population. This means of communication, therefore, is still the most important and presumably the most influential in conveying messages to large sectors of the public, thereby exposing them to frightening images that can contribute to secondary traumatization.

Contrary to the study hypotheses, problem-focused and emotion/support coping were not related to outcomes, as has been found in the context of stressful events (e.g., Penley et al., 2002). Of the coping strategies, only avoidance coping contributed to higher distress levels. This accords with other studies of coping with terror acts, which showed avoidance coping to be related to PTSD (e.g., Gil & Caspi, 2006), as well as with studies showing avoidance coping to be related to higher levels of anxiety or negative affect in other contexts (e.g., Ben–Zur, 1999, 2002a). Thus, even in a situation of uncontrollable and unpredictable traumatic events such as terror attacks, avoidance coping proves to be a detrimental coping response. In the present study, coping styles rather than situational coping were measured. Thus, although the study is cross-sectional, the use of a trait measure of coping in relation to a terror event lends support to the contribution of avoidance coping to high distress levels.

In accordance with the hypotheses posited, combined resources, namely optimism and mastery, were negatively associated with posttraumatic symptoms, as found in other studies of community disasters (e.g., Ben–Zur, 2008; Benight et al., 1999; Sumer et al., 2005) and of individually experienced stressful events (e.g., Ben–Zur & Debi, 2005; Epping–Jordan et al., 1999; Helgeson, 1999; Major et al., 1998; Scheier & Carver, 1992). These data are valuable in suggesting that problem-focused coping generally does not relate to reactions to terror acts, but resources do. This difference in results may be due to the fact that problem-focused coping involves active steps and behaviors that a person may or may not initiate to deal with the stressful encounter, depending on his or her resources and on the situational aspects of ambiguity and control; whereas optimism and mastery are sets of cognitions or beliefs that may be adopted to help people adjust to any situation.

A number of methodological limitations should be mentioned. First, the study was conducted retrospectively, at a single time point, so that all cause and effect relationships are hypothetical. Arguably, not only does media exposure affect people’s symptoms, but that people who suffer from high levels of distress and posttraumatic symptoms may be more prone to expose themselves to media coverage of terror acts.

Furthermore, the study was limited to a specific population—young college students. Indeed, this population was intentionally targeted on the assumption that students are intensive consumers of the largest variety of media. However, using this specific population makes generalizations to other populations limited.

Despite these limitations, the findings support the hypothesis that exposure to terror through the media affects the likelihood of secondary traumatization and mental distress symptoms. These results demonstrate the importance of an awareness of the risks of vicarious exposure to terror and trauma through the media. The study results imply that individual and group therapy methods should be developed for people who were vicariously exposed to terror. Further recommendations are to reduce media coverage of shocking images following terror events, which may affect the likelihood of secondary traumatization and mental distress symptoms. Additionally, the general public should be informed about the risks involved in vicarious exposure to terror through the media. These results also strengthen the notion that people should be encouraged to adopt optimistic and controllable beliefs about themselves and their environments.

Footnotes
1 The two additional factors were not used to derive coping subscales because of the relatively low intercorrelations between the coping strategies that showed high loadings on each factor.

2 It should be noted that a high level of reliability is not always expected when dealing with the frequency of several events or actions that are not necessarily related.

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Submitted: September 11, 2011 Revised: February 21, 2012 Accepted: February 23, 2012

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Source: International Journal of Stress Management. Vol. 19. (2), May, 2012 pp. 132-150)
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Development of the Coping Strategies Inventory for Trauma Counselors.
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Authors:
Bober, Ted. Ontario Medical Association, Toronto, ON, Canada, tbober@cogeco.ca
Regehr, Cheryl. Faculty of Social Work, University of Toronto, Toronto, ON, Canada
Zhou, Yanqiu Rachel. Faculty of Social Work, University of Toronto, Toronto, ON, Canada
Address:
Bober, Ted, Ontario Medical Association, 525 University Ave., Suite 300, Toronto, ON, Canada, M5G 2K7, tbober@cogeco.ca
Source:
Journal of Loss and Trauma, Vol 11(1), Jan-Feb, 2006. pp. 71-83.
NLM Title Abbreviation:
J Loss Trauma
Page Count:
13
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Crisis Intervention & Time-Limited Treatment; Journal of Personal and Interpersonal Loss; Stress, Trauma and Crisis: An International Journal
ISSN:
1532-5024 (Print)
1532-5032 (Electronic)
Language:
English
Keywords:
Coping Strategies Inventory, trauma counselors, factor analysis, internal reliability
Abstract:
There is increasing awareness about the negative consequences of counseling traumatized people. Emanating from qualitative research and clinical reflections, suggestions are frequently made regarding self-care strategies to reduce the impact. However, no tools exist for measuring these strategies to determine the effectiveness of engaging in self-care behaviors. This study evaluates the Coping Strategies Inventory which measures beliefs and behaviors regarding coping in trauma counselors. Items were derived from the practice literature and a focus group with experienced therapists. A factor analysis was conducted with a sample of 259 trauma therapists and 77 hospital workers. Results demonstrated a consistent factor structure with adequate internal reliability. The CSI may thus be useful in research on vicarious trauma and for self-appraisal of counselors. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Counselors; *Emotional Trauma; *Test Construction; *Test Reliability; Counseling; Factor Analysis; Inventories; Posttraumatic Stress Disorder
PsycInfo Classification:
Health Psychology Testing (2226)
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Coping Strategies Inventory
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Print
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20060327
Correction Date:
20130114
Digital Object Identifier:
http://dx.doi.org/10.1080/15325020500358225
Accession Number:
2006-01314-004
Number of Citations in Source:
22
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DEVELOPMENT OF THE COPING STRATEGIES INVENTORY FOR TRAUMA COUNSELORS.
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Contents
Method
Sample
Factor Analysis
Results
Reliability
Validity Criteria
CONTENT VALIDITY
Construct Validity
CRITERION VALIDITY
Discussion
References
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There is increasing awareness about the negative consequences of counseling traumatized people. Emanating from qualitative research and clinical reflections, suggestions are frequently made regarding self-care strategies to reduce the impact. However, no tools exist for measuring these strategies to determine the effectiveness of engaging in self-care behaviors. This study evaluates the Coping Strategies Inventory which measures beliefs and behaviors regarding coping in trauma counselors. Items were derived from the practice literature and a focus group with experienced therapists. A factor analysis was conducted with a sample of 259 trauma therapists and 71 hospital workers. Results demonstrated a consistent factor structure with adequate internal reliability. The CSI may thus be useful in research on vicarious trauma and for self-appraisal of counselors.

Various studies have documented the effects on counselors and others who are exposed to tragic stories presented by traumatized clients. For instance, a study of 70 human rights workers in Kosovo who were responsible for collecting data on human rights violations revealed elevated levels of anxiety in 17.1%, depression in 8.6%, and posttraumatic stress disorder symptoms in 7.1% (Holtz, Salama, Cordozo, & Gotway, [ 6]). Among lay trauma counselors who had been trained to Help bank employees following bank robbers in South Africa, 10% reported secondary traumatic stress symptoms in the high or extremely high range (Ortlepp & Friedman, [14]). Further, in a study of 173 child welfare workers exposed to both traumatic imagery through the stories of clients and direct exposure to trauma such as violence and threats directed at them, 46.7% reported traumatic stress symptoms in the severe range (Regehr, Chau, Leslie, & Howe, [16]). Despite the fact that few trauma counselors may have symptoms that reach the level for which they would qualify for a diagnosis of PTSD, qualitative studies and anecdotal reports demonstrate that exposure to traumatic material does have a significant impact on these individuals (Iliffe & Steed, [ 7]; Ortlepp & Friedman, [14]; Regehr & Cadell, [15]; Schauben & Frazier, [19]). Similar to traumatic stress, symptoms of vicarious trauma can include immediate reactions such as intrusive imagery, nightmares, increased fears for the safety of oneself and loved ones, avoidance of violent stimuli in the media, difficulty listening to clients’ accounts of events, irritability, and emotional numbing. Longer-term reactions can include emotional and physical depletion, a sense of hopelessness, and a changed world view in which others are viewed with suspicion and cynicism.

Several factors contribute to the development of vicarious trauma. In working with traumatized individuals, trauma counselors are faced with repeated descriptions of disturbing events. One aspect contributing to vicarious trauma, therefore, is the “dosage” of exposure in terms of the percentage of time spent with traumatized individuals, the types of tragedy that are described to counselors, and the impact of suffering and adversity that they witness in others (Marmar et al., [10]; Resnick et al., [18]). With repeated exposure to traumatic imagery in the context of providing therapy, workers can begin to incorporate an accumulation of the victim’s traumatic material into their own view of the self and the world (McCann & Pearlman, [11]). Further, the high-voltage nature of work with people in crisis, often in situations of urgency and emotional reactivity, can cause trauma counselors to begin to question their own competency and to feel helpless to relieve the suffering of others (Astin, [ 1]). A final set of factors contributing to the experience of vicarious trauma is specific to the individual worker. One aspect is the degree of the empathic engagement between the counselor and the client (Figley, [ 4]). In addition, trauma work has the potential to “rub old scars anew” and cause previously experienced and resolved personal traumas to resurface and cause distress (Wall, [22]).

Several authors have offered advice, emanating from both qualitative interviewing and clinical reflections, regarding self-care in order to reduce the impact of trauma counseling work (for an annotated bibliography, see O’Halloran & Linton, [13]). One suggestion is the development of personal supports and outside interests to serve as a buffer against secondary trauma (Hesse, [ 5]; Ortlepp & Friedman, [14]; Regehr & Cadell, [15]). Other forms of self-care reported as helpful include physical activity, attention to diet and rest, and diversionary activities (Iliffe & Steed, [ 7]). At work, trauma counselors are urged to reduce the caseloads of traumatized individuals that they see (McCann & Pearlman, [11]; Schauben & Frazier, [19]). In addition, trauma counselors are advised to develop professional support networks for consultation and collaboration and to engage in continuing education to reduce the impact of stress and trauma exposure (Dane, [ 3]; Hesse, [ 5]; Talbot, [21]). Counselors are also cautioned about the need to acknowledge a personal history of trauma and assess whether this history is impacting their work or their current emotional state (Sexton, [20]).

To date, however, there is no tool which measures these various forms of self-care. The development of such an empirical measure would allow for research evaluating whether these forms of self-care may in fact be protective against the development of stress and trauma symptoms in those counselors who work with traumatized individuals. This article describes the development of the Coping Strategies Inventory, a measure containing two sub-elements, (a) beliefs regarding which coping strategies will lead to lower levels of secondary trauma and (b) time spent engaging in coping strategies. Reliability and validity of the measure are addressed following testing on two populations, 259 trauma therapists and 71 hospital workers providing physical care to injured individuals.

Method
Items to be included in the scale were derived initially from a comprehensive literature search utilizing the Psychinfo database system. It was quickly determined that there are few empirical data on effective approaches for managing vicarious trauma. Therefore, we selected frequently offered suggestions and solutions to reduce the impact of vicarious trauma on therapists from qualitative studies and the clinical reflections literature. A draft measure was then presented to a focus group of experienced therapists who suggested modifications and offered further stress management strategies that had been recommended to them in workshops on managing vicarious trauma.

Clinical programs that specialized in work with victims were then identified. Finalized questionnaires were distributed with self-addressed envelopes to therapists in team meetings or by mail. A total of 580 questionnaires were distributed and 259 were returned, resulting in a return rate of 45%. A second set of questionnaires was distributed to 125 noncounseling staff members in a general hospital. This resulted in a return rate of 56.8%. This response rate is somewhat low considering average response rates reported for mail in questionnaires with physicians in the 1990s, which ranged between 57% and 63% (Cummings, Savitz, & Konrad, [ 2]); however, unlike many physician surveys, we did not use financial incentives to increase the response rate (Kellerman & Herold, [ 9]). It is possible that this resulted in a response bias, although we do not have information to determine the impact of such a bias.

Sample
The initial sample consisted of 259 individuals who identified themselves as counselors or therapists providing mental health services. Social workers comprised 47.7% of the sample. Of the remaining respondents, 15.5% identified nursing as their primary profession, 13.6% psychology, and 10% physician, fewer than 3% reported that they were from each of a variety of disciplines including child and youth worker, occupational therapist, and chaplain. The primary fields of service reported by the participants can be found in Table 1. Two hundred nine participants (80.7%) were women. The mean age of participants was 41.31 years (SD = 9.29). Participants indicated that they had worked a mean of 10.17 (SD = 6.59) years as a counselor or therapist, worked an average of 16.32 (SD = 10.88) hours per week in counseling, and worked an average of 8.36 (SD = 8.35) hours per week counseling traumatized individuals. The second sample consisted of individuals who did not provide counseling services or psychotherapy. A comparative analysis of this group and the counselor/therapist group can be found in Table 1.

TABLE 1 Comparison of Counselors and Noncounselors

Domain Counsellors N = 259 Noncounsellors N = 71
Age (years) 41.31 (9.29) 39.51
Female (%) 80.7 83.1
Education (%)
College 15.5 26.8
Bachelor’s degree 18.2 43.7
Master’s degree 50.8 22.5
Doctorate 13.2 4.2
Discipline (%)
Social work 47.7 18.3
Nursing 15.5 15.5
Physician 10.1 2.8
Physiotherapist 0 26.8
Management/business 3.1 9.9
Area of service (%)
Crisis 5.4 5.6
Inpatient 16.0 15.5
Outpatient 20.1 16.9
Hospital 24.8 56.3
Private practice 22.5 2.8
Community agency 17.4 4.2
EAP 6.2 1.4
Factor Analysis
As mentioned, the initial Coping Strategies Inventory contained two sub-elements, beliefs regarding which coping strategies will lead to lower levels of secondary trauma and time spent engaging in coping strategies. Each of these elements originally contained 27 items. In order to assess whether factor analysis would be appropriate for the initial sample of 259 therapists, Bartlett’s test of sphericity and the Kaiser-Meyer-Olkin measure of sampling adequacy (KMO) were employed. The Bartlett tests for both the Coping Strategies Beliefs (CSB) and Coping Strategies Time (CST) scales were significant, suggesting that the proportion of variance shared by the variables was appropriate for factor analysis. The KMO, based on partial correlations among the variables, was r = .76 for CSB and r = .89 for CST, suggesting that communality among the variables was adequate and appropriate for factor analysis (Norman & Streiner, [12]).

Principal components analysis was used to extract the factors, and the Cattell scree test was used to determine how many factors to retain. As most of the variables loaded on the first factor, varimax rotation was conducted to maximize the variance explained by each factor (Norman & Streiner, [12]). An orthogonal rotation yielded the best results. Factors were considered significantly loaded onto a component if the r value was above.50 (as suggested by Norman & Streiner, [12]). A final check of the factor loadings consisted of verifying that factors loading onto the same components were correlated with one another by checking the initial correlation matrix obtained during factor extraction (Norman & Streiner, [12]). The factors were named based on the commonality between the variables that loaded onto each factor, consistent with our earlier review of the literature.

Results
Twenty-seven items were analyzed using principal component analysis and the varimax rotation method for both the CSB and the CST. For the CSB, this initial pool of items was reduced to 13 items representing three factors that together accounted for 55.9% of the variance, as demonstrated in Table 2. Internal reliability coefficients for these factors ranged from.71 to.82. One other factor that had an alpha coefficient of less than.60 was rejected.

TABLE 2 Total Variance Explained for the Coping Strategies Beliefs Scale

Factor Cronbach alpha Percentage ofvariance explained Cumulative percentageof variance
1. Leisure 0.80 31.78 31.78
2. Self-care 0.82 14.78 46.56
3. Supervision 0.71 9.36 55.92
For the CST, the initial pool of items was reduced to 17 items representing four factors that together accounted for 45.7% of the variance, as demonstrated in Table 3. Internal reliability coefficients for these factors ranged from.67 to.80. The factor loadings for the final factor solution are presented in Tables 4 and 5.

TABLE 3 Total Variance Explained for the Coping Strategies Time Scale

Factor Cronbach alpha Percentage ofvarianceexplained Cumulativepercentageof variance
1. Leisure 0.80 21.20 21.20
2. Self-care 0.76 11.80 32.00
3. Supervision 0.74 7.00 39.97
4. Research and development 0.67 5.70 45.67
TABLE 4 Factor Loadings for the Final Factor Solution: Coping Strategies Beliefs Scale

Item Leisure Self-care Supervision
Time with family .72 .10 .00
Vacation/time off .72 .07 .11
Movies/TV .71 .08 .16
Hobbies .81 .11 .00
Exercise .76 .12 −.02
Stress management training (individual) .28 .55 .23
Stress management training (team) .23 .72 .21
Planning programs .15 .79 .09
Developing self-care plans .08 .61 .28
Developing team-care plans .02 .68 .30
Case discussion with colleagues .33 .19 .56
Case discussion with management .07 .14 .71
Regular supervision .00 .15 .77
Supervision regarding trauma −.07 .19 .73
TABLE 5 Factor Loadings for the Final Factor Solution: Coping Strategies Time Scale

Item Leisure Self-care Supervision Research and development
Time with family .75 .11 .05 −.06
Vacation/time off .75 .22 −.06 −.15
Movies/TV .68 −.18 .15 .00
Hobbies .81 −.19 .09 .08
Exercise .73 −.13 .02 .11
Stress management training (individual) .13 .57 .11 .35
Stress management training (team) .04 .69 .23 .30
Developing self-care plans −.06 .62 −.04 .07
Developing team-care plans −.06 .76 .18 .21
Case discussion with management .05 .46 .51 .19
Regular supervision .07 .45 .82 −.01
Supervision regarding trauma .03 .04 .76 .08
Discussing cases in team meetings .07 .13 .52 .20
Participating in research −.01 .09 .09 .55
Educating other organizations .01 .40 .01 .54
Planning programs .03 .34 .10 .62
Participating in trauma interest groups −.02 .09 .11 .74
Reliability
Reliability of this measure was assessed in terms of internal consistency of items within each subscale for the initial sample of counselors. Following this, the factor structure was assessed using the sample of 71 noncounselor health care workers. The factors in the analysis of the counselors had Cronbach alphas ranging from.67–.82. The factor structure for the noncounselors was equivalent, and the factors had Cronbach alphas which were higher than that of the original test sample, ranging from.69 to.91 for the beliefs component and.75 to.91 for the time component. This suggests that there is very high internal consistency of the items within each subscale of both the CSB and the CST (Janda, [ 8]).

Validity Criteria

CONTENT VALIDITY
Items included in the inventory were derived from the professional and academic literature on vicarious trauma and through a focus group consultation with experienced trauma counselors. In addition, the developers have over 40 combined years of trauma-related clinical experience upon which to draw. The resulting item groupings into factors was highly consistent with recommendations in the literature about healthy coping strategies for trauma counselors and means for avoiding secondary traumatic reactions. Regarding beliefs about what activities would result in lower levels of trauma (CSB), three factors emerged: leisure, self-care, and obtaining supervision. Regarding actual time spent engaging in activities (CST), four factors emerged: leisure, self-care, supervision, and research and development. Beliefs about the value of the three types of coping activities in reducing stress were significantly correlated with one another: leisure and self-care (r = .30, p ≤ .001), leisure and obtaining supervision (r = .21, p ≤ .001), and self-care and supervision (r = .46, p ≤ .001). Time devoted to stress management activities had very few significant associations among the subscales. Only time devoted to self-care within the organization and time devoted to supervision were significantly correlated with one another (r = .42, p ≤ .001), suggesting low levels of consistency between stress management activities in any one person.

Construct Validity
Construct validity was assessed by comparing the factor structure of the CSB and CST between the counselor and noncounselor groups. There was a similar factor breakdown for both groups, suggesting that the underlying constructs were supported. However, the variance explained by the factors was somewhat disappointing. Factors within the CSB accounted for 55.9% of the total variance, and factors within the CST accounted for 45.7% of the total variance, suggesting that some aspects of the construct were not adequately represented in the resulting subscales.

CRITERION VALIDITY
The major limitation of this scale is that criterion validity has not been assessed by comparing scores on this instrument with scores on other scales measuring coping strategies or coping styles. In part, this reflects the fact that while other measures have been developed measuring traumatic responses of trauma counselors, these scales do not address the issue of coping strategies. Further, coping style inventories developed by other researchers do not specifically target stressors related to trauma counseling. One interesting finding, however, is that those individuals with more education and more years of experience were equally likely to view all types of stress management (leisure, self-care, and supervision) as useful but were significantly less likely to devote time to any of these activities (this finding was independent of age). Education was negatively associated with leisure (r = − .28, p ≤ .001), self-care (r = − .28, p ≤ .001), supervision (r = − .28, p ≤ .001), and research and planning (r = − .30, p ≤ .001). Similarly, years in counseling was negatively associated with leisure (r = − .18, p ≤ .001), self-care (r = − .17, p ≤ .001), supervision (r = − .19, p ≤ .001), and research and planning (r = − .20, p ≤ .001). This was not true among the medical therapists.

Discussion
Over the last number of years, there has been increasing awareness of the impact of trauma work on therapists. Several articles in the literature have documented symptoms of posttraumatic stress, depression, and burnout identified in quantitative studies (Holtz et al., [ 6]; Ortlepp & Friedman, [14]; Regehr, Chau, Leslie, & Howe, [17]) and in qualitative and anecdotal reports (Iliffe & Steed, [ 7]; Ortlepp & Friedman, [14]; Regehr & Cadell, [15]; Schauben & Frazier, [19]). This has understandably led to concerns about the health and well-being of people devoted to helping others overcome tragedy. Stemming from this concern, suggestions are frequently made by researchers, those engaged in clinical reflection, and stress management trainers about the best means of dealing with trauma exposure as a therapist and practices to ensure that the therapist’s own mental health is protected. To date, however, no tool has been developed to measure these various strategies so that the effectiveness of engaging in such behaviors can be determined.

The Coping Strategies Inventory is a new tool which can be used in research on vicarious trauma to assess whether engaging in commonly recommended stress management behaviors does in fact lead to lower levels of distress in trauma counselors. This measure was developed based on suggestions available in the professional and academic literature and on samples of therapists and hospital workers who did not provide counseling services. The inventory is divided into two sections (a) beliefs regarding which coping strategies will lead to lower levels of secondary trauma and (b) time spent engaging in coping strategies. Analysis of each of these components resulted in a set of subscales. The CSB had three subscales—leisure, self-care, and supervision, which together accounted for 55.9% of the variance and had internal reliability coefficients of.71 to.82. Subscales were mildly to moderately correlated with one another. The CST had four subscales—leisure, self-care, supervision, and research and development—which together accounted for 45.7% of the variance and had internal reliability coefficients of.67 to.80. Only the self-care within the organizational context and supervision subscales were significantly correlated with one another at a moderate level. Thus, this scale represents an opportunity for researchers in the area of secondary or vicarious trauma to evaluate the practice wisdom that has arisen regarding managing this problem and to determine whether the suggested behaviors are in fact useful in reducing distress.

References
1 Astin, M. (1997). Trauma therapy: How helping rape victims affects me as a therapist. Women & Therapy, 20, 101–109.[CSA]

2 Cummings, S., Savitz, L., & Konrad, T. (2001). Reported response rates to mailed physician questionnaires. Health Sciences Research, 35, 1347–1355.[CSA]

3 Dane, B. (2000). Child welfare workers: An innovative approach for interacting with secondary trauma. Journal of Social Work Education, 36, 27–38.[CSA]

4 Figley, C. (1995). Compassion fatigue: Towards a new understanding of the costs of caring. In B.Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 3–28). Lutherville, MD: Sidran Press.

5 Hesse, A. (2002). Secondary trauma: How working with trauma survivors affects therapists. Clinical Social Work Journal, 30, 293–309.[CROSSREF][CSA]

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~~~~~~~~

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Predictors of compassion fatigue in mental health professionals: A narrative review.
Authors:
Turgoose, David, ORCID 0000-0001-5509-9122 . Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom, d.turgoose@ucl.ac.uk
Maddox, Lucy. Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
Address:
Turgoose, David, Combat Stress, Tyrwhitt House, Leatherhead, United Kingdom, KT22 0BX, d.turgoose@ucl.ac.uk
Source:
Traumatology, Vol 23(2), Jun, 2017. Special Issue: Secondary Traumatic Stress, Compassion Fatigue, and Vicarious Trauma. pp. 172-185.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
14
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Traumatology: An International Journal
Other Publishers:
US : Academy of Traumatology
US : Green Cross Project
US : Sage Publications
ISSN:
1085-9373 (Electronic)
ISBN:
978-1-4338-9086-4
Language:
English
Keywords:
ProQOL, compassion fatigue, mental health professionals
Abstract:
Professionals who work in mental health settings are at risk of developing psychological distress themselves. The term ‘compassion fatigue’ has been used to describe the negative effects of working in a psychologically distressing environment on a person’s ability to feel compassion for others. A number of studies have investigated predictors and correlates of compassion fatigue. However, as yet there is no consensus on which psychosocial factors are most commonly related to compassion fatigue. This review examines research on common correlates and predictors of compassion fatigue in mental health professionals. A literature search yielded 32 studies describing compassion fatigue in a range of mental health professionals and in relation to a variety of psychosocial factors. Quality of papers was variable. The review highlights several factors that were commonly associated with compassion fatigue (e.g., trauma history of mental health professionals, empathy). Some potential protective factors were also indicated, including certain behavioral and cognitive coping styles and mindfulness. Findings and implications are discussed, and directions for future studies are indicated. In particular, we highlight the need for longitudinal studies to investigate compassion fatigue’s development over time and to test models of the etiology of compassion fatigue. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Distress; *Mental Health Personnel; *Occupational Stress; *Psychosocial Factors; *Compassion Fatigue; Coping Behavior; Protective Factors
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Australia; Austria; Canada; Germany; Israel; Italy; United Kingdom; Lithuania; Norway; Switzerland; US
Tests & Measures:
Quality Assurance Checklist
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Five Facet Mindfulness Questionnaire DOI: 10.1037/t05514-000
Compassion Fatigue Self-Test DOI: 10.1037/t66725-000
Mindful Attention Awareness Scale DOI: 10.1037/t04259-000
Methodology:
Literature Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Mar 2, 2017; Accepted: Jan 15, 2017; Revised: Jan 12, 2017; First Submitted: Jul 6, 2016
Release Date:
20170302
Correction Date:
20180517
Copyright:
American Psychological Association. 2017
Digital Object Identifier:
http://dx.doi.org/10.1037/trm0000116
Accession Number:
2017-09426-001
Number of Citations in Source:
77
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Predictors of Compassion Fatigue in Mental Health Professionals: A Narrative Review
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Contents
Compassion Fatigue in Mental Health Professionals
Aim of the Current Review
Method
Design and Demographic Information
Overview of Study Quality
Results
Trauma History
Mindfulness
Empathy
Caseload
Experience and Age
Sex Differences
Coping Style
Religion
Other ProQOL Variables—Burnout
Compassion Satisfaction
Discussion
Implications
Limitations and Future Directions
Conclusions
References
APPENDIX
APPENDIX A: Study Selection Process
Full Text
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By: David Turgoose
Research Department of Clinical, Educational and Health Psychology, University College London;
Lucy Maddox
Research Department of Clinical, Educational and Health Psychology, University College London
Acknowledgement: David Turgoose is now at Combat Stress, UK veterans’ mental health charity. Lucy Maddox is now at Bristol, Avon and Wiltshire NHS Trust.

Professionals who work with highly distressed clients, such as those who have experienced trauma, are at risk of developing compassion fatigue as a result of their work (Figley, 1995). Compassion fatigue has been described as the empathic strain and general exhaustion resulting from dealing with people in distress over time (Figley, 1995). It is characterized by physical and emotional exhaustion and a pronounced reduction in the ability to feel empathy and compassion for others (Elwood, Mott, Lohr, & Galovski, 2011; Mathieu, 2007).

The notion that helping professionals can, in turn, be adversely affected through their efforts to help others in distress, is longstanding. Indeed, since initial psychoanalytic ideas relating to transference and countertransference were acknowledged, different terms have been used to capture and understand these phenomena, such as burnout, vicarious traumatization, secondary traumatic stress, and compassion fatigue. There is considerable overlap between these constructs, and the use of different terms to describe these similar concepts, has hindered our ability to understand them and how they develop (Newell, Gardell, & MacNeil, 2016). A recent chronology of the development of these constructs has added clarity and distinguished each term (Newell et al., 2016). A brief overview is offered below.

The effects of delivering trauma-focused therapies on professionals were described by McCann and Pearlman (1990) as vicarious traumatization. This was defined as the negative effects of repeatedly engaging empathically with the trauma-related material of others, which could even bring about negative changes to the professional’s fundamental beliefs about themselves, the world, and others (McCann & Pearlman, 1990).

Around the same time, secondary traumatic stress was introduced and described as the psychological distress that can occur from hearing the details of another person’s trauma (Figley, 1995). Rather than the cognitive changes described as occurring with vicarious traumatization, characteristics of secondary traumatic stress mirror those of posttraumatic stress disorder (PTSD), including symptoms of hyperarousal, avoidance, and intrusive thoughts or memories relating to the trauma of another (Bride, 2004). Indeed, diagnostic criteria for PTSD now acknowledge the potentially traumatizing effect of “repeated or extreme exposure to details of the traumatic events” (American Psychiatric Association, 2013, p. 271).

Compassion fatigue has also been distinguished from burnout, which is psychological and emotional exhaustion, associated with feelings of hopelessness and difficulties in dealing with work or in doing your job effectively, sometimes in the context of high workloads or a nonsupportive work environment (Stamm, 2010). It is also associated with a reduction in a sense of professional accomplishment (Maslach, 1982). The main distinguishing feature of burnout is the emphasis on environmental and organizational stressors as opposed to psychological and emotional processes within the individual resulting from interactions with another.

In contrast to compassion fatigue, the term compassion satisfaction has been used to describe the positive aspects of working in helping professions. Compassion satisfaction is defined as the pleasure derived from helping, affection for colleagues, and a good feeling resulting from the ability to help and make a contribution (Figley & Stamm, 1996).

The current review focuses on compassion fatigue as, in comparison to the other constructs described above, it is a useful and more general term to describe the emotional and physical fatigue experienced by professionals due to their chronic use of empathy in helping others in distress (Figley, 1995; Newell et al., 2016; Stamm, 2010). Compassion fatigue is prevalent in helping professionals more generally, and is not specific to those who work with trauma. For example, studies have investigated the prevalence of compassion fatigue in mental health professionals (Zeidner, Hadar, Matthews, & Roberts, 2013), nurses (Hegney et al., 2014), doctors (Gleichgerrcht & Decety, 2014), social workers (Simon, Pryce, Roff, & Klemmack, 2005), chaplains (Yan & Beder, 2013), and various emergency services workers (Cicognani, Pietrantoni, Palestini, & Prati, 2009).

Consistent throughout the literature is the notion that compassion fatigue can make it harder for professionals to carry out their roles with empathy and compassion. It is a concept that is widely researched and becoming a topic of interest in different helping professions (see Yang & Kim, 2012 for a review of compassion fatigue in nurses), and will be the central focus of this review. Although findings suggest that certain factors are related to compassion fatigue, research in this area is still relatively recent and a coherent picture is yet to develop.

Compassion Fatigue in Mental Health Professionals

The compassion of health care professionals in the United Kingdom was under scrutiny following serious incidents in Mid-Staffordshire National Health Service (NHS) hospital in 2008. A resulting investigation and report highlighted how a lack of compassion had led to serious failings (Francis, 2013). In response to this investigation, the government recommended that compassion should be at the forefront of effective health care (Department of Health, 2013). However, studies have suggested that compassion fatigue can occur in a range of mental health professionals and settings, such as psychologists (Aukštinaitytė & Zajančkauskaitė-Staskevičienė, 2010), psychiatric nurses in forensic units (Lauvrud, Nonstad, & Palmstierna, 2009), trauma therapists (Killian, 2008), mental health counselors (Thompson, Amatea, & Thompson, 2014), and telephone counselors (O’Sullivan & Whelan, 2011). Clinical social workers in the United States, who often carry out therapy, can also be at risk of compassion fatigue (Thomas & Otis, 2010).

In his etiological model of compassion fatigue in psychotherapists, Figley (2002) proposes that empathy plays a key role in the development of compassion fatigue. The model is based on the assumption that empathy is an important factor in developing a good therapeutic relationship and delivering an effective intervention (Figley, 1995). It suggests that through their empathic response, therapists experience the emotional distress of a client, but that this also contributes directly to the development of compassion fatigue.

The notion of empathy being regarded as crucial in the therapeutic process is longstanding. Carl Rogers outlined six “necessary and sufficient conditions of therapeutic personality change” (Rogers, 1957), which he suggested were essential for psychotherapeutic change. Two of these conditions regarded empathy, in that the therapist must both experience and communicate to the client an empathic understanding of their problem. The importance of empathy has also been detailed in more recent models of psychological treatment, such as the role of “empathic listening” within the Socratic questioning techniques in cognitive behavioral therapy (Padesky & Greenberger, 1995). Given the importance of empathy in mental health work, and the potential for compassion fatigue to reduce empathy in professionals, it is important to understand what psychosocial factors might be associated with compassion fatigue.

Aim of the Current Review

There are currently no reviews of compassion fatigue in mental health professionals. There have been past reviews involving other health professionals. For example, one review of compassion fatigue in nurses, including psychiatric nurses, found that compassion fatigue was associated with factors such as age, educational background, work hours, stress, burnout, and organizational support (Yang & Kim, 2012). Another paper has reviewed the literature on secondary traumatic stress, vicarious traumatization, traumatic countertransference, burnout, and compassion fatigue, but specifically relating to professionals who work with individuals who have experienced trauma (Collins & Long, 2003). A search of the Cochrane Library yielded no results for “compassion fatigue.”

Given the significant role of empathy and compassion in the work of mental health professionals, it seems important to understand what psychosocial factors are associated with compassion fatigue. The current review addresses the following question:

What factors are associated with compassion fatigue in mental health professionals?
Method

Relevant studies were identified via a systematic search of four databases (PsycINFO, PubMed, CINAHL, and PILOTS) for using the following search criteria: compassion fatigue AND (predict* OR risk factor* OR risk OR cause* OR correlate* OR susceptible OR susceptibility OR protect* OR resilience OR vulnerable OR vulnerability) AND (mental health nurse* OR psychiatric nurse* OR mental health professional* OR therapist* OR psycholog* OR counse?lor OR mental health physician* OR mental health professional* OR psychiatr* OR social worker* OR psychotherapist*).

Studies were included if they used quantitative analyses to investigate predictor or correlational variables of compassion fatigue; used validated measures of compassion fatigue; included participants who were in a mental health-related profession (studies that investigated compassion fatigue in the general public were excluded); had a cross-sectional, correlational, longitudinal, experimental, or quasi-experimental design; were published in peer-reviewed journals, and were published in English or where a translation into English was available. Studies published up until the end of August 2014 were considered for review. In addition to the electronic database search, a “hand search” of two relevant journals, The Journal of Traumatic Stress and Traumatology was carried out, which identified a further two studies that warranted examination. These particular journals were chosen as they were the most commonly occurring journals within the original search.

The initial search yielded a total of 477 studies, the titles and abstracts of which were screened to determine which were potentially eligible for inclusion. At this point, 439 studies were found to be duplicates or not relevant, leaving 40 (including those found in the hand searches), the full texts of which were examined in detail. Initial screening for inclusion eligibility was completed by the first author, while the second author completed reliability checks.

Following this process, eight studies were removed as they did not meet inclusion criteria. Including the two studies found in the journal hand search, a total of 32 studies met all inclusion criteria (refer to Figure A1 in the Appendix for a breakdown of the study selection process). Of those that did not meet criteria, a number of them did use compassion fatigue measures (e.g., Professional Quality of Life Scale (ProQOL; Stamm, 2010), which also includes subscales of burnout and compassion satisfaction, but did not report any findings relating to compassion fatigue (e.g., Lambert & Lawson, 2013); two were not available in English; and one used a measure of compassion fatigue to predict working alliance, rather than reporting correlates or predictors of compassion fatigue (Carmel & Friedlander, 2009).

trm-23-2-172-fig1a.gifFigure A1. Study selection flowchart.

The quality of each study was assessed using the Quality Assurance Checklist (Kmet, Lee, & Cook, 2004). The checklist comprises 14 items. Three items were not used in the present review as they are relevant only to studies that used an intervention. Each study was rated against the items on the checklist and achieved an overall score between 0 and 42 which was then converted to give a percentage score (0–100).

Design and Demographic Information
Thirty-two studies were included in the review, all of which were cross-sectional in design. While 23 studies used the ProQOL to measure compassion fatigue, different versions of the measure were used, including the third, fourth, and fifth editions (Stamm, 2010). Nine studies used versions of the Compassion Fatigue Self-Test (CFST) which, as an earlier version of the ProQOL, shares the subscales of Compassion Fatigue, Compassion Satisfaction, and Burnout. In terms of location, most (18) studies were conducted in the United States, with three from Israel, two each from Germany and Canada, and one study each from Lithuania, United Kingdom, Austria, Australia, Switzerland, Norway, South Africa, and Italy (some studies used participants from more than one country). Table 1 provides an overview of each study in the review.

trm-23-2-172-tbl1a.gifOverview of Study Characteristics, Findings, and Quality Ratings
trm-23-2-172-tbl1b.gifOverview of Study Characteristics, Findings, and Quality Ratings
trm-23-2-172-tbl1c.gifOverview of Study Characteristics, Findings, and Quality Ratings

Most studies used correlation and regression analyses to test relationships between compassion fatigue and other variables. Group differences analyses such as t tests and analyses of variance were also used, as was a chi-square analysis in one study to investigate risk of compassion fatigue. Sample sizes ranged from 13 to 1,121, with a median of 135. All studies were published in 2002 or later. The literature search was conducted in August 2014 so any relevant studies that may have been published since this date are not included.

While the focus of the present review was on mental health professionals, there was some variation in the specific job roles of participants. Sample populations included psychologists, trauma therapists, psychiatrists, telephone counselors, genetic counselors, child welfare workers, mental health social workers, employee Helpance professionals, community mental health clinicians, forensic mental health nurses, psychotherapists, family therapists, and volunteer bereavement counselors.

Overview of Study Quality
Each study was assessed using the Quality Assurance Checklist (Kmet et al., 2004), compared against the criteria in the checklist and given an overall quality rating as a percentage. The studies varied widely in terms of sample size, but each study scored at least reasonably highly for quality on the checklist, with ratings ranging from 60% to 95%, with a median of 80%.

It is noted that the way in which samples were recruited may have been open to bias. For example, many studies sent invitations to participants at random, often on a large scale, and relied on data being voluntarily returned. It is possible that participants who were experiencing higher levels of compassion fatigue may not have been as likely to take extra time to complete a battery of measures if they were already having some difficulties coping with the demands of their work. Alternatively, those who had higher levels of compassion fatigue may have been more willing to participate, driven by a need to increase awareness of the issue. Few studies discussed the impact of their recruitment strategies and the potential for bias in this way.

In addition, the studies were cross-sectional in nature and rarely did group comparisons. It is therefore possible that factors other than those being measured were influencing the amount of compassion fatigue being reported by participants. While some studies do acknowledge the limitations of cross-sectional designs, few studies discuss the possibility of extraneous variables influencing compassion fatigue. Yet it is possible that factors specific to that time were affecting levels of compassion fatigue, such as team dynamics, organizational support, or wider social or political influences on health services.

Results

A wide range of factors were investigated in relation to compassion fatigue. For example, many studies reported on the association between compassion fatigue and demographic variables such as sex (e.g., Zeidner et al., 2013), age (e.g., Connally, 2012), and ethnicity (e.g., Sprang, Craig, & Clark, 2011). Other factors related to the clinician were also investigated, such as years of work experience (e.g., Sprang, Clark, & Whitt-Woosley, 2007), caseload (e.g., Simon et al., 2006), trauma history (e.g., Killian, 2008), empathy (e.g., MacRitchie & Leibowitz, 2010), mindfulness traits (e.g., Thieleman & Cacciatore, 2014), religion (e.g., Injeyan et al., 2011), and coping methods (e.g., Jacobson, 2012). Many studies that used the ProQOL to measure compassion fatigue also reported associations with other ProQOL variables (e.g., Collins & Long, 2003), namely, burnout and compassion satisfaction. The main findings are summarized and discussed below.

Trauma History
The factor most commonly associated with compassion fatigue was participants’ own experiences of traumatic life events, with six studies reporting that higher compassion fatigue was related to previous trauma (Deighton, Gurris, & Traue, 2007; Killian, 2008; MacRitchie & Leibowitz, 2010; Nelson-Gardell & Harris, 2003; Rossi et al., 2012; Thomas & Otis, 2010). One study reported higher compassion fatigue in participants who had previously been exposed to violent crime (MacRitchie & Leibowitz, 2010). Nelson-Gardell and Harris (2003) used the Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) to assess past trauma experience. The CTQ comprises five subscales of childhood trauma: Emotional Abuse, Physical Abuse, Sexual Abuse, Emotional Neglect, and Physical Neglect. All CTQ subscales were associated with higher compassion fatigue. An additional study found that a measure of stressful life experiences was not related to compassion fatigue (Jacobson, 2012). The fact that this study reported that number of stressful life experiences was not related to compassion fatigue suggests that there is something specific about traumatic events that leave clinicians more vulnerable to compassion fatigue.

Mindfulness
Three studies assessed the link between mindfulness and compassion fatigue (Thieleman & Cacciatore, 2014; Thomas & Otis, 2010; Thompson et al., 2014), and all found that greater levels of dispositional mindfulness were associated with lower levels of compassion fatigue. Two studies (Thieleman & Cacciatore, 2014; Thompson et al., 2014) used the Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) while the third (Thomas & Otis, 2010) used the Five-Facet Mindfulness Questionnaire (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006), both of which measure dispositional mindfulness and mindfulness attitudes. It was noticeable that the relationships reported in each of these studies were relatively strong, suggesting that mindfulness might play an important protective role against compassion fatigue.

This suggests that there is emerging evidence for mindfulness being a protective factor for compassion fatigue. The two measures of mindfulness used in these studies: The MAAS and the Five-Facet Mindfulness Questionnaire, both measure dispositional mindfulness, such as the tendency to be receptive to what is happening around you. Neither measure captures whether clinicians were actually practicing mindfulness as a coping strategy or lifestyle choice. This would be a useful avenue for future research to further determine how useful mindfulness can be in building resilience against compassion fatigue.

Empathy
Five studies reported findings related to empathy and compassion fatigue (MacRitchie & Leibowitz, 2010; O’Sullivan & Whelan, 2011; Robins, Meltzer, & Zelikovsky, 2009; Simon et al., 2006; Thomas & Otis, 2010), with three reporting significant results. MacRitchie and Leibowitz (2010) found not only that participants’ level of compassion fatigue increased as level of empathy increased, but that empathy also moderated the relationship between compassion fatigue and previous trauma. In other words, for those trauma workers who had previously been victims of violent crime, the higher their level of empathy, the higher their compassion fatigue scores. While this is an interesting finding, and one which is consistent with Figley’s initial theoretical model, this study scored below the median score for study quality, mainly due to a lack estimates of variance in its results statistics, and due to having a relatively small sample size (N = 64).

Two further studies used the subscales of the Interpersonal Reactivity Index (IRI; Davis, 1983) measure of empathy to look more closely at the relationship between empathy and compassion fatigue (Robins et al., 2009; Thomas & Otis, 2010). Scores for compassion fatigue were higher as scores on three empathy subscales increased: Fantasy (the tendency to transpose oneself imaginatively into the feelings and actions of fictitious characters), Perspective Taking (the tendency to spontaneously adopt the psychological point of view of others), and Personal Distress (“self-oriented” feelings of personal anxiety in tense interpersonal settings). However, in both studies the statistics suggested that Personal Distress was most strongly related to compassion fatigue, compared with the other two subscales. The Thomas and Otis (2010) study reported the slightly stronger correlation here and was methodologically the stronger of the two studies. This finding might suggest that it is the tendency to feel distress in response to that of others that is important to the development of compassion fatigue, as opposed to other facets of empathy such as the tendency to adopt the point of view of another spontaneously.

While Simon et al. (2006) reported nonsignificant findings, the correlation coefficient was relatively large (−.40) and suggested that as empathy increased, compassion fatigue decreased. While this trend contradicts those above, it should be treated with caution, not just because it is not statistically significant but because the empathy measure was not standardized (participants were asked to rate themselves on the single item: “empathetic response to clients”).

Caseload
Four studies reported on the relationship between caseload and compassion fatigue (Deighton et al., 2007; MacRitchie & Leibowitz, 2010; Tosone, Bettmann, Minami, & Jasperson, 2010; Udipi, Veach, Kao, & LeRoy, 2008). While one study found that the two variables were not related (MacRitchie & Leibowitz, 2010), the number of patients seen per week by genetic counselors was related to higher compassion fatigue in another (Udipi et al., 2008). In professionals working with trauma victims, a high number of cases seen per week was related to higher compassion fatigue (Deighton et al., 2007) as was time spent working with victims (Tosone et al., 2010). This finding perhaps makes intuitive sense insofar as one might expect clinicians to be more prone to compassion fatigue the more they are exposed to the challenges of working with clients.

Experience and Age
Ten studies examined the relationship between amount of clinical experience and compassion fatigue (Birck, 2001; Cohen, Gagin, & Peled-Avram, 2006; Craig & Sprang, 2010; Deighton et al., 2007; Nelson-Gardell & Harris, 2003; Robins et al., 2009; Rossi et al., 2012; Thompson et al., 2014; Thomas & Otis, 2010; Udipi et al., 2008). This was typically measured by asking participants how long they had worked in the mental health field (e.g., Thompson et al., 2014), although in some studies participants were asked about how long they had worked in direct care (Robins et al., 2009), or for how long they had worked in that particular role (e.g., Rossi et al., 2012). Of these 10 studies, only three reported that experience was related to compassion fatigue. Compassion fatigue increased with years spent working in the field of trauma counseling (Birck, 2001), with a strong correlation reported, although this particular study had a very small sample size (N = 25). Participants who had worked for longer as a mental health practitioner in a children’s hospital were also more likely to report high compassion fatigue (Robins et al., 2009). However, one study found that as years spent in the mental health field increased, compassion fatigue decreased (Thompson et al., 2014), although the strength of the correlation here was small.

In terms of nonsignificant trends, three studies did report that compassion fatigue decreased as level of experience increased, although the correlations here were small (Nelson-Gardell & Harris, 2003; Thomas & Otis, 2010; Udipi et al., 2008). Similar variation was found in the association between compassion fatigue and age.

It is likely that those with more experience are assigned the most challenging cases, or expected to cope with larger caseloads than those less experienced. At the same time, it is possible that with their experience these clinicians have learned more effective ways of coping and are then not as likely to develop compassion fatigue.

Eight studies reported statistics relating age to compassion fatigue (Birck, 2001; Cohen et al., 2006; Craig & Sprang, 2010; Hatcher & Noakes, 2010; Nelson-Gardell & Harris, 2003; Rossi et al., 2012; Sprang et al., 2011; Thomas & Otis, 2010). Only one reported a significant finding, with younger participants having higher levels of compassion fatigue (Sprang et al., 2011). In those that found no relationship, three found very small trends toward compassion fatigue decreasing with age (Cohen et al., 2006; Nelson-Gardell & Harris, 2003; Thomas & Otis, 2010). Two studies reported mean compassion fatigue scores, with participants in the youngest categories (20–24 and 18–30) reporting lower compassion fatigue scores than the oldest (45+ and 50+; Hatcher & Noakes, 2010; Rossi et al., 2012), so the overall picture is very mixed.

One study in the review found that younger professionals were more likely to report compassion fatigue (Sprang et al., 2011) and we can reasonably assume that because they were younger they were therefore less experienced. Thompson et al. (2014) found that experience was associated with lower compassion fatigue. They suggested that those with more experience may be more likely to find themselves in supervisory roles and therefore less directly exposed to clients’ trauma. But many clinicians in supervisory roles still continue to see clients and, in addition, are required to hold in mind the clients of their supervisees, as well as bear any distress that those clinicians may bring to supervision, so may, in fact, be more exposed.

Sex Differences
Of the 32 studies reviewed, 12 reported data on the relationship between a person’s sex and compassion fatigue (Birck, 2001; Connally, 2012; Craig & Sprang, 2010; Deighton et al., 2007; Hatcher & Noakes, 2010; Robins et al., 2009; Rossi et al., 2012; Sprang et al., 2007, 2011; Thomas & Otis, 2010; Thompson et al., 2014; Zeidner et al., 2013).

Three studies found that being female was associated with higher levels of compassion fatigue (Sprang et al., 2007; Thompson et al., 2014; Zeidner et al., 2013), whereas another found that males reported higher compassion fatigue than females (Sprang et al., 2011). These authors found that the main predictor of compassion fatigue in their sample was job role, namely, child welfare workers. They attributed the anomaly regarding males to the fact that in their population most males were also child welfare workers.

Coping Style
Four studies used formal measures of coping style and assessed its association with compassion fatigue (Jacobson, 2012; Thompson et al., 2014; Udipi et al., 2008; Zeidner et al., 2013). Three used the Brief COPE measure (Carver, 1997) which breaks down coping style into three subscales: problem-focused, emotion-focused, and maladaptive coping (Meyer, 2001). Two studies found that the use of maladaptive coping styles was associated with higher levels of compassion fatigue (Jacobson, 2012; Thompson et al., 2014). One study, which scored highly on the quality rating, found that two of the Brief COPE items in particular, use of self-criticism and giving up, were related to higher compassion fatigue (Udipi et al., 2008). The Coping Inventory for Stressful Situations—Situation Specific Coping (Endler & Parker, 1990) was used in one study which found that task-focused coping was weakly associated with lower levels of compassion fatigue, while emotion-focused coping more strongly predicted high compassion fatigue (Zeidner et al., 2013). Some studies included variables that might be interpreted as coping methods but were not measured by formal questionnaires as above, such as social support, which was found to be related to lower compassion fatigue (MacRitchie & Leibowitz, 2010) and use of religion, which is discussed below.

Having a positive perception of one’s work environment was associated with lower compassion fatigue (Thompson et al., 2014). This includes factors such as coworker support and perceptions of fairness and support in the work organization. High emotional intelligence, as measured by the Schutte Self-Report Inventory (Schutte et al., 1998) predicted higher compassion fatigue (Zeidner et al., 2013), as did emotional separation (Thomas & Otis, 2010), measured by the Maintenance of Emotional Separation Scale (Corcoran, 1982). The ability to identify one’s own emotional states (as measured by emotional self-awareness—Emotional Self-Awareness Questionnaire; Killian, 2007) however was related to lower compassion fatigue (Killian, 2008). Being emotionally self-aware is posited as being beneficial due to allowing professionals to detect early signs of being affected by the role, and therefore in a better position to tackle it (Killian, 2008).

Religion
Participant religion and religious practices were investigated in three studies with mixed findings in relation to compassion fatigue (Sprang et al., 2011; Injeyan et al., 2011; Udipi et al., 2008) One study found that participants who took no part in religious activities were more likely to report compassion fatigue compared with those who had sporadic, active, or very active religious participation (Sprang et al., 2011). However, two studies found that the use of religion as a coping strategy was related to higher levels of compassion fatigue (Injeyan et al., 2011; Udipi et al., 2008).

Other ProQOL Variables—Burnout
Eleven studies reported on the relationship between compassion fatigue and burnout (Aukštinaitytė & Zajančkauskaitė-Staskevičienė, 2010; Birck, 2001; Collins & Long, 2003; Ray, Wong, White, & Heaslip, 2013; Robins et al., 2009; Rossi et al., 2012; Simon et al., 2006; Thomas & Otis, 2010; Thompson et al., 2014; Udipi et al., 2008; Zeidner et al., 2013). All studies found significant positive correlations between the two variables, and these relationships tended to be strong. While a commonly used measure of burnout is the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981), most studies in this review used the ProQOL to measure burnout.

Of all the variables measured alongside compassion fatigue, burnout was one of those most strongly related. Given that the ProQOL contains measures of both compassion fatigue and burnout, it is quite possible that conceptual overlap between the two constructs explains the high association. It is also possible that individuals begin to develop signs of compassion fatigue once they begin to feel burnt out, or vice versa. In one study, compassion fatigue was related to all three subscales of the MBI, and particularly strongly with emotional exhaustion (Ray et al., 2013). Potentially useful further research might involve combining the research literature on predictors of both burnout and compassion fatigue to see whether they share common predictors.

Compassion Satisfaction
In addition, eight studies investigated the relationship between compassion fatigue and compassion satisfaction (Birck, 2001; Collins & Long, 2003; Robins et al., 2009; Rossi et al., 2012; Simon et al., 2006; Thomas & Otis, 2010; Thompson et al., 2014; Udipi et al., 2008). Of these studies, six found that higher levels of compassion satisfaction were associated with lower levels of compassion fatigue, while the remaining two found nonsignificant results. As with burnout, compassion satisfaction was measured using either the ProQOL or CFST. Given that compassion satisfaction describes the potential for positive aspects of helping professions to develop, it is perhaps not surprising that it is associated with lower compassion fatigue. Professionals who are experiencing psychological distress and fatigue are less likely, it seems, to report feeling satisfaction in their role. Some studies suggested that compassion satisfaction can act as a protective factor against compassion fatigue.

Discussion

The current review aimed to determine factors most commonly associated with compassion fatigue in mental health professionals. In total, 32 studies were reviewed, with a large number and variety of variables being investigated. Despite the variation in studies, some factors were commonly reported to be related to compassion fatigue. The main factors included the professionals’ own trauma history, mindfulness, empathy, and caseload, as well as other ProQOL variables: burnout and compassion satisfaction. Other variables that were investigated report very mixed results and as such do not appear to consistently influence compassion fatigue, such as age, sex, religion, and work experience.

Those factors where a high proportion of studies found significant relationships include trauma history, certain types of empathy, and a high caseload. These could therefore be considered as the main “risk factors” for compassion fatigue in mental health professionals. Some factors, such as mindfulness, while not extensively researched, were associated with lower compassion fatigue which might indicate them as potential protective factors.

The findings seem to corroborate Figley’s theory which implicates empathy in the development of compassion fatigue (Figley, 2002). Empathy is well recognized as playing an important role in mental health care yet seems to pose a risk to the well-being of clinicians. The relationship between empathy and compassion fatigue is not made clear by cross-sectional studies, however. Empathy’s apparent role in the development of compassion fatigue suggests that those with higher empathy levels might be more vulnerable to compassion fatigue in the first instance. However, one of the effects of compassion fatigue is a reduction in an individual’s ability to feel and display empathy (Mathieu, 2007). It is therefore not necessarily clear whether we would expect empathy to correlate positively or negatively with compassion fatigue. A clinician may have developed compassion fatigue because they are highly empathic, for example, but have a low empathy score due to the effects of compassion fatigue. In order to investigate this relationship more thoroughly, longitudinal research is required.

Results from the current review, however, shed some further light on the relationship between empathy, compassion fatigue, and trauma history. It has previously been suggested that professionals with a personal history of trauma may be more vulnerable to secondary traumatic stress reactions because of the potential reactivation of traumatic memories and elicitation of intense empathic responses (Figley, 1995; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). The finding that empathy moderates the relationship between compassion fatigue and trauma history (MacRitchie & Leibowitz, 2010), suggests that clinicians who were more empathic were more likely to experience compassion fatigue, if they had a history of trauma. It is possible that empathy in and of itself does not necessarily increase a clinician’s risk of compassion fatigue, but that it does so via its relationship with their previous experience of traumatic events, and how this plays out in their interactions with clients and patients.

Given the relationship between compassion fatigue and compassion satisfaction, it may be of interest to investigate what factors are associated with higher levels of compassion satisfaction in helping professionals. Some studies have suggested that trainee professionals have lower compassion satisfaction, whereas part-time workers reported higher (Robins et al., 2009). The relationship between compassion satisfaction and empathy may also warrant further investigation. Some research has reported that compassion satisfaction is related to empathic concern as measured by the IRI (Thomas & Otis, 2010). Further research might look more closely at the relationship between different facets of empathy in relation to both compassion satisfaction and compassion fatigue.

The findings relating to trauma history have led some authors to suggest that the relationship between personal trauma history and reactions to working with traumatized others, has implications for the validity of secondary traumatic stress reactions (Elwood et al., 2011), such as compassion fatigue. If what is being conceptualized as a secondary trauma reaction can be explained by some preexisting psychological difficulty, such as PTSD from a previous trauma, then individuals’ reactions to trauma rather than their level of exposure may be more predictive of difficulties like compassion fatigue (Elwood et al., 2011).

One thing that is not reported in these studies is whether or not clinicians had subsequent difficulties relating to their traumas or if they had received appropriate help to resolve any difficulties. It has been suggested that if previous exposure to trauma goes unacknowledged or unresolved it may intensify and increase symptoms of secondary trauma (Munroe et al., 1995; Solomon, 1993). Indeed, previous research that measured secondary trauma using a PTSD scale (Impact of Events Scale; Weiss, 2007) has suggested that participants who considered their reactions to trauma to be unresolved, or who had had previous trauma therapy themselves, were more likely to have high secondary trauma (Creamer & Liddle, 2005; Hargrave, Scott, & McDowall, 2006).

A large number of studies found an association between burnout and compassion fatigue. The relationship between these two factors could be explained by some conceptual overlap. As constructs, they both purport to describe psychological and physical effects of mentally and emotionally demanding work that develop over time. Conclusive findings in research of this type might be hindered by conceptual overlap between the two constructs, which could essentially be “tapping into” a shared characteristic, such as emotional exhaustion. As such, a broader challenge for research in this area perhaps is to develop clearer distinctions between compassion fatigue and burnout.

Other similar constructs might also be investigated in future work. For example, moral distress has been reported in health professionals such as nurses and found to be related to higher compassion fatigue (Maiden, Georges, & Connelly, 2011). Moral distress has been found to exist in mental health practitioners too (Austin, Bergum, & Goldberg, 2003), suggesting it is certainly an area worth exploring in furthering our understanding of compassion fatigue in mental health professionals.

Implications
One of the most exciting implications from this review is the emergence of mindfulness playing a potentially protective role against compassion fatigue. The relationship between mindfulness and compassion fatigue could have implications for the way in which clinicians manage the stresses of their work. The findings in this review suggest the need for further, more experimental, research that would develop our understanding, such as investigating the effectiveness of mindfulness over time as an intervention in the workplace, or testing differences between groups of clinicians who use mindfulness and those who do not. Indeed, recent research has suggested that meditation practices might be effective in reducing stress and promoting resilience (Seppala, Hutcherson, Nguyen, Doty, & Gross, 2014), although this was in an undergraduate student population. An older study found that an 8-week meditation-based stress reduction program helped reduce anxiety and psychological distress in medical students, as well as increase overall empathy scores (Shapiro, Schwartz, & Bonner, 1998). In addition, further exploration of other cognitive and behavioral coping mechanisms and their impact on compassion fatigue over time would be a useful area of research.

Because professionals’ own trauma history is associated with compassion fatigue, it has been suggested that organizations should make available services that provide helping professionals with opportunities to process personal traumas (Killian, 2008). This is a potentially important finding when considering what might motivate an individual to seek a career as a mental health clinician. It is possible that some clinicians may have had significant difficulties or trauma in their past and that this motivated them to help others in similar situations. However, they may be more prone to compassion fatigue as a result. Knowing that previous trauma history is related to higher compassion fatigue, clinicians or the organizations in which they work could be more proactive in providing necessary support to protect against compassion fatigue. This might have additional implications for training organizations, who may wish to consider training health care professionals in understanding and recognition of compassion fatigue and potential risk factors, during their core training.

While most studies in the review measured and reported on a number of different variables, few conducted further analyses to look at how the different variables might interact in relation to compassion fatigue. One example to the contrary is that of MacRitchie and Leibowitz (2010) who found overall level of empathy moderated the relationship between compassion fatigue and previous trauma. It would be interesting to investigate relationships between variables that are most strongly or regularly associated with compassion fatigue. For example, it may be that clinicians with a history of trauma are more likely to engage in less effective coping strategies.

Limitations and Future Directions
The studies included in this review were cross-sectional in design, and therefore unable to clearly determine any causal relationships. This leaves many questions unanswered. For example, are clinicians more likely to develop signs of compassion fatigue because they employ maladaptive coping strategies, or do the effects of compassion fatigue lead clinicians to change the way they cope with the demands of the work? Clinicians’ own trauma history was a common predictor of compassion fatigue, but the nature of the studies does not allow us to understand what mechanisms might occur following a traumatic event that make the development of compassion fatigue more likely. As mentioned above, the extent of the impact of these traumatic events and whether or not clinicians received or indeed required support following the events is not known.

The fact that the review only included quantitative findings also limited its scope. By definition, only those variables that researchers decided to measure could be analyzed in relation to compassion fatigue, which, in turn, is limited by the availability of suitable measures. One way to broaden the scope of the review would be to include qualitative studies. Within the current review, four of the 32 studies included qualitative methods alongside quantitative (Collins & Long, 2003; Hatcher & Noakes, 2010; Killian, 2008; Udipi et al., 2008). The findings from these studies revealed further information about the use of coping strategies that clinicians described as being useful in preventing compassion fatigue. For example, using supervision as a space to debrief and share experiences of work was found to be helpful, or indeed “crucial” in dealing with the impact of working with clients (Hatcher & Noakes, 2010; Killian, 2008). Also, the study by Udipi and colleagues (2008) could potentially provide more insight into clinicians’ empathy and the emotional impact of counseling. Participants here described the draining effect of being emotionally invested in clients, and the power of emotional countertransference in provoking reactions about their own personal situations.

There are distinct overlaps between compassion fatigue and other constructs related to the deleterious effect of certain professions, namely, secondary traumatic stress and burnout. Future research might look more closely at these relationships, and consider how burnout and compassion fatigue might interact not just with each other, but with other variables such as coping styles. For example, it may be that some health professionals engage in adaptive coping styles and successfully protect against compassion fatigue. However, over time the effects of burnout might leave them less able to engage in protective activities, leaving them, in turn, more vulnerable to compassion fatigue. These are the kinds of questions that could be crucial in understanding the subtleties of how compassion fatigue develops but, as previously mentioned, can only be properly investigated through longitudinal work. Furthermore, there appears to be a scarcity of large-scale studies within this literature, with many of the reviewed articles reporting on relatively small sample sizes.

While the present review chose specifically to focus on compassion fatigue as a stand-alone construct, there is a lack of clarity about how distinct it is from other concepts, particularly secondary traumatic stress. Compassion fatigue is different from secondary traumatic stress in that it is characterized by exhaustion and a reduction in empathy; effects that accumulate over time, whereas secondary traumatic stress is more an anxiety, PTSD-like reaction to hearing about traumatic events. Nevertheless, the measures used to quantify compassion fatigue, for example, the ProQOL, are subjectively similar to those used to measure secondary traumatic stress (e.g., Secondary Traumatic Stress Scale; Bride, Robinson, Yegidis, & Figley, 2004). Because the two terms are often used interchangeably, it is possible that the current review did not detect papers that used the ProQOL measure; for example, if such studies did not specifically use the term compassion fatigue. Further research is required to clarify the conceptualizations and measurements of these constructs.

Conclusions

The findings from this review have shed light on possible risk factors for mental health professionals in the development of compassion fatigue which can make it harder for them to carry out their work. In particular, past traumas in professionals, empathy and exposure to trauma, and distress of clients (e.g., high caseload) are factors commonly associated with higher compassion fatigue. Despite this, possible protective factors, such as mindfulness, have emerged in the literature which has been associated with lower compassion fatigue and provide a possible avenue for future research.

Clearly, the factors influencing the development of compassion fatigue are numerous and the relationships between them complex. Nevertheless, this review has examined the literature and a wide range of studies in order to provide a current understanding of psychosocial factors influencing the development of compassion fatigue. The field would clearly benefit from more longitudinal research, to more accurately determine which factors make the onset of compassion fatigue more likely. This review indicates several clear gaps for future research into compassion fatigue in the mental health care professions.

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APPENDIX
APPENDIX A: Study Selection Process
Submitted: July 6, 2016 Revised: January 12, 2017 Accepted: January 15, 2017

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Source: Traumatology. Vol. 23. (2), Jun, 2017 pp. 172-185)
Accession Number: 2017-09426-001
Digital Object Identifier: 10.1037/trm0000116

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Coping with secondary traumatic stress: Differences between U.K. and U.S. child exploitation personnel.
Authors:
Bourke, Michael L.. United States Marshals Service, Alexandria, VA, US, michael.bourke@usdoj.gov
Craun, Sarah W.. United States Marshals Service, Alexandria, VA, US
Address:
Bourke, Michael L., 2604 Jefferson Davis Highway, CM-4, 11th Floor, NSOTC, Alexandria, VA, US, 22301, michael.bourke@usdoj.gov
Source:
Traumatology: An International Journal, Vol 20(1), Mar, 2014. pp. 57-64.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
8
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Traumatology
Other Publishers:
US : Academy of Traumatology
US : Green Cross Project
US : Sage Publications
ISSN:
1085-9373 (Electronic)
Language:
English
Keywords:
child exploitation, secondary stress, vicarious trauma, law enforcement, investigators, coping methods
Abstract:
Research investigating how secondary traumatic stress impacts those who work in the field of child exploitation is in its early stages. In the current study we investigate how attempts to cope with secondary traumatic stress vary between investigators in the United States and their counterparts in the United Kingdom. After examining the best-fitting models we found both similarities and differences in predictors of secondary traumatic stress. For example, the level of self-reported difficulty and frequency of interactions with disturbing media were positively related to higher secondary traumatic stress scores in both groups; supervisory support, however, was related to lower secondary traumatic stress scores only in the U.S. sample. The implications and limitations of our findings are discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Child Abuse; *Coping Behavior; *Stress; *Trauma; *Vicarious Experiences; Law Enforcement Personnel; Sex Offenses
PsycInfo Classification:
Police & Legal Personnel (4290)
Population:
Human
Male
Female
Location:
United Kingdom; US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
COPE Scale [Appended]
Marlowe-Crowne Social Desirability Scale-Short Version—Form ×2
International Physical Activity Questionnaire-Short Form
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: May 21, 2013; Revised: May 8, 2013; First Submitted: Feb 14, 2013
Release Date:
20140331
Correction Date:
20140616
Digital Object Identifier:
http://dx.doi.org/10.1037/h0099381
Accession Number:
2014-11106-008
Number of Citations in Source:
44
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Coping With Secondary Traumatic Stress: Differences Between U.K. and U.S. Child Exploitation Personnel
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✖
Contents
Research on STS in the Human Services Field
STS in Law Enforcement
Method
Sample
Measures: Dependent Variables
Measures: Independent Variables—Scales
Other Measures: Independent Variables
Data Analysis
Results
RQ1: Does the Severity of STS Differ Between Investigators Working Child Exploitation Cases in the United States and Investigators in the United Kingdom?
RQ2: Are the Predictors of STS the Same for Both the United States and United Kingdom Samples? If Not, What Factors Differ Between the Two Groups?
Discussion
Limitations and Directions for Future Research
Implications
References
Full Text
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By: Michael L. Bourke
United States Marshals Service, Alexandria, Virginia
Sarah W. Craun
United States Marshals Service, Alexandria, Virginia;
Acknowledgement:

Posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) are the two stress disorders found in the current Diagnostic and Statistical Manual (DSM-IV–TR; American Psychiatric Association, 2000). These diagnoses emerged from a recognition that profound behavioral and emotional consequences, including significant long-term symptoms, can result from traumatic happenings. The clearest cause of both disorders is direct exposure to a traumatic event, although the DSM-IV–TR (APA, 2000) indicates that both PTSD and ASD also may develop from witnessing the trauma of a close associate, friend, or family member. Secondary traumatic stress (STS) is similar to PTSD and ASD but develops not from direct experience with trauma but rather from indirect exposure to the trauma of others (Bride & Kintzle, 2011). STS can be experienced secondhand and can result from hearing about or witnessing the experiences of individuals who are not necessarily close to the observer, such as a client or a member of the general public.

STS is closely related to such concepts as compassion fatigue (Figley, 1995; Jacobson, 2012) and vicarious traumatization (VT) (Bell, Kulkarni, & Dalton, 2003; Brady, Guy, Poelstra, & Brokaw, 1999; McCann & Pearlman, 1990; L. A. Pearlman & Saakvitne, 1995; Way, VanDeusen, MartIn, Applegate, & Jandle, 2004). Although some researchers (Osofsky, Putnam, & Lederman, 2008) use these terms interchangeably, others draw distinctions between them. An in-depth discussion of these conceptual distinctions is beyond the scope of the current article; however, the development of our conceptual understanding of this issue was informed by previous work on compassion fatigue, VT, and STS.

Research on STS in the Human Services Field

Research on STS has tended to focus on those in the human services field, such as social workers (Bride, 2007), child protective services (CPS) workers (Conrad & Kellar-Guenther, 2006; Cornille & Woodard Meyers, 1999), substance abuse treatment providers (Bride, Smith Hatcher, & Humble, 2009), sexual assault counselors (Johnson & Hunter, 1997; Regehr & Cadell, 1999; Schauben & Frazier, 1995), and trauma therapists (Follette, Polusny, & Milbeck, 1994). The research suggests that 15% of social workers and 37% of CPS workers experience moderate to high levels of STS (Bride, 2007; Cornille & Woodard Meyers, 1999), and Conrad and Kellar-Guenthar (2006) reported that nearly half of CPS workers were at high risk for compassion fatigue. STS even has been observed in school personnel who report child maltreatment to CPS (VanBergeijk & Sarmiento, 2006). Similarly, sexual assault counselors showed evidence of STS and reported that stress from work was likely to carry over into their personal lives (Johnson & Hunter, 1997). In the area of substance abuse treatment, a substantial portion of counselors (19%) met the criteria for PTSD as a result of their work with traumatized clients (Bride et al., 2009), and STS was found to be related to lower job satisfaction and job commitment (Bride & Kintzle, 2011).

The factors involved in the development of STS include the amount, duration, and intensity of exposure to the trauma of others. Baird and Kracen (2006) found a positive relationship between more exposure to traumatic material and more symptoms of STS. In addition, STS also was found to be related to increased time spent with traumatized clients (Brady et al., 1999; Cornille & Woodard Meyers, 1999), possibly due to sustained exposure to graphic details about the trauma. Further, the longevity of one’s career, heavy caseloads, and long work hours all have been associated with STS in CPS workers (Cornille & Woodard Meyers, 1999).

It has been suggested that there is an ethical imperative to protect those who professionally care for others by helping them cope effectively with STS (Everall & Paulson, 2004), and researchers are beginning to explore which coping strategies are the most helpful. In a study by Pearlman (1999), therapists felt they benefited the most from discussing cases with colleagues and attending workshops. Along a similar vein, therapists reported social support (Schauben & Frazier, 1995) and peer support (Ennis & Home, 2003) were effective in reducing STS. A synopsis of vicarious trauma in sex offender therapists also suggests that support from colleagues decreases the risk for vicarious trauma (Moulden & Firestone, 2007). A more recent study sampling clinicians who provided treatment to torture survivors found that having a variety of tasks and using supervisors for support were the most common techniques used to reduce job-related trauma (Akinsulure-Smith, Keatley, & Rasmussen, 2012). A drawback to the aforementioned studies is the absence of empirical analyses to determine if the self-reported coping mechanisms were actually associated with lower STS scores.

A small subsection of extant research on this topic includes statistical testing of the relationship between coping and STS. One such study by Way and colleagues (2004) found that both “positive” coping methods (e.g., exercise and social support) and “negative” strategies (e.g., use of alcohol) were related to increased levels of STS. It appeared as if positive coping mechanisms made STS worse. However, the researchers used a cross-sectional model that prevented them from determining if the coping mechanisms were used before or after the onset of secondary stress. This means if the STS occurred before the positive coping techniques, it may have led to an increase in the use of exercise and social support. Therefore, more research is needed to dissect the relationship between coping and STS.

STS in Law Enforcement

Moving from those in the human services fields to those in various areas of law enforcement, Violanti and Gehrke (2004) found that, among investigators, seeing abused children was the most frequently (68%) identified factor they felt increased their stress, with female officers particularly affected. In work based out of the United Kingdom, Brown, Fielding, and Grover (1999) discovered that working sexual crime cases was one of three factors especially related to stress in the law enforcement setting (the others were exposure to death, disaster, and violence).

In recent years increased attention has been placed on STS experienced by law enforcement officers who investigate online child exploitation (Perez, Jones, Englert, & Sachau, 2010; Wolak & Mitchell, 2009). Online investigators experience two of the top three police stressors: violence and sexual crimes. Further, a portion of their job involves viewing recordings of violent sexual assaults, which may impact their risk for STS (Krause, 2009). It can be difficult enough for an officer to take a report pertaining to the sexual assault of a child; it is quite another thing to ask him or her to witness the assault unfold on a computer monitor. These experiences have consequences that extend beyond the workplace into other areas of their lives (Perez et al., 2010; Wolak & Mitchell, 2009).

Those who serve on Internet Crimes Against Children (ICAC) taskforces are aware of the inherent complications and emotional difficulties involved in their work. Wolak and Mitchell (2009) reported that 90% of ICAC taskforces indicated they were “somewhat concerned” or “very concerned” about their exposure to child pornography. Some of the symptoms reported include weight gain, difficulty sleeping, stress, depression, problems with sexual intimacy, and problems in romantic relationships.

As it has within the human services field, research has begun to focus on how law enforcement officers can most effectively cope with STS. There is evidence, for example, that suggests officers who seek social support and disclose traumatic events to their spouses are less likely to experience psychological distress (Davidson & Moss, 2008). Such disclosure may have unanticipated consequences, however, for the partners who then become indirectly exposed to the traumatic material. Future work should explore if such disclosures present a risk of increasing STS levels among confidantes. Studies have also found that using certain coping techniques to manage stress levels actually have the opposite effect; in one large investigation of officers, researchers discovered that officers who attempted to cope by avoiding their work experienced higher levels of anxiety (Gershon, Barocas, Canton, Xianbin Li, & Vlahov, 2009).

With regard to coping strategies, Krause’s (2009) review of the literature surrounding STS and ICAC taskforces provides suggestions on how to mitigate risk. Burns and colleagues (Burns, Morley, Bradshaw, & Domene, 2008) bolstered the literature with their qualitative study of 14 Internet child exploitation team members. Respondents stated that some strategies, such as being introduced gradually to images or using humor, helped them deal with the stresses of the job. Although Burns and colleagues’ findings provide a good foundation for this area, the study was limited by its inability to test if the reported coping strategies were statistically related to STS scores; rather, it relied on subjects’ self-reports. A subsequent study with 28 federal law enforcement agents who worked in the field of child exploitation found a positive relationship between STS and time the agents had worked in the field of child exploitation (Perez et al., 2010). In this study, STS was positively related with increased protectiveness of loved ones and more distrust of the general public. A limitation of the study by Perez and colleagues was the small sample size (n = 28), which allowed only bivariate comparisons. In addition, the sample size did not allow for the inclusion of control variables or analyses of multiple coping mechanisms utilized simultaneously.

Work involving the exploitation of children through the Internet is not limited to one country, and the pursuit of such sex offenders often crosses international borders. Law enforcement agencies from multiple countries often work collaboratively to track down offenders who utilize the Internet as a tool in their abuse and exploitation of children. For example, the FBI’s Operation Atlantic identified child sex offenders in the Netherlands, France, Spain, the United Kingdom, and Italy (FBI, 2012). Yet the majority of studies of secondary stress, to date, have focused on investigators from the United States. It is possible that the levels of STS, as well as the methods personnel use to cope with STS, vary from one country to another. Comparisons should be explored using child exploitation personnel from several countries to build a more comprehensive picture of how secondary stress can impact the lives on those who fight child exploitation and to learn more about factors that may mitigate its effects. To this end, we surveyed investigative personnel in both the United States and the United Kingdom to answer the following research questions (RQs):

RQ1: Does the severity of STS differ between investigators working child exploitation cases in the United States and investigators in the United Kingdom?RQ2: Are the predictors of STS the same for both the United States and United Kingdom samples? If not, what factors differ between the two groups?
Method

Sample
To obtain the sample from the United Kingdom, the first author spoke with a colleague who serves as a manager within Great Britain’s Child Exploitation and Online Protection Centre (CEOP). The CEOP manager then contacted each of the 43 British police agencies and the eight major law enforcement entities in Scotland and asked them to forward a survey link to their ICAC investigators. For the U.S. sample, the authors emailed every ICAC commander in the United States and asked them to forward a survey link to their ICAC personnel. The sample from the United Kingdom was recruited to participate approximately 2 months after the U.S. sample was obtained. In the email that was sent to potential participants in both countries, the authors highlighted the voluntary nature and anonymity of the study. The survey protocol received approval from a university Institutional Research Board.

Overall, 1,084 personnel opened the link to the survey; 119 did not respond to any questions. From the 965 individuals who answered at least one question, 677 worked in the United States and 288 were from the United Kingdom. Our sampling procedures prevented us from determining the precise response rate as the exact number of child exploitation personnel available to take the survey from each country is unknown.

Measures: Dependent Variables
To operationalize STS, we used Bride’s Secondary Traumatic Stress Scale (Bride, Robinson, Yegidis, & Figley, 2003). This 5-point Likert scale ranging from 1 (never) to 5 (very often) consists of 17 items that measure the degree to which respondents experience symptoms of STS over the last 7 days. The scale includes statements such as “I feel emotionally numb,” “I feel jumpy,” “I have disturbing dreams about my work,” and “I expect bad things to happen.” With the current sample of respondents from two countries, the Cronbach’s alpha was .93. In addition, using the categorizations suggested by Bride (2007), we separated respondents’ scores into no/little, mild, moderate, high, and severe levels of STS.

Measures: Independent Variables—Scales
Using the COPE scale by Carver, Scheier, and Weintraub (1989) we measured active coping (α = .69), coping through positive reinterpretation (α = .75), coping with social support (α = .83), coping with denial (α = .77), behavioral disengagement (α = .70), and planning (α = .72). The COPE subscales were measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) and the presented reliability scores are based on the current data. Moreover, we incorporated two 4-point scales ranging from 1 (not at all) to 4 (very much) to measure support from supervisors and coworkers. These two scales each had three questions: “How easy is it to talk to your immediate supervisor?”, “How much can you rely on the supervisory chain of command/coworkers when things get tough?”, “How much do your supervisors/coworkers go out of their way to support you in doing your job?”, and “How comfortable do you feel talking with other people at work about your job?” Both scales had good reliability (supervisory social support, α = .85; coworkers’ social support, α = .79). Finally, to control for social desirability, we included the Marlowe-Crowne Social Desirability Scale-Short Version—Form ×2. Fischer and Fick (1993) found that this shortened version (10 items) of the original 33-item scale improves upon the longer version and could be used to quickly measure social desirability.

To lessen the impact of cases being lost due to missing data, when a minimum of 75% of the scale items were answered, we calculated the mean score for each scale. Using the mean score also simplifies ease of interpretation in the final regressions since the scale is the same as that used by the respondents. We did not calculate the mean score for the Marlowe-Crowne Social Desirability Scale, as a sum score is easier to interpret due to binary scoring of each item in that scale.

Other Measures: Independent Variables
We examined both internal coping mechanisms (e.g., pretending the stressor doesn’t exist) as well as external strategies, such as using alcohol or tobacco and exercising. With regard to the former, survey respondents were asked to indicate if they drank alcohol, and whether their use of alcohol had increased during the past year. Tobacco use was assessed in a similar manner. To quantify physical activity, participants completed the self-administered short form of the International Physical Activity Questionnaire (Karolinska Institutet, 2002). This questionnaire divides respondents into three levels (low, moderate, or high) based on the time and intensity of physical activity during the last 7 days.

We included measures to determine how often respondents view child pornography ranging from 1 (zero times in the past six months)to 5 (every day) and how difficult it was ranging from 1 (not at all difficult) to 5 (extremely difficult) for respondents to view different types of child pornography. Finally, participants answered questions about demographics. Specifically, we asked about race (White/other), gender, marital status (married/other), level of education completed, time (in years) working in law enforcement, time (in years) working in the field of child exploitation, and age and gender of participants’ children. The sample from the United Kingdom had more women respondents (44.4% vs. 27.1%), χ2(1, N = 863) = 24.40, p < .001; fewer respondents that had children (69.0% vs. 78.4%), χ2(1, N = 875) = 8.61, p < .01; fewer married respondents (68.1% vs. 77.3%), χ2(1, N = 840) = 7.53, p < .01; and fewer respondents who served in the military (9.5% vs. 24.8%), χ2(1, N = 872) = 26.08, p < .001. There were no significant differences (p > .05) in the time spent in law enforcement (average = 15.5 years) or in the field of child exploitation (average = 5.1 years).

Data Analysis
To answer the first question about any possible differences in the levels of STS between respondents from the two countries, we conducted bivariate analyses (t tests and a chi-square test). The second research question was answered using a series of multivariate regressions.

Initially, the regression for the U.K. sample was run using the same variables that were found to be significant in the final model for the U.S. sample in previous work (see Bourke & Craun, in press, for a description of how that model was obtained). As the same variables were not significant in the U.K. model, we fitted the best model for the U.K. sample. Because of the large number of variables, a backward stepwise regression was run with a p < .10 cutoff. This was similar to the procedure used by Bourke and Craun (in press) for the U.S. sample. Since the variables rely on different scales of measurement, we included standardized coefficients. This allows the reader to better determine which constructs had the strongest impact on STS scores.

Diagnostics were performed on the regression models. We found 20 observations that were considered influential in the U.K. model. When the final U.K. regression model was rerun without the influential observations, the significance of the variables remained the same; therefore, the U.K. model presented includes the entire U.K. sample. The diagnostics for the remainder of the regression models revealed no concerns with the data.

Results

RQ1: Does the Severity of STS Differ Between Investigators Working Child Exploitation Cases in the United States and Investigators in the United Kingdom?
The results from a basic bivariate analysis illustrate that personnel working child exploitation cases in the United Kingdom have lower STS than those in the United States (1.99 vs. 2.16; t(944) = 3.40, p < .001). The value of 2 on the STS scale indicates that symptoms “rarely” occur. Table 1 illustrates the magnitude of the differences between the two countries on the individual items of the STS scale. There were only four items (heart starts pounding, trouble sleeping, trouble concentrating, and gaps in memory about cases) on the 17-item scale that did not show significant differences between personnel in the two countries. The discrepancies between the two samples remained when examining the best model from previous research (Bourke & Craun, in press) with the country variable added. Even when controlling for all other factors (see Table 2), such as social desirability score, the score of U.K. personnel was 0.11 lower than that obtained by the U.S. sample on the 5-point scale. Finally, the U.S. sample was more likely to have respondents in the severe STS category (United States: 15.3%; United Kingdom: 10.4%), whereas the U.K. sample had significantly more respondents in the low/no STS category (United States: 26.4%; United Kingdom: 36.9%), χ2(4, N = 941) = 13.15, p = .01.

trm-20-1-57-tbl1a.gifUnivariate and Bivariate Distributions of Secondary Traumatic Stress (STS) Scores by Country

trm-20-1-57-tbl2a.gifApplying Best Fitting U.S. Model to Complete Sample: Predictors of Secondary Traumatic Stress (n = 841)

RQ2: Are the Predictors of STS the Same for Both the United States and United Kingdom Samples? If Not, What Factors Differ Between the Two Groups?
When we applied the best fitting regression model from the U.S. sample to just the respondents from the United Kingdom, the significant relationships did not match what was seen with the U.S. sample (table not shown). We therefore calculated the best fitting regression model for the U.K. sample (see Table 3) and compared that model to the best fitting regression model for the U.S. sample (see Table 4).

trm-20-1-57-tbl3a.gifBest Fitting Model for U.K. Personnel: Predictors of Secondary Traumatic Stress (n = 231)

trm-20-1-57-tbl4a.gifBest Fitting Model for U.S. Personnel: Predictors of Secondary Traumatic Stress (n = 593)

We found some similarities between the two models. Coping through denial, an increase in tobacco use in the previous year, and an increase in alcohol use in the previous year were associated with higher STS scores in both U.K. and U.S. child exploitation personnel. Higher STS scores in personnel from both countries also was associated with a higher frequency of exposure to disturbing media depicting child exploitation and higher self-reported difficulty with such media. Two variables were inversely related with STS scores in both samples; namely, the ability to rely on one’s coworkers and social desirability scores.

Some relationships were only prevalent in the U.S. sample. Higher self-reported supervisor support and more frequent use of coping through social support were only related to lower STS scores with ICAC respondents from the United States. In addition, gender (being male) was related to lower STS scores only in the U.S. sample.

Discussion

A growing number of empirical research projects have examined the relationships between STS and coping in both the human service and law enforcement fields. Some of the body of literature in this area has focused on developing a better understanding of STS levels among those who investigate child exploitation through the Internet (Bourke & Craun, in press; Krause, 2009; Perez et al., 2010; Wolak & Mitchell, 2009). The current work is the first known research to explore any potential differences in STS levels and coping mechanisms between child exploitation personnel in different countries.

In the current work involving investigators from the United Kingdom and the United States, we found there was a significant difference between child exploitation personnel, with lower STS scores, on average, found among the U.K. sample. This relationship persisted even when controlling for other factors such as social desirability score.

Another crucial step in our attempt to understand intercountry differences was to explore differences in what predicts STS. It was important to avoid indiscriminately applying coping mechanisms that worked well in one country to law enforcement found elsewhere on the potentially flawed assumption that the culture and customs of one country would seamlessly transition to a population of another. When we tested the previously vetted predictive model for ICAC members in the United States on a sample of child exploitation investigators from the United Kingdom, we found it is not a “one size fits all” type of model. Although some of the relationships we had seen previously appeared to be consistent across samples, others were not applicable to both samples.

What holds true for both the U.K. and the U.S. samples is that the more interaction a person has with child pornography, and the more self-reported difficulty with this disturbing media he or she reports, the higher his or her STS score is likely to be. In addition, an increase in alcohol and tobacco consumption in the previous year is a strong warning for higher STS among child exploitation personnel. Denying that any stress is occurring is a particularly futile coping mechanism—in both samples it is significantly related to higher STS scores. This finding is similar to what Gershon and colleagues (2009) found in a sample of general law enforcement officers. As far as mitigating variables, the ability to rely on one’s coworkers for support in the job was related to lower STS scores in both the United Kingdom and United States. Finally, the importance of including the Marlowe-Crowne Social Desirability Scale as a control variable was underscored as this standardized coefficient illustrated that it was an important variable predicting STS in both samples. Previous research with law enforcement found a strong relationship between social desirability scores and the scores of self-report scales of coping with police work (Pole, Kulkarni, Bernstein, & Kaufmann, 2006), therefore the inclusion of this variable in the model helped control for any spuriousness due to the desire to present oneself in a positive light.

The sample from the United Kingdom did not have any variables that were significant only to that sample. Exercise approached the level of significance with the U.K. sample, but in the final model the variable as a whole was not significant. This mirrors the finding in the U.S. sample that exercise does not significantly reduce STS levels.

There were three relationships seen only with the sample based on ICAC personnel in the United States. First, being a male member of an ICAC was associated with slightly lower STS scores. Also, using social support as a coping mechanism and having a supervisor who provided good support when things were difficult reduced STS only among the U.S. sample. We examined the variability of social support and supervisor support in the U.K. sample in an attempt to explain the nonsignificance; however, an analysis demonstrated the standard deviations and means were similar between the two samples. Therefore, we are currently unsure what the underlying construct or reasoning is behind the differential impact of social support and supervisory support in the U.S. sample as compared to the U.K. sample. Further work is needed to determine if this finding can be replicated and further clarified.

Limitations and Directions for Future Research
The most notable limitation in the current study is our inability to determine an appropriate response rate. The Department of Justice stated in a report to Congress on child exploitation investigations that task force membership is fluid and has many part-time positions (“The National Strategy for Child Exploitation Prevention and Interdiction: A Report to Congress,” 2010). The report only provided the number of positions using full-time equivalents. Unfortunately, using full-time equivalents does not allow us to have an appropriate denominator for the response rate. Therefore, we are unsure how expansive our study is or how well it generalizes to the population we are trying to study.

A drawback with any study that is cross-sectional in nature is that one cannot determine causal relationships because it is not possible to ascertain the ordering of events. Bride (2011), along with Salston and Figley (2003), have urged researchers to develop longitudinal studies to measure STS over time. Longitudinal studies would help assess how stable STS is throughout one’s career and whether symptoms persist after a transition to a new job outside the child exploitation field.

Finally, additional variables need to be incorporated into subsequent research. For example, we did not measure a respondent’s personal history with sexual abuse or physical abuse. Future work needs to consider how previous experience with abuse as a child, as an adult, or both can interact with coping mechanisms to alter STS scores. In addition, our questions on alcohol and tobacco use were broad in nature and more specific questions about the amount and type of alcohol and tobacco use is suggested for future investigations. Moreover, current work in the field of criminology has considered the relationship between the amount of sleep obtained by law enforcement and officer safety on the job (Vila, 2009). Although most of this research focuses on an officer’s physical safety and decision making capabilities, it is prudent to consider whether fatigue may act as an accelerant in the development of STS. Longitudinal studies on STS can help determine if a lack of sleep comes before the development of STS, as a consequence of STS, or both.

Some may argue that the United States and the United Kingdom are relatively similar from a cultural standpoint, and the similarity between the countries may limit the generalizability of this study to other regions of the world. We recognize the importance of this point, because despite the similar cultures of the United States and the United Kingdom, significant differences emerged in the levels of STS and the type of coping mechanisms that appear most effective. We suggest future researchers expand beyond English-speaking countries to encompass as many different populations as possible.

Implications
The impetus for our research was the recognition that law enforcement officers who combat online criminality interact with child trauma on a daily basis, and this interaction is not limited within one country. This is the first study we are aware of that compares STS between countries. We found distinct differences between United Kingdom and United States child exploitation personnel in the relationship of different coping techniques to STS. Researchers need to consider not only expanding their pool of respondents to other countries, as child exploitation is worldwide, but also consider the country of origin of their respondents even within a single country sample.

From a practice perspective, this is an area of employee wellness with significant psychological consequences. The implications of our findings demonstrate that it is imperative for law enforcement officers, supervisors, and treatment providers throughout the world to understand how specific coping mechanisms can differentially impact STS levels across various populations and circumstances. In addition, some of the findings illustrate constructs that are similar across countries. In an attempt to reduce STS among ranks, supervisors should build an environment where support and collaboration between colleagues is encouraged, and where, if possible, officers can control when and how frequently they must interact with child pornography.

It is important to understand how this work differentially impacts law enforcement from various countries. Because child pornography images and video files can be transmitted easily and without regard to borders, efforts to maintain the health and well-being of all involved partners, no matter where they may serve around the globe, is beneficial. Interagency collaborations between those in different countries are common to find victims and offenders. By learning more about how this work affects those who combat child exploitation, we address a global need. Further, we may identify potential opportunities to support one another in decreasing STS and learn better ways of coping with the difficulties of child exploitation work.

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Submitted: February 14, 2013 Revised: May 8, 2013 Accepted: May 21, 2013

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user.

Source: Traumatology. Vol. 20. (1), Mar, 2014 pp. 57-64)
Accession Number: 2014-11106-008
Digital Object Identifier: 10.1037/h0099381

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Between harm reduction, loss and wellness: On the occupational hazards of work.Open Access
Authors:
Shepard, Benjamin C.. Human Services Department, New York City College of Technology, City University of New York, Brooklyn, NY, US, bshepard@citytech.cuny.edu
Address:
Shepard, Benjamin C., Human Services Department, New York City College of Technology, City University of New York, 300 Jay Street, Brooklyn, NY, US, 11201
Source:
Harm Reduction Journal, Vol 10, Apr 1, 2013. ArtID: 5
NLM Title Abbreviation:
Harm Reduct J
Publisher:
United Kingdom : BioMed Central Limited
ISSN:
1477-7517 (Electronic)
Language:
English
Keywords:
harm reduction, loss, wellness, occupational hazards, risk factors, occupational stress, coping behavior
Abstract:
Those working in the fields of harm reduction, healthcare, and human services must cope with a range of stresses, including post traumatic stress and vicarious trauma. Pain and loss are just a part of the job. So is dealing with premature death as a result of HIV, hypertension, and even overdose. Faced with a range of challenges, some workers in the field even turn to self-medication. For some, it is about pleasure; for others it is about alleviating suffering. In recent years, several leaders in the AIDS and harm reduction fields have died ahead of their time. Some stopped taking their medications; others overdosed. Rather than weakness or pathology, French sociologist Emile Durkheim saw self-destructive behavior as a byproduct of social disorganization and isolation, as a way of contending with a breakdown of social bonds and alienation. There are any number of reasons why such behavior becomes part of work for those involved with battling the dueling epidemics of Hepatitis C, HIV, and related concerns. Forms of stress related to this work include secondary trauma, compassion fatigue, organizational conflict, burnout, complications of direct services, and lack of funding. Faced with day-to-day struggles over poverty, punitive welfare systems, drug use, the war on drugs, high risk behavior, structural violence, and illness, many in the field are left to wonder how to strive for wellness when taking on so much pain. For some, self-injury and self-medication are ways of responding. Building on ethnographic methods, this reflective analysis considers the stories of those who have suffered, as well as a few of the ways those in the field cope with harm and pain. The work considers the moral questions we face when we see our friends and colleagues suffer. It asks how we as practitioners strive to create a culture of wellness and support in the fields of harm reduction, healthcare, and human services. Through a brief review of losses and literature thereof, the essay considers models of harm reduction practice that emphasize health, pleasure and sustainability for practitioners. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Harm Reduction; *Occupational Stress; Death and Dying; Health; Risk Factors
Medical Subject Headings (MeSH):
Adaptation, Psychological; Female; Grief; HIV Infections; Harm Reduction; Health Personnel; Health Status; Humans; Male; Occupational Diseases; Professional-Patient Relations; Risk Factors; Stress, Psychological; Suicide
PsycInfo Classification:
Personnel Attitudes & Job Satisfaction (3650)
Population:
Human
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Apr 1, 2013; Accepted: Mar 12, 2013; First Submitted: May 30, 2012
Release Date:
20130729
Copyright:
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.. Shepard; licensee BioMed Central Ltd.. 2013
Digital Object Identifier:
http://dx.doi.org/10.1186/1477-7517-10-5
PMID:
23548032
Accession Number:
2013-24868-001
Number of Citations in Source:
82
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Introduction for JHBSE special issue.
Authors:
Sherr, Michael. Department of Social Work, Cedarville University, Cedarville, OH, US, msherr@cedarville.edu
Address:
Sherr, Michael, Department of Social Work, Cedarville University, Cedarville, OH, US, msherr@cedarville.edu
Source:
Journal of Human Behavior in the Social Environment, Vol 29(1), Jan, 2019. pp. 1.
NLM Title Abbreviation:
J Hum Behav Soc Environ
Page Count:
1
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
1091-1359 (Print)
1540-3556 (Electronic)
Language:
English
Keywords:
Self-care, vicarious trauma, burnout, practice
Abstract:
The special issue provides 12 articles focusing on the roles of teaching and applying self-care strategies. Half of the manuscripts focus on self-care practices for students, while the other half emphasize effective strategies with experienced practitioners. The issue includes a good mix of conceptual articles highlighting different innovative approaches, empirical articles that evaluate the evidence of different approaches, and a few inductive 15 qualitative articles that explore the efficacy of strategies. One article documents the coping experiences of students confronted with interacting with a beloved faculty member returning after a life-threatening trauma. Taken together, the special issue makes a significant contribution to the literature by providing tangible support and guidance for educators and practitioners needing to focus on self-care practices. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Educational Personnel; *Occupational Stress; *Self-Care Skills; *Trauma; Vicarious Experiences; Self-Care
PsycInfo Classification:
Educational Administration & Personnel (3510)
Population:
Human
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20191118
Correction Date:
20200713
Copyright:
Taylor & Francis Group, LLC. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/10911359.2018.1512272
Accession Number:
2019-01058-001
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Introduction for JHBSE special issue
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The special issue provides 12 articles focusing on the roles of teaching and applying self-care strategies. Half of the manuscripts focus on self-care practices for students, while the other half emphasize effective strategies with experienced practitioners. The issue includes a good mix of conceptual articles highlighting different innovative approaches, empirical articles that evaluate the evidence of different approaches, and a few inductive 15 qualitative articles that explore the efficacy of strategies. One article documents the coping experiences of students confronted with interacting with a beloved faculty member returning after a life-threatening trauma. Taken together, the special issue makes a significant contribution to the literature by providing tangible support and guidance for educators and practitioners needing to focus on self-care practices.

Keywords: Self-care; vicarious trauma; burnout; practice

A few fundamental skills are essential for long effective careers in social work and other helping professions. The ability to develop rapport, to empathize, to communicate genuineness, and to connect with diverse clients will always be relevant for competent practice. In the same way, developing self-care practices are crucial for sustained effectiveness. Practitioners often encounter clients struggling with severe life situations and circumstances. Vicarious trauma and burnout are unfortunately common hazards for professional helpers. Without conscious focus on self-care, it is too easy for the stresses from clients to influence the personal and professional lives of helpers.

The special issue provides 12 articles focusing on the roles of teaching and applying self-care strategies. Half of the manuscripts focus on self-care practices for students, while the other half emphasize effective strategies with experienced practitioners. The issue includes a good mix of conceptual articles highlighting different innovative approaches, empirical articles that evaluate the evidence of different approaches, and a few inductive qualitative articles that explore the efficacy of strategies. One article documents the coping experiences of students confronted with interacting with a beloved faculty member returning after a life-threatening trauma. Taken together, the special issue makes a significant contribution to the literature by providing tangible support and guidance for educators and practitioners needing to focus on self-care practices.

~~~~~~~~

By Michael Sherr

Copyright of Journal of Human Behavior in the Social Environment is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.

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Experiences of compassion fatigue in direct care nurses: A qualitative systematic review.
Authors:
Salmond, Erin. School of Nursing, Rutgers University, Newark, NJ, US
Salmond, Susan. School of Nursing, Rutgers University, Newark, NJ, US, salmonsu@sn.rutgers.edu
Ames, Margaret. School of Nursing, Rutgers University, Newark, NJ, US
Kamienski, Mary. School of Nursing, Rutgers University, Newark, NJ, US
Holly, Cheryl. School of Nursing, Rutgers University, Newark, NJ, US
Address:
Salmond, Susan, salmonsu@sn.rutgers.edu
Source:
JBI Database of Systematic Reviews and Implementation Reports, Vol 17(5), May, 2019. pp. 682-753.
NLM Title Abbreviation:
JBI Database System Rev Implement Rep
Page Count:
72
Publisher:
US : Lippincott Williams & Wilkins
Other Journal Titles:
JBI Evidence Synthesis
ISSN:
2202-4433 (Electronic)
Language:
English
Keywords:
Compassion fatigue, compassion stress, nurses, secondary traumatic stress, vicarious trauma
Abstract:
Objective: The objective of this review was to describe the experiences of direct care nurses with work-related compassion fatigue. Introduction: The cumulative demands of experiencing and helping others through suffering have been considered to contribute to the potential of compassion fatigue. However, there is a lack of clarity on what specifically contributes to and constitutes compassion fatigue. Nurses suffering from compassion fatigue experience physical and emotional symptoms that leave them disconnected from patients and focused on the technical rather than the compassionate components of their role. This disconnect can also affect personal relationships outside of work. Inclusion criteria: This review included any qualitative studies describing the experiences of direct care nurses from any specialty or any nursing work setting. Methods: This review followed the Joanna Briggs Institute (JBI) approach for qualitative systematic reviews. Studies included in this review include those published in full text, English and between 1992, when the concept of compassion fatigue was first described, and May 2017, when the search was completed. The main databases searched for published and unpublished studies included: PubMed, CINAHL, Academic Search Premiere, Science Direct, Scopus, PsycINFO, Web of Science and the Virginia Henderson Library. Results: Twenty-three papers, representing studies conducted in seven countries and 821 total nurse participants, met the criteria for inclusion. From these, a total of 261 findings were extracted and combined to form 18 categories based on similarity in meaning, and four syntheses were derived: i) Central to the work of nursing and the professional environment in which nurses work are significant psychosocial stressors that contribute to compassion stress and, if left unchecked, can lead to compassion fatigue; ii) Protection against the stress of the work and professional environment necessitates that the individual and team learn how to respond to ‘the heat of the moment’; iii) Nurses and other administrative and colleague staff should be alert to the symptoms of compassion fatigue that present as profound, progressive, physical and emotional fatigue: a feeling that the nurse just can’t go on and a sense of being disconnected and drained, like a gas tank on empty; and iv) Keeping compassion fatigue at bay requires awareness of the threat of compassion fatigue, symptoms of compassion fatigue, and the need for work-life balance and active self-care strategies. Conclusions: The major conclusions of this review are that compassion fatigue prevention and management must be acknowledged, and both personal and organizational coping strategies and adaptive responses are needed to keep nurses balanced, renewed and able to continue compassionate connection and caring. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Nurses; *Occupational Stress; *Posttraumatic Stress; *Compassion Fatigue; Nursing; Occupational Health
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Methodology:
Literature Review; Systematic Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20201026
Copyright:
Unauthorized reproduction of this article is prohibited.. Joanna Briggs Institute. 2019
Digital Object Identifier:
http://dx.doi.org/10.11124/JBISRIR-2017-003818
PMID:
31091199
Accession Number:
2019-61004-009
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Preventing vicarious traumatization of mental health therapists: Identifying protective practices.
Authors:
Harrison, Richard L.. Department of Educational and Counseling Psychology, and Special Education, University of British Columbia, Vancouver, BC, US, dr.richardharrison@shaw.ca
Westwood, Marvin J.. Department of Educational and Counseling Psychology, and Special Education, University of British Columbia, Vancouver, BC, US
Address:
Harrison, Richard L., Vancouver Couple and Family Institute, Suite 270, 828 W. 8th Ave, Vancouver, BC, Canada, V5Z 1E2, dr.richardharrison@shaw.ca
Source:
Psychotherapy: Theory, Research, Practice, Training, Vol 46(2), Jun, 2009. pp. 203-219.
NLM Title Abbreviation:
Psychotherapy (Chic)
Page Count:
17
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Psychotherapy; Psychotherapy: Theory, Research & Practice
Other Publishers:
US : Division of Psychotherapy (29), American Psychological Association
ISSN:
0033-3204 (Print)
1939-1536 (Electronic)
Language:
English
Keywords:
vicarious trauma, prevention, compassion fatigue, countertransference, empathy, mental health therapists
Abstract:
This qualitative study identified protective practices that mitigate risks of vicarious traumatization (VT) among mental health therapists. The sample included six peer-nominated master therapists, who responded to the question, ‘How do you manage to sustain your personal and professional well-being, given the challenges of your work with seriously traumatized clients?’ Data analysis was based upon Lieblich, Tuval-Mashiach, and Zilber’s (1998) typology of narrative analysis. Findings included nine major themes salient across clinicians’ narratives of protective practices: countering isolation (in professional, personal and spiritual realms); developing mindful self-awareness; consciously expanding perspective to embrace complexity; active optimism; holistic self-care; maintaining clear boundaries; exquisite empathy; professional satisfaction; and creating meaning. Findings confirm and extend previous recommendations for ameliorating VT and underscore the ethical responsibility shared by employers, educators, professional bodies, and individual practitioners to address this serious problem. The novel finding that empathic engagement with traumatized clients appeared to be protective challenges previous conceptualizations of VT and points to exciting new directions for research, theory, training, and practice. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Coping Behavior; *Protective Factors; *Psychotherapeutic Processes; *Therapists; *Vicarious Experiences; Countertransference; Emotional Trauma; Empathy; Fatigue; Occupational Stress; Psychotherapists; Compassion Fatigue
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Middle Age (40-64 yrs)
Tests & Measures:
Professional Quality of Life: Compassion Fatigue and Satisfaction Subscales, R-III
Grant Sponsorship:
Sponsor: Social Sciences and Humanities Research Council of Canada, Canada
Other Details: Doctoral dissertation
Recipients: No recipient indicated

Sponsor: Michael Smith Foundation for Health Research
Recipients: No recipient indicated

Sponsor: WorkSafe BC, Worker’s Compensation Board of British Columbia, Canada
Recipients: No recipient indicated
Methodology:
Empirical Study; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20090706
Correction Date:
20151207
Copyright:
American Psychological Association. 2009
Digital Object Identifier:
http://dx.doi.org/10.1037/a0016081
PMID:
22122619
Accession Number:
2009-08897-006
Number of Citations in Source:
41
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PREVENTING VICARIOUS TRAUMATIZATION OF MENTAL HEALTH THERAPISTS: IDENTIFYING PROTECTIVE PRACTICES
This content may contain URLs/links that would redirect you to a non-EBSCO site. EBSCO does not endorse the accuracy or accessibility of these sites, nor of the content therein.
✖
Contents
Review of the Literature
VT Versus Countertransference and Burnout
Managing CT
Transforming VT
Method
Results
Countering Isolation in Professional, Personal and Spiritual Domains of Life
Developing Mindful Awareness: Integrated Practice of Spirituality
Consciously Expanding Perspective To Embrace Complexity
Active Optimism
Holistic Self-Care
Maintaining Clear Boundaries and Honoring Limits
Exquisite Empathy
Professional Satisfaction
Creating Meaning
Discussion
Implications for Practice
Implications for Training
Limitations and Implications for Future Research
Summary
References
APPENDIX
APPENDIX A: Illustrative Examples of Data Analysis Process
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By: RICHARD L. HARRISON
Department of Educational and Counseling Psychology, and Special Education, University of British Columbia;
MARVIN J. WESTWOOD
Department of Educational and Counseling Psychology, and Special Education, University of British Columbia
Acknowledgement: This article was based on the doctoral dissertation research by the principal author, which was generously funded by the Social Sciences and Humanities Research Council of Canada and the Michael Smith Foundation for Health Research in partnership with WorkSafe BC (Worker’s Compensation Board of British Columbia). The primary author wishes to thank his dissertation committee (Drs. Marvin Westwood, Marla Buchanan, and William Borgen) for their insight, rigor, and warmhearted support.

The risks of working directly with traumatized individuals on a regular basis are well documented (Arvay, 2001; Buchanan, Anderson, Uhlemann, & Horwitz, 2006; Figley, 2002; Pearlman & Mac Ian, 1995). McCann and Pearlman (1990) first identified the problem of vicarious traumatization (VT), which they defined as the cumulative transformative effects upon therapists resulting from empathic engagement with traumatized clients. As part of their work, these clinicians must listen to graphically detailed descriptions of horrific events and bear witness to the psychological (and sometimes physical) aftermath of acts of intense cruelty and/or violence. The cumulative experience of this kind of empathic engagement can have deleterious effects upon clinicians, who may experience physical, emotional, and cognitive symptoms similar to those of their traumatized clients (Pearlman & Saakvitne, 1995a, 1995b; Sexton, 1999). However, there is consensus in the field that there is not enough empirical literature on the definitive factors that contribute to VT, nor the practices that may prevent or ameliorate its harmful effects (Arvay, 2001; Figley, 2004; Pearlman, 2004).

Although research and theory have begun to emerge about VT vulnerability and treatment (Figley, 1995, 2002; Saskvitne & Pearlman, 1996), it is equally important to understand what protects and sustains clinicians in their work with traumatized populations. When individuals trained in the helping professions abandon the field, because of a perceived burden of caring and an insufficient ability to balance work with other aspects of life, this constitutes an enormous loss of resources and potential. When clinicians continue working, despite suffering from the damaging effects of VT, this constitutes a tremendous disservice to both clients and therapist, and the health of our community is undermined. It is imperative to address these concerns on ethical grounds, as clinicians and researchers alike must strive to provide appropriate, effective care for traumatized clients as well as those who work with them.

To date, very little is known about the success and satisfaction of clinicians who are able to manage in the workplace despite the potentially noxious demands of their work with traumatized clients. This study explored individual and organizational practices that contribute to the professional satisfaction and well-being of experienced clinicians who work with traumatized clients and to the sustainability of their efforts in the workplace. The purpose of the investigation was to gain and share knowledge about these protective practices, and ultimately contribute to the prevention of VT.

Review of the Literature

Over the past 15 years, researchers and theorists have given increasing attention to the construct of VT, defined by Pearlman and Saakvitne (1995b) as the negative “transformation in the inner experience of the therapist that comes about as a result of empathic engagement with clients’ trauma material” (p. 31). McCann and Pearlman (1990) first identified and conceptualized VT as an interactive, cumulative, and inevitable process, distinct from burnout or countertransference (CT). They posited that all therapists working with survivors of trauma experience pervasive and enduring alterations in cognitive schema that impact the trauma worker’s feelings, relationships, and life. Whether these changes are destructive to the therapist and to the therapeutic process, depends, according to these authors, largely on the extent to which clinicians are able to engage in their own process of integration and transformation of clients’ horrific traumatic material.

Figley (1995, 1999, 2002) identified a related construct, Secondary Traumatic Stress (STS), which he described in terms of “the cost of caring for others in emotional pain” (Figley, 1995, pp. 9) that has led clinicians to abandon their work with traumatized persons. According to Figley, both direct and indirect exposure to traumatic events can be traumatizing and lead to a similar set of PTSD-like symptoms. He proposed the existence of secondary traumatic stress disorder (STSD), a syndrome of symptoms that parallel those of PTSD, among those who care for victims of trauma. In the case of STSD, the primary exposure to traumatic events by one person becomes the traumatizing event for the second person. Figley considers STS to be a natural, treatable, and preventable consequence of empathic engagement with suffering people. He recognized the importance of warning clinicians in training of the risks associated with caring for the traumatized. He also recognized the potential for clinicians suffering from STS to find a renewed sense of hope, joy, and purpose. Figley also popularized the term Compassion Fatigue, previously employed by Joinson (1992) to describe burnout among nurses. The terms STS and Compassion Fatigue are used interchangeably.

Arvay (2001) provided an overview of research findings on STS, most of which involved the use of surveys and standardized instruments. She suggested that VT and STS are the same phenomenon. The number of traumatized clients in a therapist’s caseload appeared to be a factor related to development of STS. Working exclusively with traumatized clients was found to be positively correlated with development of STS symptoms, as were years of experience in the field and level of education. Younger clinicians, and those with less than a master’s degree were found to be more vulnerable. The research was inconclusive (or contradictory) with regard to whether therapist personal history of trauma is correlated with the risk of STS. There was a consensus that VT/STS is distinct from burnout.

VT Versus Countertransference and Burnout
Unlike CT, which is typically construed as a short-term response that occurs and is contained within the context of a therapy session, VT involves “long term alteration in therapists own cognitive schemas, or beliefs, expectations, and assumptions about self and others” (McCann & Pearlman, 1990, p. 132). Moreover, VT stands in clear contradistinction to the classical definition of CT, as described by Hayes (2004), because traumatic events in the client’s life account for clinician VT. Whereas the clinician is the locus of origin for classical CT, which is elicited by the client’s material but based upon preexisting personal characteristics of the therapist (e.g., unconscious, childhood based, inner conflict). Classical CT is understood to be an intrusion of a clinician’s own unresolved material, including previous trauma experiences, retaliatory or aggressive fantasies, and so forth. Hayes differentiated between the classical and subsequent, expanded, definitions of CT. There appears to be some overlap between the construct of VT and an expanded, totalistic definition of CT, in which “all therapist reactions to a client, whether conscious or unconscious, conflict-based or reality-based, in response to transference or some other material, were considered CT” (Hayes, 2004, p. 6). Nonetheless, VT extends beyond the latter, inasmuch as it is cumulative across clients, manifests outside the therapy hour, and permeates the clinician’s life and worldview. Gelso and Hayes offered a third, “integrative conception” (Hayes, 2004, p. 7) of CT, in which CT reactions may include conscious responses to phenomena other than transference, provided the source of these reside within the therapist. In contrast to this integrative conceptualization of CT, VT originates in external traumatizing events. Moreover, while unmanaged CT risks injuring the therapeutic process and client treatment outcomes (Hayes, 2004), VT risks damaging the therapist. Consequently, VT extends beyond and differs from even the most encompassing definitions of CT. Walker (2004) underscores this difference, stating:

[R]esearchers… agree that working with traumatized clients has potentially considerable and often long lasting negative effects on therapists (see also Kirk, 1998; Walker, 1992). These are different from countertransference responses in that they have an ongoing and extensive effect that impacts powerfully on many aspects of the therapist’s self and world. (pp. 179)
According to Pearlman and Saakvitne (1995a; 1995b), VT increases therapist susceptibility to some CT responses, which may be less recognizable and hence more problematic in therapy. Notwithstanding differences between VT and CT, knowledge about CT management is presumably germane to VT prevention (see below).

McCann and Pearlman (1990) suggested that there is some overlap between conceptualizations of VT and burnout, inasmuch as “symptoms of burnout may be the final common pathway of continual exposure to traumatic material that cannot be assimilated or worked through” (p. 134). In burnout, the nature of the external event is the source of distress (as contrasted with the internal focus of CT). Burnout is related to the work situation (e.g., a high stress work environment with low rewards, in which minimum worker goals are unachievable, or in which worker lacks control over unfair conditions) (Maslach, 1982; Maslach, Schaufeli, & Leiter, 2001) but not to the interpersonal interactions specific to VT (Pearlman & Saakvitne, 1995a, 1995b). Burnout lacks the specificity of therapist exposure to the emotionally disturbing images of suffering and horror characteristic of serious traumas (McCann & Pearlman, 1990).

Managing CT
According to Hayes (2004), research and theory suggest that therapist self-insight, self-integration, conceptual ability, empathy, and anxiety management facilitate management of CT. Hayes, Gelso, Van Wagoner, and Diemer (1991) conducted a survey study designed to provide an initial empirical basis for understanding the management of CT from the perspective of experts in the field. Their findings suggested that CT stems from a therapist’s inability to disengage from identification with a client, rather than from empathy itself, which involves a process of partial or trial identification balanced with relative disengagement (standing back and observing). Their findings suggested that therapist self-integration and self-insight, including cohesion of self, self—understanding, and differentiation of self from others, played the most important role in managing CT. Similarly, Van Wagoner, Gelso, Hayes, and Diemer (1991) identified “five qualities theorized to be important in the management of countertransference feelings” (p. 412). Based on survey data completed by 93 experienced counseling professionals, they found that reputedly excellent therapists, when contrasted with therapists in general, were viewed by colleagues as: (a) having greater insight into the nature and basis of their feelings; (b) possessing increased capacity for empathy; (c) better able to differentiate between client needs and their own; (d) less anxious both in session with clients and in general; and (e) more adept at case conceptualization, all of which were theorized to contribute to better management of CT or overidentification. However, the authors stated “much caution must be exercised in generalizing from perceptions to actual behaviors of excellent therapists” (p. 420).

Coster and Schwebel (1997) researched psychologist well-functioning (which they originally called unimpairment), defined as “the enduring quality in one’s professional functioning over time and in the face of professional and personal stressors” (p. 10). Content analysis of interviews with six practicing psychologists with 10 years’ postdoctoral experience yielded 10 themes as important contributors to well-functioning: Peer support, stable personal relationships, supervision, a balanced life, affiliation with a graduate department or educational institution, personal psychotherapy, continuing education, family of origin as source of personal values, awareness of cost of impairment, and coping mechanisms (such as vacations, relaxation, rest, exercise, spirituality, and time spent with friends). Self-awareness/monitoring for early signs of potential impairment and personal values rated as the top two reasons for psychologists’ well-functioning on a questionnaire in a second study. Coster and Schwebel (1997) emphasized the importance of normalizing vulnerability to impairment: Accepting signs of impending impairment (as normal) is crucial to prevention of more serious problems. The authors advocated a strong role for professional organizations in the promotion of professional well-being and called for further investigation to correct an existing imbalance in professional education, wherein prevention of impairment does not receive ample emphasis.

Ladany, Friedlander, and Nelson (2005) addressed the important role supervision plays in CT management. Similarly, Walker (2004) asserted that supervision acts as an important protective factor for both CT and VT by “ensuring early recognition and response, and thereby acting as a protection against burn out and consequent damage to the therapist and to their client” (p. 179). Bernard and Goodyear (2004) propose that supervision serves a restorative purpose, beyond its formative and normative functions; they cite Hawkins and Shohet (1989), who state it is the responsibility of the supervisor “to provide supervisees the opportunity to express and meet needs that will help them avoid burnout (p. 12).” Moreover, the supervisory relationship is widely considered to be a crucial element of productive supervision (Bernard & Goodyear, 2004; Bradley & Ladany, 2001; Holloway, 1995; Nelson, Gray, Friedlander, Ladany, & Walker, 2001).

Transforming VT
McCann and Pearlman (1990) drew upon their own work experience to posit strategies for the transformation of VT. According to these authors, clinicians must acknowledge, express and work through painful experiences in a supportive environment—otherwise, therapist numbness and emotional distance risk interfering with ongoing empathic engagement with clients. They suggested that weekly case conferences and other groups for clinicians who work with traumatized clients can counter professional isolation and provide emotional support by helping to normalize and elucidate therapist reactions to client trauma. Furthermore, they recommended that clinicians receive regular supervision, balance caseloads with victim and nonvictim clients, balance clinical work with other professional responsibilities, such as teaching and research, and maintain balance between personal and professional life. They identified other coping strategies, including: advocacy, enjoyment, realistic expectations of self in the work, a realistic worldview (that includes the darker sides of humanity), acknowledging and affirming the ways in which trauma work had enriched lives (of others and their own), maintaining a sense of hope and optimism, and a belief in the ability of humans to endure and transform pain. Similar recommendations for ameliorating VT have been proffered by Saakvitne and Pearlman (1996), Pearlman and Saakvitne (1995a, 1995b), and Yassen (1995).

Method

A purposeful sampling procedure was used to recruit peer and organizationally nominated therapists who met the following inclusion criteria: (a) trained at the masters or doctoral level; (b), minimum of 10 years’ professional experience with traumatized clients; and (c) self-identified as having managed well in this work. Potential participants were recruited through flyers distributed through professional networks and asked to complete the Professional Quality of Life: Compassion Fatigue and Satisfaction Subscales, R-III (Pro-QOL) (Stamm, 2003), a short quantitative measure used for screening purposes only. Those who scored below average on the Burn Out and Compassion Fatigue subscales of the Pro-QOL (i.e., self-reports suggested they suffered less burnout and VT than the average practitioner) were invited to participate in the study. Clinicians who participated in the study had between 10 and 30 years of experience working primarily with traumatized clients in organizational (e.g., hospital, community mental health, residential program for alcohol and drug abuse) and/or independent practice settings. Their clientele included survivors of sexual and/or physical abuse perpetrated during childhood and/or adulthood; pediatric and adult palliative care patients and their families; survivors of torture and natural disasters; refugees from countries at war; firefighters; bank tellers involved in robberies; and people with a history of abuse dealing with poverty, racism, substance abuse, and suicidal ideation. Participants ranged in age from 49 to 59 years old and included female and male therapists of diverse sexual orientations (heterosexual, lesbian, and gay) who came from a range of religious backgrounds, including Judaism, Catholicism, Christianity, and Native American spirituality. The sample size (n = 6) allowed for in-depth exploration of the research questions.

Harrison collected narrative data through interviews, which took place in three phases. In an initial, structured interview, each clinician provided information about their age, work setting, caseload, years of experience, and social supports. The second phase involved open-ended, individual interviews (lasting approximately 2 hr) in which clinicians were asked, “How do you manage to sustain your personal and professional well-being, given the challenges of your work with seriously traumatized clients?” and “How could protective practices best be engaged in order to mitigate the risks of VT and sustain the efforts of others who work with traumatized clients?” With one exception, interviews were conducted in the clinician’s workplace. Research conversations were recorded on audiotape, transcribed, and submitted to a multistage process of analysis. Transcriva software was used to store and partially analyze the data.

Data analysis was based upon Lieblich, Tuval-Mashiach, and Zilber’s (1998) typology of narrative analysis, with a primary focus on thematic content analysis within and across participants’ narratives. Through multiple readings of each individual transcript, Harrison selected passages relevant to the research questions and coded these according to emergent and convergent themes, through a process of constant comparison. He concomitantly drew concept maps and wrote reflexive memos in a research journal. To confirm the validity of identified themes, we submitted the coded interview transcripts to a peer-review process.

To further ascertain descriptive and interpretive validity (Maxwell, 1992), Harrison subsequently wrote and sent a detailed letter to each clinician, organized by the coded themes that had emerged in their respective research interview. This allowed us to share and receive feedback on our data analyses, and to verify that any interpretation on our part, which we regard as inevitable and inherent to the process of descriptive qualitative research (Alverson & Skoldberg, 2000; Sandelowski, 2000) was held to a minimum and did not stray from clinicians descriptions of their lived experiences. Harrison then arranged a third interview as a follow-up/member check, to incorporate any requested revisions. After incorporating minimal clarifications and corrections offered by the research participants we conducted a categorical content analysis across clinician narratives. Through multiple readings of the six letters, we subsumed the various codes into nine major convergent themes, presented below. As a further validity check, the authors subsequently sent this manuscript to all six research participants who read it and endorsed the accuracy of the cross-narrative themes identified below. Please refer to Appendix for illustrative examples of our multistage process of data analysis.

Results

The research findings describe how these exemplary clinicians engage in protective practices that mitigate the risks of VT. We have articulated these in terms of nine major themes: countering isolation (in professional, personal and spiritual realms); developing mindful self-awareness; consciously expanding perspective to embrace complexity; active optimism; holistic self-care; maintaining clear boundaries and honoring limits; exquisite empathy; professional satisfaction; and creating meaning. These themes are integrally interrelated and constellate in myriad ways. Indeed, we have come to view the researched phenomenon as a fractal, whose intricacy is such that the overall pattern occurs in each part. Below, we describe the nine salient themes that emerged within and across clinicians’ narratives of practices that protect and sustain them in their work with traumatized clients, thereby mitigating the risks of VT.

Countering Isolation in Professional, Personal and Spiritual Domains of Life
The first major theme has multiple subsets: Research participants counter isolation by drawing upon continuity in relationships in professional, personal, and spiritual realms, all of which risk being adversely affected by their work. Doing so helps them restore balance.

Supervision as relational healing

All clinicians spoke of the important role supervision plays in mitigating risks of VT. Regardless whether it takes place within an informal peer group, an organizational setting, or as paid consultation, they described how supervision helps decrease their isolation, and some said supervision helps diminish feelings of shame about VT symptoms. Most attend at least one peer supervision group. This practice enhances their self-awareness and ability to “self-monitor,” and reinforces their commitment to implement self-care practices, as needed. Moreover, peer supervision groups provide a forum in which these clinicians benefit from learning about each other’s strategies to address VT symptoms. This form of support within the professional realm also helps therapists maintain healthy relationships and balance in their personal lives by helping them recognize when “overloaded with my work or carrying too much.” In turn their personal relationships further sustain them in their professional efforts.

Training, professional development, and organizational support

Clinicians also underscored the importance of good training, ongoing professional development, mentorship, and organizational support. These practices anchor them within a professional community, which decreases isolation, anxiety, and despair that can arise when clinicians feel solely responsible for redress of daunting and highly distressing problems. All participants asserted that organizations that employ therapists have a responsibility to value and foster clinician self-awareness by dedicating time and space for self-reflection at work and creating forums in which therapists can discuss VT in an open and nonjudgmental environment. Similarly, they recommend employers remain aware of how the work is affecting clinicians and institute policy to hold caseloads to reasonable levels. Additionally, some said nonauthoritative, inclusive administrative styles that convey appreciation for clinicians’ expertise can enhance a sense of belonging, and professional satisfaction. One clinician spoke of the need for early, explicit training in self-awareness and self-care strategies.

I really want people to get training (in self-care) before they go out and start working. I really want them to learn how to take care of themselves first, instead of having to learn on the job! Because sometimes the damage is already done and people have to leave early in their career because nobody taught them how to take care of themselves! I’d really like for that to be promoted as a part of professional practice. Just as you have to be really good at your communication with your clients, you have to be really good at self-care or all is lost. And people are too important to lose. People shouldn’t go to work and be hurt to the point that they have to go on disability. So I think that, just like we do communication classes, we should do self-awareness classes.
Diversity of professional roles

All participants were involved in a variety of professional responsibilities (i.e., some combination of direct practice, teaching, supervising, and/or administration). Several explicitly stated that they found this to be protective and sustaining of their professional efforts, because this diversity expanded their professional role and put them into contact with a larger community, thus allowing them to feel a sense of interconnection and renewed hope.

Personal community

All participants value the role played by their personal community of family and/or friends in helping them to maintain balance and separate work from the rest of their life. Most described belonging to a rich network of mutually caring relationships, upon which they can rely when in personal need. Some contrasted the reciprocity in these nonprofessional relationships to the asymmetry of their professional role and explained that the former helps them to maintain clear, consistent boundaries with clients from whom they expect nothing in return (and whom they actively discourage from taking on a caregiving role in the therapy relationship). Because these clinicians are nourished and sustained by relationships in the personal realm, they find their professional caregiving role less depleting. Some have developed strategies to connect physically with loved ones and seek solace when distraught, in a way that neither betrays client confidentiality nor burdens relational partners with potentially harmful details. This kind of physical contact with trusted close others acknowledges and helps clinicians contain the challenging knowledge and experiences that they acquire as a consequence of their work. In addition, they look to their relationships outside the professional domain for opportunities to experience levity and joy, to counterbalance or expand the restricted and “skewed perspective” on life that they otherwise risk developing based upon the frequent and repeated stories of suffering and cruelty to which they are exposed at work. Moreover, the participants rely on personal community to help them gain awareness at those times when professional concerns are intruding upon personal life.

Spiritual connection

Participants further described experiencing a sense of connection to a spiritual realm or a sense of larger meaning that transcends individual boundaries and reason. This sense of interconnectedness with the mysterious transcendent (e.g., “this other realm… the mystery stuff”), which is tacitly known and cannot be clearly articulated through words or otherwise apprehended, is sustaining of therapists’ professional efforts and personal well-being because it helps counter isolation and despair. These clinicians are comforted by the belief that they are part of something larger, meaningful and good, that they are not alone in their efforts, and that these are not futile. This felt sense of spiritual interconnection reinforces their positive disposition and renews their conviction that: (a) people are resilient and can heal; (b) growth can occur in the wake of trauma; (c) life is about more than suffering; (d) their professional efforts are meaningful; and (e) they are not solely responsible in their efforts to heal trauma. In these ways, spiritual connection inspires these clinicians and helps them to keep going despite the difficult challenges of their work. Most described time spent in nature as an important aspect of this sense of spiritual connection. Below a research participant described how her personal, highly cognitive version of interconnection with humanity, nature, and the “web of life” helps her persevere:

When I go walking by the ocean, which I do very frequently, I always think about and pay attention to how the ocean persists, and that’s how humanity persists, people persist, you know, that kind of idea. Persevering and persisting and maintaining, right? It is important for all of us who do this work, I think, to have a sense of being connected, to being part of the web of life somehow, however we define that in whatever kind of way that is. Because trauma is so isolating, and we get isolated. So however you create meaning helps to break that down. I think you have to do it in the “big web of life”, I will call it—some people call it “spiritual”, and I think you have to do it in terms of being with some other folks who are not helpers. So from the big to the small. It just reminds me that I am part of this web of life, I am one of the threads and my job is to do my part good enough.
Developing Mindful Awareness: Integrated Practice of Spirituality
The practice of mindfulness (present focused attending to minute, ongoing shifts in mind, body, and the surrounding world), integrated into daily life from initial waking to final moments before sleep, helps most of these therapists to develop enhanced patience, presence and compassion. Mindulness, as described by participants, involves curiosity and holistic awareness of one’s experience in relation to both external and internal environment. Breathing consciously and redirecting attention to their embodied experience of the here-and-now helps these therapists to stay calmly focused and grounded, which allows them to be less reactive and engage with greater equanimity. This contributes to increased ability to embrace complexity and tolerate ambiguity, as well as enhanced capacity to hold multiple perspectives, engage in both/and thinking, and remain hopeful in the face of suffering.

Mindfulness enhanced clinicians’ ability to engage in many of the other protective practices identified below. Profound awareness and acceptance of “what is” helps them accept limits (including those of personal vulnerability, range of personal influence, responsibility for change, and limits of the known and knowable) and maintain clarity about self in relation to others, both in terms of interconnections and boundaries. Mindful awareness also helps participants recognize if and when their interpersonal boundaries are at risk of becoming overly permeable, as well as other times when they need to take action to restore balance in their lives (e.g., employ imagery or ritual, engage in self-care practices, seek consultation, and reach out to personal community). In addition, moment-by-moment embodied awareness of self and surroundings helps therapists develop the kind of interpersonal presence and clarity crucial to the practice of exquisite empathy (described below). Moreover, we propose that because it is impossible to be truly present in two places at once, the practice of mindful self-awareness helps these clinicians keep personal and professional realms separate. Their ability to fully engage in the present moment, while in the personal realm, protects them against intrusions from the professional realm.

Most clinicians related mindful awareness to their practice of integrated spirituality and sense of purpose. Through mindfulness practice they seek to make “connections between mind, body, and spirit,” to maximize and enrich every moment and interaction with heightened attention and loving acceptance. They described how this in turn facilitates professional satisfaction and related sense of making a meaningful contribution to life through work. While some currently or previously engaged in a structured meditation practice to develop mindfulness, others had never done so.

Consciously Expanding Perspective To Embrace Complexity
Participants consciously challenge negative cognitions to expand their perspective when caught up in despair. They purposefully remind themselves of other ways of viewing life by cuing themselves through self-talk, use of imagery or metaphor, time in nature, or interactions with people in other lines of work, to encompass wider horizons of possibility and counterbalance their skewed perspective on the world. Because these clinicians are able to embrace cognitive complexity, tolerate ambiguity, and simultaneously hold multiple perspectives (including those of client and self), they can accept the inevitability of pain and suffering as well as life’s potential for beauty, joy and growth. Therefore, even the cumulative knowledge of clients’ horrific experiences of trauma does not eclipse their positive worldview or sense of hope and purpose (more below). Moreover, they are able to see a “gift” side of loss, which is to say that devastating experiences can also be generative, and that these are not mutually exclusive. They recognize that positive growth does not diminish or efface agonizing pain; rather, pain and positive transformation coexist. This awareness is sustaining of clinicians because it allows for the possibility that clients, too, can achieve an expanded perspective that embraces life’s pain and beauty in the wake of devastating trauma. The research participants have been inspired by their experiences of witnessing and accompanying clients who have done so. They described their lives as having been “enriched,” deepened, and “empowered” by their vicarious experiences of client posttraumatic growth (Calhoun & Tedeschi, 1998, 1999; Tedeschi & Calhoun, 1995), as well as personal experiences of trauma and subsequent growth.

Furthermore, conscious shifts in perspective help these clinicians counter isolation and tolerate ambiguity. They remind themselves that they are not in it alone, that others are doing similar work to redress abuse, and that change is incremental and happens slowly over time. A clinician who worked in a residential treatment program described how such shifts in cognitive perspective are protective:

You have to keep reminding yourself that behind the clouds there is sun. I’m standing in a dark place too, but I know beyond it there is something more. And the thing is it depends on your perspective. I mean, there is beauty even in the SUFFERING of these youth as they come in there. Their resiliency. If you have any idea of the human suffering, the human misery that some people have experienced, and yet there they are. Like, what a heroic story. It’s a great tale of heroism. It’s remarkable. You can either see the darkness of it or a very heroic story. It’s both.
Ultimately, this expanded perspective encompasses openness to the unknown, and a belief or tacit sense that meaning and purpose transcend the limits of individual identity, language, and quantifiable knowledge. Participants accept their inability to articulate or apprehend this mysterious, transcendent unknown. They do not feel a need to name or otherwise define it (although several associate it with light). Many equated this elusive realm with their sense of spirituality, which they primarily practice outside the context of organized religion (most of the clinicians were raised in a religious tradition, which they subsequently left or moved beyond). Remaining open to the idea that some aspect of life transcends personal boundaries and interconnects all people makes trauma work less distressing for these clinicians, because it counters isolation on a larger scale (as described above), and helps them to feel that life is meaningful, even when difficult. Many equated their calling to trauma work with some ineffable or elusive purpose. Moreover, some took solace in mystery, itself, and found it comforting to accept that some things are beyond the ken of human understanding.

Active Optimism
The belief that people can heal is central to a positive disposition, which envelops and underlies the phenomenon of clinicians who manage well in their work with clients who have experienced serious traumatic events. Research participants shared an overarching positive orientation, conveyed in terms of an ability to maintain faith and trust in: (a) self as good enough; (b) the therapeutic change process; and (c) the world as a place of beauty and potential (despite and in addition to pain and suffering). These three attributes parallel the core assumptions that Janoff-Bulman (1992) identified as being shattered by experiences of trauma. The clinicians in our study viewed the world as ultimately benevolent, the therapeutic enterprise as meaningful, and self as good and capable in their professional endeavors. There is a circular quality to this positive orientation, inasmuch as the ability to sustain hope and maintain faith that things get better informs many of the protective practices these exemplary clinicians engage in, which in turn serve to renew their enduring hope and trust. Several explicitly equated optimism with awareness. One clinician drew upon a Buddhist parable to describe this:

I don’t see the people I work with as TRAUMA!! (booming voice) You know, I see them as people (softer) who in some way are very stuck in some holes and they believe that it is dark and fearful and they cannot get out of the hole. And for me, you know, life has holes. Big holes, little holes, but there is no life with no holes. And if I can almost like tell people, have a peek in the road, you know, get off the hole. But the awareness is not just where you ARE if you are in a hole. The awareness is there are holes and I accept it. And I also feel very… faithful [trusting] that I can get out of the hole. That life is not a hole. And that’s how I protect myself. I accept my holes and I don’t feel I get dragged in people’s holes. I feel very sad, very sorry, but I feel very… empowered, I feel very honored that I am asked to Help people. And that for me is something that I grab like you know, a real light switch.
These clinicians put their optimism into action, through proactive problem solving. They approach problems as solvable. When the scope of a problem is too large, they look at what small part they can address, which may take the form of advocacy or self-talk to let go of anger and dwell in acceptance. This active approach to problem solving also informs how they respond to the unique challenges of their work with traumatized clients. For instance, they use their heightened self-awareness to recognize how work is affecting them, then determine what to do about this. Most have consciously developed a plan or personalized set of strategies to counter VT and recommend that other therapists do so, as well. Their practice of active optimism involves creating time and space for self-care practices to restore balance in their lives. They have purposefully developed strategies to separate work and personal life, as well as effective communication skills to deal with problems in either of these realms. Sometimes active problem solving involves using imagery or ritual to maintain clarity around boundaries or provide closure (more below). In addition, participants consciously seek out opportunities for laughter or to take in beauty, and some have deliberately joined book clubs populated by members in different lines of work, to be reminded of other perspectives on life. Moreover, most participants create and enact optimism by purposefully planning pleasurable activities, including travel or time in nature. One clinician described this as follows:

One of my strategies is to always have something to look forward to. I always plan for something good to come next. And that’s been a comfort. I mean, as soon as I finish one thing, there is the seed for something more. I never go without, even if the seed is a teeny tiny little kernel, even if I don’t have the money even if I don’t have the time yet, the seed is started and so it’s a beginning place.
Holistic Self-Care
These clinicians take a holistic approach to self-care, which they consider crucial to their ability to maintain personal and professional well-being. They attend to physical (e.g., healthy diet, ample sleep, regular exercise, holding and being held), mental (e.g., training, continuing education, mindful awareness), emotional (e.g., personal therapy, trusting relationships, laughter and joy, emotional expression, release or redirection of anger), spiritual (e.g., meditation, time spent in nature, creating meaning and purpose), and aesthetic (purposefully “bringing beauty in”) aspects of self-care. Some think of self-care in terms of practicing what they teach, or “walking my talk.” They practice self-care within both the personal and professional realm, and their ability to separate these two realms of life is itself a form of self-care. Self-care provides balance, and at times “closure.” Moreover, it is renewing and consequently allows them to be more present when engaging in both personal and professional relationships. They recommend all clinicians who work with trauma engage in self-care practices, including some form of personal therapy. Many have found group-based therapy to be particularly helpful. Moreover, these clinicians recognize that there is an ethical component to self-care. If they do not take care of themselves, they are at risk of harming others. Consequently, they strongly believe that taking care of caregivers needs to become a higher priority in health care and related fields. They think that there is a need to incorporate self-awareness and self-care into professional training, at an early stage. Below, a clinician talked about the importance of daily self-care in her life:

I get up every morning at five o’clock, and I have a friend, and we walk for about an hour and 10 minutes, Monday to Friday. We don’t miss, doesn’t matter if it’s raining. Sometimes we walk in silence, sometimes we talk, but if I miss that, my day is totally different. That gets me grounded, that gets me connected. I see the seasons change, I am aware of things, I have a friend that I really love and care about with me every morning, and it’s something I just—it’s REALLY IMPORTANT TO ME. So walking becomes really, it is a walking meditation {laughs} to some extent.
Maintaining Clear Boundaries and Honoring Limits
These clinicians maintain clear and consistent boundaries in multiple realms of interaction. They accept, honor and maximize limits, including those of their professional role in relationship to clients. All participants acknowledge their own limits, including personal vulnerability to VT, and they believe that it is imperative for others in this work to do so, as well. In addition, they maintain clarity about the limits of their sphere of influence. They avoid dual relationships, and recognize that as therapists, they are not responsible for making change in clients’ lives.

Furthermore, participants hold realistic expectations of self, other, and the world, and do not confuse the ideal with the actual or the likely. They recognize that change unfolds slowly, in small increments, and that larger scale change is a community rather than an individual responsibility. However, some do engage in advocacy. One said, “I do advocacy work, but only when I feel passionate about it. I’m really also very able to say ’NO. I give at the office,’ so to speak.” She recognizes that taking on too much volunteer work can interfere with the balance in life that she requires to sustain her professional efforts as a clinician. Moreover, these exemplary clinicians have developed a range of strategies to help maintain boundaries (both psychological and physical) between work and personal life. These include use of supervision, peer consultation, personal therapy, physical self-care and/or mindful attending to unresolved material in order to “process” it and to achieve closure; personal rituals before and after work; meditation practice; taking time off work to travel; and consciously setting temporal and spatial limits between professional and personal realms (e.g., keeping work-related books at the office, limiting time spent debriefing with partners, not working on one’s birthday), among others.

Perhaps most importantly, they maintain clear boundaries with regard to the distinction between empathy and sympathy. While remaining highly attuned to clients, they do not engage in emotional fusion or otherwise confuse clients’ feelings or experiences with their own. Instead, they maintain firm interpersonal boundaries that are sufficiently permeable to allow them to experience intimate connection within the context of a present-oriented professional relationship “with the person here and now”, without losing personal perspective. Moreover, participants are attentive to those times when clients’ stories resonate more powerfully with the therapist’s personal history, in which case they may seek supervision or personal therapy to help maintain clarity and manage what gets stirred up for them. In these ways, exemplary clinicians differentiate between their own worldview and those of traumatized clients with whom they empathize. This clarity around boundaries is helpful to clients and protective of therapists. One clinician explained that although he feels “connected” and is often deeply touched by clients’ stories of prior traumatic events, he remains clear that:

It’s still their story. It’s not my story. [It] doesn’t get painted on my wall, you know. It passes through. I don’t lose myself in it. I don’t have to. I can care [but] I’m not in [the trauma story]. I didn’t have that thing happen to me. Certain stories you, know are ones that are harder for me for whatever reason, and of course, I’m in peer support groups, I have places to go to talk about stuff with people, I swim, I hike a lot, I live with someone, and I have those places to be with people, unload distress in an appropriate way [when] certain themes become cloudier for me around [whether] it’s their story or is it my story.
Moreover, these exemplary clinicians employ visualizations, metaphor, and personal ritual as a self-management strategy to simultaneously stay fully present in sessions and maintain consistent boundaries when client material risks encroaching upon their personal life or perspective. This allows them to remain empathically engaged, highly “present and connected,” yet protected and distinct in their role as attuned, caring witness to client stories of traumatic experience. Below, a clinician described one such strategy:

I try to think of myself as a screen door, where the wind blows through and doesn’t attach to the screen. It’s an image that I find particularly helpful. I see their story as the wind and I’m the screen. They will have stories that could, if forceful like a gale wind, be dangerous and something to be contended with, but if my door is solid and my screen allows for air to move through it, then even a gale force wind can pass through my screen door.
Exquisite Empathy
Most of the clinicians described how intimate empathic engagement with clients sustains them in their work. This finding surprised us, because we went into the research thinking that empathic engagement was a risk factor rather than a protective practice. However, when clinicians maintain clarity about interpersonal boundaries, when they are able to get very close without fusing or confusing the client’s story, experiences, and perspective with their own, this exquisite kind of empathic attunement is nourishing for therapist and client alike, in part because the therapists recognize it is beneficial to the clients. Thus the ability to establish a deep, intimate, therapeutic alliance based upon presence, heartfelt concern, and love is an important aspect of well-being and professional satisfaction for many of these clinicians. One research participant elaborated on this:

I actually can find sustenance and nourishment in the work itself, by being as present and connected with the client as possible. I move in as opposed to move away, and I feel that is a way that I protect myself against secondary traumatization. The connection is the part that helps and that is an antidote to the horror of what I might be hearing. It’s about working with the heart from a place of warmth and care and even love.
Professional Satisfaction
All participants take satisfaction in being effective in their work, making a meaningful contribution through their professional efforts, and being highly skilled at what they do. In these ways, they find the work deeply rewarding. They are honored by their professional role, which has “expanded and enriched” their life in nonmonetary (as well as fiscal) ways. They consider it to be an extraordinary privilege to Help people who have experienced trauma, and this sustains them in their professional efforts. Clinicians suggested that organizational cultures and managerial styles that value therapist expertise and afford practitioners greater professional autonomy further contribute to professional satisfaction. One said:

I mean I have been very, very privileged. I have experienced things… the depth of things or the beauty of things or the wisdom of things in this healing process that other people have never ever had. Most people, I think, don’t ever get a sense to touch that kind of depth or that kind of stuff, so I wouldn’t quit my job.
Creating Meaning
Finally, these therapists recognize the importance of their ability to create or perceive meaning, regardless whether through belief in an ultimate universal goodness, an elusive transcendent greater purpose, their commitment to family, work, and/or community building, or a sense of interconnection with the efforts of others in continuity over time. This last finding relates back to the notion of countering isolation in the spiritual domain of life. Furthermore, it parallels the work of Briere and Jordan (2004) and van der Kolk and McFarlane (1996), who found that the process of making meaning beyond concrete events helps to contextualize and reduce the threat of trauma. Below, a clinician explained how creating meaning sustains her professional efforts:

Even though I’ve known people who have gone through difficult things, [and I] have had difficult experiences in my own life, I have a belief that there is some meaning or purpose in that, even if I’m not aware of it. That makes it more tolerable. That makes it more endurable.. When I just accept that the universe wanted me to have these experiences, and that they were meant to be helpful, supportive, then it all makes sense. And so then that is the ultimate goodness coming through. The ultimate goodness, which is, you know, we are meant to be here. We are meant to have experiences that challenge us and cause us pain, but ultimately it is about the goodness. Because then, it feels like, people [clients] will not be left only with pain and suffering, that they too will have the opportunity to process and work through this to a point where they make those connections to the goodness. They can look back and say, “That was really terrible and awful, and… That’s not all that’s there.”
Discussion

This study yielded the novel finding that empathic engagement can be a protective practice for clinicians who work with traumatized clients. This finding challenges prior assumptions about the causality and inevitability of VT. Clinicians who engaged in what we have called “exquisite empathy” (a discerning, highly present, sensitively attuned, well-boundaried, heartfelt form of empathic engagement) described having been invigorated rather than depleted by their intimate professional connections with traumatized clients. Previously, therapist empathy for traumatized clients had consistently been depicted as a key risk factor for VT. Consequently, the current study challenges prior conceptualizations of VT and points to exciting new directions for research and theory, as well as applications to practice.

Notwithstanding the differences between the constructs of CT and VT, prior research and theory on CT management may help explain our novel finding that a discerning form of empathic engagement characterized by “exquisite listening,” loving attunement, and therapist ability to differentiate self from clients, appeared to be protective for some clinicians in their work with traumatized clients. Hayes and colleagues (Hayes et al., 1991; Van Waggoner et al., 1991) previously offered initial evidence in support of a similar hypothesis: that enhanced capacity for empathy plays a principal role in clinicians’ ability to manage CT. These authors suggested that CT stems from a therapist’s inability to disengage from identification with a client, rather than from empathy itself, which involves a process of partial or trial identification balanced with relative disengagement (standing back and observing). Their findings also suggested that self-integration and self-insight, including cohesion of self, self—understanding, and differentiation of self from others, played the most important role in managing CT (Hayes et al., 1991).

Similarly, our current findings suggest that effective, protective empathic engagement with traumatized clients involves neither overidentification with nor avoidance of clients’ traumatic material. Rather, exquisite empathy requires a sophisticated balance on the part of the clinician as s/he simultaneously maintains clear and consistent boundaries, expanded perspective, and highly present, intimate, and heartfelt interpersonal connection in the therapeutic relationship with clients, without fusing, or losing sight of the clinician’s own perspective. Moreover, we believe that, for some clinicians, efforts to avoid or resist the intensity of clients’ trauma stories may be counterproductive. Instead, our findings suggest that some clinicians may benefit from accepting their relationship to clients’ traumatic material and integrating this aspect of their professional life into their identity. This is in keeping with the literature on PTSD treatment, which guides therapists to help traumatized clients integrate traumatic experiences into their identity and self story, rather than splitting these off (Herman, 1992).

Implications for Practice
If VT is indeed a form of trauma, in which clients’ accounts of traumatic experiences become the traumatic stressor for clinicians, it follows that clinicians may benefit from embracing their professional relationship to clients’ traumatic material rather than attempting to distance themselves from this aspect of their work. Exquisite empathy may be a way of accomplishing this, because it affords clinicians opportunity to ethically benefit from “healing connections” (Mount, Boston, & Cohen, 2007, p. 372) with clients, without ever sacrificing clients’ needs to their own. In this sense, exquisite empathy may constitute a form of mutual, reciprocal, healing connection, in which clients and clinicians alike benefit from the latter’s caring, well-boundaried, ethical attunement to the client.

Additional findings herein appear to be verifying of previous recommendations for ameliorating VT and underscore the ethical responsibility shared by employers, educators, professional bodies, and individual clinicians to create time and space to address this serious problem (e.g., through: regular supervision, within the context of a supportive supervisory relationship; peer and social support networks; life-work balance; self-care, including personal therapy, as needed; and self-reflection within and beyond the workplace). Moreover, many of our results reinforce Coster and Schwebel’s (1997) recommendations for psychologist well-functioning. However our findings about exquisite empathy and mindful self-awareness are notable additions to this prior research.

Results related to the important role that supervision and therapist self-care appear to play in mitigating the risks of VT could help inform the decision making processes of community agencies with regard to how to best support clinical staff, and also be highly beneficial to individuals in independent practice. Based upon these qualitative research findings, we recommend that greater time and attention be dedicated to therapist self-reflection and self-care as crucial components of ethical practice. Moreover, all clinicians who work with traumatized clients are advised to access ongoing, regular supervision and be part of either formal clinical teams or informal peer networks, to minimize risk of harm to self or clients. We consider it a shared responsibility on the part of employing organizations, professional bodies, and independent practitioners to ensure that clinicians have access to and take advantage of these supportive resources. Furthermore, we recommend that clinicians acknowledge the importance of both their professional and nonprofessional relationships, and actively nurture these. Our results suggest it is important to the well-being of therapists, clients, and our communities that no clinician should work with trauma in isolation.

The current research may also raise questions about the value of organizational policy and structure in some community agencies, where programs for traumatized clients (e.g., sexual abuse) are staffed separately from other therapy services. This practice typically does not promote balance within caseloads or among professional tasks. All of the peer-nominated exemplary clinicians who participated in the current study had some diversity in their professional responsibilities as well in the type of traumatized clients that they treated. Furthermore, most of their caseloads offered some balance between trauma and nontrauma clients. It is not clear why therapists who worked exclusively providing direct service to clients traumatized by a similar type of traumatic stressor did not present for inclusion in the study, but one possible hypothesis may be that they are not managing as well as those who have greater balance in professional responsibility or diversity of clientele.

Implications for Training
In addition, the results from this study suggest it may be helpful to future clinicians and clients alike to incorporate mindfulness training in therapist education, along with curriculum that invites (and teaches) trainees how to expand perspective to embrace complexity, tolerate ambiguity, recognize their own limits, and differentiate between empathic engagement and sympathetic overidentification with clients. Finally, there is an ethical obligation to warn trainees about the risks of the working with traumatized clients, as well as to teach them about protective practices. In this way, training could also serve a self-screening function that might prevent future VT and professional attrition. Well-informed trainees who are uncomfortable with ambiguity and/or who experience a significant degree of interpersonal isolation could elect not to pursue this kind of work, or alternatively, actively seek to develop more expansive cognitive and social practices.

Limitations and Implications for Future Research
Although the qualitative research design and small sample size precludes generalizing from the data, the current findings may be helpful to others in the fields of psychology, psychiatry, social work, psychiatric nursing, and related health care disciplines, at the levels of education, training, and practice. It is, however, important to underscore the potential for individual differences among clinicians who work with traumatized clients. Consequently, we offer our results and recommendations tentatively, in the absence of further data from future studies with larger sample sizes. Moreover, the validity of our findings could be strengthened through future research comparing clinicians who are managing well in their work with traumatized clients with those who are faring less well. This kind of additional research is warranted to further explore the current findings and assess their representativeness, particularly the novel finding that empathic engagement appeared to be a protective practice for some clinicians.

Summary

Although previous research has been conducted on VT, there is a great paucity of research investigating protective practices that mitigate the risks for clinicians who work with seriously traumatized clients. Consequently, this study makes an important contribution to the existing literature and begins to fill a gap that deserves continued attention. Moreover, this study augments the existing literature, much of which has been based upon quantitative research, by offering thick, rich description of the lived experiences of exemplary clinicians who are managing well despite the risks of this work. While the current findings confirm and extend prior research, they also depart from previous literature in interesting ways. Most notably, the finding that exquisite empathy seems to be a protective practice for some clinicians challenges previous ways of conceptualizing VT and points to exciting new applications to practice and avenues for further study.

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APPENDIX
APPENDIX A: Illustrative Examples of Data Analysis Process
The following excerpts are offered to illustrate our iterative data analysis process. We have entered corresponding codes to replicate the process of recording emergent codes.

JoyOne of the things that I do is I have supervision (1), and that is really helpful to me, and we have a vicarious [trauma] group (2) that I go to once a month, and it’s from people in the service and we have a little bit of a core group. There is about seven or eight of us (3) from different teams who come together, and it is a place where for an hour and a half, at least, what we do is that we talk about, uhm, it started off us trying to really connect (4) with each other and not just tell horror stories (5,6), which were re-traumatizing? {giggle} to starting to trust each other (7) where we talk about ourselves (6) and some of the things that we notice might be going on for us, and different things that we are doing to help with some of those symptoms (8) that might be coming up. It’s almost kind of like going on Weight Watchers, too. You have other people that you can talk to (9) so that it keeps it in your mind (6) that that’s something that is telling you that you need to do some shifting here around some things (10,11,12).RHI just want to stay with that for a second. Does that also mean that having other people helps you remember it is important to YOU?. is it also being sort of being almost accountable to more than just yourself?JoyYes it is. but on a very personal level again (13), right? And that is why I say it’s almost like weight watchers, because when you tell somebody and you open up and it is no longer a secret (9,14) and you are no longer ashamed (15) about the fact that, you know, you are more irritable and you are snapping at somebody (5,6), and you know that and you actually put that out as a reality (9,16), then other people know that and then they are interested (17), they care, and they inquire about that (18) {laughs}.RHSo you are building relationships (exactly), and I assume – you are making a gesture with your hands {hands offering forth from chest] – by “put that out there,” you mean put the words out there?JoyYes. So that helps you do. It helps you keep on track about those things and keep more mindful (19,20,21). The other thing I do that is just like the people I work with, is that it takes away some of the shame when you say these things (14,15,16).Codes(1) Supervision; (2) VT group; (3) Peer group; (4) Connection/build relationships; (5) Attentive to risk of VT; (6) Self-awareness; (7) Build trusting relationships; (8) Share strategies; (9) Counter isolation; (10) Make a shift; (11) Belief that something can happen; (12) Active problem solving; (13) Personal relationships; (14) Open up; (15) Counter shame; (16) “Express” reality; (17) Being witnessed; (18) Create caring networks; (19) Keep on track; (20) Self-monitoring; (21) Mindfulness.
Harrison highlighted and coded the original transcript in the margins. Through multiple readings, the following codes emerged: supervision; VT group; peer group; personal relationships; connection; attentive to risk of VT; self-awareness; build trusting relationships; share strategies; counter isolation; make a shift; belief that change can happen; active problem solving; being witnessed; open up; counter shame; express “reality”; being witnessed; create caring networks; keep on track; self-monitoring; mindfulness. These codes were then incorporated into a larger concept map that explored relationships between: self-monitoring/mindfulness, self-awareness re: risks and signs of VT, belief in the ability to shift, intention/decision to shift, forming personal relationships in professional contexts, supervision, personal therapy, countering isolation, decreased shame, being witnessed by caring others, shared strategies, active problem solving, enhanced personal relationships, and decreased VT symptoms. The codes that emerged from the transcript excerpt above were ultimately subsumed primarily under the cross-narrative themes, countering isolation (in professional, personal and spiritual realms), developing mindful self awareness, and active optimism.

The following is an excerpt from the detailed letter Harrison sent to “Joy” to share his interpretive analysis of their research interview conversation and check its validity:

Dear Joy,I am writing you this letter to share my emergent understandings of our research conversations about how you manage to maintain your personal and professional well-being given the challenges of your work with clients who have experienced serious trauma. In talking with you, I got the sense that awareness, focus, and presence within each unfolding moment, accompanied by a strong commitment to personal responsibility, well-developed abilities to check in with yourself and self-regulate as necessary, your rich relational life, and your enduring belief in both people’s ability to heal and the inevitability of change, all play an important role in your ongoing, evolving practice of personal and professional well-being. You have developed strategies and opportunities to care for yourself emotionally, physically and spiritually, and you actively and consistently engage in these with commitment and purpose. This allows you to experience profound and sustained interpersonal contact and connection (with self and others), while maintaining a clear sense of personal perspective and boundaries in relationship to others. I will elaborate on these and other themes below:Relational Self-Healing: Supervision, Peer Support, Personal TherapyYou are involved in several different peer supervision/support groups, which help mitigate effects of VT. You have built trusting professional relationships where you can share your concerns about VT symptoms. Doing so helps minimize isolation and shame, because you are able to give voice to your awareness of how trauma work is affecting your life. When you “put that out as reality” and it is witnessed by caring others, this reinforces your commitment to taking active responsibility for your well-being (which is informed by your enduring conviction that people, including yourself, can heal). You are able to benefit from shared strategies of other group members, and they also help you self-monitor by checking in with you periodically to ask how you are doing. Drawing on this support, you are better able to recognize and deal with your tendency to internally distance yourself from your partner and others, when you are feeling too “filled up” with work. You also use supervision and personal therapy to help manage those times when work begins to intrude upon personal life. All of this helps you maintain enhanced relationships in your personal life, which further sustain you professionally.
The participant subsequently confirmed the validity of Harrison’s initial analysis of their research interview. After conducting a thematic content analysis across participant narratives, Harrison sent each participant the following email, along with a copy of this manuscript, as a further validity check:

Dear (participant),I hope this email finds you well.I have just finished a manuscript based on my dissertation research that I am submitting for publication. I am hoping you will be able to read through the attached draft, and let me know whether all of the findings apply to you, or whether some of the “cross narrative themes” articulated do not fit for you. This would allow me to incorporate any necessary corrections.Thanks again for your participation in the research.warm Regards,Richard
All of the participants wrote back to endorse the accuracy of the research results, as presented in this article. Below are examples of their replies:
Richard,I have no problem with any of the “cross narrative themes.” I think it is an excellent paper.FrankHI Richardarticle is good! Nothing I disagreed with and I was interested to read some of the other comments. Good job!regards, AbigailAll looks good to me, Richard. and Congratulations on a job well done.ErnestHi Richard – I am happy to read that you are attempting to get your work published. I think it is an important piece of work that was well down.As with your dissertation, the paper is beautifully written and captures your passion. It is interesting to me that the nature of your research really has to do with connection, spirituality, life!!! and that you have been able to combine the intellect and the emotion and produce a very beautiful paper.I am very happy to have been a part of your paper and I have no objection to anything – I think you did a wonderful job.Good Luck,Joy
This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user.

Source: Psychotherapy. Vol. 46. (2), Jun, 2009 pp. 203-219)
Accession Number: 2009-08897-006
Digital Object Identifier: 10.1037/a0016081

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Prevalence and predictors of secondary traumatic stress symptoms in health care professionals working with trauma victims: A cross-sectional study.Open Access
Authors:
Ogińska-Bulik, Nina. Department of Health Psychology, Institute of Psychology, University of Lodz, Lodz, Poland
Gurowiec, Piotr Jerzy, ORCID 0000-0002-2238-2519 . Institute of Health Sciences, University of Opole, Opole, Poland
Michalska, Paulina, ORCID 0000-0003-2179-0307 . Department of Health Psychology, Institute of Psychology, University of Lodz, Lodz, Poland, paulina.michalska@now.uni.lodz.pl
Kędra, Edyta, ORCID 0000-0001-8341-6156 . Medical Institute, State Higher Vocation School in Glogow, Glogow, Poland
Address:
Michalska, Paulina, paulina.michalska@now.uni.lodz.pl
Source:
PLoS ONE, Vol 16(2), Feb 23, 2021. ArtID: e0247596
NLM Title Abbreviation:
PLoS One
Publisher:
US : Public Library of Science
ISSN:
1932-6203 (Electronic)
Language:
English
Keywords:
secondary traumatic stress symptoms, prevalence, predictors, health care professionals, trauma victims, occupational load, job satisfaction, social support, cognitive processing of trauma
Abstract:
Introduction: Medical personnel is an occupational group that is especially prone to secondary traumatic stress. The factors conditioning its occurrence include organizational and work-related factors, as well as personal features and traits. The aim of this study was to determine Secondary Traumatic Stress (STS) indicators in a group of medical personnel, considering occupational load, job satisfaction, social support, and cognitive processing of trauma. Material and methods: Results obtained from 419 medical professionals, paramedics and nurses, were analyzed. The age of study participants ranged from 19 to 65 (M = 39.60, SD = 11.03). A questionnaire developed for this research including questions about occupational indicators as well as four standard Assessment tools: Secondary Traumatic Stress Inventory, Job Satisfaction Scale, Social Support Scale which measures four support sources (supervisors, coworkers, family, friends) and Cognitive Processing of Trauma Scale which allows to evaluate cognitive coping strategies (positive cognitive restructuring, downward comparison, resolution/ acceptance, denial, regret) were used in the study. Results: The results showed that the main predictor of STS symptoms in the studied group of medical personnel is job satisfaction. Two cognitive strategies also turned out to be predictors of STS, that is regret (positive relation) and resolution/acceptance (negative relation). The contribution of other analyzed variables, i.e., denial, workload and social support to explaining the dependent variable is rather small. Conclusions: Paramedics and nurses are at the high risk of indirect traumatic exposure and thus may be more prone to secondary traumatic stress symptoms development. It is important to include the medical personnel in the actions aiming at prevention and reduction of STS symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Job Satisfaction; *Social Support; *Trauma; *Health Personnel; *Compassion Fatigue; Epidemiology; Medical Personnel; Work Load
Medical Subject Headings (MeSH):
Adult; Aged; Burnout, Professional; Compassion Fatigue; Cross-Sectional Studies; Female; Health Personnel; Humans; Job Satisfaction; Male; Middle Aged; Prevalence; Risk Factors; Social Support; Young Adult
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Poland
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Secondary Traumatic Stress Inventory
Cognitive Processing of Trauma Scale–Polish Version
Social Support Scale
Job Satisfaction Scale
Grant Sponsorship:
Sponsor: University of Opole, Poland
Other Details: Internal grant “Application for funding a research project under a grant for maintaining research potential in 2020- WPBIN1/19”
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Supplemental Data:
Tables and Figures Internet
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Feb 23, 2021; Accepted: Feb 9, 2021; First Submitted: Aug 8, 2020
Release Date:
20211118
Copyright:
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.. Ogińska-Bulik et al.. 2021
Digital Object Identifier:
http://dx.doi.org/10.1371/journal.pone.0247596
PMID:
33621248
Accession Number:
2021-21890-001
Number of Citations in Source:
80
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Prevalence and predictors of secondary traumatic stress symptoms in health care professionals working with trauma victims: A cross-sectional study
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Contents
STS among medical personnel
Professional load, work satisfaction, social support and cognitive trauma processing versus s…
Occupational load characteristic
Job satisfaction
Social support from the work environment
Cognitive trauma processing
Aim of the study
Materials and methods
Participants
Measures
Statistical analyses
Results
Discussion
Limitations of the study
Implications for practice
Conclusions
Supporting information
Footnotes
References
Full Text
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Introduction

Introduction: Medical personnel is an occupational group that is especially prone to secondary traumatic stress. The factors conditioning its occurrence include organizational and work-related factors, as well as personal features and traits. The aim of this study was to determine Secondary Traumatic Stress (STS) indicators in a group of medical personnel, considering occupational load, job satisfaction, social support, and cognitive processing of trauma. Material and methods: Results obtained from 419 medical professionals, paramedics and nurses, were analyzed. The age of study participants ranged from 19 to 65 (M = 39.60, SD = 11.03). A questionnaire developed for this research including questions about occupational indicators as well as four standard Assessment tools: Secondary Traumatic Stress Inventory, Job Satisfaction Scale, Social Support Scale which measures four support sources (supervisors, coworkers, family, friends) and Cognitive Processing of Trauma Scale which allows to evaluate cognitive coping strategies (positive cognitive restructuring, downward comparison, resolution/acceptance, denial, regret) were used in the study. Results: The results showed that the main predictor of STS symptoms in the studied group of medical personnel is job satisfaction. Two cognitive strategies also turned out to be predictors of STS, that is regret (positive relation) and resolution/acceptance (negative relation). The contribution of other analyzed variables, i.e., denial, workload and social support to explaining the dependent variable is rather small. Conclusions: Paramedics and nurses are at the high risk of indirect traumatic exposure and thus may be more prone to secondary traumatic stress symptoms development. It is important to include the medical personnel in the actions aiming at prevention and reduction of STS symptoms.

People who professionally help trauma victims are indirectly exposed to it themselves. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the etiological factor (experience of a traumatic event) was extended to include indirect exposure to a traumatic event [[ 1]].

Secondary trauma concern professionals who provide Helpance to trauma victims and sufferers. A special place among them has the representatives of the medical personnel who are often the first to contact trauma victims [[ 2]]. Witnessing the death of patients as well as the necessity to conduct difficult conversations with patients and their families causes stress and negative emotions as well as their suffering in many of them. Exposure to indirect trauma may be connected with various mental health disorders, above all Secondary Traumatic Stress (STS), which is also described as Secondary Traumatic Stress Disorder (STSD). Some authors describe that STS, defined as stress resulting from helping or willing to help individuals experiencing trauma, may lead to secondary post-traumatic stress disorder; persistence of high STS symptoms allows for the diagnosis of STSD [[ 3]].

The notion of secondary traumatic stress was popularized by Charles Figley [[ 3]] who described it as stress connected with helping other suffering people or trauma victims. It is defined as the behavioral and emotional outcomes experienced by an individual upon gaining knowledge of another person’s stressful experiences [[ 3]]. The introduction of secondary traumatic stress was preceded by the notion of compassion fatigue [[ 3]]. It was initially used in relation to nurses and then broadened to therapists and other professionals dealing with the mental health of people who were exposed to traumatic events. Figley [[ 3]] stressed that these professionals are the first to ease the pain and suffering of people who experienced trauma. Yet, while helping others they also become trauma victims. Another term used in relation to the discussed phenomenon is the Vicarious Traumatization (VT). This term was introduced by McCann and Pearlman [[ 5]] to describe the changes in the therapist’s worldview which occur as a result of empathic engagement in helping patients who experienced trauma. Vicarious traumatization means the transformation of the internal experience of helpers resulting from their therapeutic work for the client. This concept, as underlined by Tosone et al. [[ 6]] has a slightly softer overtone than secondary traumatic stress but most often these terms are treated as synonyms.

STS symptoms are related to thoughts, emotions, and behaviors resulting from the knowledge about traumatic events experienced by others but also from engagement in helping the trauma victims. They include the same symptoms which occur in PTSD and are experienced by people directly exposed to trauma [[ 3], [ 7]]. Therefore STSD may also be referred to as secondary PTSD [[ 3]]. According to the new DSM-5 classification [[ 1]], the occurring symptoms belong to the fourth category, which is intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.

STS among medical personnel
Medical personnel representatives—nurses, doctors, paramedics, that is people who have direct contact with patients and those who suffer because of their conditions or injured in accidents—are subject to negative consequences of exposure to trauma [[ 8]–[13]]. As underlined by Beck [[14]], STS is perceived as a professional risk factor among health care professionals. Research carried out within this scope confirms the high risk of STS occurrence in this professional group.

The studies conducted among paramedic personnel, the majority of which consisted of doctors, in 10 hospitals of one of the States in the USA shows that nearly 13% meet the STS criteria and almost 34% presented at least one symptom included in the scope of each of three STS categories, that is an intrusion, arousal and avoidance [[15]]. One of the studies mentioned by Nimmo and Huggard [[12]] shows that more than half (54%) of doctors who participated in the study met the criteria of compassion fatigue or STS. Yet, it results from other studies presented by the authors that the intensity of STS among doctors was low. Symptoms of secondary traumatic stress were also revealed by ambulance personnel in the study of Argentero and Setti [[16]].

Research carried out among nurses working in emergency rooms in Scotland shows that 75% of them presented at least one symptom included in the STS scope [[17]]. According to studies [[18]], 64% of Irish nurses working in emergency medical services met the STS criteria Similarly, 52.3% of emergency nurses in Jordan revealed a high or severe level of secondary traumatic stress [[19]]. High risk of the occurrence of secondary traumatization in this professional group is confirmed by study results which show that 86% of nurses participating in the study presented a moderate or high level of compassion fatigue [[20]]. Other studies mention frequent STS symptoms occurrence among oncology and critical care nurses [[21]–[23]]. High risk of STS symptoms occurrence is also observed among nurses who work in palliative care and cancer wards. Nurses who deal with the seriously ill, wounded, and those facing the end-of-life over extended periods of time are at particular risk of negative effects of indirect trauma [[11], [20], [24]]. It is confirmed by the literature review by Ortega-Compos et al. [[25]] which shows that 19% of cancer ward nurses present low compassion satisfaction, 56% moderate or high level of burnout, and 60% moderate or high level of compassion fatigue.

Polish studies confirm the high risk of STSD occurrence among the medical personnel. In research concerning nurses working in palliative care [[26]] escalation of STS symptoms (measured by means of Secondary Traumatic Stress Scale) was reported in 38.9% of participants. Moderate STS symptoms were observed in 23.6% and 37.5% of participants showed low levels of STS symptoms. In studies in which Posttraumatic Checklist—PCL-5 was applied to evaluate STS symptoms [[13]] it was reported that among 5 professional groups (therapists, paramedics, nurses, social workers, and probation officers) the highest level of STS symptoms was presented by medical personnel and high probability of STSD occurrence was noted in 45.8% of paramedics and 40% of nurses employed in posttraumatic and palliative care wards.

Professional load, work satisfaction, social support and cognitive trauma processing versus s…
Several theoretical models have been developed to explain the nature of secondary traumatization and describe the factors that determine the occurrence of secondary traumatic stress. One of the most important concept that directly relates to secondary trauma is Ecological Framework of Trauma by Dutton and Rubinstein [[27]]. The authors distinguished several elements of the model such as: ( 1) traumatic events experienced by the victim, ( 2) coping strategies understood as cognitive and behavioural efforts undertaken by the helper, ( 3) posttraumatic reactions of the helper, ( 4) subjective factors that include personal resources (especially high self-esteem), professional resources (experience, training), vulnerability (own trauma history), satisfaction levels, both in life and at work, and environmental factors that include social support and working environment; the context of trauma worker works. The authors paid attention mostly to personal and environmental factors. These factors influence the emotional reactions of those helping people working with trauma victims that may be reflected as secondary traumatic stress. Coping strategies are also important, due to the fact that coping activity is aimed to master the requirements of an individual’s traumatic situation. Another notable concept is Constructivist self-development theory by McCann and Pearlman linked to previously described phenomenon of Vicarious Traumatization [[ 5]]. The theory evokes changes in cognitive patterns or beliefs, and therefore may be relevant to secondary trauma. It is worth mention that models developed for PTSD, i.e., the Cognitive shattered assumptions theory by Janoff-Bulman [[28]], PTSD Development model [[29]] and Emotional processing model [[30]] may also be used to explain mechanisms of secondary traumatization. The applicability of these models to STS symptoms results primarily from symptomatic similarity between STS and PTSD (as indicated by Figley) and analogical factors that influence the occurrence of these two-side consequences of trauma. These models treat posttraumatic disorders as errors in cognitive trauma processing which leads to the occurrence of distorted beliefs concerning the world and self. Such distortions entail intensive emotional reactions, mostly in the form of anxiety and foster the occurrence and sustainment of trauma symptoms.

Taking into account the assumptions of above models and studies conducted in the field of secondary trauma [[13], [31]], it can be pointed out that special attention is focused on factors connected with work environment including occupational load, job satisfaction, social support as well as individual characteristic including cognitive trauma processing skills.

Occupational load characteristic
Steed and Bicknell [[32]] report the fact that occupational load, especially in the form of numerous patients and a long time devoted to working with them is the main environmental risk factor of secondary trauma occurrence. Yet, the conducted study does not give an explicit image of connections between variables. Studies related to various professional groups, i.e. therapists [[32]], trauma counselors [[33]], other professionals [[34]] show positive links between occupational load and STS symptoms. Research carried out among nurses [[35]] also provided data pointing toward the positive link between occupational load and STS symptoms. Positive links between occupational load in the form of e.g., years of practice and STS were also revealed by emergency nurses [[36]]. Similar, years of work experience found to be positively associated with the level of compassion fatigue among oncology and critical care nurses [[38]] and the group of paramedics [[40]]. Hinderer et al. [[37]] found that the number of hours worked per shift was associated with greater STS. Yoder [[41]] stressed that heavy workload causes secondary traumatic stress among nurses from different hospital wards, i.e. emergency unit, oncology unit, or intensive care unit.

Other data do not confirm the connection between occupational characteristic and secondary traumatization symptoms [[42]–[44]]. Similarly, the study by Duffy, Avalos, and Dowling [[18]] conducted among emergency nursing did not confirm the link between STS and workload and experience. Baird and Jenkins [[45]] indicate that those seeing more trauma clients reported less distress. In the study of Mooney et al. [[46]] oncology and intensive care nurses with more years of experience revealed a lower level of compassion fatigue than nurses with less experience. This issue required further analyses.

Job satisfaction
Few studies were conducted in relation to links between job satisfaction and STS symptoms. The majority of them are focused on satisfaction from helping to treat it as opposed to compassion fatigue [[47]] and not on the general feeling of work satisfaction. The negative connections of satisfaction from helping with STS symptoms, compassion fatigue, and burnout were presented in the study of American nurses [[37]]. Low job satisfaction, more work hours, and second-hand smoke exposure were related to secondary traumatic stress, explaining 9% of the variance in nurses from the central part of China [[35]]. Another study [[48]] showed that nurses more satisfied with the job reported a lower level of compassion fatigue than their less satisfied colleagues. Kelly and Lefton [[49]] indicated that job satisfaction played the role of predictor for STS; reduce the severity of secondary traumatic stress symptoms and increase compassion satisfaction among critical care nurses.

The negative connection between work satisfaction and STS symptoms was revealed in other professional groups as well. Studies conducted on consultants working with substance addicts serve a good example [[50]]. It was also reported in it that work satisfaction mediated the link between STS and engagement in work. In Polish research of professionals who help trauma victims [[13]] job satisfaction was not connected to STS symptoms. Similar results were obtained in the study of Balinbin et al. [[51]] among nurses. Some research [[52]] indicated inverse relationships; secondary traumatic stress leads to job dissatisfaction. The scarcity of research on this topic and ambiguous results point to the need for further studies.

Social support from the work environment
Social support understood as help available for an individual in stressful situations [[53]] may serve a protective role in the process of secondary traumatization. The available data do not provide a clear view of the dependence between social support and the negative consequences of secondary trauma. It is connected with the ambiguity of the social support construct, its types (perceived obtained), kinds (emotional, informational, instrumental) and sources (spouse, parent, colleague, supervisor).

In case of specialists working with trauma victims, it seems that the particular role is played by support of the work environment, that is supervisors and coworkers. It can reduce stress levels and influence the levels of experienced emotions—increasing the positive and lowering the negative ones—as well as correct distorted cognitive schemes [[54]]. From research conducted among Chinese oncology nurses results that support from organization was identified as significant protector of compassion fatigue [[39]]. The obtained support may, therefore, be the factor protecting against the development of STS.

Manning-Jones et al. [[31]] present data showing that 95% of examined professionals working with trauma victims engage in peer support and 58% declare that they were supported by supervisors. Moreover, in the group of nurses, the support provided by colleagues or coworkers was the main negative STS predictor. Research conducted with nurses working in emergency rooms [[18]] and intensive care [[55]] units showed that support from coworkers plays a significant role in alleviating STS symptoms. In a study by Jonsson and Halabi [[56]] lack of support in the work environment was connected with the occurrence of STS.

Research conducted with rescue workers, involved in critical operations of various kinds in constant contact with traumatized subjects [[11]] provided data that shows that work-related factors, especially support in the work environment are connected with the occurrence of STS symptoms. In Polish research [[13]] STS symptoms correlated negatively with the support obtained from coworkers in the group of therapists. Yet, no such relation was reported in the group of paramedics and nurses.

Other studies showed a significant role of support obtained from relatives and friends in alleviating the negative consequences of secondary traumatization among nurses [[57]]. Similarly, Von Rueden et al. [[59]] underline that the nurses who obtained social support from relatives and friends experienced STS symptoms less frequently in comparison to those for whom such support was not provided. In Poland, there is no studies of nurses which shows the relations between support from their friends and family and STS symptoms.

Cognitive trauma processing
According to the previously mentioned models and theories, the significant role in the development of STS is played by cognitive trauma processing [[ 5], [13], [27]–[30]]. Cognitive trauma processing may be mirrored in the undertaken cognitive countermeasures. Their aim is to give meaning to the experienced and adjustment to the new reality, changed as a result of experienced trauma. Williams, Davis and Millsap [[60]] list several factors as indicators of effective trauma processing, including a decrease in the level of negative emotions (especially feelings of guilt or shame), the assimilation of information about the traumatic event, the acceptance of the event, the perception of its positive aspects, and desensitization, manifested as a gradual reduction of the perceived stress and negative emotions associated with ruminating on the event. Such cognitive trauma processing is often realized through cognitive coping strategies in the form of positive cognitive restructuring, downward comparison, resolution/acceptance, regret and denial.

Research including correctional psychologists [[61]] provided data pointing towards the occurrence of the negative relations of beliefs relating to both the goodness of the surrounding world and its comprehensibility to STS symptoms. In the study of five groups of professionals working with trauma victims (therapists, paramedics, nurses, social workers, and probation officers) a significant role of cognitive trauma processing in the occurrence of STS symptoms was confirmed [[13]]. Positive links between STS symptoms and interference in core beliefs (evaluated by means of Core Beliefs Inventory), rumination about the traumatic events experienced by patients (evaluated by means of Event Related Rumination Inventory) as well as negative coping strategies (evaluated by means of Cognitive Processing of Trauma Scale), that is regret and denial were confirmed. Few studies of relations between cognitive trauma processing and negative consequences of secondary exposure to trauma refer directly to medical personnel. Results of research conducted among paramedics [[10]] provided data pointing towards the fact that dysfunctional beliefs and dysfunctional strategies of coping with intrusion played a predictive role for PTSD and STS symptoms.

Aim of the study
The adopted research model refers mainly to Ecological Framework of Trauma by Dutton and Rubinstein [[27]] which includes four elements: ( 1) traumatic events experienced by the victim, ( 2) coping strategies undertaken by the helper, ( 3) posttraumatic reactions of the helper, ( 4) subjective and environmental factors, including personal resources, work environment, job satisfaction, and social support.

The undertaken research aimed at indicating the determinants of secondary traumatic stress symptoms among medical personnel exposed to trauma experienced by their patients. The determinants included environmental and work-related variables, i.e., occupational load expressed in the form of three indicators, that is work experience as paramedic/nurse, number of hours per week devoted to helping patients as well as workload expressed by the proportion of work devoted to direct help for patients in reference to the entire performed work. Work-related and environmental variables included also job satisfaction and social support provided by supervisors and coworkers. Moreover, the support provided by family and friends was also taken into consideration as well as individual factors, i.e., cognitive trauma processing in the form of five cognitive strategies of coping with trauma experienced by patients.

It was hypothesized in the study that STS symptoms will be positively connected with the occupational load indicators and negatively with job satisfaction and social support. It was also hypothesized that the main determinant of STS will be cognitive trauma processing and that negative strategies (regret, denial) will be positively linked with STS symptoms and positive strategies, especially resolution/acceptance and positive cognitive restructuring will be linked negatively.

Materials and methods

Participants
The research project was specifically approved by the Bioethics Committee of Opole Medical School (no 81/P1/2019). Informed consent (oral before, and written during filling the questionnaires) was obtained from all participants included in the study. 430 representatives of medical personnel who provide medical help to trauma victims were included in the study (the sample consists of individuals who were exposed to secondary trauma). The questionnaires were delivered to medical staff who had previously consented (written) to participate in the project. The study was anonymous and voluntary, and conducted in the period from November 2019 to February 2020 in 12 units and included voivodeship rescue stations, emergency medical teams, emergency wards in several Polish hospitals as well as cancer wards, intensive care units, and hospices. The questionnaires were delivered to and collected by the authors or persons trained by the authors during medical staff working hours. The study inclusion criterion was performing the profession of a paramedic or nurse and work with people who had traumatic experiences (struggling with illness. i.e., stroke, heart attack, cancer or after an accident).

The analysis included the results of 419 (11 questionnaires were dropped out due to the missing data; only participants with complete questionnaires were included in the analyses) people in the age from 19 to 65 years (M = 39.60, SD = 11.03). Among study participants, there were 137 (32.7%) men and 282 (67.3%) women. The studied group included paramedics (n = 201) where 60.2% were men and nurse staff (n = 218) in which there was a significant majority of women (92.7%). The majority of paramedics provide help for people who experienced various accidents, especially road accidents (57.2%) but also after traumatic events such as strokes and cardiac infarction (42.8%). Nurse staff included people working with cancer patients (87.7%) and accident sufferers (18.3%). Work experience of the medical personnel who participated in the study amounted at from 1 year to 43 years (M = 12.18, SD = 9.75), the number of work hours devoted to helping injured patients amounted at 2 to 90 (M = 38.24, SD = 15.65), and workload expressed by a percent of work devoted directly to providing help to patients in relation to the whole performed work from 2 to 100% (M = 69.11, SD = 31.89).

Measures
The survey developed for the research was used. It included questions about age, types of events which were experienced by patients, work experience as a paramedic/nurse, number of work hours per week devoted to working with patients, workload expressed in the percentage of work devoted to providing direct help for patients in relation to the whole performed work as well as four standard assessment tools described below.

Secondary Traumatic Stress Inventory—STSI is a modified version of the Posttraumatic Stress Disorder Checklist—PCL-5 developed by Weathers et al. [[62]]. The inventory is a self-assessment tool intended for testing people who provide help for trauma victims. Similarly to PCL-5 which was adapted to Polish conditions [[63]], it consists of 20 statements/accounts of traumatic events (range = 0–80; “Repeated, disturbing, and unwanted memories of the stressful experience”) referring to symptoms included to 4 criteria of PTSD, that is B. Intrusion; C. Persistent avoidance of stimuli connected to trauma; D. negative alterations in cognitions and mood; E. alterations in arousal and reactivity. The modification of the tool consisted of completing the instructions with the information about the occurrence of mentioned reactions in connection to the help provided to trauma victims. Some statements were completed with the phrase “of my patients”. According to the instruction the study participant shows to what extent the mentioned reactions occurred to them within last month in connection to the provided help and evaluates it using a five-level scale from not at all (0); slightly ( 1); moderately ( 2); significantly ( 3) to very much ( 4). Cronbach’s alpha indicator for Secondary Traumatic Stress Inventory amounts at 0.90 and is following for particular factors: 0.71; 0.85; 0.89; 0.87.

Job Satisfaction Scale is a modified version of Diener’s Satisfaction with Life Scale [[64]], designed to evaluate the general life satisfaction, developed by Zalewska [[65]]. The tool consists of 5 items. After the alterations, the statements refer to the Assessment of work (“In many aspects my work is almost perfect”). The study participant uses a seven-point scale of responses from 1 –”I certainly agree” to 7 –”I certainly disagree”. All statements are a part of one dimension (range = 7–35) and are internally highly consistent in a heterogeneous sample of employees and particular professional groups. Cronbach’s alpha for scale is 0.86.

Social Support Scale—What Support Can You Expect is a part of the Psychosocial Work Conditions questionnaire [[66]] and allows to evaluate the support received from the work environment, i.e. supervisors and coworkers as well as support outside of work, i.e. from family and friends (score range for each subscale = 8–40; “To what extent can you expect that someone helps you in a certain way?”). The tool consists of 8 statements for which participants answer on a 5-point scale from 1 (very small extent) to 5 (very large extent). Psychometric properties of the scale are satisfactory (support from supervisors: α = 0.94, coworkers: α = 0.92, friends outside of work: α = 0.89 and family: α = 0.89).

Cognitive Processing of Trauma Scale (CPOTS) by Williams, Davis and Millsap [[60]] was adapted to Polish conditions by Ogińska-Bulik and Juczyński [[67]]. A version adjusted for the study of people indirectly exposed to trauma was applied in the research. The tool consists of 17 statements (“Overall, there is more good than bad in this experience”) and measures five aspects of cognitive processing: positive cognitive restructuring (3 items; score range = 0–18), downward comparison (3 items; score range = 0–18), resolution/acceptance (4 items; score range = 0–24), denial (4 items; score range = 0–24), and regret (3 items; range = 0–18). Study participants address each statement on a seven-point scale from 0 (I certainly disagree) to 6 (I certainly agree). The result of each scale is calculated separately. The reliability of the Polish version of CPOTS evaluated by means of Cronbach’s alpha coefficient is satisfactory. The coefficients are 0.84 for positive cognitive restructuring, 0.89 for downward comparison, 0.82 for resolution/acceptance, 0.56 for denial and 0.72 for regret.

Statistical analyses
The IBM SPSS, version 25 software was used to verify the obtained data. The two-tailed probability value of < 0.05 was considered to be statistically significant. The first step of data analysis consisted of the calculation of descriptive statistics that included mean and standard deviation for secondary traumatic stress, occupational characteristic, job satisfaction, source of social support and cognitive coping strategies. Additional for demographic characteristic frequency and percentage were computed. T-Student’s test was implemented to compare the differences in the prevalence of secondary traumatic stress between nurses and paramedics as well as between men and women. Pearson’s correlation coefficients were applied to analyze the relations between the variables. The Benjamini-Hochberg procedure was done for multiple comparisons. A multivariable stepwise regression analysis was used in order to find a dependent variable (STS) predictors among independent variables (occupational load characteristic, job satisfaction, cognitive trauma processing, and social support). To assess model fit, R2 was used. Moreover, regression analysis provided data that include adjusted R2,R2-changes, standardized regression coefficient (β), unstandardized regression coefficient (B), F-statistic, confident intervals for B, and p-value. Multicollinearity was checked by using tolerance (> 0.10) and variance inflation factor (< 5). The effect size for multiple regression analysis was > 0.35.

Results
The intensity of STS symptoms in the studied group of medical personnel who provides help for sufferers (Table 1) is higher than in standardization tests [[63]] which included people who directly experienced various traumatic events (M = 26.0, SD = 18.66, p<0.001). Considering 33 points assumed as a cut-off point for the general STS result [[13]] it is reported that 237 people which constitutes 56.6% of study participants show low or moderate STS symptom levels. In turn, high levels of these symptoms signifying a high probability of STSD diagnosis occurred in 182 people which is 43.4% of study participants. The nurse staff representatives manifested slightly higher levels of STS symptoms (M = 32.23, SD = 20.69) in comparison to paramedics (M = 29.67, SD = 18.28), yet, this difference is not statistically relevant (t(417) = -1.336, p > 0.05). In both groups the percentage of people with high risk of STSD occurrence is similar; in the paramedics’ group, it amounts to 43.3% and among nurses– 43.6%. Gender did not differentiate the level of STS symptoms (men: M = 30.32, SD = 18.31; women: M = 31.33, SD = 20.20; t(417) = -0.496, p > 0.05). Positive, although weak links occur between the age of study participants and STS (r = 0.123, p<0.05).

Graph

Table 1 Descriptive statistics and correlation coefficients among analyzed variables (N = 419).

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1. STS total –
2. STS intrusion 0.908*** –
3. STS avoidance 0.832*** 0.771*** –
4. STS negative alternations in cognitions and mood 0.963*** 0.815*** 0.759*** –
5. STS alterations in arousal and reactivity 0.945*** 0.785*** 0.715*** 0.886*** –
6. Work experience 0.083 0.117* 0.106* 0.053 0.066 –
7. Number of working hours -0.208** -0.224** -0.198** -0.205** -0.157** 0.085 –
8. Workload -0.119* -0.126** -0.099* -0.121* -0.092 0.137** 0.540*** –
9. Job satisfaction -0.401*** -0.355*** -0.322*** -0.399*** -0.376*** -0.025 0.130** 0.120* –
10. SS supervisors -0.103* -0.092 -0.088 -0.097* -0.100* -0.110* 0.011 0.083 0.355*** –
11. SS coworkers -0.070 -0.023 -0.016 -0.082 -0.099* -0.113* -0.112* -0.032 0.280*** 0.618*** –
12. SS family -0.236** -0.225 -0.154** -0.218** -0.236** -0.055 -0.030 -0.095 0.339*** 0.214** 0.397*** –
13. SS friends -0.278*** -0.313*** -0.256*** -0.251*** -0.229** -0.112* 0.113* 0.112* 0.495*** 0.471*** 0.269*** 0.491*** –
14. CPOT positive cognitive restructuring -0.170** -0.150** -0.098* -0.184** -0.156** 0.032 0.154** 0.074 0.355*** 0.187** 0.152** 0.277*** 0.316*** –
15. CPOT downward comparison -0.040 -0.047 -0.045 -0.017 -0.050 0.026 0.101* 0.076 0.180** 0.083 0.024 0.150** 0.206** 0.587*** –
16. CPOT resolution/acceptance -0.320*** -0.289*** -0.248*** -0.310*** -0.307*** 0.031 0.180** 0.132** 0.405*** 0.168** 0.108* 0.287*** 0.352*** 0.674*** 0.510*** –
17. CPOT denial 0.175** 0.150** 0.152** 0.197** 0.137** 0.041 0.088 0.026 0.108* 0.064 -0.080 0.015 0.168** 0.429*** 0.627*** 0.333*** –
18. CPOT regret 0.181** 0.158** 0.136** 0.195** 0.157** 0.005 0.089 0.064 0.139** 0.137** -0.049 -0.043 0.206** 0.393*** 0.474*** 0.289*** 0.695*** –
Mean 31.00 7.98 3.26 10.22 9.55 12.18 38.24 69.11 21.28 23.44 27.95 29.80 25.78 8.66 8.14 12.20 8.61 6.42
Standard deviation 19.59 4.93 2.28 7.35 6.51 9.75 15.65 31.89 6.65 8.38 7.38 7.062 8.42 4.23 4.43 5.46 5.22 4.15
1 STS = secondary traumatic stress; SS = Social support; CPOT = cognitive processing of trauma;

2 *p < 0.05;
3 **p < 0.01;
4 ***p < 0.001. (two-tailed).
5 *p < 0.05 not significant after Benjamini-Hochberg correction for multiple comparisons.
Using Pearson’s correlation coefficients the links between variables in the entire research group were determined (Table 1).

It results from the data presented in Table 1 that STS symptoms are slightly connected with the occupational load indicators (the number of work hours per week r = -0.208, p < 0.01; workload r = -0.119, p < 0.05). Job satisfaction is found to be related significantly to STS total score (r = -0.401, p < 0.001) and all STS symptoms. It can be noticed that three sources of social support are connected with STS (family r = -0.236, p < 0.01; friends r = -0.278, p < 0.001; supervisors r = -0.103, p < 0.05). Cognitive trauma processing in the form of four out of five cognitive coping strategies is associated with the negative consequences of secondary exposure to trauma (regret r = 0.181, p < 0.01; denial r = 0.175, p < 0.01; positive cognitive restructuring r = -0.170, p < 0.01; resolution/acceptance r = -0.320, p < 0.001).

Then it was checked which of the included variables explained the predictive role of STS symptoms, considering general results and particular criteria as the variables to be explained. The obtained results are presented in Table 2.

Graph

Table 2 Regression analysis for variables predicting STS (total score) in the examined group of medical staff (N = 419).

Secondary Traumatic Stress
Predictors B BE β R2 T p-value 95.0% CI for B
Job satisfaction -0.844 0.145 -0.286 0.16 -5.818 < 0.001 -1.129; -0.559
Resolution/acceptance -0.989 0.170 -0.276 0.06 -5.805 < 0.001 -1.324; -0.654
Regret 1.019 0.267 0.216 0.06 3.813 < 0.001 0.494; 1.544
Denial 0.685 0.215 0.182 0.02 3.184 < 0.01 0.262; 1.108
Number of working hours -0.177 0.052 -0.141 0.01 -3.384 < 0.01 -0.279; -0.074
SS friends -0.264 0.113 -0.114 0.01 -2.344 < 0.05 -0.486; -0.043
SS coworkers 0.232 0.115 0.087 0.01 2.000 < 0.05 0.004; 0.458
Work experience 0.172 0.082 0.086 0.01 2.089 < 0.05 0.010; 0.344
F(8,410) 25.920
R 0.580
R2 0.336
Adj.R2 0.323
R2-changes -0.002
6 B = unstandardized regression coefficient; BE = B error; β = standardized regression coefficient; t = t-test value; p = the level of significance (two-tailed); 95.0% CI = confident intervals; R = correlation coefficient; R2 = determination coefficient; Adj.R2 = adjusted R2. Cohen’s f2 = 0.51
7 Tolerance range from 0.493 to 0.967; VIF range from 1.053 to 2.528.
Thirteen variables were introduced into the regression model, i.e., work experience, number of working hours, workload, job satisfaction, social support from supervisors, coworkers, family and friends, and cognitive coping strategies in the form of positive cognitive restructuring, downward comparison, resolution/acceptance, regret, denial. Data presented in Table 2 show that finally eight variables entered the regression equation and explained almost 34% variance of the dependent variable (negative consequences of exposure to trauma). The main predictor of STS symptoms was job satisfaction (β = -0.286, p < 0.001) which explains the most, that is 16% of the variance of the general STS result. A negative relation between variables occurs. This means that the bigger satisfaction with work, the lower levels of STS symptoms. Cognitive coping strategies such as regret (β = 0.216, p < 0.001) or resolution/acceptance (β = -0.276, p < 0.001) explain 6% each. Regret strategy presents a positive relation while resolution/acceptance, a negative one. The share of other variables amounts to less than 2%.

Satisfaction with work was also the main predictor of symptoms included in four STSD criteria (Table 3). For intrusion the predictive role was played mainly by resolution/acceptance (β = -0.236), job satisfaction (β = -0.223) and regret (β = 0.208). Avoidance is mostly explained by the satisfaction with work (β = -0.225), denial (β = 0.223) and resolution/acceptance (β = -0.170). Cognitive and emotional alterations were explained by job satisfaction (β = -0.314) and two coping strategies, that is resolution/acceptance (β = -0.282) and denial (β = 0.202), alterations in arousal and reactivity: by job satisfaction (β = -0.294) resolution/acceptance (β = -0.272) and regret (β = 0.196).

Graph

Table 3 Regression analysis for variables predicting STS factors in the examined group of medical staff (N = 419).

Secondary Traumatic Stress factors
Predictors Β R2 p F R2 for model
Intrusion 23.200 0.312
Resolution/acceptance -0.236 0.13 <0.001
Job satisfaction -0.223 0.08 <0.001
Regret 0.208 0.04 <0.001
SS friends -0.195 0.02 <0.01
Denial 0.160 0.01 <0.01
Number of working hours -0.158 0.01 <0.05
SS coworkers 0.135 0.01 <0.05
Work experience 0.119 0.01 <0.05
Avoidance 15.089 0.249
Job satisfaction -0.225 0.10 <0.001
Denial 0.223 0.04 <0.001
Resolution/acceptance -0.170 0.04 <0.01
Regret 0.152 0.01 <0.01
SS friends -0.142 0.01 <0.05
Number of working hours -0.140 0.01 <0.05
SS coworkers 0.127 0.01 <0.05
Work experience 0.109 0.01 <0.05
Downward comparison -0.100 0.01 <0.05
Negative alterations in cognitions and mood 38.995 0.321
Job satisfaction -0.314 0.16 <0.001
Resolution/acceptance -0.282 0.06 <0.001
Denial 0.202 0.06 <0.001
Regret 0.196 0.03 <0.01
Number of working hours -0.149 0.01 <0.05
Alterations in arousal and reactivity 28.749 0.258
Job satisfaction -0.294 0.14 <0.001
Resolution/acceptance -0.272 0.05 <0.001
Regret 0.196 0.04 <0.01
Denial 0.131 0.01 <0.05
Number of working hours -0.098 0.01 <0.05
8 Abbreviations as in Table 2.
9 Cohen’s f2 = 0.45 (intrusion), 0.33 (avoidance), 0.47 (negative alterations in cognition and mood), 0.35 (alterations in arousal and reactivity).
Discussion
Representatives of medical staff who participated in the study and who professionally provide help to sufferers show relatively high levels of secondary traumatic stress symptoms. It rendered higher than in PCL-5 standardization tests [[63]] with people who directly experienced various types of trauma and higher in relation to the representatives of other occupational groups which provide help for trauma victims such as therapists, social workers and probation officers [[13]]. As many as 43% of study participants present a high probability of the development of secondary posttraumatic stress disorder while in the group of therapists it amounted to only 7.5%.

The obtained results seem to show the medical personnel may be characterized by insufficient competences of coping with trauma experienced by others. The lack of sufficient competence to cope may also be related to the depletion of resources as a result of the high demands imposed by the poorly supportive environment and the burdensome working conditions [[68]]. https://pubmed.ncbi.nlm.nih.gov/?term=Ruotsalainen+JH&cauthor%5fid=25391582 et al. [[70]] found that medical personnel may suffer from work-related stress as a result of lack of skills, low social support at work, and organisational factors, which can also result in inefficiency in dealing with trauma. This is an alarming phenomenon and it shows the need of including the medical staff in actions aimed at protection against the negative consequences of the experienced stress, especially through facilitating the development of trauma coping skills.

It should be underlined that the research conducted worldwide and in Poland confirm the high risk of secondary posttraumatic stress disorders among medical personnel, especially nurses [[ 8], [11]–[13]]. It is of significance that in the case of medical staff—as opposed to other occupational groups whose members provide help for people who experienced trauma—the indirect exposure often coexists with direct traumatic experiences, including assault and aggression attacks from patients as well as other personal traumatic experiences. Interesting in this context is research conducted by Regehr et al. [[71]]. In this study higher levels of distress were found among paramedics who developed secondary trauma compared to experiencing direct trauma, as a result of working with a traumatized individual. The authors stressed that the empathetic relationship developed between the paramedic and the victim increases the vulnerability to experience an emotional response to the victim’s suffering and develop symptoms of traumatic stress as a result.

A high risk of STSD occurrence among the medical personnel may result from the character of the performed work, everyday contact with suffering, pain, looking at mutilation, and death. This issue may be especially important in the present time of COVID-19 pandemic when stress connected with danger to one’s health and life joins the regular stress factors related to providing help to the injured. During the pandemic, competence to deal with traumatic situations (both one’s own and others’) effectively and large social support network are all the more desirable.

Among the analyzed variables the strongest relations with STS symptoms were presented by job satisfaction which seems to be playing a protective role as it prevents and alleviates the negative consequences of secondary exposure to trauma which are expressed in the form of STS symptoms. What is more, satisfaction with work was also the main predictor of symptoms included in all four STS dimensions. The obtained data confirm the results of research conducted among advisors working with substance abusers [[50]] in which job satisfaction mediated the relation between STS and engagement in work. It should be taken into account that low job satisfaction may be the reason for STS development. It is worth noting that the inverse relationship between variables is also possible. Some studies [[52]] found that secondary traumatic stress leads to job dissatisfaction. It means that the increase in STS may be accompanied by a decrease in job satisfaction.

The remaining work-related variables in the form of number of working hours per week and workload were negatively—although to a small extent—connected with STS symptoms in correlation analyses (it suggests that they may play a protective role). Taking into account regression analyses, number of working hours and work experience found to be predictors of STS; but weak and less relevant. It means that occupational load indicators play significantly lesser role in the occurrence of negative consequences of indirect trauma exposure. Possibly, the routine resulting from everyday contact with patients constitute a barrier against STS symptoms for the medical staff. It should be underlined that the data available in references do not provide a clear picture of interdependencies between the variables. This constitutes a need for further research in this area. According to some researchers [[32], [72]] the influence of occupational load on the consequences of secondary exposure to trauma is overemphasized. They underline that it is not the burden of working with traumatized people but rather qualifications, experience and training are the factors influencing the occurrence of negative consequences of secondary trauma exposure and if so that what will be their extent.

Among the four analyzed sources of support, the strongest links to STS symptoms are related to support obtained from family and friends than from supervisors and coworkers. This is rather consistent with the results of the mentioned research [[57]–[59]], but it stands in opposition to the results of the study conducted among medical personnel that indicates the relation of STS and social support obtained from the work environment [[18], [31], [55]]. The two source of social support play a predictive role for STS symptoms, i.e., friends and coworkers. It is interesting that social support from coworkers found to be a positive indicator of STS and may be identified as risk factor. However, the role of social support in STS prediction is negligible. The less significant role of social support for the STS symptoms may be connected with the character of the performed work. Other professionals working with trauma victims, especially therapists are supervised and use a full range of workshops and training aimed at increasing their competencies and developing resilience to stress. This is a rare case for medical personnel who is overworked. Social support may be significant in preventing other negative consequences of occupational stress, including burnout syndrome. Moreover, the dependence between social support and STS may have various forms. Support does not have to be directly connected to the increase in STS symptoms but it can mediate between secondary exposure to trauma and STS. In such a case it functions as a mediator.

Cognitive trauma processing, as results from the conducted study, is significant for the occurrence of STS symptoms, although its role turned out limited. The results of correlation analysis indicated that STS symptoms are positively connected with negative strategies and negatively with positive ones. Only the strategy of downward comparison is not significantly statistically connected with the STS symptoms. Resolution/acceptance, denial and regret (in small extent) presented themselves as predictors of STS symptoms but their share in the explanation of the dependent variable is significantly lower than the share of job satisfaction. The regret strategy is connected with self-blame. This means that the specialists blame themselves for patient’s pain and suffering which can significantly increase the susceptibility to the occurrence of secondary traumatic stress disorders. The strategy of denial through avoiding the processing of information related to client’s trauma may be another STS risk factor. In turn, the rational attitude, that is the effort to solve the problem or accept the situation when solving it is impossible (resolution/acceptance), allows decreasing the level of STS symptoms.

The limited share of cognitive strategies of coping with trauma in the prediction of STS symptoms may result from e.g., stability of possessed cognitive schemes and weaker engagement of the medical personnel in the processing of trauma experienced by others. This would correspond with other data obtained by Michael et al. [[10]] which show that people facing direct threat reported more negative posttraumatic cognitions than those faced with an indirect threat.

Limitations of the study
There are certain limitations to the conducted research. It was a cross-sectional study which does not allow to draw conclusions related to the cause and effect dependencies. Subjective indicators of indirect exposure to trauma e.g., in the form of Assessment of the size and meaning of the influence of the events experienced by patients treated as the severity of the perceived trauma were also not taken into account. The influence of personal traumatic experiences that could affect the level of STS symptoms was also not analyzed. The analyses did not include a certain place of work (hospital, ward) because of the possible simultaneous employment of study participants in multiple places. It should be underlined that the study group was not homogeneous. Men constituted the majority of the group of paramedics while the group of nurses included mainly women. Age, gender and occupational group were not taken into account in further analysis. Due to the complexity of the social support variable and possible overpowering of the study, the results should be interpreted with caution.

Despite the indicated limitations, the results of the conducted study contribute new information within the conditioning of negative consequences of indirect exposure to trauma among the medical personnel. It shows that the cognitive models developed for PTSD may be applied to STS. Moreover, the research in this topic available in the literature referring to the medical staff include first and foremost nurses, therefore, the additional advantage of the conducted study was the extension of the sample by the group of paramedics.

The conducted study may also inspire further research in which other indicators of cognitive trauma processing, such as disruptions in basic convictions or ruminating the events experienced by the patients as well as personal features of helpers including the feeling of self-sense of self-efficacy in coping with trauma experienced by others should also be included. The analyses indicating the mediational role of job satisfaction, social support, and cognitive trauma processing in the relationship between occupational load and STS symptoms would also be useful. Longitudinal study that allow capturing the changes in the range of STS symptoms is also necessary. It should be remembered that the indirect exposure to trauma leads not only to negative consequences but it also may be a source of positive posttraumatic changes in the form of vicarious growth after the trauma.

Implications for practice
The conducted research may also have the practical implications for the development of prevention programs aiming at the decrease of levels of STS symptoms and lowering the risk of STSD occurrence among medical personnel, nurses and paramedics. The procedures designed to increase the level of satisfaction with work seems to be important. These interventions should focus on improving the source of job satisfaction such as the perceived ability to deliver good patient care, good relationships, respect from the superiors, supportive leadership, good salary, competitive pay and bonuses, participation in developing own work schedule, job security, self-growth in the form of professional training and job promotion, job autonomy, opportunity to decision-making and develop multidisciplinary actions in the context of health [[73]–[76]]. Nikić et al. [[77]] also point out the need for improving the communication skills and health as interventions that may lead to increase job satisfaction among health care workers. It should also be taken into consideration that high job satisfaction may favour the occurrence of secondary posttraumatic growth (SPTG). This is indicated by the research of Ogińska-Bulik and Juczynski [[13]] which informs about a positive relationship between job satisfaction and SPTG in a group of therapists and nurses working with trauma victims. Moreover, the development of competences of coping with trauma considering the alteration of cognitive coping strategies from negative to positive as well as encouragement to use of various self-care practices is also advisable. The significance of such practices is mentioned by Molnar et al. [[78]]. Encouraging to search and use not only social support from the close ones but also various forms of support like participation in workshops, training, supervision, or debriefing is also recommended. According to Calderón-Abbo et al. [[79]] these forms of support may significantly contribute to the prevention of negative results of indirect exposure to trauma. A significant role for the reduction of STS symptoms is also attributed to psychoeducation aimed at providing and broadening the knowledge about STS and developing coping skills. Molnar et al. [[78]] underline their importance and efficiency in lowering the intensity of STS symptoms in pediatric nurses. It may also be useful for professional competences. Several studies mentioned by Molnar et al. [[78]] show that the development of such competencies contributed to the reduction of STS symptoms in professionals who work with trauma victims. Med-Stress program developed by Smoktunowicz et al. [[80]] and aimed at counteracting the occurrence of secondary traumatization among medical personnel is used in Poland.

Conclusions
Paramedics and nurses are at the high risk of indirect traumatic exposure and thus may be more prone to secondary traumatic stress symptoms development. From all analyzed variables in the study, eight turned out to be the predictors of STS. The main predictor of STS symptoms was job satisfaction. The predictive role for STS was also demonstrated by two cognitive coping strategies i.e., regret (positive relation) and resolution/acceptance (negative relation). The contribution of other analyzed variables, i.e., denial, number of working hours, work experience, social support from friends and coworkers to explaining the dependent variable, was rather small. It is important to include the medical personnel in the actions aiming at prevention and reduction of STS symptoms.

Supporting information
S1 Table. STROBE checklist for cross-sectional studies.

(DOC)

Footnotes
1 The authors have declared that no competing interests exist.

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Self-reported symptoms of burnout in novice professional counselors: A content analysis.
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Cook, Ryan M.. University of Alabama, Tuscaloosa, AL, US, rmcook@ua.edu
Fye, Heather J.. University of Alabama, Tuscaloosa, AL, US
Jones, Janelle L.. University of Alabama, Tuscaloosa, AL, US
Baltrinic, Eric R.. University of Alabama, Tuscaloosa, AL, US
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Keywords:
novice professional counselors, burnout, content analysis, conceptualization, symptoms
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This study explored the self-reported symptoms of burnout in a sample of 246 novice professional counselors. The authors inductively analyzed 1,205 discrete units using content analysis, yielding 12 categories and related subcategories. Many emergent categories aligned with existing conceptualizations of burnout, while other categories offered new insights into how burnout manifested for novice professional counselors. Informed by these findings, the authors implore counseling scholars to consider, in their conceptualization of counselor burnout, a wide range of burnout symptoms, including those that were frequently endorsed symptoms (e.g., negative emotional experience, fatigue and tiredness, unfulfilled in counseling work) as well as less commonly endorsed symptoms (e.g., negative coping strategies, questions of one’s career choice, psychological distress). Implications for novice professional counselors and supervisors are offered, including a discussion about counselors’ experiences of burnout to ensure they are providing ethical services to their clients. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
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Journal Article
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Burnout or compassion fatigue? A comparative concept analysis for nurses caring for patients in high-stakes environments.
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Wynn, Franklin, ORCID 0000-0002-6704-5436 . University of Texas at Tyler, Tyler, TX, US, frankjwynn@swbell.net
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Wynn, Franklin, University of Texas at Tyler, Tyler, TX, US, frankjwynn@swbell.net
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International Journal for Human Caring, Vol 24(1), 2020. pp. 59-71.
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Int J Hum Caring
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US : Springer Publishing
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US : Allen Press Inc.
US : International Association for Human Caring
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1091-5710 (Print)
2578-2304 (Electronic)
Language:
English
Keywords:
burnout, compassion fatigue, concept analysis, nursing
Abstract:
Burnout and compassion fatigue are two distinct concepts experienced by nurses caring for patients in high-stakes environments. Nurses often do not recognize which concept they are experiencing due to the similarities and interchangeable use of these terms in literature. Nurses in high-stakes settings need to have these concepts further explored as they impact their physical and psychological health. This comparative concept analysis examines these terms using Walker and Avant methodology. Defining attributes, antecedents, consequences, empirical referents, and constructed cases are discussed. This analysis adds to the nursing knowledge needed to support nurses in achieving optimal occupational health and well-being. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
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*Nurses; *Nursing; *Occupational Stress; *Caring Behaviors; *Compassion Fatigue; Coping Behavior; Well Being; Occupational Health
PsycInfo Classification:
Professional Psychological & Health Personnel Issues (3400)
Health & Mental Health Services (3370)
Population:
Human
Methodology:
Literature Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20210809
Copyright:
International Association for Human Caring. 2020
Digital Object Identifier:
http://dx.doi.org/10.20467/1091-5710.24.1.59
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2020-84552-007
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Burnout or Compassion Fatigue? A Comparative Concept Analysis for Nurses Caring for Patients in High-Stakes Environments
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✖
Contents
Purpose
Method
Uses and Definitions of Burnout and Compassion Fatigue
Burnout
Compassion Fatigue
Results
Critical Attributes
Stress
Exhaustion
Ineffective Coping
Lack of Empathy
Antecedents
Consequences
Empirical Referents
Burnout
Compassion Fatigue
Synthesized Definition
Constructed Cases
Burnout
Model Case
Contrary Case
Compassion Fatigue
Model Case
Contrary Case
Discussion
Conclusion
Disclosure
Funding
Acknowledgments
References
Full Text
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Burnout and compassion fatigue are two distinct concepts experienced by nurses caring for patients in high-stakes environments. Nurses often do not recognize which concept they are experiencing due to the similarities and interchangeable use of these terms in literature. Nurses in high-stakes settings need to have these concepts further explored as they impact their physical and psychological health. This comparative concept analysis examines these terms using Walker and Avant methodology. Defining attributes, antecedents, consequences, empirical referents, and constructed cases are discussed. This analysis adds to the nursing knowledge needed to support nurses in achieving optimal occupational health and well-being.

Keywords: burnout; compassion fatigue; concept analysis; nursing

Burnout and compassion fatigue are a growing concern for nurses working in high-stakes environments, such as emergency rooms, critical care, and oncology units, where patients have potential for life-threatening health outcomes ([ 4]; [17]; [38]; [51]). Nurses in these settings must frequently make urgent critical decisions, resolve ethical dilemmas, and participate in extensive multidisciplinary collaborations ([15]; [22]). At the same time, they also witness the extensive trauma and suffering of their patients and experience grief and bereavement as patients succumb to death ([16]; [28]; [37]; [44]). As these investments are physically and emotionally demanding, nurses in high-stakes environments are at an increased risk for burnout and compassion fatigue.

Although burnout is a term that nurses are often more familiar with, many find it confusing to distinguish from compassion fatigue ([36]; [37]; [47]). This could be related to the common use of both terms interchangeably in the literature, often to describe one congruent experience ([ 4]; [19]; [29]). The distinction of these concepts is further complicated by the reporting of similar outcomes such as stress, exhaustion, mood swings, difficulty with managing personal conflicts, detachment in caregiving, and poor job satisfaction ([15]; [19]; [27]).

Purpose
The purpose of this article is to provide an in-depth analysis of the concepts of burnout and compassion fatigue in the context of high-stakes nursing environments. An analysis contrasting these concepts was not found in the literature; however, a comparison of this type is needed to provide clarity of these terms that distinguishes them as two separate phenomena. Moreover, understanding how these concepts agree and how they are different will help nurses cope with caring for high-stakes patients and support them in achieving optimal occupational health and well-being.

The methodology of [49] was used to analyze the related concepts of burnout and compassion fatigue. This multi-step process is expected to define, clarify, and operationalize the ill-explained aspects of phenomena into constructs that can be understood and utilized in practice ([49]). The analysis began with an exhaustive search to identify the uses and definitions of burnout and compassion fatigue in the literature. From these articles, critical attributes and antecedents have been identified so that each term can be recognized within a context. To further Help in the recognition and proper use of the terms burnout and compassion fatigue, consequences for each term are discussed to expand on how they can be experienced. Measurement of each concept is described as empirical referents. The information gleaned from the analysis for each concept is then compared and contrasted to allow for the synthesis of these concepts and correct distinction of them within constructed cases (model and contrary). After this synthesized comparison, the reader is expected to be able to discern what each concept is and is not; particularly in the context of healthcare and high-stakes nursing environments.

Method
Literature was searched using Academic Search Complete, CINAHL Complete, Health Source Nursing Academic Edition, and PsycINFO databases. Keywords for the search included burnout, compassion fatigue, concept analysis, antecedents, attributes, empirical referents, and consequences for each respective concept. The search was limited to the English language and the years 1974 through 2019. After retrieving the initial yield from the combined searches, abstracts were reviewed for applicability to high-stakes environments or caring for high-stakes patients. A total of 52 articles were included in this comparative concept analysis.

Uses and Definitions of Burnout and Compassion Fatigue

Burnout
[13] first introduced burnout in literature as a term that was used to describe a “loss of charisma” for work among healthcare workers. This loss of charisma was attributed to workers feeling worn out, or tired, in performing their work duties ([13]). In 1981, Maslach and Jackson further expanded the concept of burnout by describing it as a combination of symptoms they coined burnout syndrome, which are feelings of increased emotional exhaustion, depersonalization, and lack of personal accomplishments. This revised definition provided more clarity to what a “loss of charisma” may look like in individuals experiencing burnout.

The concept of burnout has been found commonly discussed among disciplines with high stress and performance expectations, such as nursing, law enforcement, social work, education, and athletics ([ 3]; [12]; [21]; [40]). Table 1 shows that descriptors such as an exhaustive, strung-out state related to meeting job demands were common across the various definitions of burnout; particularly in the nursing, law enforcement, and social work literature.

Compassion Fatigue
In 1992, Joinson first introduced the term compassion fatigue in the field of nursing and defined it as the loss of a nurse’s ability to nurture their patients. However, many of the definitions observed in the literature are derived from [11] definition; which is recognized as the most common definition of compassion fatigue. Figley defined compassion fatigue as a feeling of biological, psychological, and social exhaustion caused by prolonged exposure to compassionate stress.

TABLE 1. Definitions of Burnout

Source Definition
Classical Definition (derived from the field of Psychology) The loss of charisma for work attributed to feelings of being worn out, or tired, in performing work duties (Freudenberger, 1974).
Burnout syndrome: the increased emotional exhaustion and depersonalization experienced from a lack of personal accomplishments (Maslach & Jackson, 1981).
Nursing “A prolonged response to chronic emotional and interpersonal stressors on the job” (Jenkins & Warren, 2012, p. 391).
“The physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations” (Jenkins & Warren, 2012, p. 391).
The failure of an organization to provide support that is adequate to the needs of employees (Schaufeli & Greenglass, 2001).
Law Enforcement A psychological syndrome to chronic interpersonal stressors on the job that develops from an imbalance between the demands placed on individuals and their ability to cope that results in feelings of exhaustion, cynicism, detachment, ineffectiveness, and a personal lack of accomplishment (Finney et al., 2013).
A stress response that includes exhaustion, cynicism, diminished professional and personal efficacy (Klinoff et al., 2018).
Social Work “Symptoms, including feelings of hopelessness, that are related to difficulties in dealing with work or managing one’s job effectively” (Thomas, 2013, p. 372).
Education The negative attitudes experienced from the exhaustion of emotional resources and lack of personal achievements (Savas et al., 2014).
Athletics A period of staleness and slumps experienced from physical and emotional exhaustion, poor performance, and depersonalization (Akhrem & Gazdowska, 2016).
Table 2 shows that across nursing practice, definitions of compassion fatigue are similar, with the nurse’s loss of self in caregiving as a major focus. Additionally, Table 2 shows that in other disciplines (social workers, mental health workers, lawyers, and family caregivers) compassion fatigue has been used in association with individuals that are susceptible to witnessing adverse events that may affect their ability to care for others ([ 1]; [ 6]; [ 8]; [19]; [33]; [45]; [46]).

Results

Critical Attributes
Critical attributes are the variables required for a concept to exist and are intended to facilitate a distinction between concepts ([49]). Table 3 identifies the critical attributes of burnout and compassion fatigue. Each attribute is discussed separately in the following discussion to provide clarity to their role within each respective concept.

Stress
The role of stress is a critical attribute to both burnout and compassion fatigue as both concepts arise from chronic activations of stress responses in the body. Stress is the shifting in homeostasis that occurs in response to physical or psychological stimuli ([14]; [25]). When exposed to stress, the sympathetic nervous system releases hormones that include catecholamines and glucocorticoids ([25]). Initially, this hormonal release serves as a compensation mechanism within the body to help an individual overcome a perceived state of instability within their environment. However, the repeated activation of this process is not healthy as these hormones increase respiratory rate, heart rate, and blood pressure which eventually tires and wears the body out ([25]). Since glucocorticoids also serve a role in helping the body to maintain immunity, repeated exposure to stress also reduces the body’s ability to fight infection; making individuals more susceptible to illnesses ([25]).

TABLE 2. Definitions of Compassion Fatigue

Source Definition
Classical Definition (derived from the field of Psychology) A feeling of biological, psychological, and social exhaustion caused by prolonged exposure to compassionate stress (Figley, 1995).
Nursing The loss of a nurse’s ability to nurture their patients (Joinson, 1992).
The stress obtained from the progressive and cumulative therapeutic use of oneself to continuously provide patient care (Coetzee & Klopper, 2010).
The nurse’s inability to love, nurture, care for, or empathize with another’s suffering as a result of prolonged physical, emotional, and spiritual self-sacrifices in care delivery (Harris & Griffin, 2015).
The repeated activation of empathic and sympathetic responses to pain and distress in patients and their loved ones that deplete or exhaust compassionate stores in nurses (Pembroke, 2015).
Social Work The repeated exposure to trauma that reduces the empathetic ability of others (Adams et al., 2006; Thieleman & Cacciatore, 2014; Thomas, 2013)
Mental Health Workers The “reduced capacity for empathy as manifested through emotional, behavioral, physical, spiritual, interpersonal, and cognitive reactions experienced by a disaster mental health service provider or any individual helping a traumatized person” (Burnett, 2017, p. 1).
Lawyers “The cumulative emotional, psychological and physical effects of exposure to the pain, distress or injustice suffered by clients” (Norton et al., 2016, p. 988).
Family Caregivers A “condition experienced by caregivers who provide daily care to seriously ill or dying family members and are simultaneously exposed to the patient’s pain while experiencing their own emotional pain” (Lynch & Lobo, 2012, p. 2128).
TABLE 3. Definitions of Critical Attributes of Burnout and Compassion Fatigue

Burnout
Stress The shifting in homeostasis that occurs in response to physical or psychological stimuli (Goodnite, 2014; Laukhuf & Laukhuf, 2016).
Exhaustion An extension of one’s self, either mentally or physically, that leaves an individual worn out or tired (Lee et al., 2016).
TABLE 3. Definitions of Critical Attributes of Burnout and Compassion Fatigue

Compassion Fatigue
Stress The shifting in homeostasis that occurs in response to physical or psychological stimuli (Goodnite, 2014; Laukhuf & Laukhuf, 2016). With compassion fatigue, stress is a result of the nurse–patient relationship (Lachman, 2016).
Exhaustion The feeling that an individual has nothing more to give. With compassion fatigue, exhaustion results from an individual’s continual giving of self and presents when an individual’s biological, psychological, and social resources have been depleted (Figley, 1995).
Ineffective Coping An individual’s inability to cope despite the coping mechanisms utilized.
Lack of Empathy The loss of ability to relate to patients and their associated thoughts, feelings, and experiences (Lynch & Lobo, 2012).
In high-stakes environments, the stress associated with burnout is the result of the demands of the work environment. Nurses in these settings have reported having inadequate support, or the feasibility of accessing support, from employers, managers, and peers as a continuous stressor within the workplace ([48]). Despite the lack of support, nurses are still expected to manage a workload that includes extensive problem solving, multitasking, and critical thinking due to the increased acuity levels of their patients ([ 4]; [22]). Nurses’ workload consistently elicits activation of the body’s stress response, which in turn increases the incidence or potential to experience burnout as the body tires from persistent exposure to work-related stressors.

The stress experienced with compassion fatigue results from secondary traumatic stress, which is a type of emotional stress. Secondary traumatic stress results from memories of a traumatic event that influences an individual’s desire to help relieve suffering ([19]). For example, memories from a patient dying in pain is a traumatic event that influences how a nurse compassionately cares for a patient in a similar situation. The constant recall of this traumatic event activates the nurses’ stress response and results in compassion fatigue as the individual becomes weary in their emotions, thoughts, and feelings; similar to the process seen in posttraumatic stress disorder (PTSD), where a traumatic event is the trigger of an individual’s stress response ([42]).

Exhaustion
Like stress, exhaustion is also an attribute of both burnout and compassion fatigue, but the degree experienced varies with each concept. With burnout, exhaustion can be physical, emotional, or both. It occurs when there has been an overextension of self that leaves an individual worn out or tired ([27]). Exhaustion associated with burnout is often resolved by removing stressors through periods of rest, changes in environment, or behavior. Ultimately, with burnout, exhaustion feels like an individual has participated in a strenuous workout and needs to rest to catch their breath.

With compassion fatigue, exhaustion is the feeling that an individual has “nothing more to give.” It results from an individual’s continual giving of self and presents when an individual’s biological, psychological, and social resources have been depleted ([11]); even after attempts to replenish have occurred. With compassion fatigue, the feeling of exhaustion is draining and leaves the individual with a sense of emptiness. There is a desire to rest but the individual does not feel a sense of recharge or energy after doing so; such as a battery that does not hold a charge no matter how long it is left on a charger.

Ineffective Coping
Ineffective coping is a critical attribute of compassion fatigue and occurs when an individual is unable to cope despite the coping mechanisms utilized. The ability to cope is essential for nurses. When coping is ineffective, nurses no longer have the tools needed to manage the stress and exhaustion of providing patient care, which leaves them with an inability to restore themselves from a depleted state. Rebounding from this state of depletion is difficult because nurses with compassion fatigue are often attempting to cope using approaches that have previously been successful for them. For this reason, multiple approaches such as self-care practices, renewal strategies, and colleague support are often needed to help nurses overcome compassion fatigue states ([36]; [37]).

Lack of Empathy
A lack of empathy is an additional critical attribute of compassion fatigue. [29] argued that a loss of empathy occurs as part of a shift in which one is attempting to manage the stress of caregiving. During this shift, nurses lose their ability to empathize; their sensitivity to the patient’s needs is lost and they do not understand or place themselves within the context of the patient’s feelings, thoughts, and perspectives ([29]). As a result, they experience compassion fatigue because patient experiences are no longer relatable ([29]).

Antecedents
Antecedents are events or incidents that take place before individuals experience an associated concept ([49]). They are important to the understanding of a concept because they clarify critical attributes by framing the context in which a concept is experienced ([49]). Antecedents of burnout and compassion fatigue are based on factors from the workplace and patient experiences.

With burnout, antecedents are workplace driven ([16]). Typically, a nurse in a state of burnout is dissatisfied with some condition of the workplace which they have failed to influence or change ([ 2]; [15]). This may include a lack of organizational or managerial support, high workloads, role conflicts, and perceived unfairness in the workplace ([ 2]; [15]). As nurses fail at influencing these stressors, they experience increased feelings of anxiety, depression, frustration, and exhaustion. Over time, these factors cause nurses to experience breaks in their persistence. Although high-stakes environments are stressful, persistence is necessary for the nurse’s success as it provides momentum; or the push that keeps nurses going despite how they feel ([19]). When nurses have a break in their persistence, they feel the need to be recharged or to seek a period of rest and thus experience burnout.

The antecedents of compassion fatigue are patient-centered. Typically, a nurse with compassion fatigue has experienced repeated exposure to direct observation of patient’s fear, pain, and suffering during which time they have developed an intimate nurse–patient relationship ([ 5]; [28]). This causes the nurse to experience a large degree of emotional trauma ([19]) that leads to stress (secondary traumatic stress).

Interestingly, burnout is also an antecedent of compassion fatigue. Although burnout is relieved with periods of rest, over time there is a tendency to physically and emotionally deplete nurses’ coping reserves when instances of burnout are continuously experienced. An indication of this is when nurses begin to demonstrate neurotic behavior ([52]). Neurotic behavior includes being overly emotional, anxious, hypersensitive, worried, moody, or depressed ([52]). These traits contribute to passive coping strategies, with individuals coping away from a stressor instead of toward the stressor ([52]). When individuals cope passively, they experience less efficiency and accomplishment, which leads to their lack of energy to directly confront stressors head on ([52]). When this happens, compassion fatigue results.

Consequences
Consequences are outcomes that occur as a result of a concept being experienced ([49]). Although there are similarities in the consequences of burnout and compassion fatigue, there are also some noted differences. With compassion fatigue, the consequences are the result of unresolved elements of burnout that present with greater intensity. The effects on the occupational health and well-being of nurses provides a good illustration. Nurses with burnout experienced depression, insomnia, and decreased libido, which contributed to tiredness and lack of energy ([15]; [27]). Likewise, nurses with compassion fatigue experienced physical and mental fatigue, but often to the degree of weight gain/loss ([19]; [35]). Nurses with burnout also developed negative outlooks, mostly toward work situations, that decreased interpersonal communication and led to challenges with maintaining positive relationships with others ([15]). The same effect is also seen with compassion fatigue, but challenges with communication extended into relationships in one’s personal life and included emotional breakdowns ([19]; [35]).

Both burnout and compassion fatigue result in workplace imbalances ([35]; [37]). Turnover rates in high-stakes environments are among the most notable ([38]). Turnover results when nurses began to seek other work opportunities to eliminate the stress of the workplace. As turnover rates increase, the stress in the workplace intensifies as nurses begin to adjust to staffing shortages, which subsequently adds to the experience of burnout. Turnover also contributes to low job satisfaction, which with compassion fatigue, was a driving cause for a nurse’s consideration of leaving the profession ([35]; [37]).

Depersonalization is another consequence of both burnout and compassion fatigue. Depersonalization occurs when nurses lack human feelings or emotions in how they provide care, which results in substandard care ([19]). With burnout, depersonalization often presents as a coping mechanism used to manage exhaustion ([27]) and is not from a standpoint of lacking empathy for the patient. Nurses with depersonalization due to burnout often become “robotic” and focus on moving from task to task, or patient to patient, to “hurry up and finish.” With compassion fatigue, the severity of depersonalization is to the degree that nurses view patients as “objects” ([27]). An example of this would be when the patient goes from being referred to as “Ms. Johnson” to “the patient in room 501.”

The ultimate consequence of burnout and compassion fatigue is poor patient outcomes. When nurses were experiencing burnout and compassion fatigue, patients experienced decreased quality of care ([15]; [32]), as they were more prone to adverse events from nursing errors ([19]; [26]; [35]; [38]). [32] argued that burnout rates among nurses in hospitals contributed to the decline in recommendations of the same facility by patients to their friends and family, as assessed through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This finding suggests that patients can sense the stress of the working environment through the care received. As patients tend to rely on nurses to alleviate the stress of their disease ([ 5]; [28]), these feelings may inadvertently cause patients to question if their care is ideal and in turn result in additional patient stress. Additionally, patient dissatisfaction with care can influence the Medicare and Medicaid reimbursements hospitals receive if patients continuously return negative HCAHPS scores ([17]). Therefore, it is in the best interest of hospitals to address both burnout and compassion fatigue in nurses to prevent potential financial and other losses.

Empirical Referents
[49] noted empirical referents as ways in which a concept can be measured. Empirical referents are summarized in Table 4 for both concepts.

Burnout
The Oldenburg Burnout Inventory, Rescue Worker Burnout Questionnaire, and Copenhagen Burnout Inventory are some of the instruments which have been utilized to measure burnout. However, it is the Maslach Burnout Inventory (MBI) that is the most commonly used tool across disciplines ([15]; [27]; [38]). The MBI is a 22-item assessment that uses a 7-point Likert scale to assess burnout through three subscales: emotional exhaustion, depersonalization, and personal accomplishment. It has demonstrated validity and reliability ([31]). The higher an individual’s score on the MBI, the greater the degree of burnout ([31]). On average, medical professionals have normative subscales scores of approximately 22 for emotional exhaustion (range = 0–54), seven for depersonalization (range = 0–30), and 37 for personal accomplishment (range = 0–48; [38]).

Compassion Fatigue
A major problem with tools used to assess compassion fatigue is the limitation of addressing multiple variables associated with the phenomenon ([39]). For instance, several instruments such as the MBI, Oldenburg Burnout Inventory, Copenhagen Burnout Inventory, Impact of Event Scale, Connor–Davis Resilience Scale, and Ways of Coping Questionnaire have been used in compassion fatigue research although they only measure a single aspect of compassion fatigue; mainly burnout or stress ([ 7]; [37]). Interventions that collectively targeted multiple compassion fatigue variables were found most effective in reducing compassion fatigue in nurses ([ 8]; [18]; [36]; [37]; [42]; [50]).

The Professional Quality of Life Scale (ProQOL; [43]) is one instrument that evaluates multiple compassion fatigue variables: increased burnout, secondary traumatic stress, and reduced compassion satisfaction. However, these variables are independent subscales and are not totaled to formulate a compassion fatigue composite score ([43]). This creates a limitation in utilizing this tool for research. An alternative instrument, The Nurses’ Compassion Fatigue Inventory (NCFI; [39]), offers a more robust assessment of compassion fatigue. The NCFI is a 35-item assessment that uses a five-point Likert scale ranging from one (never) to five (always). All 35 items are added together to form a composite compassion fatigue score, which can range from 35 to 175. The higher the composite compassion fatigue score, the more severe an individual’s level of compassion fatigue ([39]). [39] further break scores down by three classifications: low (scores ranging from 35 to 81.6), moderate (scores ranging from 81.6 to 128.2) to high (128.2–175). The Cronbach’s alpha for the instrument is α =.94. The tool was validated by [39] through exploratory factor analysis and revealed a six-factor model that explained 66.24% of the total variance of compassion fatigue. These six factors included limited personal capabilities, caring infirmity, psychosomatic disorders, emotional fatigue, social isolation, and incompetence in self and family management. For these reasons, the NCFI empiric referent would be essential to any initiative or study focused on influencing compassion fatigue outcomes.

TABLE 4. Empirical Referents of Burnout and Compassion Fatigue

Instrument Concept(s) Measured Definition of Burnout and/or Compassion Fatigue Subscales
MBI Versions:
MBI-Human Services Survey

MBI-Human Services Survey for Medical Personnel

MBI-Educators Survey

MBI-General Survey

MBI-General Survey for Students

Burnout Burnout is a syndrome that includes emotional exhaustion, depersonalization, and a lack of personal accomplishments (Maslach & Jackson, 1981; Maslach, Jackson, & Leiter, 1996). Subscales for the Human Services Survey, Human Services Survey for Medical Personnel, and Educator Survey versions:
Emotional exhaustion

Depersonalization

Personal accomplishment

Subscales for the General Survey and General Survey for Students versions:
Exhaustion

Cynicism

Professional efficacy

Oldenburg Burnout Inventory Burnout Burnout is exhaustion and an individual’s level of disengagement from work (Demerouti, Bakker, Vardakou, & Kantas, 2003).
Exhaustion

Disengagement

Copenhagen Burnout Inventory Burnout Burnout is physical and psychological fatigue and exhaustion (Kristensen, Borritz, Villadsen, & Christensen, 2005).
Personal burnout

Work-related burnout

Client-related burnout

ProQOL Compassion Satisfaction Compassion Fatigue (determined from burnout and secondary traumatic stress) Burnout is the associated feelings of hopelessness and difficulties in dealing with work or in doing one’s job effectively (Stamm, 2010). Compassion fatigue is the negative aspect of helping those who experience traumatic stress and suffering and can include elements of burnout and secondary traumatic stress (Stamm, 2010).
Burnout

Secondary traumatic stress

Compassion satisfaction

Nurses’ Compassion Fatigue Inventory Compassion Fatigue Compassion fatigue is an occupational hazard of clinical practice that places a caregiver in a state of extreme fatigue and undermines their ability and desire to tolerate the agony of others (Sabery, Tafreshi, Hosseini, Mohtashami, & Ebadi, 2017).
Limited personal capabilities

Caring infirmity

Psychosomatic disorders

Emotional fatigue

Social isolation

Incompetence in self and family management

Impact of Event Scale Distress for any specific life event Burnout and/or compassion fatigue not assessed
Avoidance

Intrusions

Impact of Event Scale—Revised Distress for any specific life event Burnout and/or compassion fatigue not assessed
Avoidance

Intrusions

Hyperarousal

Connor–Davis Resilience Scale Resilience Burnout and/or compassion Fatigue not assessed No subscales
Ways of Coping Questionnaire Coping processes Burnout and/or compassion fatigue not assessed
Confrontive coping

Distancing

Self-controlling

Seeking social support

Accepting responsibility

Escape-avoidance

Planful problem solving

Positive reappraisal

Note. MBI = Maslach Burnout Inventory; ProQOL = Professional Quality of Life Scale.

Synthesized Definition
After careful analysis, consideration of literary findings, and with respect to all multidisciplinary aspects, synthesized definitions of both burnout and compassion fatigue are derived to support an understanding among nurses caring for patients in high-stakes environments. Burnout is the experience of physical or mental exhaustion nurses feel from prolonged workplace stress for which coping helps to resolve. Compassion fatigue is the experience of physical or mental exhaustion that arises from patient care in which the nurse is left drained, without empathy, and unable to effectively cope.

Constructed Cases

Burnout

Model Case
Nurse A works on an inpatient oncology unit. Her unit includes a mixture of patients such as chemotherapy admissions, postoperative patients, and patients experiencing treatment/disease-related complications. On average, Nurse A has five patients each shift.

Over the last 6 months, the hospital administration decided to designate Nurse A’s unit as an overflow area for patients from two other units. Many nurses, including Nurse A, are not happy about this change. Several of the nurses resigned which has now left the unit understaffed. Due to her skill set and expertise, Nurse A is assigned to take on a sixth patient during some shifts, as well as help precept new staff as they are hired.

As time has passed, Nurse A feels continuously tired at the end of her shift (exhaustion). She moves continuously from the time she clocks in till the time she clocks out. Many shifts she skips her lunch break just to ensure she can leave work on time. Knowing that her shifts are intense (stressful), Nurse A sleeps in longer on her days off and goes to the spa for a massage. Although this recharges her to start her next shift, she mentally anticipates the tired feeling she will experience when she goes back to work. However, she knows her patients need her. She goes back to work ready to give them her best effort.

Contrary Case
Nurse B works on the same inpatient oncology unit as Nurse A. She also has been asked to take on an extra patient and precept new staff. She also leaves the hospital at the end of each shift feeling tired (fatigue); but as if she has had a good workout at the gym. She feels her shifts are intense (busy), but to the degree where she feels continuously occupied but not rushed or pressured. She is consistently able to take her lunch and break periods and uses this time to relax and regroup. She prepares for her shifts by getting adequate rest on her days off and returns to work restored and ready to make a difference with her next group of patients.

Compassion Fatigue

Model Case
Nurse C works on an inpatient oncology unit where oncology patients are routinely admitted for chemotherapy and treatment associated complications. As a result, Nurse C sees patients throughout their treatment and has a rapport with many. While delivering care, she frequently engages with patients as they express their care experiences including fear of death, pain, nausea, and other side effects of treatment.

Over the last few weeks, Nurse C has left the hospital after her shift with feelings that she is stretched thin both mentally and physically (exhaustion). She has lost several close patients throughout her last few shifts. She constantly worries (stress) about how their loved ones are doing. She frequently has thoughts of “what is it now” when call lights go off. She has lost her ability to connect with patients. She provides patient care “on the surface,” handling only those concerns that cannot wait till the next shift. She neglects the emotional needs of her patients (lack of empathy), often leaving out of the room in a hurry when patients attempt to confide in her because she does not want to hear another sad story. She has attempted to meditate to relieve her stress but finds this only results in her staring into space and becoming increasingly frustrated (ineffective coping).

Contrary Case
Nurse D works on the same oncology unit as Nurse C. Over the last few weeks, she too has left the hospital at the end of her shift feeling “stretched thin” (exhaustion). She spends her shift addressing the emotional concerns of her patients, including sitting with the family of a patient that died mid-shift (empathy). To alleviate the stress of the day, she meditates over a warm bubble bath when she gets home and finds meaning in the care she delivered (effective coping). She wakes up the next morning feeling recharged and ready to take on the next group of patients.

Discussion
Caring for patients in high-stakes environments can be difficult for nurses who are experiencing burnout or compassion fatigue. The ability to recognize both concepts is pivotal in helping nurses to establish strategies that help them cope and achieve optimal occupational health. This concept analysis has discussed several distinctions between the two concepts that can be used in this regard. Perhaps the most significant is the identification of burnout as an antecedent of compassion fatigue. This aspect is important because burnout was found to be modifiable through periods of rest, changes in environment, or behavior, giving it the potential to be resolved with the removal of stressors. In addition, burnout is often a result of conflicts between employer–employee relationships and not conflicts in the nurse–patient relationship ([16]; [26]). Therefore, if one could address and manage burnout appropriately, it could reduce the chance that a nurse develops compassion fatigue and result in better occupational health.

There are also several elements of burnout and compassion fatigue that overlap. This concept analysis has noted that in the areas of overlap, the severity differs. For instance, stress and exhaustion are critical attributes of both concepts. However, with burnout, stress and exhaustion result in the nurse being in a tired state; with compassion fatigue, the result is that a nurse is in a drained state. As the intensity of stress and exhaustion experienced in the workplace could be a contributor to both concepts, research should focus on interventions that help nurses manage their stress ([ 2]; [27]). Effectively coping with workplace stress has the potential to influence workplace sustainability; positively impacting both burnout and compassion fatigue through a reduction in turnover rates and improved job satisfaction. As one’s satisfaction helps to determine their outlook toward the stress experienced in high-stakes environments, understanding this phenomenon will help to identify specific strategies nurses need to overcome burnout. It will also help to bring an understanding of how burnout develops into the associated concept of compassion fatigue.

Caring for high-stakes patients involves a large degree of empathy because of the potential life-threatening outcomes these patients are at risk of experiencing. This analysis identified a lack of empathy as one of the differences between compassion fatigue and burnout. Yet, a deeper understanding of empathy is needed concerning what influences nurses to lose this ability among high-stakes patients. Studies using qualitative methods could help to provide this understanding.

Conclusion
This concept analysis has conceptually differentiated between the concepts of burnout and compassion fatigue in the context of high-stakes environments and discussed their relevance as two distinct concepts in nursing practice. From this analysis, nurses can identify burnout and compassion fatigue in both themselves and their colleagues, as well as develop appropriate interventions to support their coping efforts. Understanding burnout and compassion fatigue are key in helping nurses to achieve optimal occupational health. Thus, the definitions of burnout and compassion fatigue in this analysis serve to enhance conceptual understanding, reasoning, and encourage communication among nursing staff caring for patients in high-stakes environments.

Disclosure
The author(s) have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding
The author received no specific grant or financial support for the research, authorship, and/or publication of this article.

Acknowledgments
The author wishes to acknowledge Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN; Danita Alfred, PhD, RN; and E’Loria Simon-Campbell, PhD, RN for their guidance and encouragement in writing this manuscript.

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~~~~~~~~

By Franklin Wynn

Reported by Nurse

This article is copyrighted. All rights reserved. Source: International Journal for Human Caring

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‘Your soul feels a little bruised’: Forensic interviewers’ experiences of vicarious trauma.
Authors:
Middleton, Jennifer, ORCID 0000-0003-4544-8194 . Kent School of Social Work, University of Louisville, Louisville, KY, US
Harris, Lesley M., ORCID 0000-0002-1981-064X . Kent School of Social Work, University of Louisville, Louisville, KY, US, lesley.harris@louisville.edu
Matera Bassett, Dawn. Department of Social Work, Metropolitan State University of Denver, Denver, CO, US
Nicotera, Nicole, ORCID 0000-0001-7672-1021 . Graduate School of Social Work, University of Denver, Denver, CO, US
Address:
Harris, Lesley M., Kent School of Social Work, University of Louisville, 216 Oppenheimer Hall, Louisville, KY, US, 40292, lesley.harris@louisville.edu
Source:
Traumatology, Vol 28(1), Mar, 2022. pp. 74-83.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
10
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Traumatology: An International Journal
Other Publishers:
US : Academy of Traumatology
US : Green Cross Project
US : Sage Publications
ISSN:
1085-9373 (Electronic)
Language:
English
Keywords:
vicarious trauma, forensic interviewing, secondary trauma, child sexual abuse, forensic social work
Abstract:
Vicarious trauma among social workers is well documented in the literature, yet there is a paucity of research in this area pertaining to forensic interviewers. Forensic interviewers who conduct structured interviews with children who have made allegations of abuse might be particularly vulnerable to vicarious trauma as a result of their work. Using a phenomenological approach, qualitative interviews were conducted with nine forensic interviewers throughout one western state in the United States. Findings indicate that forensic interviews are significantly impacted by their work and report experiencing vicarious trauma across three realms: within the interview, outside of the interview but within their professional role, and in their personal lives. Implications for practice include Helping organizations develop and target interventions that promote healthy coping responses to the inevitable traumatic nature of the work. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Forensic Assessment; *Interviewers; *Social Workers; *Trauma; *Vicarious Experiences; Soul; Test Construction
PsycInfo Classification:
Professional Psychological & Health Personnel Issues (3400)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jan 14, 2021; Accepted: Nov 13, 2020; Revised: Nov 13, 2020; First Submitted: Jul 12, 2020
Release Date:
20210114
Correction Date:
20220404
Copyright:
American Psychological Association. 2021
Digital Object Identifier:
http://dx.doi.org/10.1037/trm0000297
Accession Number:
2021-07081-001
Number of Citations in Source:
49
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“Your Soul Feels a Little Bruised”: Forensic Interviewers’ Experiences of Vicarious Trauma
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Contents
Theoretical Orientation
Method
Phenomenological Approach
Researcher Subjectivity and Reflexivity
Procedure
Instruments
Data Analysis
Results
Triggers
Coping Responses
Cognitive Dissonance
Syncretism
Discussion
Implications
Limitations
Conclusion
References
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By: Jennifer Middleton
Kent School of Social Work, University of Louisville
Lesley M. Harris
Kent School of Social Work, University of Louisville;
Dawn Matera Bassett
Department of Social Work, Metropolitan State University of Denver
Nicole Nicotera
Graduate School of Social Work, University of Denver
Acknowledgement: The authors have no known conflict of interest to disclose.

On the front lines, social workers and other helping professionals are frequently exposed to secondary traumatic material disclosed by their clients, thereby increasing their risk of developing vicarious trauma (Lerias & Byrne, 2003). Research on the secondary impact of trauma, particularly among helping professionals who work with survivors of trauma, suggests a negative impact on the quality of client care (Conrad & Kellar-Guenther, 2006; Tehrani, 2011), as well as potential adverse consequences for the worker and the agency (Arnold et al., 2005; Horwath & Tidbury, 2009; Regehr et al., 2004; Schauben & Frazier, 1995; VanDeusen & Way, 2006).

Although the impact of secondary trauma exposure on social workers and other helping professionals is fairly well documented in the literature, there is a paucity of research in this area pertaining to forensic interviewers, particularly in regards to vicarious trauma. Yet, forensic interviewers who are tasked with routinely interviewing children who are victims or witnesses to a criminal act may be particularly vulnerable to vicarious trauma as a result of their work. The limited research conducted with forensic interviewers regarding their work-related trauma experiences is focused primarily on disengagement and secondary trauma (Bonach & Keckert, 2012; Perron & Hiltz, 2006). Findings from these preliminary studies indicate that while tenure and interviewing load are related to higher levels of disengagement among interviewers (Perron & Hiltz, 2006), external social support and internal job support are important predictors of interviewer’s levels of secondary traumatic stress (Bonach & Keckert, 2012). However, research also suggests that vicarious trauma has a direct effect on turnover among professionals who work in fields closely related to forensic interviewing (Middleton & Potter, 2015). Due to the dearth of research available regarding vicarious trauma, and the implications that high annual turnover rates have for the organizations that employ forensic interviewers, there continues to be a need to understand how forensic interviewers are impacted by the content of interviews.

This study focuses on forensic interviewers who work specifically with children and youth who have reported sexual abuse, physical abuse, and/or witnessing violence. While there has been an increase in the number of empirically supported publications pertaining to the process and procedures of forensic interviewing, few studies address the training, support, and consequences related to forensic interviewers (Perron & Hiltz, 2006). Vicarious trauma is indicated as a potential consequence of forensic interviewing due to constant exposure to traumatic material within the interview setting. Forensic interviewers typically work within a multidisciplinary investigative team, comprised of professionals from law enforcement, social services, medical staff, and prosecution teams. However, forensic interviewers are often the first professionals to directly speak with children about their alleged abuse (i.e., sexual, physical, or witness of violence). Their role requires them to “determine whether or not abuse has occurred and, if so, elicit detail in a court suitable manner” (Perron & Hiltz, 2006, p. 216). To make this determination, the forensic interviewer must maintain a neutral stance and utilize developmentally sensitive and noncoercive techniques to gather details of the abuse event in a legally defensible manner (Lamb et al., 1998). The demands of the forensic interview are often difficult to balance, as the content of the children’s stories and the responses of the children during the interview are considerable sources of traumatic stress and their role does not allow the interviewers to voice empathy with the child in order to prevent bias in the interview process (Perron & Hiltz, 2006).

The imbalanced role of forensic interviewers combined with the traumatic details that children report are factors that lead to occupational stress, burn out, secondary trauma and/or vicarious trauma. The occupational stress of social workers serving traumatized populations has begun to receive significant attention as a workforce issue within child welfare organizations. This kind of occupational stress has been most commonly referred to as: compassion fatigue (Figley, 1995), secondary traumatic stress (Figley, 1995; Stamm, 1999), and vicarious traumatization (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). Although overlap exists between the concepts underlying these terms, there are differences. Specifically, compassion fatigue is viewed as the helper’s reduced capacity for compassion and encompasses the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by another person (Figley, 1995). Secondary traumatic stress refers to a cluster of psychological symptoms that mimic posttraumatic stress disorder (PTSD) acquired through exposure to persons suffering trauma (Figley, 1995; Stamm, 1999). Vicarious traumatization involves profound changes to professionals’ cognitive schemas and core beliefs about themselves, others, and the world, that occur as a result of exposure to graphic and/or traumatic material relating to their clients’ experiences (Trippany et al., 2003).

It is important to note that vicarious trauma “has been conceptualized as being exacerbated by, and perhaps even rooted in, the open engagement of empathy, or the connection, with the client that is inherent in counseling relationships” (Trippany et al., 2003, p. 31). Because of the nature of forensic interviewing, this type of engagement may present differently for an interviewer, indicating a unique effect for the interviewer. More specifically, forensic interviewers do not typically have an ongoing relationship with the child they are interviewing. Rather, while a deep, intense connection with the child may occur during the interview, once the interview ends, the opportunity for the forensic interviewer to continue the connection ends. However, by listening to explicit details of children’s traumatic experiences during the forensic interview process, interviewing professionals “become witness to the traumatic realities” that children themselves experience and “this exposure can lead to transformation within the psychological functioning” of interviewing professionals (Trippany et al., 2003, p. 31). In such a manner, vicarious trauma effects transcend the forensic interview itself.

Theoretical Orientation

Vicarious trauma is grounded in constructivist self-development theory (CSDT; McCann & Pearlman, 1990). This theory depicts the resulting changes from vicarious trauma to be pervasive, cumulative, and permanent. Because vicarious traumatization is a theory-driven construct, emphasizing more gradual, covert, and permanent changes in a helping professional’s cognitive schema, it may hold significant implications for understanding workforce outcomes such as job retention. For this reason, the term vicarious traumatization is employed throughout this paper except in cases where another term has been used specifically by other scholars’ research that we reference. By the same token, for the purposes of this study, vicarious traumatization is defined as the response of helping professionals who have witnessed, have been subjected to explicit knowledge of, or had the responsibility to intervene in a seriously distressing or traumatic event.

CSDT is the theoretical orientation that was originally applied to primary trauma survivors, but is now used to help explain the impact of trauma, particularly vicarious trauma, on helping professionals. In an effort to describe the effects of vicarious trauma experiences, McCann and Pearlman (1990) conceptualized the impact within CSDT. CSDT combines psychoanalytic theories, such as self-psychology and object relations theory, with social cognition theories to develop a framework for understanding the phenomenon (Pearlman & Mac Ian, 1995). CSDT perceives individuals’ adaptations to trauma “as interactions between their own personalities (defensive styles, psychological needs, coping strategies) and salient aspects of the traumatic events, all in the context of social and cultural variables that shape psychological responses” (Pearlman & Mac Ian, 1995, p. 558). Thus, although the context for the trauma survivor may include social and cultural details pertaining to the traumatic event and its aftermath, when applying this theoretical tenet to forensic interviewing, the context for the forensic interviewing professional may include the interview room itself, as well as the culture and climate of the professional’s organization and team. In this manner, a professional’s immediate work environment (e.g., peer support, supervisor support, child advocacy setting, interview room) may help shape the interviewer’s psychological response as it is contained within the worker’s professional role (e.g., professional efficacy, professional satisfaction).

Our qualitative study adds to this limited research. Gaining insights into this issue is key for future development and testing of approaches that promote effective and appropriate organizational responses to forensic interviewers experiencing vicarious traumatization. Forensic interviewers may experience vicarious trauma in an ongoing, cumulative fashion due to their often-daily exposure to traumatic material, which could have a significant impact on their professional life and personal life, as well as their ability to maintain a healthy work-life balance. Although this is an understudied area, the implications of this experience can include negative professional efficacy, burnout, and high turnover rates, which can be costly to the organizations who employ forensic interviewers, and can negatively impact case outcomes for children and families. Organizations who employ forensic interviewers as well as other mental health professionals should be attuned to the nature of vicarious trauma among forensic interviewers in order to provide support for this workforce.

This study aims to provide an exploratory context to understand and describe the experiences of vicarious trauma through the lens of forensic interviewers. Therefore, the primary research question guiding this study is, “How do forensic interviewing professionals experience vicarious trauma?” The secondary question is, “What is the textual and structural experience of the phenomenon of vicarious trauma?”

Method

Phenomenological Approach
The current study utilized a descriptive phenomenological approach (Husserl, 1964, 1970; Koch, 1995) in order to explore and describe the subjective and unique meanings of forensic interviewers’ vicarious trauma. This included an in-depth understanding of forensic interviewers’ everyday experiences, and activities as they perceived them, with the analytic goals of the research team to interpret and understand the phenomena of vicarious trauma with all of the forensic interviewers’ contradictions (Annells, 1999; Caelli, 2000; Giorgi, 2005; Husserl, 1964; Van Manen, 1990), and how the meaning of vicarious trauma is generated and transformed throughout their work roles. Specifically, a phenomenological approach was used because the researchers did not want to influence the interviewees’ definition and perception of vicarious trauma; rather, the researchers wanted to see what would emerge, or be defined by the participants when forensic interviews reflected in their experiences in their working environment (Patton, 2002; Rubin & Rubin, 2011).

The research team used data grounded in the interviews to devise the structure of the phenomenon portraying the vicarious trauma experienced by forensic interviewers. Due to the fact that vicarious trauma is an understudied topic, phenomenology was a reasonable approach, which encourages the research team to pay attention to the participants’ subjectivity, individual life situation and circumstance, which enables and facilitates the description of human experience (Archer, 2000; Caelli, 2000; Giorgi, 2005; McCosker et al., 2003).

Researcher Subjectivity and Reflexivity
Jennifer Middleton was a forensic interviewer for 7 years, and worked as a forensic interviewer at two children’s advocacy center agencies, interviewing over 4,000 children during her career. She also codirected the state’s peer review team and provided forensic interviewing training to local social services and law enforcement personnel. She has not practiced forensic interviewing for several years, but the shared identity of having been a forensic interviewer impacted her relationships with the participants by being able to acknowledge similar experiences and connect emotionally with the participants during interviews. This connection allowed for deep, raw, reflective responses on the part of the participants. Through this process, Jennifer Middleton learned how to be “the instrument,” as it is natural to identify with some of the same experiences, because common experiences are bound to happen and they are part of the reflexive process (Rennie, 2004). Throughout the data analysis, Jennifer Middleton was reminded of her career as a forensic interviewer and found parallels between her experiences and those of the participants, which allowed her to integrate her own biases within the data collection and analysis (Maxwell, 2012). Due to the subject matter so closely reflecting Jennifer Middleton’s experiences with vicarious trauma throughout her career, she employed certain safe guards to reduce researcher subjectivity throughout data collection and analysis, including the utilization of bracketing (Tufford & Newman, 2012), field notes, consultation, and pre/post interview reflection journaling.

Procedure
Purposive typical case sampling (Patton, 2002; Rubin & Rubin, 2011) was utilized to recruit forensic interviewers throughout a large, western state in the United States. Rather than focusing on the number of participants, it was essential to elicit the unique experience of each forensic interviewer (Kleiman, 2008). The majority of the forensic interviewers who were interviewed were social workers. In this particular western state, there is only an average of 10–15 total full time forensic interviewers at any given time in the entire state, and a majority of the interviewers are housed within child advocacy center settings. A total of nine interviews were completed out of 12 potential, invited participants for a participation rate of 75%.

Instruments
A demographic questionnaire and a semistructured interviewing protocol was utilized, which included several sociodemographic questions, as well as six questions pertaining to the overall aim of the study. Findings from the larger study have been published elsewhere (McDonald et al., 2017). However, this article addresses the data related to one of those questions: Describe a typical forensic interview. Try to pick an interview that you feel has had a lasting impact on you. Walk me through from your perspective. All interviews were audio-recorded, and the average length of the interview was 2.5 hr.

Data Analysis
The research team analyzed the interview transcripts using Colazzi’s (1978) approach, which is commonly used in studies utilizing phenomenology. Our process involved first recording the individual preunderstandings of vicarious trauma by each member of the research team to bracket our experiences (Tufford & Newman, 2012) as persons with expertise in (a) forensic interviewing, (b) child welfare, and (c) qualitative methodology.

The team then read all of the interview transcripts in their entirety in order to gain an overall understanding of the phenomenon of vicarious trauma within the context of forensic interviewers. This also gave the team the opportunity to record key defining features of each of the stories, including characteristics, life situations, styles of communication in order to preserve the subjectively of each of the participant’s stories. The researchers then each coded half of the interview transcripts, identified meaning units, and noted how in vivo codes clustered. The researchers were sure to extract exact words, sentences and phrases which described the phenomenon of vicarious trauma. From there, the researcher came together to develop an initial codebook, which was comprised of the most frequent and significant meaning units, and to integrate biases as a part of the analysis process (Maxwell, 2012). The codebook was then transferred into Atlas.ti, and the team then coded all of the transcripts as a group using the codebook. In Atlas.ti, the team utilized the family manager function to create code families for each of the realms, elements and properties of vicarious trauma. Once the code families were created, the team engaged in an intercoder reliability test. The researchers met frequently to discuss coding and analysis, maintained memos related to all analytic decisions (Charmaz, 2014) and their agreement level as measured by Cohen’s kappa was 95.07% (Cohen, 1968; De Vries et al., 2008; Landis & Koch, 1977).

The research team then developed an exhaustive description of vicarious trauma within the forensic interviewers’ context. Our initial analysis indicated forensic interviewers experience vicarious trauma at three different points of their life experiences. As the researchers delved further into the codes and quotations described by participants, the need for the in vivo groupings to be organized into three specific coding families became clear. The overarching categories developed by the researchers included: (a) within the forensic interview; (b) outside the interview: professional role; and (c) outside the interview: nonprofessional role. These three categories supported by properties, or characteristics that comprised each category. It was later agreed that the research team would replace the word “categories” with “realms” in order to emphasize that the forensic interviewers were impacted in three specific locations or arenas of their everyday lives.

In an effort to understand “the heart of the matter,” emphasis in this final stage was placed on examining how the themes link together in a meaningful way. The overarching question the researchers asked is, “What is the textual and structural experience of the phenomenon?” Therefore, we engaged in analytic exercises such as examining creation of verbal expressions of vicarious trauma, grounded in the voices of forensic interviewers to describe the essence of the experience of vicarious trauma, as well as the structure of vicarious trauma (Priest, 2002). We maintained a connection to the original data to describe the core meaning of vicarious trauma within the forensic interviewers’ context with the goal of creating thick and rich description and structure of the phenomenon (Dinkel, 2005).

Results

The sample contained predominantly female (78%) forensic interviewers with a mean age of 38 years. The dominant ethnicity of the participants was Euro American/Caucasian (77.8%) and 44.4% of the forensic interviewers reported being parents. Education level varied with five participants completing a 4-year degree and the remaining four completing a Master’s degree. In regards to professional experience, five of the forensic interviewers indicate working at child advocacy centers (55.6%), two at law enforcement (LE) agencies (22.2%), and two at departments of human services (DHS/DSS; 22.2%). The majority of the participants reported being very satisfied (56%) with their jobs. Other participants reported being satisfied (33%) or very unsatisfied (11%) with their jobs. In regards to years of experience in the field, participants reported an average of 9.5 years, with a range of 2.5 to 18 years. In regard to forensic interviewing specifically, the participants reported a mean of 5.5 years of experience, with a range of 0.5 to 18 years. When comparing the research sample to the parent population, the researchers concurred that the sample is representative of the larger parent population of forensic interviewers throughout the United States.

The findings revealed that forensic interviewers shared common intrinsic responses that were brought on by vicarious trauma. Another common theme was that forensic interviewers were working within the context of an inadequate “system” which led to feeling unsupported by the structures which were meant to protect children. This created barriers to syncretism, and having work-related stress and trauma “spill out” into their personal lives. Forensic interviewers who had years of experience commonly turned to disengagement from the emotional intensity of the work as a self-protection strategy.

The results of this study included descriptions of the elements, realms and properties of vicarious trauma for forensic interviewers (Table 1). Within each of the realms named (a) within the forensic interview, (b) outside of the forensic interview: professional role and (c) outside the forensic interview: nonprofessional role. Three realms were the locations in which the forensic interviewers reported being impacted by vicarious trauma. Within the forensic interview space, forensic interviewers described “the actual interview room” were they were conducting interviews with the child. Forensic interviewers reported that stepping into the room created a change within their physical state. One forensic interviewer stated, “I think there’s this weird thing that happens, like when you go into that room, there’s a shift for me.” Outside of the forensic interview, and working in their professional role, forensic interviewers experienced trauma through interactions with coworkers (the investigative team), viewing evidence and photographs, documentation and attending meetings. While working in their office space, forensic interviewers were not as impacted by immediate trauma, but were impacted by the strain and weight of the work or “feeling burned out at work.” Another forensic interviewer described the process, “I was feeling like we were spinning our wheels and there was just a constant influx of kids coming in. Um, who horrible, horrible things had happened to them. Um, and it was kind of never ending. And so I think in that way my world view got skewed.” Lastly, work stress crept into the nonprofessional roles occupied at home and in the community, when the forensic interviewer was completely removed from work. One forensic interviewer described how the job impacted her worldview,

I guess I call it your soul gets a little, um, jaded in a way, I guess. You know it becomes a little bit harder to see good things that happen in life and in the world. Um, and, and, and so, yeah, you just, your soul feels a little bruised, I guess would be a way of describing it.
Additionally, the forensic interviewers report experiencing four distinct elements of vicarious trauma, regardless of which realm they were in. These four elements include: triggers, coping strategies, cognitive dissonance, and syncretism. Each element of vicarious trauma and its corresponding properties are described in Table 1 and in detail below.

trm-28-1-74-tbl1a.gifElements, Realms and Properties of Vicarious Trauma for Forensic Interviewing Professionals
Triggers
Interviewers identified triggers that commonly occurred within the interview itself. The participants described that triggers often stimulated trauma and stress. At times, triggering was subtle, meaning that it varied in terms of the intensity experienced by the forensic interviewers. Triggers were often difficult to anticipate, so caught interviewers “off guard” in the midst of the interview with the child.

A social worker describes a triggering moment, and the conflict that she experienced trying to contextualize her work-role. She said, “I can see it in my mind’s eye, because I’m visual which makes it difficult to separate completely from it.” The social worker goes on to describe how descriptions of sexual abuse could also be triggering and elicited a lasting physical response from her, “. . . he put his penis where? . . . and it felt like what? It’s all here (gestures to head). But it gets here (gestures to heart) it gets down to an emotional level afterwards.”

These are examples of triggers that occur in the mind’s eye; interviewers discussed how visualizing the graphic details of the abuse incident were triggering for them. Specifically, the forensic interviewers identify three types of interviews or scenarios which are the most difficult and cause the most vicarious trauma: disclosures of severe physical trauma (within the interview); tentative disclosures (within the interview); and system failures (outside interview professional role crosses over into within the interview). When identifying the type of interview that is most traumatic, the participants describe how disclosures of severe physical trauma as a result of child sexual abuse impacted them the most. One participant describes an interview in which a young child needed to have his anus and colon stitched back together due the tearing caused by the sodomy. Other participants identify similar types of sexually abusive behaviors that can be “traumatic to hear.” The participants report it is challenging for them to maintain professional composure throughout the interview process due to the traumatic nature of the abuse scenarios. Forensic interviewers describe that as a result of these types of interview dynamics, they sometimes feel “helplessness” and “guilty.”

When working with children who are in the tentative phase of the disclosure process (e.g., a series of disclosures of abuse followed by recantations of these disclosures), participants describe having to “push a child” to talk about their experience. When the child is visibly upset and resistive to questioning, it is difficult for the interviewer. In response to this, one participant reports having to “turn-off your humanness” and “sacrifice yourself.” Another participant describes this process:

It is vital to this child’s welfare, for me to get what I need, and maybe that is what overrides my desire to not react in shock, but, you know, show empathy in that moment. Um, and I never get to show the empathy, actually, as I’m thinking out loud. I never get to show that. I get what I get, I get what I need, and then we’re done. And then I never see him again.
Also within the interview, forensic interviewers discuss how the child’s physical and emotional response to disclosing abuse is a trigger for them. One forensic interviewer describes this process, “So, after all of that, then she started to disclose about her dad . . . she was terrified that she was going to be killed . . . she started to really fall apart . . . at one point disassociated so severely that she was almost in a coma.”
Within the forensic interview, the most common trigger reported by participants was related to the child’s communication, with frequencies split somewhat evenly across a child’s verbal versus nonverbal communication. Another forensic interviewer described how the child’s body language impacted her ability to keep her composure during the interview while the child was disclosing, “She sat in fetal position in the chair, she would put her head down.”

Outside of the interview, while still in their professional role, forensic interviewers describe viewing traumatic photos as being a significant trigger, causing them to feel overwhelmed. One participant who was considering leaving her role as a forensic interviewer at the time of the interview said, “To see a photo of a battered child is something that I still don’t know if I have room for.”

In addition, one interviewer reported being more impacted by a particular case because she was alone at the child advocacy with no support staff present, while conducting a late-night interview. She said, “I was doing the interview by myself. I don’t recall anybody else being there [at the child advocacy center].” The isolation of being the only forensic interviewer on the investigative team, combined with late night hours without the support of coworkers increased feelings of stress and isolation within the forensic interviewers’ work role. Another forensic interviewer went further to say that the disclosure of sexual abuse often feel like “a burden” and creates further distancing from peers within the work role. She describes this state, “I think it adds to the feeling of isolation. I have to protect everybody from what I’m walkin’ around with.”

Several participants reported that they felt most impacted when the system failed the child. Participants generally describe the system as encompassing what occurs from the time a child discloses through the child protection process and concluding with the criminal prosecution outcome. One participant describes her guilt about the systemic process which led to the outcome where “we put him [perpetrator] back in the house to do it all over again.” She then reported not wanting to continue with reinterviewing the child [upon subsequent disclosure] because of “my own guilt” for “the system failing her.” When discussing criminal prosecution outcomes, another participant reported, “the results (of the criminal prosecution) were so horrible . . . I felt guilty for having to prod her to tell.”

Not surprisingly, outside of the interview, in their personal life realm, interviewers report that their own history of abuse and trauma is a trigger for them to experience vicarious trauma. One forensic interviewer explained, “My own trauma, and my own abuse. For years, therapists have said, and I had no idea what they were talking about, you’re intellectualizing it, you’re intellectualizing it . . . one of the things that I’ve been working on for twenty years.”

Coping Responses
Interviewers described that over time, they developed very specific coping responses to the stress that they experienced in their work role. These responses included (a) shifting into a mode within the interview setting, (b) becoming hyper-competent within their professional role as a forensic interviewer, (c) engaging in high risk behavior as a way to cope with stress outside of their work role, and (d) disassociating from reality outside of their workplace.

In regards to coping responses, when forensic interviewers conducted interviews they all report “shifting into a mode” to conduct the interview and gather the details regarding the child’s experience. Once the forensic interviewers have shifted, they describe the ability to take in the information by “becoming disengaged and more technical” and by “intellectualizing the trauma.” One of the participants said that she has “trained” herself much like an “actor” to be emotionally “muted in that moment.” Another participant explained that she initially trained herself to mute her emotional responses in order to cope with the traumatic information that the children would share within the interview setting. One forensic interviewer stated, “I had to sit on my hands so that she [the child] would not see me trembling.”

The process of “shifting into a mode” helped modulate disengagement and engagement for forensic interviewers. The process of shifting was used to accomplish two tasks which were required to meet the expectations of their work roles. Participants reported most commonly shifting to a disengaged mode in order to (a) modulate emotionality, or being able to cope effectively as a professional who was hearing about traumatic violent and sexual abuse from the child. On the other hand, participants reported most commonly shifting to an (b) engaged cognitive mode in order to gather details regarding the traumatic event from the child’s perspective in order to gather the needed details from the child to be able to give evidence to the investigative team. One forensic interviewer describes this process:

And during the interview, during that moment where I’m getting information, I believe that I am consciously aware of obtaining the facts, getting everything that I need, despite getting this traumatic information. I don’t react to it right in that moment. I don’t know where I go. I mean, I’m there, but I don’t react. I get the information. I hang in there as long as I need to. I don’t show any shift in any kind of response. Even if the child is disclosing in a painful way.
Specifically, when engaging in a professional role outside the interview, the forensic interviewers noted that circumstances of the case, system failures, and job demands trigger vicarious trauma. In order to cope with this, forensic interviewers commonly and clearly identify going into a hyper-competent framework, as they report focusing on being the “best” interviewer, or admit to hiding their responses from other professionals and coworkers. One forensic interviewer describes, “I’m able to just do that one thing, and do that one thing really well.” Some participants noted that this response sometimes mirrored the abused children that they interviewed who became hyper-vigilant as a response to trauma, and not wanting to burden their parents.
As stated earlier, forensic interviewers experienced their work role as isolating, both physically (being the only one on the team) and emotionally. One interviewer described being secretive about being impacted by the interview she completed,

I was also afraid of showing anybody, this new team of people I’m working with, that, maybe I couldn’t do it. I was afraid to let on that I was having an emotional response. It was all I could do to not cry, and to just keep my shit together, and focus on whatever I was supposed to do. I feel a very strong responsibility to keep my own emotionality about the case, to myself. I rarely even share with my coworkers. There is a self-imposed sense of. . .‘they have enough of their own trauma. Go somewhere and deal with your own.’
In regard to coping responses outside of work, interviewers predominantly describe engaging in risky personal behaviors such as unprotected sex, sex with strangers, drinking and driving, and extreme sports (e.g., skydiving). One forensic interviewer described high risk behavior as a way of “resisting” the impacts of vicarious trauma when she went home at the end of the day, “Wanting to fight it, wanting to do something, wanting to change it, and I can’t, and so I sit in that frustration and, and, and, and (sighs), then maybe I just drink until I can’t even, till I don’t think about it anymore.” It is evident that these are coping responses related to the challenging nature of forensic interviewing because interviewers would say that they would do these things because they are thinking, “kids are getting fucking fucked, so fuck it.”
Cognitive Dissonance
Forensic interviewers also experienced trauma through cognitive dissonance, or conflicting thoughts or beliefs that occur at the same time, or when engaged in behaviors that conflict with one’s beliefs, such as sitting calmly with a child and processing stories of sexual abuse and violence without acting or being able to protect the child. One forensic interviewer reported that being in this position confused her, “I’m so deeply impacted by human suffering, that it’s puzzling to me . . . how I can sit there and intellectualize it.”

If there is no formal disclosure by the child during the course of the interview, and no corroborating physical evidence, in many cases, the child may return to the home with the accused perpetuator of sexual abuse. Often children are scared and nervous in the interview setting, placing the forensic interviewer in the difficult role of having to ask the child to disclose potentially painful and traumatic information in order to protect the child in the future. When referencing vicarious trauma, this interviewer describes how during a forensic interview, she experienced the conflicting role of the forensic interviewer—gathering details for the case versus attending to the child’s immediate emotional needs.

It was the only time I’ve ever really felt like, I mean I, I really keep the kids that I’m interviewing, um, in perspective, and I, you know, I try to really care for their feelings, but I also, you know have to keep in mind that I’m trying to get information to be able to do something about it.
Interviewers described experiencing cognitive dissonance outside of the interview setting, as a professional trying to make sense of the injustice and trauma contained within these cases. This often led the conflicting feelings of taking in anger and injustice versus moving on with one’s career and leaving the job due to vicarious trauma. One forensic interviewer was considering leaving her position due to the traumatic impact of the work, “If it would change things for this child, or that child, or children to come, to sit in the anger, and the injustice and the trauma of it all, I would stay there, but it isn’t, so I don’t know how to stay there . . . and I know I’m not gonna make any sense of it.”
Cognitive dissonance is also noted by forensic interviewers when they attempt to engage in the personal realm of their lives. Forensic interviewers often reported feeling constrained by the function of their work, which was in direct conflict with their training (most often social work/being an agent of change). One forensic interviewer describes the challenges of not being able to let go of the exposure of trauma that she experienced at work when she went home at the end of the day:

Maybe it’s a subconscious needing to make it ok . . . an attempt at resisting the information I’ve just been given. Ah, resisting, not denial. Wanting to fight it, wanting to do something, wanting to change it. And I can’t. So I sit in that frustration . . . I live in a constant state of, ‘this will never make sense’. . .
Syncretism
Forensic interviewers reported that one of the greatest barriers to coping with vicarious trauma in their work role involved not being able to achieve syncretism. Syncretism is viewed as a process that helps individuals achieve complete self-realization and build a social structure in which the physical, mental and spiritual needs of all people can be fulfilled. As previously stated, forensic interviewers often have to reinterview young children who the system previously failed. This is an example of how forensic interviewers commonly struggle with moving toward building meaning and fulfillment within their work roles. One forensic interviewer describes not being able to achieve syncretism due to system failures, which inhibited their ability to build or maintain credibility and trust with the children that they interviewed:

. . . he was put back in her home, to do it to her again, and (sniffs), I just, um, so that’s what makes me so sad, is just to see a little girl who this has happened to again. It’s not like I couldn’t sit there and know in my heart, we’re gonna fix this, we’re gonna, we’re gonna take him out of this home and we’re gonna get him some help. We promised her all these things before, and we, and it didn’t work. So, why would she trust us, why would she trust anyone? And she loves her brother (sniffs), who’s her perpetrator, and so, our credibility was . . . was in the toilet, you know (sniffs).
Along those same lines, interviewers also commonly struggle with achieving syncretism outside of the interview setting, while still at work. This often led to the feeling of losing sense of reality after leaving the interview room and returning to the office space. One interviewer described what she experienced shortly after completing an interview, when she returned to her office to decompress.
Is there something I can identify with in this case? If there is, what does that mean? Does that mean that there’s more for me to heal? Or, does that just mean that I identify at a level that is bringing it closer to me? And, maybe I don’t identify at all. It’s just wrong. There are times . . . I wish that I knew exactly what triggers it. Not often, but there are times when I have actually said out loud recently, ‘I have no room to know that this is real.’ What does that mean?
In an effort to describe how interviewers make meaning of the work, forensic interviewers often describe their meaning making process being impacted by intense feelings of vicarious trauma, even after their work day is over. Forensic interviewers often struggled to feel the benefits of their work in helping children, which often led to depression after they returned to their homes. These feelings are powerful and often unpredictable:
It isn’t until I leave the building, that I feel (deep breath). . . how the vicarious trauma is gonna present. Then it comes. Sometimes it’s anger. Sometimes it’s sadness. Sometimes it’s anger I think or sadness, but there’s a common theme of incredible helplessness and despair.
Discussion

Forensic interviewers reported that they experienced vicarious trauma in three realms of their lives: (a) within the interview space, (b) outside of the interview while working, and (c) in their personal lives outside of work. The participants all experienced four distinct elements of vicarious trauma, within each realm, which included, triggers, coping strategies, cognitive dissonance, and syncretism. Our findings indicate that forensic interviewers engage in many strategies to cope with vicarious trauma within their work role that actually make them better at their job, such as hyper-competence or vigilance. These coping strategies may garner forensic interviewers positive attention in the workplace, which may further reinforce their behavior. It is only when the impacts of vicarious trauma leak out into the forensic interviewer’s personal life through engagement in high-risk behavior and disassociation that they might experience negative reinforcement, which can potentially push them further away from peers and family. The research team also noted that activities outside the work place often involved adrenaline-seeking behaviors, such as sky diving and sexual encounters with strangers. Future research should examine the relationship between adrenaline seeking and vicarious trauma.

Both cognitive dissonance and barriers to syncretism were noted as two elements of vicarious trauma. Although, our participants were interviewing children, these results are similar to studies on clinical professionals who interview offenders who have committed sexual crimes. Barros et al., (2020) found that the clinicians described a process of becoming more “pessimistic, skeptical, and hopeless about human nature” the longer they stayed in the job. In a study on forensic interviewers’ burnout and coping mechanisms, it was found that forensic interviewers experienced burn out due to their work-lives, such as being consistently overwhelmed at work, not being supported by leadership and the organization, and having more intensive and consistent exposure to images of child sexual abuse (Fansher et al., 2020).

Our participants reported that they were often triggered within their workplace, but outside of the forensic interview. Having to review disturbing images of children that involved physical or sexual abuse created a long-lasting psychological impact and contributed to vicarious trauma. In a study that examined the impact of viewing similar photos, but within law enforcement computer forensics, the researchers found that secondary traumatic stress and burnout spilled over into their participants’ home and personal lives. This caused the participants to become more withdrawn from family and friends over time as a coping mechanism. Unlike the forensic interviewers that were interviewed for this study, the participants in law enforcement professionals scored high on self-efficacy, or believed that their work was making a difference in the world (Perez et al., 2010). Their ability to achieve some kind of syncretism in the work place might have mitigated the impact of vicarious trauma. Unlike the law enforcement professionals, the forensic interviewers interviewed in our study coped through mechanism such as, “turn-off your humanness” and “sacrifice yourself,” which they ultimately found to be maladaptive coping strategies, which increased vicarious trauma over time. In addition to other studies, the researchers found that participants with great connections and support from coworkers have lower rates of STS and burnout (Perez et al., 2010), thus again pointing to organizational factors having a significant impact on employees’ ability to engage in this work long term.

Forensic interviewing is a highly specialized field, in which individuals need several years of training to gain clinical expertise. Interviewers described the importance of considering the realm in which vicarious trauma elements occur, the specific types of triggers, and their own often-fluctuating baseline capacity when predicting a coping response. Perhaps one explanation or framework for understanding this phenomenon lies is the analogy of the teeter totter, depicting a continuum of coping or shifting responses ranging from engagement-type responses to disengagement-type responses. Within this analogy, different types of triggers predict the tilting of the teeter totter, while the base of the scale consists of the forensic interviewer’s initial capacity or baseline for trauma exposure as experienced in professional and nonprofessional roles outside of the forensic interview setting. In a study that focused on students who were learning how to be forensic interviewers, they found that role play was the most critical component to training. Forensic interviewers should have ample opportunities within their training to not only role play the forensic interviewer, but also role play the child being interviewed (Duron & Cheung, 2016). This study also mentions noting psychological and physical responses noted by the interviewer, and the importance of students knowing firsthand what it is like to explain sexual details in a child’s language.

Implications
When considering the phenomenon of vicarious trauma, of particular note in the current research study was the participants’ report of use of a shift or mode to modulate levels of engagement and disengagement within the forensic interview. Prior research infers that disengagement is a negative outcome of vicarious trauma (Perron & Hiltz, 2006). However, the current study suggests that disengagement, when utilized intentionally, may in fact have a positive impact on the forensic interviewer’s experience of vicarious trauma. Further research is needed to clarify the function of disengagement.

Moreover, because forensic interviewers experience the impact of vicarious trauma in compartmentalized realms of their lives, self-care frameworks and interventions should promote posttraumatic growth and include opportunities for forensic interviewers to practice different, targeted coping and recovery strategies, depending on the time point and realm they are currently experiencing. One core skill in building resiliency to vicarious trauma is an awareness of our physical, emotional, and cognitive reactions during the different time points in relation to initial trauma exposure: before, during, immediately after, and later/ongoing (Middleton, 2015). Awareness allows us to recognize trauma reactions, choose responses and control reactions, and develop plans for managing vicarious trauma and strengthening our resiliency long term. One such strategy, termed “The Four Quadrants of Self-Care,” has been found to help may be useful when helping professionals implement intentional self-care planning and man also be useful in helping forensic interviewers mitigate the impact of vicarious trauma across the different realms (Middleton, 2015).

Another area warranting additional research concerns forensic interviewers’ positionality and disempowerment as identified by participants. Betrayal trauma theory could be applied to this finding as interviewers report experiencing vicarious trauma caused by the very system they are a part of and serve (Freyd, 1994). This might help explain why disengagement, much like dissociation experienced by child victims due to betrayal trauma, is such a common coping response for forensic interviewers.

In summary, not only does the current study have implications for forensic interviewers and their unique experience of vicarious trauma, the study also has organizational and policy implications for all first responders and their agencies. Perron and Hiltz (2006) found that although forensic interviewers experience a significant amount of stress while interviewing children who are victims of physical and sexual abuse, the organizations that they work for may have the capacity to buffer this stress. Suggestions from other studies involving professionals similar to forensic interviewers, found that leadership at organizations can lessen vicarious trauma experienced by employees by rotating their employees to different positions to take a break from viewing graphic images, decreasing workloads, and increasing leaderships’ support regarding employee stress (Perez et al., 2010).

In studies involving forensic interviewers, burnout and job satisfaction, it was found that organizational factors again played into higher levels of job satisfaction and control, such as flexible scheduling, having effective and supportive supervision, and mentorship of less experienced forensic interviewers. Supportive work environments also included positive relationships with coworkers, which led to high satisfaction and less burnout (Chiarelli-Helminiak, 2014). Organizations could enforce policies that decrease vicarious trauma, such as minimizing employee’s exposure to graphic content and images, or limiting the number of interviews that forensic interviewers should engage in over the course of a day. Another study on forensic interviewers (McDonald et al., 2017) suggests that organizations can increase support for forensic interviewers by not having them work in isolation (such as the case of our participant who worked late nights, and often by herself). This study also suggests that employees and leaders be trained in the Sanctuary Model, which is an evidence-based, trauma-informed organizational development approach, which enables teams to design their own workplaces, and increase moral climates of agencies. These practices have shown to increase retention and decrease vicarious trauma in the workplace (Bloom, 2017).

Limitations
Several limitations exist in regards to the current study. Although the sample represents almost 100% of forensic interviewers in the state, it only represents one state. In addition, while this is probably representative of forensic interviewers around the United States, we still need to include other groups, including more nonwhite participants to better understand the phenomenon. The forensic interviewers who participated in our study were not asked about their own trauma histories; however, these narratives appeared in the interviews. Further research is needed to understand how previous trauma impacts vicarious trauma, which was a limitation of our current study.

Conclusion

We have often tried to understand vicarious trauma and other occupational stressors and health hazards (such as secondary trauma, compassion fatigue, and burnout) within a framework of symptoms. However, understanding how vicarious trauma functions within each of the three realms compartmentalized by the interviewers themselves, we can help organizations develop and target interventions that promote healthy coping responses to the inevitable traumatic nature of the work.

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Submitted: July 12, 2020 Revised: November 13, 2020 Accepted: November 13, 2020

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Source: Traumatology. Vol. 28. (1), Mar, 2022 pp. 74-83)
Accession Number: 2021-07081-001
Digital Object Identifier: 10.1037/trm0000297

Result List Refine Search PrevResult 28 of 68 Next
Secondary traumatic stress among emergency nurses: Prevalence, predictors, and consequences.
Authors:
Ratrout, Hamza Fathi, ORCID 0000-0001-6195-8755 . Department of Medical Surgical Nursing, College of Nursing, King Saud University, Riyadh, Saudi Arabia, hratrout@ksu.edu.sa
Hamdan‐Mansour, Ayman M., ORCID 0000-0002-9855-951X . Department of Community Health Nursing, Faculty of Nursing, University of Jordan, Amman, Jordan
Address:
Ratrout, Hamza Fathi, King Saud University, P.O. Box 642, Riyadh, Saudi Arabia, 11421, hratrout@ksu.edu.sa
Source:
International Journal of Nursing Practice, Vol 26(1), Feb, 2020. ArtID: e12767
NLM Title Abbreviation:
Int J Nurs Pract
Publisher:
United Kingdom : Wiley-Blackwell Publishing Ltd.
Other Publishers:
United Kingdom : Blackwell Publishing
ISSN:
1322-7114 (Print)
1440-172X (Electronic)
Language:
English
Keywords:
emergency department, nurses, prediction, prevalence, secondary traumatic stress
Abstract:
Background: Nurses working in emergency units are in direct contact with traumatic events. Trauma effects do not solely affect patients and their caregivers and, rather, extend to secondarily influence nurses themselves. Secondary exposure to trauma may result in symptoms similar to symptoms experienced by the patient themselves. No previous study investigated the secondary traumatic stress among emergency nurses in Jordan. Purpose: To identify prevalence, predictors, and consequences of secondary traumatic stress among nurses working in emergency departments. Method: A descriptive correlation design was utilized to collect data using self‐report questionnaires from 202 nurses working at eight emergency departments in Jordan. Findings: The study revealed that almost half of the sample reported high to severe levels of secondary traumatic stress. The analyses showed that nurses who demonstrated lower empathy (P = .016) and greater coping capacity (P < .001) tended to develop more secondary traumatic stress. Organizational factors were not significant predictors of secondary traumatic stress. Conclusion: A significant proportion of emergency nurses suffer secondary traumatic stress that is found also to be associated with psychical factors. Emergency nurses need to consider the consequences of secondary traumatic stress on their health and quality of care provided. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Caregivers; *Emergency Services; *Nurses; *Trauma; *Compassion Fatigue
Medical Subject Headings (MeSH):
Adaptation, Psychological; Adult; Compassion Fatigue; Emergency Nursing; Emergency Service, Hospital; Empathy; Female; Humans; Jordan; Male; Middle Aged; Prevalence; Stress, Psychological; Surveys and Questionnaires
PsycInfo Classification:
Inpatient & Hospital Services (3379)
Population:
Human
Male
Female
Location:
Jordan
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Scale of Perceived Organizational Support-Arabic Version
Coping Inventory Scale-Arabic Version
Life Events Checklist, Fifth Version-Arabic Version
Secondary Traumatic Stress Scale-Arabic Version
Job Satisfaction Index-Arabic Version
Multidimensional Scale of Perceived Social Support-Arabic Version
Toronto Empathy Questionnaire–Arabic Version DOI: 10.1037/t56682-000
Grant Sponsorship:
Sponsor: King Saud University, College of Nursing Research Center, Saudi Arabia
Recipients: No recipient indicated

Sponsor: King Saud University, Deanship of Scientific Research, Saudi Arabia
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jun 4, 2019; Revised: Mar 3, 2019; First Submitted: Oct 27, 2018
Release Date:
20210325
Copyright:
John Wiley & Sons Australia, Ltd.. 2019
Digital Object Identifier:
http://dx.doi.org/10.1111/ijn.12767
PMID:
31328356
Accession Number:
2020-09977-001
Result List Refine Search PrevResult 29 of 68 Next
Secondary trauma and compassion fatigue in foster carers.
Authors:
Hannah, Beatrice. Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom, Beatrice.hannah@kcl.ac.uk
Woolgar, Matt. Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
Address:
Hannah, Beatrice, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, Denmark Hill, London, United Kingdom, SE5 8AF, Beatrice.hannah@kcl.ac.uk
Source:
Clinical Child Psychology and Psychiatry, Vol 23(4), Oct, 2018. pp. 629-643.
NLM Title Abbreviation:
Clin Child Psychol Psychiatry
Page Count:
15
Publisher:
US : Sage Publications
ISSN:
1359-1045 (Print)
1461-7021 (Electronic)
Language:
English
Keywords:
Foster carers, looked after children, compassion fatigue, secondary trauma, burnout, job retention
Abstract:
Background: With the number of children being placed in the care of local authorities increasing, the need to recruit and retain foster carers is essential. Compassion fatigue is recognised as a negative effect for professionals working with adults and children who have experienced trauma. This study aims to confirm the proof of concept within foster carers and to explore the potential risks associated with intent to continue fostering, overall job satisfaction and psychological factors (avoidant coping) that could be targets for interventions. Methods: In total, 131 foster carers completed an online survey including self-report measures of compassion fatigue and associated risk factors. Results: Results confirm the existence of compassion fatigue among foster carers with rates in line with previous studies on other professionals working with children. High compassion fatigue was associated with lower intent to continue fostering and lower job satisfaction. Avoidant cognitive styles of psychological inflexibility and thought suppression were associated with compassion fatigue. Conclusion: The confirmation of compassion fatigue among foster carers and the potential risks to job retention are important findings for social care. The associations with avoidant cognitive styles have clinical implications for potential interventions. Recommendations for further research and the limitations of this study are also discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Caregivers; *Foster Care; *Occupational Stress; *Trauma; *Compassion Fatigue; Coping Behavior; Foster Children; Job Satisfaction; Risk Factors; Employee Retention
Medical Subject Headings (MeSH):
Adult; Caregivers; Compassion Fatigue; Female; Foster Home Care; Humans; Male; Middle Aged; Psychological Trauma
PsycInfo Classification:
Community & Social Services (3373)
Population:
Human
Male
Female
Location:
United Kingdom
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Secondary Trauma Stress Scale
Intent to Continue Scale
Professional Quality of Life Scale DOI: 10.1037/t05192-000
White Bear Suppression Inventory DOI: 10.1037/t01583-000
Job Satisfaction Scale
Acceptance and Action Questionnaire II DOI: 10.1037/t11921-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20200521
Copyright:
The Author(s). 2018
Digital Object Identifier:
http://dx.doi.org/10.1177/1359104518778327
PMID:
29848049
Accession Number:
2018-48236-011
Result List Refine Search PrevResult 30 of 68 Next
Secondary traumatic stress and veterinarians: Human–animal bonds as psychosocial determinants of health.
Authors:
Hanrahan, Cassandra, ORCID 0000-0003-1241-553X . School of Social Work, Faculty of Health, Dalhousie University, Halifax, NS, Canada, Cassandra.Hanrahan@dal.ca
Sabo, Brenda M., ORCID 0000-0001-5455-6686 . School of Nursing, Faculty of Health, Division of Palliative Care Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
Robb, Paul. Dartmouth Veterinary Hospital, Dartmouth, Halifax, NS, Canada
Address:
Hanrahan, Cassandra, School of Social Work, Faculty of Health, Dalhousie University, Room 3212, LeMarchant Street, P.O. Box 15000, Halifax, NS, Canada, B3H 4R2, Cassandra.Hanrahan@dal.ca
Source:
Traumatology, Vol 24(1), Mar, 2018. pp. 73-82.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
10
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Traumatology: An International Journal
Other Publishers:
US : Academy of Traumatology
US : Green Cross Project
US : Sage Publications
ISSN:
1085-9373 (Electronic)
Language:
English
Keywords:
secondary traumatic stress, veterinarian medicine, veterinary social work, human–animal interactions, human–animal bonds
Abstract:
Among health care professionals, veterinarians and veterinarian technicians (VVT) have been largely overlooked in terms of the consequences of preferred coping style, stress management, and care work (e.g., burnout, secondary traumatic stress [STS], and moral distress). STS, often referred to as compassion fatigue, can have serious negative physical, emotional, psychological, and spiritual impacts. Although trauma research has begun to shed light on the development of STS as an adverse consequence of care work, a limited understanding exists within the extant literature about the role of other factors such as individual coping style on the development of STS among health care professionals in general, but among veterinarians specifically. This lack of attention on VVT is not surprising when one considers disproportionate lower ranking of veterinarian medicine within the larger medical hierarchy, in which doctors of humans are generally bestowed with greater prestige. Within trauma research, no understanding exists within the extant literature about the relational significance of human–animal bonds in veterinary settings regarding the development of STS, and how they may function as social determinants of health, impacting both professional and organizational well-being. This discussion article seeks to add clarity to the issue as well as challenge current perceptions of veterinary work, its health consequences on VVT, and anthropocentrism in research more generally. Implications for education and research are provided. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Interspecies Interaction; *Veterinary Medicine; *Health Personnel; *Posttraumatic Stress; *Compassion Fatigue; Coping Behavior; Psychosocial Factors; Stress Management
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Sep 28, 2017; Accepted: Aug 2, 2017; Revised: Jul 14, 2017; First Submitted: Apr 3, 2017
Release Date:
20170928
Correction Date:
20201116
Copyright:
American Psychological Association. 2017
Digital Object Identifier:
http://dx.doi.org/10.1037/trm0000135
Accession Number:
2017-43375-001
Number of Citations in Source:
132
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Secondary Traumatic Stress and Veterinarians: Human–Animal Bonds as Psychosocial Determinants of Health
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Contents
Veterinary Settings and Occupational Stresses
Trauma, Bonds, and Contradictions: A Matrix of Complex Emotions
The Need to Expand the Scope of STS Research When Considering Veterinarians
Innovative Collaborations Between Veterinarians and Social Workers
Implications for Education and Research
Footnotes
References
Full Text
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By: Cassandra Hanrahan
School of Social Work, Faculty of Health, Dalhousie University;
Brenda M. Sabo
School of Nursing, Faculty of Health, Division of Palliative Care Faculty of Medicine, Dalhousie University, and Beatrice Hunter Cancer Research Institute, Halifax, Nova Scotia, Canada
Paul Robb
Dartmouth Veterinary Hospital, Dartmouth, Nova Scotia, Canada, and Eastern Shore Veterinary Hospital, Porters Lake, Nova Scotia, Canada
Acknowledgement: This article, written in collaboration, draws on Cassandra Hanrahan’s work on anthropocentrism in heath, in combination with the practice experience of a veterinarian and the secondary traumatic stress work of a clinical nurse researcher and academic.

Secondary traumatic stress (STS), often referred to as compassion fatigue, can have serious negative physical, emotional, psychological, and spiritual impacts. It has been described by Charles R. Figley (1995) as the “natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping, or wanting to help, a traumatized or suffering person” (p. 7). Although the symptoms are virtually identical, STS differs from posttraumatic stress disorder in that the person experiencing posttraumatic stress disorder is also the one suffering and experiencing the traumatic stress firsthand. Thus, care workers in any number of the helping fields and professions, ranging from community-based nonprofits to government agencies and from independent practice to health care institutions, are particularly at risk for developing STS.

Research has identified a number of factors that may increase the risk of occupational stress and, more specifically, STS for care workers. These factors include organizational issues (e.g., lack of control, poor leadership, and the disparity between discipline and organizational philosophies), empathic capacity, moral/relational issues, futility of care, and the witnessing, or being a recipient, of narratives of pain, suffering, and trauma (Austin, Goble, Leier, & Byrne, 2009; Maytum, Bielski-Heiman, & Garwick, 2004; Mealer, Shelton, Berg, Rothbaum, & Moss, 2007; Sabo, 2006; Sabo & Vachon, 2011; Simon, Pryce, Roff, & Klemmack, 2006). Although trauma research has begun to shed light on the development of STS as an adverse consequence of care work, a limited understanding exists within the extant literature about the role of other factors such as individual coping style on the development of STS among health care professionals in general, but among veterinarians specifically.

There are limited well-designed research studies focused on coping mechanisms, self-care strategies, and longitudinal studies using validated reliable survey instruments within the context of compassion fatigue or STS (Scotney, McLaughlin, & Keates, 2015). Not unlike their medical counterparts who provide care for humans, veterinarians are hesitant to acknowledge distress or access mental health services, which may further contribute to their overall risk for adverse consequences such as secondary trauma, burnout, and suicide (Larkin, 2013; Platt, Hawton, Simkin, & Mellanby, 2012). This lack of attention on veterinarians and veterinarian technicians (VVT) is not surprising when one considers disproportionate lower ranking of veterinary medicine within the larger medical hierarchy, in which doctors of humans are generally bestowed with greater prestige. As noted by the authors of Zoobiquity: What Animals Can Teach Us About Being Human, “the human medical establishment has an undeniable, though unspoken, bias against veterinary medicine” (Natterson-Horowitz & Bowers, 2012, p. 9). Further contributing to the invisibility of VVT in mainstream trauma research are the ways in which other health professions such as clinical psychology and human medicine, especially the specialty of psychiatry, have “lagged significantly behind veterinary medicine in the recognition of the value of the human–animal bond” (Hines, 2003, p. 10).

That VVT and students of these programs are generally overlooked in terms of STS is of significant concern given (a) their frequent exposure to trauma, (b) the contextualizing presence of the human–animal bond (HAB), and (c) the deleterious historical impact of humanism as an increasing source of moral conflict and distress for some VVT. Thus, one cannot consider the nature of STS in the lives of VVT without taking into account the myriad relational dynamics and often conflicting interactions that occur as part of the day-to-day work. In light of the considerable absence of consideration of VVT in trauma literature, this article explores the relational significance of HAB in veterinary settings regarding the development of STS, positing they should be regarded as significant social determinants of health, impacting both professional and organizational well-being. The article begins with a discussion of veterinary settings, exploring a range of occupational stresses in relation to suicidal behavior and psychosocial issues, and moves into contextualized discussions about the matrix of complex emotions that characterizes the work of VVT, and the need to expand the theoretical framework and ontological scope of STS research when considering VVT. It concludes by presenting examples of innovative interprofessional collaborations between social work and veterinary medicine, and a brief discussion about implications for education and research.

Veterinary Settings and Occupational Stresses

Acknowledging and honoring the emotional lives of companion animals is critical when considering the role veterinarians play in the delivery of care not just for nonhuman animals but also for their human companions. Veterinarians, like their human care provider counterparts, have responsibility for life and death. They are faced with cases of trauma, illness, injury, abuse, terminal illness, and death. Life and death situations have been further effected by the rapid advances in veterinary science and technology, permitting more complex levels of care for critically ill animals. Although palliative care in some cases can extend the quality of life of an animal, it is not uncommon for human companions of animals to request interventions that carry little hope for a successful outcome, creating the perfect storm for ethical dilemmas and occupational stress such as STS (Cohen, 2007). In contrast to life-sustaining decisions regarding palliative patients, VVT are frequently requested to provide euthanasia services for healthy animals often resulting in conflicts of interests (Baran et al., 2009).

Moreover, research suggests that as many as “70% of clients are affected emotionally by the death of their pet and that as many as 30% of clients experience severe grief in anticipation of or after the death of their pet” (Dunn, Mehler, & Greenberg, 2005, p. 59). The loss of a companion animal is an emotional event, yet this loss and its associated grief may not be acknowledged and validated, leading to what has been termed disenfranchised grief (Meyers, 2002) for the human companion. The lack of socially sanctioned grief over the loss of a family companion animal further reinforces the delegitimization of such grief. The human companion may then turn to the veterinarian for comfort and solace at the loss of a companion animal (Stutts, 1996). For example, “although caring deeply about their clients, most veterinarians and their staff are often overwhelmed and ill-equipped to deal with individuals’ emotional responses to the illness or death of a beloved companion animal” (Pilgram, 2010, p. 702). How and in what way bereavement support is provided and perceived has the potential to either mitigate or exacerbate the grief experienced by the human companion. Moreover, individuals expect compassionate therapeutic care and communication from veterinarians around loss (Blackwell, 2001).

A systematic review of suicidal behavior and psychosocial issues among veterinary surgeons noted a lack of research exploring factors that may contribute to suicidal behavior or poor psychosocial health; however, many of the studies were of poor or ambiguous quality (Platt et al., 2012). The authors cited low response rates across studies, lack of appropriate measures, and a general failure to include mental health-specific diagnostic measures and instruments. Additionally, the majority of studies included in the review were cross-sectional in nature rather than longitudinal, retrospective, or prospective and may be contributors to the overall poor quality of the studies. A cross-sectional study of veterinarians in New Zealand (response rate 48.6%; N = 926) that looked at sources of stress, forms of social support, and levels of distress found worrisome factors such as increased rates of suicide or suicidal ideation, with at least 2% of veterinarians having attempted suicide and another 30% having considered it (Gardner & Hini, 2006). Moreover, European, Australian, and German studies have highlighted poorer mental health within the veterinarian profession when compared with the general population or health care professionals. These studies reported a mortality rate from suicide four times that of the general population and twice that of other health care professionals (Bartram & Baldwin, 2010; Harling, Strehmel, Schablon, & Nienhaus, 2009; Smith, Leggat, Speare, & Townley-Jones, 2009). Similar rates have been reported in England and Wales, with rates three times that of the general population (Mellanby, 2005); reviews have also shown suicide rates ranging from 41.8 to 52.6 per 100,000 members of the veterinarian profession (Platt, Hawton, Simkin, & Mellanby, 2010). Possible factors contributing to the high rates may include personal factors, work-related stressors, gender, age, and contextual factors such as attitudes around death and dying, euthanasia of companion animals, and disenfranchised grief (Bartram & Baldwin, 2010; Pilgram, 2010), but more research is needed to fully understand the complex interactions on risk for suicide.

Perhaps most startling is evidence suggesting that veterinarians may experience stress, anxiety, and depression as early as their first year of study (Strand et al., 2012). In a sample of first-year veterinary students at three American universities, between 32% to 68% of students reported symptoms of clinical depression (Hafen, Reisbig, White, & Rush, 2008). Mental health concerns may persist beyond university leading to burnout (Hatch, Winefield, Christie, & Lievaart, 2011; Miller, 2004), substance misuse (Harling et al., 2009), depression (Rohlf & Bennett, 2005; Rollin, 2011; Shaw & Lagoni, 2007; Shirangi, Fritschi, Holman, & Morrison, 2013; Strand & Faver, 2005), relational issues (Bartram & Baldwin, 2010), and suicide (Bartram & Baldwin, 2010; Gardner & Hini, 2006; Platt et al., 2010, 2012). These findings should come as no surprise in a society that frequently fails to adequately acknowledge the multiple contradictory relationships people have with other animals, grief associated with the loss of a companion animal (Dunn et al., 2005), or, when it does, suggests normal human grief as time bound (Penman, Breen, Hewitt, & Prigerson, 2014).

Trauma, Bonds, and Contradictions: A Matrix of Complex Emotions

Indeed, the sheer number of animals and suffering that animal care workers encounter on a daily basis is much higher than that in the human health and related care fields (Figley & Roop, 2006). Animal care workers, especially those in organizations like shelters, rescue centers, and rehabilitation sanctuaries, sites at which VVT are regularly employed, can treat hundreds of animals daily in some instances (Figley & Roop, 2006). In addition to the staggering volume of animals, there are also many risk factors for compassion fatigue that are present in animal care fields and professions that inexorably render exposure to trauma within such settings. According to Strand et al. (2012), risk factors include the following:

Performing and/or witnessing euthanasia; treating animals cruelty cases; limited financial resources on the part of the organization or animal owner [sic]; volume of distressed clients and animals; the constant stream of unwanted and sick animals; and conflict within the workplace. (p. 257)
Recent studies suggest that VVT are at a higher risk of not only developing compassion fatigue but also committing suicide than their counterparts in any other care field (Ayl, 2013; Bartram & Baldwin, 2010; Bartram, Yadegarfar, & Baldwin, 2009). According to one U.K. study, “the veterinary profession has around four times the proportion of all deaths certified as suicide than would be expected from the proportion for the general population, and around twice that for other healthcare professionals” (Bartram et al., 2009, p. 1076). Regrettably, few animal care professions including veterinary practice are organized to include resources for self-care. Although the philosophies that organize and inform veterinary clinics and animal sanctuaries may differ, it is worth considering the premise of the The Kerulos Center’s study (Bradshaw, Borchers, & Muller-Paisner, 2012, Caring for the Caregiver: Analysis and Assessment of Animal Care Professional and Organizational Well-Being). Writing about the lack of social support as a leading factor in undermining the well-being of overworked and underappreciated animal care workers in underfunded sanctuaries, Dr. Gayle Bradshaw argues that the ability to care for animals well is directly linked to the well-being of the caregivers. According to Dr. Bradshaw,
. . . animal wellbeing is affected by human caregiver skills and wellbeing. Wellbeing is a function of internal and external resources—physical, social, emotional, and educational. The recent succession of sanctuary collapses illustrates the direct relationship between caregiver wellbeing, organizational health, and animal care quality. It is not unreasonable to expect that stresses on individuals and organizations will continue and increase, particularly in the current, unstable economic climate. However, despite the fact that animal care professionals are exposed to stressors comparable to human health counterparts, animal caregivers are allocated few to no resources that support their ability to deliver high quality care. (p. 3)
Moreover, the presence of HAB that shape and inform veterinary and other animal care environments, characteristically render such unique relational contexts and circumstances even more complex (Allen, 1985; Ayl, 2013; Hines, 2003). The American Veterinary Medical Association (AVMA, 2017a) defines the HAB as follows:
the mutually beneficial and dynamic relationship between people and animals that is influenced by behaviors that are essential to the health and well-being of both. This includes, but is not limited to, emotional, psychological, and physical interactions of people, animals, and the environment. (para. 1)
Ironically, the unique combination of frequent trauma exposure and HAB creates relational and situational dynamics about which veterinarians receive little to no training in core curriculum (Fogle, 1999). Notwithstanding recent initiatives to include self-care into curriculum in some veterinary colleges in Canada and the United States—such as, for instance, the Western College of Veterinary Medicine’s (WCVM) first social worker position intended to provide social work support to a range of people including animal owners, clinical faculty, and staff, and veterinary students at this regional veterinary college and its veterinary medical center (Neufeld, 2015)—significant gaps in veterinary medical curricula continue to exist (Adams, Conlon, & Long, 2004; Shaw & Lagoni, 2007; Sherman & Serpell, 2008), despite the leadership of veterinary medicine in the recognition and development of HAB (Hines, 2003).
Insofar as HAB are those mutually positive relationships between humans and other animals, the larger history of human–animal interactions (HAI) points to an anthropocentric world that industriously produces a range of contradictory interactions and associations between humans and other animals that involve all manner of usury, exploitation, and violence (Evans, 1906/1987; Serpell, 1996). In the Company of Animals (Serpell, 1996), a comprehensive study of the history of HAIs from hunter/gatherer to tribal and urban societies, Serpell contends that the denigration of nonanthropocentric activities (including some pet-keeping relationships) and attitudes was essentially part of basic survival. It is worth quoting Serpell at length to capture the extensive reach of humanism in shaping human beliefs regarding other species:

Affectionate or empathetic perceptions of animals or nature are incompatible with our unsympathetic treatment of economically useful species. The harsh and implacable philosophies that underwrite this treatment were spawned in an era in which moral reservations about ruthless exploitation were out of place. It was necessary instead, to suppress empathetic feeling, to cultivate detachment, to conceal the facts or distort them, and where possible to shift the blame for what was happening away from the perpetrators. Above all, it was necessary to fabricate an image of humanity—more especially western humanity—that was separate and apart from the rest of creation, sacred and superior, answerable to no one but God and, more recently, Mammon. (p. 235)
Not only did humanism separate out the human from all other species, it also assigned to the latter a secondary or lower status, and consequently, a contemptuous regard for nonhuman animals within mainstream human society (Ryan, 2011; Serpell, 1996). The history of humanism as an organizing force of the western culture, including the world of medicine and related health professions (Ryan, 2011), may be contributing to the moral distress and cognitive dissonance experienced by VVT and other animal care workers today. As previously described, although the organizational philosophies of sanctuaries and rescue centers may differ from that of veterinary clinics, the following findings from the Caring for the Caregiver (Bradshaw et al., 2012) report may indeed be relevant to veterinary clinical settings and related organizational structures:
The between-species legal inequality is an intrinsic source of tension between the goals of animal care (animal wellbeing) and those of the greater society (anthropocentric privilege). This misalignment often undermines the ability of caregivers to protect their charges. For example, the status of animals-as-property can impede intervention on behalf of the animal victim, where a comparable situation for human victims of violence or neglect would permit, indeed mandate, intervention. (p. 5)
This anthropocentric ontology or worldview has forcibly resulted in a corresponding lack of general recognition of the mutual benefits of HAB, let alone the role for many humans of companion animals as attachment figures, and even for some, as significant others (Sable, 1995). As an expression of species bias, anthropocentrism gives rise to the additional injurious phenomenon of disenfranchised grief (Meyers, 2002), defined as that which “persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported” (Pilgram, 2010, p. 701).
The Need to Expand the Scope of STS Research When Considering Veterinarians

The past 20 years have seen a surge in research linking exposure to pain, suffering, and trauma with the experience of STS related to the provision of care by health care professionals (Abendroth & Flannery, 2006; Adams, Boscarino, & Figley, 2006; Figley, 1999; Joinson, 1992; Sabo, 2006). Researchers suggest that the phenomenon is connected to the therapeutic relationship between the provider and client, in that the traumatic or suffering experience of the client triggers a response on multiple levels in the provider. In particular, an individual’s capacity for empathy and ability to engage in, or enter into, a therapeutic relationship is considered to be central to STS. Theorists argue that individuals who display high levels of empathy and empathic response to a client’s pain, suffering, or traumatic experience are more vulnerable to experiencing STS (Adams et al., 2006; Figley, 2002). Researchers suggest the corollary of the ability to be empathic and compassionate is the capacity to work with clients to lessen their pain and suffering or ensure a “good death” (Bergum & Dossetor, 2005).

Paradoxically, people who empathize with and care deeply for nonhuman animals are often ridiculed even pathologized, for allegedly using companion animals as “substitutes for so-called ‘normal’ human relationships” (Serpell, 1996, p. 24). This particular theory trivializes not only the topic of “pet-keeping” specifically (Serpell, 1996) but also that of HAB more generally. Throughout Western history, nondominant groups—such as Blacks, Jews, indigenous, and other racialized people; women and witches; and spiritualists and visionaries—have been animalized as a means of moral debasement and rational for oppression and enslavement. The pairing of some groups of humans with nonhuman animals, such as the poor with vermin, and woman with bitch, is intended to signify the alleged depravity of the human entity through association with the devalued animal other (Adams, 1990; Adams & Donovan, 2007; Evans, 1906/1987; Patterson, 2002; Serpell, 2002; Spiegel, 1997). In examining the history of pet-keeping in its myriad forms and meanings, Serpell (1996) argued that, in the West,

there are no reasonable grounds for regarding the mundane majority of pet-owners as potential zoophiles or fanatics any more than there is reason to treat all alcohol drinkers as embryonic dipsomaniacs. Pet-keeping undoubtedly does involve a degree of sentimentality, but this is not sufficient reason why the subject should be ignored or ridiculed. Much, if not most, of what people derive from close relationships involves sentiment, and there does not appear to be any obvious justification for repressing or belittling such feelings when they are applied to animals. (p. 42)
Thus, given the nature of the work undertaken by VVT, including the numerous risk factors for STS that are present in veterinary settings, making exposure to trauma a near constant, combined with the presence of HAB, which increase the levels of emotional complexity—it is therefore reasonable to assume that they are at risk for the development of STS. In practice, VVT not only provide care for nonhuman animals but also are often a main source of emotional support for the humans involved in those animals’ lives (Holcombe, Strand, Nugent, & Ng, 2016). Notably, the AVMA (2017a) maintained that
the veterinarian’s role in the human-animal bond is to maximize the potentials of this relationship between people and animals and officially recognizes: (a) the existence of the human-animal bond and its importance to client and community health, (b) that the human-animal bond has existed for thousands of years, and (c) that the human-animal bond has major significance for veterinary medicine, because, as veterinary medicine serves society, it fulfills both human and animal needs. (para. 1–2)
Although VVT, as health professionals, are trained to attend to the physical needs of nonhuman patients, gaps within education may leave them inadequately prepared to deal with the experiences of biophilia, defined as the “innate tendency to focus on life and lifelike processes” that involve “a deep and complicated process in mental development” (Wilson, 1984, p. 1), that can often be confusing or disorienting in an anthropocentric world that readily objectifies nonhuman animals both as individuals and as species collectives. Such circumstances give mixed messages to VVT and indeed anyone who cares for nonhuman animals, and this can be readily observed in the emotional aftermath and disenfranchised grief human companions experience following a traumatic event or loss of a nonhuman animal (Adams et al., 2004; Shaw & Lagoni, 2007; Sherman & Serpell, 2008). This is not dissimilar to health care professionals serving only humans who frequently fail to enter into difficult conversations with patients and families because they feel inadequately skilled or prepared or out of fear that in the process of supporting the individual, they may cause further distress (Stajduhar, 2011; Thorne et al., 2005).
Invariably, VVT typically work with two service-user groups, both of whom experience pain and suffering, whether physical or emotional/psychological. The terms of the veterinarian–client–patient relationship (VCPR) outlined in the AVMA’s Principles of Veterinary Medical Ethics (Principle II; AVMA, 2017b) distinguishes human service users as clients from nonhuman animal service users as patients, and as noted in the AVMA reference guide on VCPR, serves as “the basis for interaction among veterinarians, their clients, and their patients and is critical to the health of your animal” (AVMA, 2017c, para. 1). The distinction in terminology, however, signaling the difference between who receives medical diagnoses and interventions, and who requests and pays for those services—does not, ultimately, guide VVT in how to “maximize the potentials of the HAB” (AVMA, 2017a, para. 1). As noted earlier, veterinary medical curricula rarely includes the study of HAB and HAI (Adams et al., 2004; Shaw & Lagoni, 2007; Sherman & Serpell, 2008), and this gap in education and training can have serious health consequences, resulting in VVT becoming enmeshed in complex emotional scenarios owing to the multiple roles imposed on them by circumstances (Bradshaw et al., 2012), for which they have little to no training.

In addition to the two roles associated with the two client groups for whom VVT serve as physician to patients and emotional support worker or ad hoc counselor to clients, respectively, there are also the dual roles associated with the “care–kill paradox” (Bradshaw et al., 2012). In Caring for the Caregiver, Bradshaw finds that “in many instances, caregivers are simultaneously an instrument of animal salvation and euthanasia” (p. 7). Research shows that the adverse effects of living with such a contradiction become not only a characteristic of occupational self-identity for animal shelter workers (Arluke & Sanders, 2009; Baran et al., 2009; Bradshaw et al., 2012), but also a significant risk factor for a range of psychological disturbances. According to Bradshaw et al. (2012), “caregivers who endure this ‘care-kill paradox’ often exhibit symptoms of unresolved grief, high blood pressure, depression, susceptibility to illness, cognitive impairment, irritability, increased conflict, aggression, suicidality, high rates of employee turnover, and substance abuse” (p. 7). However, for some practitioners, euthanasia may not be a paradox but rather viewed as a continuity of care, especially when it comes to the perceived differences regarding production animals versus companion animals. This particular distinction may help to further distinguish between the terms euthanize, slaughter, and kill.

Feeling overwhelmed, helpless, and unable to respond to the needs of their human clients, particularly if there has been minimal educational training on grief counseling or supportive communication around delivery of bad news (Pilgram, 2010), or experiencing guilt over euthanization (Cohen, 2007; Morrisey & Voiland, 2007; Rollin, 2011) may increase the likelihood of risk for occupational stress such as STS. Moreover, research also suggests that VVT as a population of care providers may be more reticent to seek intervention (Rank, Zaparanick, & Gentry, 2009).

To date, with the exception of the emerging body of academic literature about the developing field of veterinary social work (VSW) “as a specialized area of social work practice” (Strand et al., 2012, p. 245), there is a paucity of research on the adverse occupational consequences that may occur as a result of caring for both companion animals and their humans. In capturing the current challenges to and opportunities for health for VVT, it is necessary for STS research to extend its scope to incorporate the extensive literature on HAI and on HAB more specifically, to better understand the complexity of the emotional circumstances created in the presence of HAB, and their unique impacts on VVT, whose personal values and interests may or may not always be in sync with those of the anthropocentrically privileged world.

Much of the research exploring and substantiating the human health benefits that include physiological, psychological, emotional, and spiritual benefits that can develop out of interactions between humans and other animals, companion animals in particular, draws on relatively recent interprofessional health collaborations and is strongly informed by transdisciplinary perspectives, correlating to research from the humanities, the social, and natural sciences (Barker, Rogers, Turner, Karpf, & Suthers-McCabe, 2003). These studies are collectively categorized as HAB, HAI (Arluke & Sanders, 2009; Taylor & Signal, 2011), human animal studies, and critical animal studies (DeMello, 2010; Taylor, 2013). These innovative fields evaluate and challenge norms and expand conceptual and disciplinary boundaries, as well as practice principles by exploring the cultural and cross-cultural meanings of HAI in the lives of individuals, including health professionals, families, and communities.

A groundswell of publications, including peer-reviewed articles in academic journals and books, academic and professional conferences, and specialized research institutes in these innovative fields of study, explore the meanings of nonhuman animals in relation to humans and vice versa, as well as to our shared environments. They include a wide range of contributions from virtually all disciplines including in abridged format: sociology and anthropology (Arluke & Sanders, 2009; Flynn, 2000b, 2008; Noske, 1989, 1997, 2008; Serpell, 1996, 2002), psychology (Levinson, 1969, 1964; Taylor, 2003; Walsh, 2009a, 2009b), political and moral philosophy (Francione, 2009; Regan, 1983/2004; Singer, 1975/2009), feminist and ecofeminist theory (Adams, 1994, 1995; Adams & Donovan, 2007; Besthorn & McMillen, 2002; Glasser, 2011), law (Francione, 1995, 2000), ethics (Botes, 2000), nursing (Johnson & Meadows, 2010; Johnson, Odendaal, & Meadows, 2002), social work (Faver, 2009; Hanrahan, 2011, 2013, 2015; Risley-Curtiss, 2010a, 2010b; Tedeschi, Fitchett, & Molidor, 2005; Wolf, 2000; Yarri, 2006; Zilney, & Ziley, 2005), veterinary medicine (Arkow, 1998; Catanzaro, 2003; Hart, 2000a, 2000b, 2010; Rowan & Beck, 1994), biology and ethology (Bekoff, 2007; Wilson, 1984), and history of science (Haraway, 2003, 2008).

Although studies exploring occupational stress (e.g., burnout and STS) are increasing, there appears to be limited research focused on health-seeking behavior associated with psychological stress arising out of veterinary care work (Nett et al., 2015). In the study by Nett et al. (2015), the authors noted that veterinarians were less likely to seek help and more negative about the benefits of treatment for mental health than the general population in the United States. Furthermore, “of the 1,077 respondents classified as having current psychological distress, 633 (59%) were not currently receiving mental health treatment” (p. 950). Their findings coupled with research from the United Kingdom, France, Australia (Platt et al., 2012), and New Zealand (Gardner & Hini, 2006) suggest a need for more research into the psychological impact of veterinary work and barriers to health-seeking behavior and interventions.

This is all the more pressing when one considers the relatively recent growth in the practice of “pet-keeping” in the West since the mid-20th century, combined with the changing cultural attitudes toward animals, and thus the increasing visibility of and expectations on veterinarians, especially those in small animal practice. Serpell (1996) suggests that,

far from being perverted, extravagant, or the victims of misplaced parental instincts, the majority of pet owners are rational people who make use [sic] of animals to augment their existing social relationships, and so enhance their own psychological and physical welfare. (p. 147)
Consequently, the increased ubiquity in the West of companion animals in the lives of individuals and families has direct impact on veterinary practice that is rendered more complex “as a result of the growing body of knowledge providing evidence about the complexities associated with the HAB” (Holcombe et al., 2016, p. 73). According to Holcombe et al. (2016), however, “[d]espite this positive change in direction, this shift is not without risk of increasing the psychological stress that can lead to veterinarians and their staff developing compassion fatigue” (p. 73).
Innovative Collaborations Between Veterinarians and Social Workers

Innovative collaborations between veterinarians and social workers with specialized training in key areas including HAIs and veterinary sciences are gaining momentum in an effort to address the emotional needs of both veterinarian practitioners and the human companions of the nonhuman patients receiving care. VSW is gradually becoming integrated into veterinary clinics, veterinary medical programs/colleges, and hospitals, playing a key role in counseling and supporting vet practitioners and students, as well as human companions of the animal patients (Dunn et al., 2005).

As an innovative interdisciplinary and interprofessional partnership between social work and veterinary medicine, VSW is a specialized approach to working with human–other animal relationships that “not only adheres to the ethics, practice, and paradigm of social work, but also relies on the expertise of the veterinary medical profession for attending to the needs of animals” (Strand et al., 2012, pp. 246–247). At the University of Tennessee, in the first-of-its-kind joint program between the College of School of Social Work and the College of Veterinary Medicine, VSW is defined as a subspecialty of “social work practice that attends to the human needs that arise in the intersection of veterinary medicine and social work practice” consisting of four major areas that are as follows: (a) grief and pet loss, (b) animal-Helped interactions, (c) the link between human and animal violence, and (d) compassion fatigue management, for people working with animals that are abused, neglected, or need to be euthanized (Veterinary Social Work, n.d., para. 1). Within this particular model, the four areas of focus highlight specific ways in which nonhuman animals are meaningful to and impact human lives. The area of grief and loss recognizes the significance of the HAB, validating the ensuing grief that is often experienced with the loss or death of a companion animal (Carmack, 1985; Morley & Fook, 2005; Sable, 1995). Animal-Helped interactions encompass the multiple ways human health and welfare can be augmented throughout the life span with diverse animal-Helped therapies and activities (Chandler, 2005; Fine, 2015; Levinson, 1964, 1972; Netting, Wilson & News, 1987). The link, as it is referred to in the literature, exposes animal cruelty as a form of human violence that is often an indicator of other forms of violence in families such as domestic and other interpersonal violence (Adams, 1994, 1995; Ascione, 2008; Ascione & Arkow, 1999; Faver & Strand, 2003; Flynn, 1999, 2000a, 2000b).

In Canada, the first full-time veterinary social worker position was created in 2015 at the WCVM in conjunction with the Faculty of Social Work, University Regina, placing the incumbent at the forefront of a critical new vocation. The term VSW has also been used to describe community veterinary outreach clinics that have been established across Canada to provide pro bono preventive veterinary services to people who are homeless or at risk of becoming homeless and who have companion animals. The Canadian community veterinary outreach clinics are organized under the auspices of the not-for-profit community-based group community veterinary outreach (Community Veterinary Outreach, 2014):

Community Veterinary Outreach’s One Health engagement initiatives leverage the human-animal bond and veterinary care to engage marginalized pet owners in social services and health care directly at veterinary outreach clinics. One Health Engagement initiatives integrate community-level collaboration of veterinary teams with social service workers and human health care providers. This collaboration cooperatively improves the health and welfare of humans and animals, demonstrating that veterinary care can act as a gateway to improve health and social service delivery for underserved and marginalized populations. (Personal Communication with CVO founder and Director Michelle Lem)
Additionally, the community veterinary outreach clinics may also offer veterinary professionals supplemental opportunities to experience meaningful work satisfaction.
Implications for Education and Research

With a lack of research exploring occupational stress and STS among VVT, it is critical to address what appears to be a rising work-related health concern. Understanding, in greater depth, the emotional matrix surrounding VVT, as well as their preferred coping style in managing stress related to their work, is an important first step. To this end, the popular alternative to the medical model, the biopsychosocial model (Pattyn, Verhaeghe, Sercu, & Bracke, 2013) may constitute an effective framework for investigating HAB and their impacts on the physical, psychological, and social dimensions of lived experience by VVT.

Innovative initiatives that not only focus on increasing awareness of the potential adverse consequences this population of care providers may experience but also engage VVT are needed. As explained earlier, VSW, as an original interprofessional response to STS, constitutes an emerging body of theory and practice to which trauma research should relate. Additional steps might be to normalize the emotional consequences of the work VVT do as well as the grief associated with caring and loving relationships. Intervention studies are also needed to develop, implement, and evaluate strategies to more effectively support psychosocial health and well-being. Historically, health care has had a tendency to rely on limited short-term interventions with little attention to evaluate the effectiveness of the intervention. Over the past decade, for example, one large health authority in Canada has implemented a number of occupational stress-reduction strategies, few of which have been in place for longer than 12 months. This does not afford enough time to accurately assess their effectiveness to enhance health care professionals’ stress management skills, to reduce occupational stress and sick time, to evaluate overall cost – benefit ratio, or provide time to systematically evaluate processes that may underlie the success or failure of an intervention (Egan, Bambra, Petticrew, & Whitehead, 2009; Murta, Sanderson, & Oldenburg, 2007; Semmer, 2006).

Moreover, education on self-care and potential risks of care work must be embedded in curriculum as well as organizational structures for VVT to ensure optimal psychosocial health and well-being. To emphasize this point, it is worth quoting Bradshaw et al. (2012) at length:

Human health care organizations commonly provide their staff (e.g., nurses, social caregivers, hospice caregivers, family caregivers) some level of institutional resources as support to offset the stresses deriving from intrinsic (e.g., client trauma) and extrinsic (e.g., fiscal and legal shortfalls) sources. In recognition of the negative correlation relationship between performance and workplace stress, human hospitals and other helping organizations offer health and stress management programs, and encourage high standards for professional behavior via frequent performance assessments. Resources include counseling, continuing education in subjects related to their work, training in conflict resolution and interpersonal skills, and self-care tools. However, for cultural and fiscal reasons, these resources are not usually made available to animal caregivers and their organizations by funders. (p. 17, italics not in original)
Additionally, courses on HAI, HAB, and grief and grief management should be provided, given the changing cultural ideas about nonhuman animals in Western society, the known connections between animal cruelty and other forms of human violence, and the supportive role VVT play in caring not only for the companion animal but also for the companion animal’s person or people, who will frequently turn to them for support.

The consequences of care work are not the sole domain of health professionals working with human patients and their human families. As research continues to uncover, acknowledge, and validate the HAB and its implications for emotional distress when they are disenfranchised, veterinarians are expected to provide emotional and bereavement support for an animal’s human companion at the time of loss or critical illness, and also presumably to fare independently of such bonds themselves as professionals. Without adequate education and training, veterinarians may find themselves increasingly overwhelmed and at ever greater risk for occupational stress such as STS. There is a critical need to extend the theoretical focus of trauma research concerning VVT using a contextualized intersectional approach that recognizes peoples’ connections and bonds to other-animal companions as well as the broader anthropocentric sociopolitical milieu in which we all live and work. Such an approach is decidedly interprofessional and interdisciplinary and draws on the ever-expanding academic fields of HAI, human–animal studies, and critical animal studies, all of which take up in varying ways the study of human–animal relations. By highlighting the relational significance and pivotal role of HAB in veterinary settings and extending our understanding of such bonds as social determinants of health impacting both professional and organizational well-being, we will be in a better position to put in place resources to support the emotional well-being of veterinarians, their human clients, and other animal patients.

Footnotes
1 The use of the term pet-keeping is borrowed from HAI historian James Serpell and is a deliberate choice over the more common phrase companion animal ownership, a phrase that takes for granted the proprietorial association between human and nonhuman animal.

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Submitted: April 3, 2017 Revised: July 14, 2017 Accepted: August 2, 2017

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Source: Traumatology. Vol. 24. (1), Mar, 2018 pp. 73-82)
Accession Number: 2017-43375-001
Digital Object Identifier: 10.1037/trm0000135

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Landers, Ashley L.. Virginia Polytechnic Institute and State University, Blacksburg, VA, US, land0552@vt.edu
Dimitropoulos, Gina. University of Calgary, Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
Mendenhall, Tai J.. University of Minnesota, MN, US
Kennedy, Alison. University of Minnesota, MN, US
Zemanek, Lindsey. University of Minnesota, MN, US
Address:
Landers, Ashley L., Department of Human Development and Family Science, Marriage and Family Therapy Program, Virginia Tech, 7054 Haycock Road, Office 202C, Falls Church, Blacksburg, VA, US, 22043, land0552@vt.edu
Source:
Family Relations: An Interdisciplinary Journal of Applied Family Studies, Vol 69(2), Apr, 2020. pp. 308-319.
NLM Title Abbreviation:
Fam Relat
Page Count:
12
Publisher:
United Kingdom : Wiley-Blackwell Publishing Ltd.
Other Journal Titles:
The Coordinator; The Family Coordinator; The Family Life Coordinator
Other Publishers:
United Kingdom : Blackwell Publishing
ISSN:
0197-6664 (Print)
1741-3729 (Electronic)
Language:
English
Keywords:
spouses, law enforcement, secondary trauma
Abstract:
Objective: To explore the lived experiences of secondary trauma among partners of law enforcement professionals (LEPs). Background: Stress is a common occurrence for LEPs. Although research suggests that LEPs are directly affected by trauma exposure, few studies focus on the secondary trauma of partners or spouses of LEPs. Method: Utilizing transcendental phenomenological inquiry, in‐depth qualitative interviews were conducted with a purposeful sample of eight spouses of law enforcement recruited from community groups and police departments. Results: The results revealed three overarching themes of how participants experienced being partnered with an LEP: (a) types of trauma exposure, (b) the ripple impact of trauma, and (c) strength of couples and how they cope with trauma. Conclusion: Findings suggest that spouses are both affected by trauma and serve a supportive role to LEPs following trauma exposure. Because secondary trauma can exacerbate existing difficulties in communication and emotional intimacy within couples’ relationships, a greater understanding of the impact of trauma on law enforcement couples may lead to greater resources to help support couples wherein one individual is directly exposed to work‐related trauma. Implications: Family professionals should promote healthy responses and coping among law enforcement couples following exposure to traumatic events. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Emotional Trauma; *Law Enforcement; *Spouses; *Compassion Fatigue
PsycInfo Classification:
Police & Legal Personnel (4290)
Marriage & Family (2950)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Grant Sponsorship:
Sponsor: American Association of Marriage and Family Therapy, Research and Education Foundation, US
Other Details: Graduate Student Research Award
Recipients: No recipient indicated
Methodology:
Empirical Study; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20191024
Correction Date:
20210902
Digital Object Identifier:
http://dx.doi.org/10.1111/fare.12393
Accession Number:
2019-63589-001
Number of Citations in Source:
35
Images:

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Backing the Blue: Trauma in Law Enforcement Spouses and Couples
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Contents
Secondary Traumatic Stress Theory
Literature Review
Present Study
Method
Sampling and Sample Characteristics
Procedures
Data Analysis
Credibility and Trustworthiness
Results
Theme 1: Types of Traumatic Event
Theme 2: The Ripple Impact of Trauma
Impact of the trauma on the LEP
Impact of trauma on the spouse
Theme 3: The Strength of Couples and How They Cope With Trauma
Individual coping
Couple coping in response to trauma
Supportive role in response to trauma
Composite Description of the Essence
Discussion
Clinical Implications
Strengths and Limitations
Conclusion
Author Note
References
Full Text
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Objective: To explore the lived experiences of secondary trauma among partners of law enforcement professionals (LEPs). Background: Stress is a common occurrence for LEPs. Although research suggests that LEPs are directly affected by trauma exposure, few studies focus on the secondary trauma of partners or spouses of LEPs. Method: Utilizing transcendental phenomenological inquiry, in‐depth qualitative interviews were conducted with a purposeful sample of eight spouses of law enforcement recruited from community groups and police departments. Results: The results revealed three overarching themes of how participants experienced being partnered with an LEP: (a) types of trauma exposure, (b) the ripple impact of trauma, and (c) strength of couples and how they cope with trauma. Conclusion: Findings suggest that spouses are both affected by trauma and serve a supportive role to LEPs following trauma exposure. Because secondary trauma can exacerbate existing difficulties in communication and emotional intimacy within couples’ relationships, a greater understanding of the impact of trauma on law enforcement couples may lead to greater resources to help support couples wherein one individual is directly exposed to work‐related trauma. Implications: Family professionals should promote healthy responses and coping among law enforcement couples following exposure to traumatic events.

Keywords: couples; law enforcement; secondary trauma

Stress is a common occurrence for law enforcement professionals (LEPs) who experience crime, violence, and life‐threatening situations as part of their daily work (Abdollahi, [ 1]; Hartley, Violanti, Sarkisian, Andrew, & Burchfiel, [14]; Woody, [35]). When an LEP is exposed to a traumatic event, time and space constraints limit opportunities to process the experience (Gershon, Barocas, Canton, Li, & Vlahov, [13]). The resulting psychological challenges may filter through to the LEP’s family life, whose spouse must often manage residual spillover from the work. Indeed, it is not uncommon that traumatic stress can spill over into the couple’s relationship, parenting, and family life (Johnson, Todd, & Subramnian, 2005).

Although research suggests that LEPs are directly affected by trauma exposure, few studies focus on the influence of trauma on law enforcement (LE) spouses and couples (see Alexander & Walker [ 3]; Maynard, Maynard, Mccubbin & Shao, 1980; Meffert et al., [21]; Miller, [23]; Roberts & Levenson, [32]). The investigations that have focused on LE spouses suggest that police work has a detrimental impact on LE spouses (Alexander & Walker, [ 3]) and that those in close contact with the traumatized person also experience symptoms of traumatization (Henry et al., [15]; Nelson & Wampler, [26]; Regehr, [30]). This is illustrated when, during times of stress, LE spouses exhibit their own physiological arousal (Roberts & Levenson, [32]). Although symptoms of secondary traumatic stress have been found in LE spouses (Meffert et al., [21]), few studies have explored the role of LE spouses and the types of coping mechanisms that help alleviate traumatic stress for the LEP, the spouse, and the couple.

LE spouses may experience secondary trauma as a result of their spouse’s work. They may also experience stress and depression as their spouse struggles with trauma (Meffert et al., [21]). Stress can be due to issues with work schedule demands, the LEP being absent or suddenly called away, a traumatic event, or worrying about the spouse’s safety (Maynard et al., [20]; Miller, [23]). Spouses of LE deal with high degrees of both stress and exhaustion, which coupled together increase the likelihood for negative coping (Roberts & Levenson, [32]). Stress is associated with couples’ relationship quality (Lambert, Engh, Hasbun & Holzer, [17]), which can be explained to some extent by spillover of work into family life. For example, the authoritarian leadership (e.g., chain of command, top‐down orders, and obedience; Woody, [35]) that serves as a protective factor for LEPs on the job may infiltrate the couple’s relationship. This can contribute to issues with dyadic communication and emotional intimacy (Johnson, Todd & Subramanian, [16]). There is also pressure for couples to behave in a way that aligns with expectations of police families to remain loyal to the institution or profession (Miller, [23]). For instance, LEPs are socialized to be “tough” on the job, and in a parallel process, their spouses are socialized to be “strong.” There is tremendous pride within the LE community, but there is also pressure and minimal space for vulnerability (AbuseofPower.info, [ 2]; Miller, [23]).

Family support is critical for reducing the negative impact of stressful work in other professions (e.g., firefighters; Regehr, Dimitropoulos, Bright, George, & Henderson, [31]). This support appears to act as a moderator between traumatic stress exposure and negative symptoms (e.g., posttraumatic stress indicators; Regehr, [30]). Spouses of LEPs play a supportive role directly related to the LEP’s trauma experiences (Henry et al., [15]). This role can be manifested in various ways, including exuding patience and listening following a traumatic event. Spouses may also play instrumental roles, such as taking on additional responsibilities to lighten the LEP’s burden after a traumatic event. Particular coping mechanisms, such as acceptance, social support, and communication, Help with managing the impact of trauma in LEP couples (Henry et al., [15]; Maynard et al., [20]). Given that couple coping mechanisms lead to improved outcomes for both the couple and each member, this may be a crucial avenue of research.

Because there is a high prevalence of trauma exposure and traumatic stress in LEPs (Abdollahi, [ 1]; Hartley et al., [14]), more studies exploring LE couples are needed. Such work will Help clinicians to better understand how trauma affects the couple relationship and how to reduce its negative impact. Studies focusing on spouses of LE are particularly important because of the role that they play in moderating the relationship between traumatic stress and negative outcomes (Regehr, [30]; Regehr et al., [31]). The present study fills a gap within the literature pertaining to the need for more information on how spouses of LEPs perceive themselves as being affected by the trauma. Understanding these couples can inform interventions for those suffering from trauma within this population, which in turn may lead to greater resilience for LE couples.

Secondary Traumatic Stress Theory
LEPs are often exposed to traumatic events throughout the course of their work. Traumatic stress refers to the stress that occurs during or after an LEP’s direct exposure to a distressing event involving a perceived threat (e.g., being targeted with gun shots), witnessing a traumatic event in person (e.g., watching someone commit suicide), or extreme or repeated exposure to aversive details of an event or images of child abuse (Miller, [22]; Perez, Jones, Englert, & Sachau, [28]). Some LEPs exhibit symptoms of posttraumatic stress after traumatic stress exposure, including recurrent, intrusive, and distressing memories of the event (American Psychiatric Association, [ 4]; Robinson, Sigman, & Wilson, [33]). LEPs may also exhibit secondary traumatic stress, which is defined as the natural consequence of “behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping or want to help a traumatized or suffering person” (Figley, [12], p. 7). Secondary traumatic stress results from working with traumatized persons (e.g., interviewing crime victims, investigating child abuse allegations) or from reviewing evidence (Perez et al., [28]). The spouse of an LEP can also experience secondary traumatic stress when the LEP is exposed to a traumatic event (Meffert et al., [21]). In this instance, secondary traumatic stress emerges from the spouses’ empathy toward and contact with their spouse (Meffert et al., [21]). Spouses’ stress reactions in such instances are considered secondary (in response to) the LEPs’ direct exposure to trauma.

Literature Review
The health of family members influences the quality of family relationships (Proulx & Snyder, [29]). One aspect of health is stress (or the absence of stress), which affects relationship quality. High levels of work‐induced stress are associated with negative couple interactions (Crouter, Perry‐Jenkins, Huston, & Crawford, [10]). Furthermore, traumatic stress has a negative impact on couples’ relationships and family life (Johnson, Todd, & Subramnian, 2005). Among high stress professions, family support has been found to play a critical role in reducing the detrimental impacts of work (e.g., in firefighter and paramedic populations; Regehr, [30]; Regehr et al., [31]). Spouses of high stress professionals appear to take pride in and serve as sources of support, but they also encounter a number of challenges, such as secondary traumatic stress.

Stress is a common aspect of the LE profession, but few studies have focused on the impact of trauma on LE spouses and couples (exceptions include Alexander & Walker, [ 3]; Maynard et al., [20]; Meffert et al., [21]; Miller, [23]; Roberts & Levenson, [32]). A few key findings from this small body of research suggest stress associated with LE work adversely affects LE spouses and families (Alexander & Walker [ 3]). In other words, LEPs carry job‐related stress into the home with them, which affects their marital interactions (Roberts & Levenson, [32]). Said research also shows that LE spouses play important supportive roles (e.g., it appears that the coping mechanisms of LE spouses’ aid in management of the stress associated with the LE profession; Maynard et al., [20]).

Present Study
Given the high prevalence of trauma exposure and subsequent traumatic stress in LEPs, studies focusing on the impact of trauma on spouses of LE are needed. The purpose of this study was to explore the lived experiences of LE spouses. The central themes investigated were related to stressors stemming from trauma exposure and strategies contributing to couple health in the aftermath of trauma exposure.

Method
Phenomenological inquiry within a social constructionist paradigm was used to explore the lived experiences of trauma and its subsequent impact on couples’ relationships. The philosophical underpinnings of social constructionism suggest that there is no universal objective experience; lived experiences and their meanings with a phenomenon are, instead, socially constructed realities. For example, in this study, LE spouses describe their experiences within the framework of their understanding of police work. Transcendental phenomenological inquiry was selected over other qualitative approaches based on the exploratory nature of the research question (Denzin & Lincoln, [11]), as well as its fit with the first author’s philosophical stance as a postmodern social constructionist. Phenomenology involves conscious intention; those who use this approach ascribe to the belief that the reality of a phenomenon may only be understood by an individual’s experience of it in a constructivist sense (Creswell, [ 8]; Moustakas, [25]). Phenomenology is not rooted in the simplification or reduction of phenomena to explain causal relationships. It is rather intended to explore how individuals describe their experiences through their own senses (Creswell, [ 8]).

Sampling and Sample Characteristics
A purposeful sample was recruited from two community groups for partners and spouses of LE and three police departments within one Midwestern state. Inclusion criteria required that participants be partnered with or married to an LEP—police, corrections officers, state patrol officers, sheriff deputies, and troopers (Bulletproof Vest Partnership, [ 6])—who had been exposed to traumatic events (as self‐reported by participants), regardless of the length of the relationship or the length of the LEP’s service, and resided in state. Exclusion criteria included individuals who were under 18 years of age, required a translator to communicate in English, or were unable to provide informed consent due to a developmental disability or cognitive impairment. Ten individuals who were screened for inclusion and exclusion criteria qualified and were subsequently invited to participate in the study. Two women who initially expressed interest in participating later declined to take part due to time and scheduling restrictions. The final sample size of eight was sufficient to conduct analyses using a phenomenological approach (Creswell, [ 8]).

Participants ranged in age from 31 to 42 years of age (M = 35.6, SD = 4.2) and all were married Caucasian females in their current relationship for 4 to 14 years (M = 10.9, SD = 4.6). All of the participants had children (M = 2.3, SD = 1.0). Their highest completed education ranged from some college to a doctorate; half held a master’s degree or higher. Six participants were employed full‐time (e.g., nurse practitioner, mental health professional, speech and language therapist, laboratory technician, information technology project analyst) and the other two were a stay‐at‐home mother and a college student. Seven couples were mixed‐gender and one couple was same‐gender (women). Our sample of highly educated Caucasian women is consistent with samples reported in previous research on LEP partners and spouses (Meffert et al., [21]).

Procedures
After obtaining informed consent, participants were interviewed individually in their homes or another preferred meeting space by the first and last authors, conjointly. Each interview was guided by the following statements and questions:

Please think of an occasion when you noticed that your partner’s exposure to a traumatic event(s) had a direct impact on your relationship; describe your experiences, as well as how you attributed meaning to this situation.
Similarly, but stated differently to see if it jogs any other thoughts: In what ways do you believe your partner’s exposure to the traumatic event(s) affects your relationship?
Now we would like to follow‐up on some areas in the relationship, some that you may have already touched on and others you may not have. [Follow‐up questions were asked regarding couple communication, quality time, conflict, intimacy, family relationships, roles within the relationship, spiritual beliefs, and coping mechanisms.]
How does your partner’s exposure to the traumatic event(s) affect you? (Again, you may or may not have touched on some of this already.)
Think of an occasion when you noticed that the traumatic event(s) had a direct impact on you; describe your experiences as well as how you attributed meaning to this situation. What were your reactions (thoughts, feelings)? How did you cope?
Interviews were audio‐recorded and lasted 90 to 150 minutes. The recordings were then transcribed verbatim, and transcripts were checked against audio‐recordings to verify accuracy.

Data Analysis
Interview transcripts were read in their entirety before coding. In accordance with Moustakas’s approach (1994), horizonalization was employed wherein statements were identified that provided rich information about the experiences of participants. Next, statements that were irrelevant to the topic, repeated, or overlapping were deleted to create a clear picture of the pertinent statements. The important statements that remained were then clustered into meaning units and themes. Themes were then synthesized into a description of participants’ experiences. This included both textual and structural components of description—that is, both what and how it was experienced. Lastly, composite descriptions of the meanings and essence of the experiences were constructed. The essence is a synthesis of the textual and structural descriptions of participants’ experiences, which captures the essence of the meaning ascribed to the experience (Moerer‐Urdahl & Creswell, [24]).

Credibility and Trustworthiness
In an effort to limit potential bias, we practiced epoche by intentionally setting aside preconceived notions of the phenomenon (Moerer‐Urdahl & Creswell, [24]; Moustakas, [25]). The first author had both personal and professional relationships with a number of LE couples. Interviewers illuminated ideas and potential biases that each respectively held, and, once illuminated, they were able to suspend them. For example, a potential bias could be that all LE spouses are resilient and offer support to their LEP partner. Ways these biases were suspended included regular discussions and consultations with other authors, as well as member‐checking our findings (i.e., seeing whether participants agreed with our conclusions). To increase trustworthiness, the same two researchers were present for each of the interviews, which ensured a consistent understanding of interviewee. An audit trail was used for reflexivity to document the thinking processes of the researchers during data collection (Creswell & Miller, [ 9]). The first and last authors initially analyzed the same two transcripts. There was a high level of consistency (92%) between them; therefore, no independent analysis for verification was needed. Each researcher then went on to analyze a unique half of the remaining transcripts. Finally, after all of the transcripts were coded, the first and last authors looked at the coding together to verify that there were no discrepancies. In instances of discrepancy, the coding was discussed, and a mutually agreeable code was selected.

Results
Three themes revealed how participants experienced being partnered with an LEP who was exposed to traumatic events. The first theme related to types of traumatic events. The second theme concerned the ripple impact of trauma, which had two subthemes: (a) impact on the LEP and (b) the ripple impact on the spouse. The third theme revolved around the strength of couples and how they cope with trauma, which had three subthemes: (a) individual coping, (b) couple coping, (c) supportive role (see Table ). The number following quotes represent the randomly assigned identification number designated to that participant.

Subthemes or Meaning Units and Supporting Statements

Subthemes or meaning units Supporting statements
Types of traumatic events • “It turns out that it was a man who had committed suicide by standing in front of a train. So pretty much worst‐case scenario for a death scene.”
• “He had a coworker that he helped resuscitate that died. And he was young.”
Impact on law enforcement professional • “I think for guys and especially guys in a stereotypically macho profession, they’re not supposed to talk about it, not supposed to talk about their feelings, they’re not supposed to, so they internalize.”
• “He tends to just keep everything bottled up. And really just gets really rude and crabby and it just turns into a fight. And he’ll pick a fight about something ridiculously stupid so we’ll have fights over 5 dishes that got left in the sink.”
Impact on spouse • “I mean there’s—with his accidents and all that there’s limits to our quality of time. It’s really been affected with the shift work and then with the accidents, because he’s not able to do many things and it’s the damage of the job that does it. You know he wouldn’t have had these things if he was an accountant.”
• “I think that anytime she’s at work whether it’s on patrol or even a crime scene thing after hours, or now even going to court, whether or not I am consciously aware of it, I am aware of it, that there is danger. And there isn’t that same sense of danger when she’s at home with us.”
Individual coping • “I think for me it is, for my personality is it is. Yeah I think for me it’s helpful to have my schedule and my routine and my own purposes.”
• “I actually find a lot of comfort in talking with the other women.”
Couple coping • “I took the kids everywhere, I made appointments, I did everything. Again, not okay, but I got used to doing it and why change when he was home. And he didn’t want to do it anyway. He just wanted to do what he wanted to do.”
• “I think sometimes he comes home with an attitude or like a shield and I think that sometimes it gets hard, ya know to deal with that, because I’d like to know what’s happening, but at the same time I don’t. So it’s hard. But then if he just, you know, if I say did you have a bad day or did something happen and it’s just, ‘Yeah it was just not a good day’. And I just kind of know the fact that something happened and I don’t want to know anyway.”
Supportive role • “I am the safe person that he can say, yeah it completely sucked to see somebody run over by a train.”
• “I’m there when he needs to talk to someone … I like to see myself as the person that he can confide it.”
Theme 1: Types of Traumatic Event
Participants identified numerous types of traumatic events to which their LEP spouses had been exposed, including death scenes involving citizens, infants, or fellow officers; injury of fellow officers; emergency response situations, such as disasters and fires; domestic disputes; medical emergencies (e.g., performing CPR); and motor vehicle accidents. Although all of the incidents were traumatic, some participants noted that the LEPs were affected differentially by different types of traumas; events involving children, suicide, and officer death were reported to have the greatest impact on the LEP from the perspective of the spouse.

Most partners talked about the LEP witnessing or responding to violence or death. For example, one participant stated that her spouse’s “first suicide … [was] a gentleman who had shot himself in the head. There was brain matter everywhere, so his job at the scene was to pick it up and put it in a bag” (782). Another stated that the LEP “did CPR on a baby that didn’t make it” (786). Others described direct injuries to the LEP or a colleague, such as the death of a partner, a broken shoulder while pursuing or apprehending suspects, and being severely injured to the point that survival was in question for a few days. Although each exposure was considered traumatic according to the partner of the LEP, not all were equal in their impact. Impacts on the couple are described in Theme 2.

Theme 2: The Ripple Impact of Trauma

Impact of the trauma on the LEP
Participants’ descriptions of the ripple impact of trauma fell within two subthemes: (a) how the trauma affected the LEP (emotionally and behaviorally) and (b) how the LEP’s spouse was affected by secondary traumatic stress. Participants described a wide range of emotional reactions in the LEP following the traumatic event(s), including mood changes, detachment, internalizing, hypervigilance, reexperiencing or replaying the event, anxiety, and avoidance. Many participants talked about the emotional impact of trauma on the LEP. For example, one stated that “he had gone to a death scene, and he didn’t talk about it, and then for about a week he was just like horrible; he was just rude and mean and short‐tempered and just completely crabby” (783). Another paraphrased the LEP as saying “that picture [of a suicide] just keeps flashing in my mind” (782) with regard to one traumatic experience and “I can always remember that screeching noise that something’s coming to hit me” (782) in reference to an out‐of‐control car.

Other participants described the LEP’s behavioral reactions to trauma. For instance, one spouse said that the LEP had “never used to carry his weapon when he was off duty and now he carries it all the time” (783). She continued in noting that nowadays “he’s never off duty; he is always on … when I go out with him, he has to sit where he can see the exit” (783). Thus, the impact of trauma on LEPs often seemed to be manifested in hypervigilant behavior that signified they were always on guard and cognizant that the next traumatic event could occur at any time.

Impact of trauma on the spouse
Participants described their own emotional reactions to secondary trauma. For instance, one participant said, “I play the event of the resuscitation in my brain or what I think it was even though I never saw it” (781). Another said, “I am more nervous about him going to work now. I think it’s because an officer was killed during a domestic dispute” (783). The spouse of the LEP who now sits with a view of the exit indicated that she had adopted his newfound and consistent sense of insecurity because during moments when “he’s not scanning the room, then I have to scan the room” (783). More generally, participants described experiences with nausea, intrusive thoughts, anxiety, shaking, confusion, mood changes, fear, and worry stemming from their own responses to the LEP’s exposure to traumatic events.

Participants described experiencing a sense of “worry” for both themselves and their partners. Given incidents that had occurred with other LEPs, one partner acknowledged that she had “worries about being a widow and raising my kids without their father” (781). Similarly, another participant framed concern about the dangers of the job by juxtaposing LEPs with those engaged in a more conventional workplace: “I don’t necessarily have to worry that my husband is going to go to work and have an affair with his secretary like someone might if their husband had an office job. Instead I worry about him getting shot” (783). Another partner described encountering conflicted emotions and guilt after an officer’s death within the larger LE community because, mixed with worry and sadness for the surviving spouse, there was a sense of relief that it was not her own husband who had died (784). Another participant described the emotional toll that such incidents produce by instilling chronic worry because “you have that knowledge that [being killed on‐the‐job as an LEP] does happen” (781).

Theme 3: The Strength of Couples and How They Cope With Trauma

Individual coping
Participants described coping mechanisms that entailed both seeking and providing personal support within the LE community, whether in spousal support groups or from other LEPs and spouses. For example, one participant stated, “I have deepened my bonds with other law enforcement wives … I get personal and emotional relief from talking to [them]” (783). This participant elaborated by conveying how these groups counter feelings of isolation among those who worry: “It’s nice to … not feel alone, to know that even though we’re all thinking these terrible thoughts, at least we’re thinking them together” (783). Another stated that all the wives “were just calling each other and being our own support and calling tree” (784). This same participant described her relationships with the other wives as “friendship” and “support.” Another participant stated, “I get an emotional bubble of support from these people that I know that are out there. That has meant a tremendous amount [to] me” (785), and another maintained that “I’m in that wives’ group that makes sure you get support … we’re a close‐knit group, [and we] talk a lot” (789).

Couple coping in response to trauma
Participants reported coping as a couple by communicating about exposure to traumatic events, providing mutual support and understanding to one another, being conscious about coping as a couple unit, demonstrating flexibility, and prioritizing quality couple time. One stated: “If something bad happens, we get really cohesive” (781). Couple coping inevitably entailed prioritizing the relationship and enjoying one another’s company. For example, humor was crucial for at least one couple: “Humor helps, so that’s probably the one thing we rely on. And we have to remind each other kinda like, ‘lighten up’ when someone takes things too seriously” (787). Others described resilience coming from having “a well of good times” together (786) so that “in the midst of the bad times [they could] remember the good times” (782). Increasing communication, shared exercise, and maintaining a simplified or routine schedule were other modes of couple coping described by these LE wives in the aftermath of traumatic experiences. The strength of couples’ unions and coping sequences emerged from their shared experience of living with the trauma.

Supportive role in response to trauma
Participants described playing a supportive role to the LEP by being empathic, taking on additional responsibilities, providing emotional support, caregiving, using humor, providing encouragement, being flexible, and adapting to the needs of the LEP. Openly communicating about traumatic event exposure and processing trauma were important for many of these LE participants; they made conscientious efforts to make themselves available to the LEP by “being there when he needs to talk to someone [because] … I like to see myself as the person that he can confide in” (783). They understood that processing traumatic experiences took time and that there were no shortcuts: “There’s nothing I can do but be supportive and talk if he wants to” (788).

Composite Description of the Essence
Exposure to traumatic experiences has an impact on LEPs, as evidenced in the wide range of emotional and physical responses described by these participants, such as internalizing symptoms, emotional detachment, reexperiencing the event, and hypervigilance. Emotional and physical reactions to LEP trauma are experienced by LE spouses as well. Participants in this study described providing a supportive role by offering emotional support, caregiving, being flexible, and communicating effectively. Couple coping strategies are employed after exposure to a traumatic event, including increased communication, mutual support and listening, engaging in activities together, and renegotiating roles and responsibilities. Trauma influences the value and priority of family, the responsibilities of each spouse, parenting practices, utilization of extended family support, and the necessity to access support from the LE community. The essence of LE participants’ exposure to traumatic events was that “it could happen to any officer at any time” (783), which left these wives to grapple with the reality that any traumatic events experienced by other LEPs “could have [occurred on] his shift or his incident” (781), and occasionally did.

Table displays the final model of findings that emerged across all three themes and their subthemes. In summary, partners of LEPs and the couple’s relationship were affected by secondary traumatic stress. Secondary traumatic stress was manifested in both emotional and behavioral ways, as evidenced by how partners described the LEP’s emotions and behavior (and their own reactions to the trauma). LE couples displayed a range of coping behaviors in response to the trauma, while partners operate within a supportive role.

Synthesized Findings

(Sub)Theme Findings
Type of traumatic events Stress, death scene, officer death, trial, bad call (emergency response), domestic dispute, schedule, death of child, accused of wrongdoing, bit by canine.
Ripple impact of trauma
Impact of trauma on law enforcement professionals Difficulty emotionally engaging, fatigue, arguments, short‐tempered, quiet, tired, internalizing, stress/anxiety, emotionally detached/numb, trained to handle these things, wants to be alone, hard to wrap head around, hypervigilance, needs time to process, loss/grief, re‐experiencing/replaying the scene avoidance/shutting down, challenge of job, transitioning, rigidity, missing friend/family time, changes in interactions between spouses, flashbacks.
Impact of trauma on partner of law enforcement professionals Nausea, making medical decisions, crying, different type of deployment, hypervigilance, balancing needs/ adaption of environment, intrusive thoughts, paralyzed, scary, significant meaning, emotional process, anxiety, tunnel vision, communication stressful, questioning, confusion, worry, life changing, shaky hands, tension, arguments, stress, grief, disrupted sleep, fear, intrusive memories, fear of being widow, pit of my stomach, difficulty relating, sinking feeling, uneasy, moodiness, confusion, reframing role reversal, guilt, notification, gratitude, change in intimacy, resentment.
The strength of couples and coping
Individual coping Support from other law enforcement wives, journaling, routine, have own purpose, keep going, being part of the law enforcement community alcohol/tobacco use, religion, mental reframing/preparation, use resources service, support to other law enforcement families.
Couple coping Increase communication, coping together as a team, date nights, make us a priority preparation, being flexible, mutual support/understanding.
Supportive role Empathetic, medical decision‐making, grateful it’s not me, worker mode, joking run the household/take on responsibilities encourage being a team, emotional support, flexible, safe person, communication, caregiving.
Discussion
Trauma exposure among LEPs has increasingly come to the attention of both researchers and the lay public, but less attention has been paid to LE partners or spouses. Given that stress is commonplace for LEPs (Abdollahi, [ 1]; Hartley et al., [14]; Woody, [35]) and that family support reduces the detrimental impact of trauma in other service professionals (e.g., firefighters; Regehr et al., [31]), the purpose of this study was to explore the lived experiences of LE spouses. Findings coalesced around three themes: (a) perceptions of types of traumatic events, (b) the ripple impact of trauma on the LE and the couple, and (c) couple strengths and coping.

A major finding of this study is that LEP spouses experience stress when LEPs are exposed to trauma, a phenomenon often referred to as secondary traumatic stress (Roberts & Levenson, [32]). This finding is consistent with Regehr et al. ([31]), who found that spouses of firefighters are both affected by and supportive after trauma exposure. We also found that LEPs’ reactions to traumatic events are often transferred to their spouses, as described by the participants in this study and manifest as secondary traumatic stress symptoms (e.g., nausea, intrusive thoughts, anxiety, worry); this finding is consistent with other literature (e.g., Henry et al., [15]; Regehr, [30]).

Research and clinical literature regarding the effects of (and treatments for) trauma exposure have been disproportionately focused on the people who are directly exposed (Henry et al., [15]). This is important work because of the deleterious impact(s) that traumatic events and subsequent recovery processes can have on surviving victims, which is well documented (Miller, [23]). Further, the long‐term ramifications of trauma exposure may contribute to a host of negative outcomes, such as increased likelihood of marital problems and, for some, even divorce (Becker et al., [ 5]; Lane, Lating, Lowry, & Martino, [18]). However, most LEPs (and indeed, most people) reside within social systems of couple, family, and community groupings, and significant others within these systems are (a) often affected by secondary trauma and (b) can serve as resources for support and coping among those directly exposed to traumatic events (Lev‐Wiesel & Amir, [19]). Research is only beginning to broaden its scope to include the voices of significant others in exposed professionals’ lives; the study presented here is one such investigation.

Our findings further advance extant knowledge about how to engage the spouses of high‐risk individuals such as LEPs in attending to their own well‐being while synchronously supporting their partner and effectively coping as a couple and family. A wide variety of traumatic events can occur within one’s work as a police officer, and these events transpire within an ongoing and stressful job context (Hartley et al., [14]; Woody, [35]). Advancing the notion that LE personnel’s trauma affects their marital and family life, our findings show considerable impact on spouses whose trauma arose from knowing about the traumatic experiences of their partners (Maynard et al., [20]; Meffert et al., [21]). These impacts, like people directly exposed, cut across physical, psychological, and social levels of functioning and put couples at risk for a host of difficulties that could go unnoticed if services target LEPs but not their spouses and families (Woody, [35]). Further, spouses represent an important source of support for LEPs, but the capacity of a spouse’s help is reduced when they too are hurting. And when two spouses are struggling, individually, their marriage and family are at increased risk for discord and dissolution (Lambert et al., [17]). Alongside services for LEPs, then, employers and community agencies should offer support systems for spouses (individually) and couples/families (collectively); the majority of our participants suggested that this was a much‐needed source of support. Thus, employers and community agencies should provide spouse and family support as standard and ongoing practice—not only after an individual has died.

LEPs may not seek formal avenues of help, but they often turn to their spouses following trauma exposure. Family support, particularly spousal support, appears to alleviate negative symptoms associated with traumatic stress exposure (Regehr, [30]; Regehr et al. [31]). LE spouses offer direct support following an LEP’s trauma exposure. How support is offered varies by relationship but may include practicing patience and listening (Henry et al., [15]). The present study also unveiled a new layer: Although LE wives offer profound support to LEPs, such support is not always reciprocated. Some have to look outside the couple relationship to get their emotional needs met after the LEP’s trauma exposure. Partners were expected to be resilient and supportive in helping LEPs resolve trauma. However, there appeared to be little space for LE spouses to process their own secondary trauma within the couple’s relationship; rather, they often turned to the greater LE community (e.g., other LE spouses and spousal support groups).

The manners in which participants in our study described how they cope are informative for these and related types of service professionals. Although some coping strategies are individual in both frame and nature (e.g., prioritizing self‐care activities) and applicable to each spouse respectively, others are purposively designed for couples and families. Coping mechanisms Help LE families in reducing the detrimental impact of trauma. LEPs receiving (and offering) support to each other creates a space whereby others who are intimately familiar with the stressors of this type of job are able to connect and support one another. This is relevant to LE spouses as well, insofar as LE spouses share a common experience, which thereby produces empathy, support, suggestions, and fellowship that may be more authentic and helpful than can be offered by a clinician, family member, or other person who does not have personal experience with being married to an LEP (Miller, [23]). Community organizations and groups facilitating these types of connections are well placed, and employers should work actively to learn about (if extant), create (if not extant), and make these resources known to their workforce.

Clinical Implications
Our participants described many experiences and practices that align with what was already known to be optimal relationship strategies. With regard to coping with trauma exposure (direct and secondary), however, communication within the couple relationship stood out as key. This skill is essential for any healthy couple or family (Carr, [ 7]; Thomas & Olson, [34]), but works in some unique ways within couples who live with the ongoing stress of LE, particularly when there has been exposure to trauma. It is important for these couples to feel a sense of permission or safety when asking (and answering) questions about each other’s day‐to‐day experiences and to maintain a mutually responsive and supportive presence with and for each other when particularly painful or evocative experiences occur. The intentional scheduling of time for communication may be beneficial for LE couples (Miller, [23]). In a similar manner to the beneficial processes outlined earlier (i.e., LE spouses talking with other LE spouses, and LEPs talking with their professional peers), future efforts to create and facilitate forums where families can connect with other families could be a useful resource. Creating space, for example, in which a couple that has been married for several years could share their wisdom with a comparatively less experienced couple could also be supportive in a way not accessible via a textbook or conventional clinical setting.

Our finding that LE spouses carry tremendous burden and caretaking responsibilities for the LEP is consistent with other areas of caregiver burden research (e.g., Parks & Noviello, [27]). The supportive caretaking role can be stressful for LE spouses, who are left to find ways to manage and cope with chronic and traumatic stressors. Using a family systems or systemic approach, couple and family therapists should assess the degree of caregiver burden experienced by LE spouses. Recognizing that LE couples are exposed to secondary traumatic stress and its associated symptoms, therapists can educate couples about such stresses and the types of resources that may benefit them (consistent with practical recommendations from Parks & Noviello, [27]). Couples may benefit from learning coping strategies that reduce both the impact of secondary trauma and caregiver burden. Knowing that partners of LE are likely to provide caregiving, and are unlikely to be cared for, therapists can use this knowledge to ask about and assess alternative means of support available to partners. At the very least, clinicians should have awareness that LE spouses carry this burden. In turn, clinicians can be intentional in asking partners about their experiences, the impact of trauma on the couples’ relationships, and how respective partners are coping.

Strengths and Limitations
This study extends previous research on partners of first responders (e.g., firefighters) by exploring the experiences of law enforcement spouses. Although understanding the lived experiences of LE spouses with regard to (secondary) trauma can contribute to couple health, this study is not without limitations. Caution must therefore be exercised when drawing conclusions based on content presented here. The findings of this study may be specific to this particular sample, but may not represent the experiences of all LE wives or couples. We also relied on single reporters (i.e., only one half of a couple); experiences of the LEPs were not directly captured. The limited sample diversity is also important to acknowledge because our sample comprised Caucasian women, the majority of whom were in mixed‐gender marriages and were well educated. The stress and coping behaviors of this sample were therefore taking place from a relatively privileged position in society. For these reasons, additional studies are needed that use different methodologies to draw more generalizable findings, examine change over time, assess dyadic couple data, and draw samples from other diverse populations.

Conclusion
Traumatic experiences affect LEPs, and their emotional and physical reactions to trauma appear to carry over to their spouses. The investigation described here captures the essence of the lived experiences of these spouses related to stressors and coping strategies that they employ. It is crucial for researchers and professionals to understand the challenges faced by LE couples and families after exposure to a traumatic experience or event. By exploring the impact(s) of trauma on the couple system, this study illuminates the importance of the supportive role that LE spouses play for LEPs.

Author Note
This research was supported by an American Association of Marriage and Family Therapy Research and Education Foundation Graduate Student Research Award.

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~~~~~~~~

By Ashley L. Landers; Gina Dimitropoulos; Tai J. Mendenhall; Alison Kennedy and Lindsey Zemanek

Reported by Author; Author; Author; Author; Author

Source: Family Relations: An Interdisciplinary Journal of Applied Family Studies, 20200401, Vol. 69 Issue 2, p308, 12p
Item: 2019-63589-001

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Reducing compassion fatigue in inpatient pediatric oncology nurses.
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Authors:
Sullivan, Courtney E.. St. Jude Children’s Research Hospital, Memphis, TN, US, courtney.sullivan@stjude.org
King, Amber-Rose. St. Jude Children’s Research Hospital, Memphis, TN, US
Holdiness, Joni. St. Jude Children’s Research Hospital, Memphis, TN, US
Durrell, Judith. St. Jude Children’s Research Hospital, Memphis, TN, US
Roberts, Kristin K.. St. Jude Children’s Research Hospital, Memphis, TN, US
Spencer, Christopher. St. Jude Children’s Research Hospital, Memphis, TN, US
Roberts, Joshua. Baptist Memorial Health Care Corporation, Memphis, TN, US
Ogg, Susan W.. St. Jude Children’s Research Hospital, Memphis, TN, US
Moreland, Meredith W.. Emory Healthcare, Atlanta, GA, US
Browne, Emily K.. Transition Oncology Program, St. Jude Children’s Research Hospital, Memphis, TN, US
Cartwright, Carla. St. Jude Children’s Research Hospital, Memphis, TN, US
Crabtree, Valerie McLaughlin. Psychosocial Services, St. Jude Children’s Research Hospital, Memphis, TN, US
Baker, Justin N.. Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN, US
Brown, Mark. St. Jude Children’s Research Hospital, Memphis, TN, US
Sykes, April. St. Jude Children’s Research Hospital, Memphis, TN, US
Mandrell, Belinda N.. Division of Nursing Research, St. Jude Children’s Research Hospital, Memphis, TN, US
Address:
Sullivan, Courtney E., courtney.sullivan@stjude.org
Source:
Oncology Nursing Forum, Vol 46(3), May, 2019. pp. 338-347.
NLM Title Abbreviation:
Oncol Nurs Forum
Page Count:
10
Publisher:
US : Oncology Nursing Society
ISSN:
0190-535X (Print)
1538-0688 (Electronic)
Language:
English
Keywords:
compassion fatigue, compassion satisfaction, burnout, secondary traumatic stress
Abstract:
Objectives: To develop an evidence-based compassion fatigue program and evaluate its impact on nurse-reported burnout, secondary traumatic stress, and compassion satisfaction, as well as correlated factors of resilience and coping behaviors. Sample & Setting: The quality improvement pilot program was conducted with 59 nurses on a 20-bed subspecialty pediatric oncology unit at the St. Jude Children’s Research Hospital in Memphis, Tennessee. Methods & variables: Validated measures of compassion fatigue and satisfaction (Professional Quality of Life Scale V [ProQOLV]), coping (Brief COPE), and resilience (Connor-Davidson Resilience Scale-2) were evaluated preprogram and at two, four, and six months postprogram, with resilience and coping style measured at baseline and at six months postprogram. RESULTS: Secondary traumatic stress scores significantly improved from baseline to four months. Select coping characteristics were significantly correlated with ProQOLV subscale scores. Implications for Nursing: Ongoing organizational support and intervention can reduce compassion fatigue and foster compassion satisfaction among pediatric oncology nurses. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Neoplasms; *Nurses; *Occupational Stress; *Pediatrics; *Compassion Fatigue; Caregiver Burden; Hospitalization; Hospitalized Patients; Nursing; Stress Reactions; Oncology
Medical Subject Headings (MeSH):
Adaptation, Psychological; Adult; Bereavement; Burnout, Professional; Compassion Fatigue; Depression; Education, Nursing, Continuing; Female; Follow-Up Studies; Grief; Health Behavior; Humans; Job Satisfaction; Male; Nurse-Patient Relations; Nurses, Pediatric; Nutritional Support; Oncology Nursing; Pediatric Nursing; Pilot Projects; Resilience, Psychological; Young Adult
PsycInfo Classification:
Impaired Professionals (3470)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Professional Quality of Life Scale V
Brief COPE
Connor-Davidson Resilience Scale-2
Grant Sponsorship:
Sponsor: St. Jude Auxiliary Cancer Center, US
Grant Number: CA21765
Other Details: National Cancer Institute–designated cancer centers
Recipients: No recipient indicated

Sponsor: National Cancer Institute, US
Recipients: No recipient indicated

Sponsor: American Lebanese Syrian Associated Charities, US
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20201026
PMID:
31007264
Accession Number:
2019-54902-008
Images:
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Understanding how social worker compassion fatigue and years of experience shape custodial decisions.
Authors:
Denne, Emily, ORCID 0000-0001-9316-2997 . Arizona State University, Tempe, AZ, US, ed96@evansville.edu
Stevenson, Margaret, ORCID 0000-0002-1613-6768 . University of Evansville, Evansville, IN, US
Petty, Taylor. University of Nebraska-Lincoln, Lincoln, NE, US
Address:
Denne, Emily, ed96@evansville.edu
Source:
Child Abuse & Neglect, Vol 95, Sep, 2019. ArtID: 104036
NLM Title Abbreviation:
Child Abuse Negl
Publisher:
Netherlands : Elsevier Science
ISSN:
0145-2134 (Print)
1873-7757 (Electronic)
Language:
English
Keywords:
social workers, compassion fatigue, job experience, child custody case judgments, decision making, child custody, neglect, mothers, social worker attitudes
Abstract:
Background: Compassion fatigue (i.e., a worker’s diminished ability to empathize with clients) is common among ‘helping workers’ and can result in psychological detachment from clients as a coping mechanism. Objective: In the present research, we explored the relationship between social workers’ compassion fatigue and years of job experience on hypothetical child custody case judgments. Participants and setting: In two separate studies, individuals with experience working with children in child dependency court (predominantly social workers, Study 1: N = 173, Study 2: N = 119) were recruited on Amazon’s Mechanical Turk and read a vignette depicting a mother attempting to regain custody. Results: Supporting hypotheses, compassion fatigue significantly mediated the relationship between increased years of social worker job experience on recommendations that a neglectful mother receive custody, Indirect Effect = .06, CIs [.026, .127] (Study 1). We also found preliminary support for our hypothesized theoretically derived serial path model, in which (a) social worker compassion fatigue predicts anticipated secondary traumatic stress associated with the child neglect case, B = .54, p = .0001; (b) secondary traumatic stress predicts detachment from the neglected child, B = .27, p = .0003; (c) detachment from the child predicts job efficacy cynicism B = .65, p < .0001; and (d) job efficacy cynicism predicts decisions to allocate custody to the neglectful mother, B = .46, p = .005 (Study 2). Conclusion: Our research shows that compassion fatigue among social workers may change the lens through which they perceive cases of child abuse. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Child Custody; *Child Neglect; *Social Workers; *Compassion Fatigue; Decision Making; Health Personnel Attitudes; Mothers; Test Construction
Medical Subject Headings (MeSH):
Adaptation, Psychological; Burnout, Professional; Child; Child Protective Services; Compassion Fatigue; Decision Making; Female; Humans; Mothers; Social Work; Social Workers; Surveys and Questionnaires
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Mother Rehabilitation Scale
Good mother scale
Child Potential With Mother Scale
Impulsive Mother Scale
Compassion fatigue scale
Grant Sponsorship:
Sponsor: University of Evansville, US
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jul 11, 2019; Accepted: Jun 3, 2019; Revised: May 20, 2019; First Submitted: Feb 7, 2018
Release Date:
20190826
Correction Date:
20201001
Copyright:
All rights reserved.. Elsevier Ltd.. 2019
Digital Object Identifier:
http://dx.doi.org/10.1016/j.chiabu.2019.104036
PMID:
31302577
Accession Number:
2019-44877-001
Number of Citations in Source:
43
Result List Refine Search PrevResult 34 of 68 Next
Secondary traumatic stress and self-care inextricably linked.
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Authors:
Owens-King, Allessia P.. Department of Social Work, Salisbury University, Salisbury, MD, US, apowens@salisbury.edu
Address:
Owens-King, Allessia P., Salisbury University, Department of Social Work, 1101 Camden Avenue, Salisbury, MD, US, 21801, apowens@salisbury.edu
Source:
Journal of Human Behavior in the Social Environment, Vol 29(1), Jan, 2019. pp. 37-47.
NLM Title Abbreviation:
J Hum Behav Soc Environ
Page Count:
11
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
1091-1359 (Print)
1540-3556 (Electronic)
Language:
English
Keywords:
Secondary traumatic stress, social worker self-care, social work education, workforce
Abstract:
Increasingly trauma scholars are exploring the susceptibility of mental health providers to secondary trauma reactions. The current study explores the relationship between clinical social work practice with trauma-exposed clients and secondary traumatic stress among social workers. The intent of this study is to identify the role various factors play in the development of secondary trauma (also known as compassion fatigue). A simple random sample of National Association of Social Workers members were asked to participate. Participants completed an online survey that explored their exposure and responses to secondary traumatic stress. The online survey consisted of standardized measures including the Secondary Traumatic Stress Scale and The Coping Strategies Inventory which assesses secondary trauma and self-care strategies, respectively (Bober, Regehr, & Zhou, 2006; Bride, Robinson, Yegidis, & Figley, 2003). The magnitude of work (the extent and intensity of time working with trauma-exposed clients) is assessed by a non-standardized measure which consists of clinical caseloads composition questions. Job satisfaction is measured by items taken from the National Association of Social Workers’ workplace questionnaire (Whitaker & Arrington, 2008). 161 social workers completed the online survey. It required approximately 35 minutes to complete. This project empirically demonstrated that high-magnitude social work practice (providing therapeutic intervention to trauma survivors, i.e. military service members and veterans) is associated with higher levels of secondary trauma. There is also empirical evidence that self-care strategies can mitigate the impact of the secondary trauma. Educational and workforce implications for study findings are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Mental Health Services; *Self-Care Skills; *Social Workers; *Trauma; *Compassion Fatigue; Social Work Education; Self-Care
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Coping Strategies Inventory
Grant Sponsorship:
Sponsor: Atlantic Philanthropies
Grant Number: 25461
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20191118
Correction Date:
20200713
Copyright:
Taylor & Francis Group, LLC. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/10911359.2018.1472703
Accession Number:
2019-01058-005
Images:
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Secondary traumatic stress and self-care inextricably linked
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Contents
Introduction
Background
Theory
Purpose
Research hypotheses
Methods
Measures
Data collection & analysis
Study sample
Results
Implications
Conclusion
References
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Increasingly trauma scholars are exploring the susceptibility of mental health providers to secondary trauma reactions. The current study explores the relationship between clinical social work practice with trauma-exposed clients and secondary traumatic stress among social workers. The intent of this study is to identify the role various factors play in the development of secondary trauma (also known as compassion fatigue). A simple random sample of National Association of Social Workers members were asked to participate. Participants completed an online survey that explored their exposure and responses to secondary traumatic stress. The online survey consisted of standardized measures including the Secondary Traumatic Stress Scale and The Coping Strategies Inventory which assesses secondary trauma and self-care strategies, respectively (Bober, Regehr, & Zhou, 2006; Bride, Robinson, Yegidis, & Figley, 2003). The magnitude of work (the extent and intensity of time working with trauma-exposed clients) is assessed by a non-standardized measure which consists of clinical caseloads composition questions. Job satisfaction is measured by items taken from the National Association of Social Workers’ workplace questionnaire (Whitaker & Arrington, 2008). 161 social workers completed the online survey. It required approximately 35 minutes to complete. This project empirically demonstrated that high-magnitude social work practice (providing therapeutic intervention to trauma survivors, i.e. military service members and veterans) is associated with higher levels of secondary trauma. There is also empirical evidence that self-care strategies can mitigate the impact of the secondary trauma. Educational and workforce implications for study findings are discussed.

Keywords: Secondary traumatic stress; social worker self-care; social work education; workforce

Introduction
In the last several years, there has been a renewed recognition of work-related stress and strain within helping professions. Employers of helping professionals (i.e. social workers) are plagued with attrition and turnover in the face of increased demand and area shortages (Baird & Jenkins, 2003; Bureau of Labor Statistics, 2018; Cunningham, 2003; Zlotnik, DePanfilis, Daining, & Lane, 2005). Work-related stress is a well-known concept with roots in countertransference and burnout literature (Figley, 1995; McCann & Pearlman, 1990; McCann et al., 1990; Stamm, 1999). Study of the work stress and strain within the social services field was popularized by Freudenberger (1975). Freudenberger saw burnout as performance and enthusiasm decline (Freudenberger, 1975; Maslach, Schaufeli, & Leiter, 2001). Burnout is also defined as work-related exhaustion on multiple levels (emotional, physical psychological, and spiritual) (Collins & Long, 2003; Newell & MacNeil, 2010).

Both burnout and secondary traumatic stress (STS) literature highlight work-related triggers to emotional reactions. Like burnout, secondary trauma is an occupational hazard, which contributes to worker attrition (Abu-Bader, 2000; Baird & Jenkins, 2003; Boscarino, Adams, & Figley, 2010; Bride & Kintzle, 2011; Cieslak et al., 2014; Collins & Long, 2003; Stamm, 1999). However, secondary trauma literature is made distinct by the focus on specific and acute emotional reactions to “witnessing” traumatic events endured by clients (Cunningham, 2003, 2004). Specific emotional reactions highlighted in the secondary traumatic stress literature include instructive thoughts, insomnia, and hyper-vigilance, reactions on par with primary trauma reactions (Bride, 2004, 2007; Bride & Kintzle, 2011; Owens, 2014). Furthermore, STS reactions are specific to work with trauma-exposed populations whereas burnout can occur in any profession. There has been a resurgence of interest in secondary trauma with an emphasis on susceptibility to reactions and how to migrate its impact (Choi, 2017; Hensel, Ruiz, Finney, & Dewa, 2015; Owens, 2014). Furthermore, the recent changes to the diagnostic criteria for trauma and stress-related disorders within the Diagnostic and Statistical Manual of Mental Health Disorders (DSM- 5) highlight the growing recognition of consequences related to indirect exposure to traumatic events (American Psychiatric Association, 2013).

The current study examines secondary traumatic stress (STS) among 161 members of the National Association of Social Workers. Specifically, this study assessed the relationship between work with traumatized clients and level of secondary traumatic stress among social workers. This investigation builds on empirical studies regarding the range and scope of traumatic events (Baird & Jenkins, 2003; Bride, 2007; Owens, 2014).

Background
Increasingly trauma scholars are exploring the susceptibility of mental health providers to secondary trauma reactions. This study’s purpose is to document the prevalence and correlates of secondary trauma among social work professionals Helping trauma-exposed clients. Secondary trauma, also referred to as compassion fatigue and vicarious trauma, is defined as emotional reactions (e.g. hyper-arousal) to indirect exposure to traumatic situations (Bride, 2007; Dekel & Solomon, 2007; Kintzle, Yarvis, & Bride, 2013). Mental health professionals are inevitably confronted with the traumas and psychosocial problems experienced by clients.

Social work scholars believe that regular contact with trauma-exposed clients can have a negative effect on the well-being of mental health professionals (Collins & Long, 2003; Bride, 2007; Figley, 2002; Cieslak et al., 2014; Harrington, 2007; Hensel et al., 2015; Kanno, 2010). Several practice-focused researchers suggest that all therapists, across practice orientations, are challenged when working with trauma-exposed clients (Bride, 2007; Figley, 1995, 2002; Owens, 2014). According to the American Psychiatric Association, trauma reactions are likely to occur in individuals who experience “repeated or extreme exposure to adverse details of traumatic events” (American Psychiatric Association, 2013, p. 271). Likewise, the National Child Traumatic Stress Network (NCTSN) asserts professionals Helping trauma survivors are likely to experience emotional stress responses that include, memory problems, hyper-arousal reactions, avoidance behaviors, and re-experiencing personal trauma (National Child Traumatic Stress Network [NCTSN], 2017).

Additional empirical research suggests that providing mental health care increases the risk of a range of secondary trauma reactions among mental health professionals (Beder, 2009; Bride, 2007; Bride & Figley, 2009; Kintzle et al., 2013; Owens, 2014). Interventions found to effectively Help trauma survivors, namely cognitive behavioral therapy (CBT), prolonged exposure therapy (PE) and cognitive processing therapy (CPT), encourage disclosure of distorted thoughts and detailed descriptions of historical trauma during treatment (VanWinkle & Safer, 2011). Practice interventions and other work duties will not allow social workers to “skip over” detailed disclosures by clients (Allen, 2005, p. 5). Social work professionals are oftentimes inundated with accounts of catastrophes, indecencies, tragedies, disasters, and injustice.

Similarly, stressors arise from several features of social work case management namely, providing environmental support for clients, linking clients with community resources, consulting with stakeholders, monitoring client activities, and examining client compliance with organizational policies (Walsh, 2010). These responsibilities permit social workers to experience client’s living conditions (that are oftentimes meager), witness client distress “in the moment”, encounter resistance from clients who may be court mandated and who often have multiple conditions and complex problems. The National Association of Social Workers report that many social workers regularly consider personal safety while working (Center for Health Workforce Studies School of Public Health and National Association of Social Workers Center for Workforce Studies, 2006). Furthermore, monitoring client activities and policy compliance regularly makes the social worker a bearer of bad news and the deliverer of sanctions. Thus, the nature of social work, whether the emphasis is therapeutic interventions or case management support, has an inherent risk for secondary trauma (Figley, 1995; Lazarus, 1993; Voss-Horrell, Holohan, Didion, & Vance, 2011).

Theory
Chronic stress theory, an elaboration of stress theory, guides this investigation. It serves as the theoretical base because it postulates that ongoing and recurring exposure to work-related stressors has psychological consequences (Carter, Dyer, & Mikan, 2013; Dekel & Solomon, 2007; Lazarus, 1999). Dekel and Solomon (2007) suggest that close and prolonged interaction with traumatized or victimized persons is a chronic stressor, which may contribute to secondary traumatic stress. Chronic stress theory supports the position that one’s work responsibilities (i.e. learning of deliberate acts of cruelty and administering therapeutic intervention that require the recall of challenging experiences) can be determinates for secondary trauma reactions (Dekel & Solomon, 2007; Stamm, 1999). In addition, chronic stress theory provides a framework in which organizational and personal factors are examined with regard to secondary trauma (Owens, 2014). For instance, if when accept the premise that exposure to chronic stressors impacts work performance then human service organizations, schools of social work, licensing boards and other governing bodies, could enact and enforce workplace policies (such as caseload limits, required vacation use and self-care related continuing education) that can ameliorate secondary trauma reactions.

Purpose
This study explores the prevalence and effects of secondary traumatic stress (STS) on social work professionals. It also expands the empirical knowledge base regarding the relationship between secondary trauma reactions and work with trauma-exposed clients.

Research Questions & Hypotheses

( 1) To what extent are social workers experiencing secondary traumatic stress symptoms?

( 2) What are the direct and indirect effects of work with trauma-exposed clients on levels of secondary traumatic stress for social workers?

Research hypotheses
It is hypothesized that the greater the magnitude of work with trauma-exposed clients, the greater level of STS experienced by social workers. It is hypothesized that self-care strategies and job satisfaction will moderate the direct effects of work with trauma-exposed clients on the levels STS experienced by social workers.

Methods

Measures
This investigation explores the factors that place social workers at risk and guard against secondary traumatic stress (STS). Participants are asked to complete standardized and non-standardized instruments using an online survey. The standardized measures used to investigate study variables include The Secondary Traumatic Stress Scale (STSS), the study’s dependent variable, which measures levels of secondary trauma in social work professionals (Bride, Robinson, Yegidis, & Figley, 2003).

Secondary trauma reactions are defined as the presence of intrusive thoughts, hyper-arousal and avoidant behaviors due to work-related emotional distress (Bride et al., 2003). This measure consists of 17 items on a five-point Likert-type scale of indirect trauma exposure. The instrument asks respondents about their experiences with intrusive thoughts, hyper-arousal, and avoidant behaviors as a result of work-related distress. Possible question responses range from never to very often (Bride, 2007; Bride et al., 2003).

The first independent variable, the magnitude of work is measured by 11 items. The magnitude of work refers to the extent and intensity of time spent working with trauma-exposed clients. Participants are asked to report the proportion of clients with trauma histories and disorders compared to their total number of clients. The second independent variable, self-care, will be measured by the Coping Strategies Inventory (CSI). The CSI allows for responses ranging from “not at all helpful”/”not at all” to “always helpful”/”frequently” (Bober, Regehr, & Zhou, 2006). For this study, self-care refers to a clinician’s behaviors and activities that may guard against or exacerbate STS. The third independent variable, job satisfaction, is measured by 17 items taken from the National Association of Social Workers’ standardized workplace questionnaire (Whitaker & Arrington, 2008). Job satisfaction refers to “an individual’s subjective, emotional reaction to his or her work and an overall sense of satisfaction or dissatisfaction with regard to work” (Abu-Bader, 2005, p. 8). The responses range from not applicable ( 1) to always ( 6) regarding the level of agreement with statements.

The relationships between STS and three independent variables were examined. Those variables include the magnitude of work with trauma-exposed clients, self-care strategies, and job satisfaction. The dependent variable was transformed using the Log10 method in order to meet the statistical test normality assumptions (Abu-Bader, 2011). Throughout this report, results will be based on analysis with the transformed dependent variable, STSLog.

Furthermore, the magnitude of work variable total score was computed using 11 items. The value of which was negatively skewed, skewness coefficient (.673/.191) = −3.52. In this case, the variable was reversed and transformed using the square root method (Abu-Bader, 2011). Similarly, job satisfaction scores were negatively skewed, with a skewness coefficient (.861/.192) = −4.48. The same method was used to reverse and transform the job satisfaction values. The conversion of the data helps the variable distribution approach a normal curve without changing the data meaning (Abu-Bader, 2011, p. 60). Throughout the document, results will be based on analysis with the converted independent variables, SQRT_ MAG11, and SQRT_ JOBSAT. The values for the independent variable, self-care, were normally distributed. No transformation needed.

Data collection & analysis
Online survey research is a growing survey modality with various research advantages (Couper, 2000). Literature suggests online surveying can provide greater access to populations. Furthermore, online data collection allows greater respondent privacy, which likely limits response errors such as satisficing, providing inaccurate yet plausible answers (Tourangeau, Rips, & Rasinski, 2000, p. 17). In addition, nearly all social work professionals utilize computers for scheduling, billing, and team communication or case documentation. All data will be stored on the Qualtrics platform, which is password and firewall protected (Qualtrics Company, 2011). In total, the survey includes 84 questions and requires approximately 35 minutes to complete.

Study sample
A participant email list was purchased from InFocus Marketing Incorporated. InFocus Marketing Incorporated manages the distribution of both email and traditional mail lists for the National Association of Social Workers. In order to purchase the list, researchers must provide obtain approval for the NASW and submit an IRB approval letter (InFocus Marketing, 2018). The National Association of Social Workers is the largest professional organization of social work with over 100,000 members. To be a full NASW member, individuals must be credentialed by a state as a social worker with an independent license, supervised certification, registration or another state-level social work title (NASW, 2012). The participation request was emailed to a simple random sample of 5000 social workers who self-identified as members of the National Association of Social Workers with mental health as their specialty practice area. The response rate for this study was 3.21%.

Participants of this study are 161 social work professionals. The majority of participants are white females (n = 139; 86.7%) with an average age of 51 years. Most participants hold master’s level social work professionals with over 11 years of experience in the mental health field (n = 100; 62.2%). With regard to health, nearly all participants perceived their personal health to be good, very good or excellent (n = 146; 91.8%). Table 2 outlines additional participant demographics.

Variables.

Dependent Variable/STSLog Secondary traumatic stress
Independent Variable 1/SQRT_ Mag11 Magnitude of work with trauma-exposed clients
Independent Variable 2/Self-care Self-care strategies
Independent Variable 3/SQRT_ JOBSAT Job satisfaction
Description of sample (n = 161).

Variable n % m (sd)
Age 159 98.7 51 (13)
Education Masters (MSW) 151 94
Other/Missing 10 6
Gender Female 126 78.3
Male 35 21.7
Race White 139 86
Other 22 14
Years of Experience 1-10 years 61 38
11+ years 100 62
Licensure Advanced Clinical 124 77
Graduate 26 16
BA/BASW 7 4
Other 4 3
Results of the multiple regression analysis.

Factors R R2a β t P F P
Magnitude of work with trauma-exposed clients .41 .17 −.44 −6.2 <.000 32.12 <.001
Self-care .47 .23 −.24 −3.4 <.010 23.13 <.001
STS module content.

Module objectives Define and review of secondary traumatic stress Establish “universal” self-care behavior
Readings (completed before class) Bride et al. (2007) Figley and Nash (2007) Kintzle et al. (2013) NCTSN (2017)
Instructor resources In-class discussion prompts
“Let’s discuss secondary traumatic stress (STS)? How is STS defined? What are the other terms used to describe secondary traumatic stress reactions? What does STS look like in social workers?”

“In the world of medicine, providers are taught the “universal precautions” that they must utilize when providing medical care (Potter, Perry, Hall, & Stockert, 2013). These include handwashing, using protective barriers like gloves, and safe handling of contaminated material. Let’s draft our own set of “universal” self-care behaviors that can guard against secondary trauma.

Below are suggested for “universal” self- care behaviors for instructors to offer if student discussion stalls:

Acknowledge and respond to the impact of trauma-informed treatment on you.

Seek out strengths-based supervision to both novice and mature colleagues.

Act towards colleagues in a sensitive manner, assuming that your co-worker has a trauma history that may be triggered by work.

Each day set aside time to engage in activities that renew your spirit.

Use vacation days to for vacation.

Results
Results of this study confirm findings from earlier research (Bride, 2007; Owens, 2014). Namely, that mental health professionals are experiencing symptoms of secondary traumatic stress. Furthermore, findings here provide evidence that work demands are associated with secondary trauma. However, levels of secondary traumatic stress are low, with a STSLog mean = 1.5 (STS raw data mean = 34, SD 12.2). The study participants’ magnitude of work with trauma exposure clients (i.e. military service members and veterans) is moderate, SQRT_MAG11 mean = 3.8, SD =.87 (magnitude raw data mean = 32, SD 6.5). Thirty-seven percent (37%) of participates manage caseloads with 30 or more clients. The majority of clients Helped by participants have multiple mental health disorders, 67%. Thirty-three percent (33%) of participants manage caseloads with clients that live with both chronic physical and mental health conditions. Although the overall levels of STS for study participants are low, the data supports the position that greater the magnitude of work with trauma-exposed clients, the greater level of STS.

Levels of STS are influenced by social workers self-care and level of job satisfaction. Participants of this study regularly engage in self-care activities mean = 62, SD 14.4. Furthermore, participant levels of job satisfaction are high, mean = 5.4, SD 1.1 (job satisfaction raw data mean= 72, SD 12). The data supports the position that self-care strategies and job satisfaction have some influence on levels STS. It follows that social workers, like the study participants, who regularly practice self-care and have high levels of job satisfaction will have low levels of secondary traumatic stress.

The results of the stepwise multiple regression analysis show that two factors, magnitude of work with trauma-exposed clients and self-care are significant predictors of secondary traumatic stress (F = 22.13, p≤.001). The magnitude of work with trauma-exposed clients was the strongest factor associated with secondary traumatic stress (Beta of -.44 (p ≤.001). It accounted for 17% of the variance in secondary traumatic stress. The second strongest predictor was self- care (Beta of -.24 (p ≤.001) which accounted for an additional 6% of the variance in secondary traumatic stress. This model explains 23% of the variance in secondary traumatic stress (R =.47). However, about 77% of the variance in STS is unexplained by this model. Contrarily, data did not support the position job satisfaction moderates the levels STS experienced by social workers. These findings suggest that job satisfaction is not a significant predictor of secondary traumatic stress for study participants. This is contrary to other research findings regarding secondary trauma risk and resilience factors (Bride, Jones, & MacMaster, 2007; Owens, 2014).

These results indicate that secondary traumatic stress reactions are a function of the magnitude of work with traumatized clients and the amount of engagement in self-care activities by the social worker. Findings here underscore the essential role of self-care plays in mitigating the impact of STS among practitioners.

The limitations of this study revolved around sample selection. Although nearly 200 persons participated in the study, there is limited diversity with regard to race and gender among participants. The majority of participants were women with a white racial background. The average age of participants was 51 years. While women from a white background make-up a large portion of the social work workforce, systematically including participants from diverse backgrounds and recruiting more participants from multiple age groups, may offer a clearer picture of secondary trauma’s impact on the profession (NASW, 2012). Future research is needed to explore social worker early in their career to assess experiences with secondary trauma.

Implications
As social workers, we are taught that at times during work we will not be comfortable. Social workers are trained to put our issues to the side and provide the service our clients deserve. However, we must acknowledge and address the real risk of STS. We must also provide tools to promote self-care to mitigate the impact of demanding work by practitioners.

Little emphasis has been given to self-care within the social work education curriculum compared to other job performance issues like ethics and competent intervention (Huss, Sarid, & Cwikel, 2010; Moore, Bledsoe, Perry, & Robinson, 2011; Newell & Nelson-Gardell, 2014). In part, this is explained by limited empirical existence about occupational hazards (Figley, 2002). More and more empirical research, along with the investigation described here, supports anecdotal knowledge about social work occupational hazards (Badger, Royse, & Craig, 2008; Bride, 2007; Moore et al., 2011; Owens, 2014).

The study results have implications for social work education. Now that there is more evidence that STS existence, instructors must make time in the classroom to discuss the hazards associated with social work practice, clinical or case management. Also, since research indicates that self- care can slow the development of STS creating course content on that topic is recommended. Instructors can enhance existing curriculum with secondary trauma material so to improve the real-world utility of course content. Knowing which factors strongly predict STS (e.g. magnitude of work and self-care activities) can help educators to plan course content that address professional well-being.

Furthermore, the ethical guidelines that govern professional behaviors specifically state that social workers should not practice under impairment (NASW, 2018). This study provide evidence that secondary trauma is experienced by social workers, therefore educators have an ethically bound duty to prepare students for the possibility of STS as a result of their work. Such preparation can surely minimize the impact on work quality. One way to educate social work students about the real risk of secondary trauma would be to have readings and in-class activities on the topic (Moore et al., 2011). The readings could review the components of STS and in-class activity can revolve around how to minimize STS’s impact on personal well-being. Table 4 outlines a module that introduces secondary trauma material within a course.

Additionally, the results of this study have workplace implications. The study shows that social worker duties are connected to secondary trauma reactions. There is evidence that the magnitude of work (e.g. proportion of one’s caseload that requires work with trauma-exposed clients) contributes to secondary traumatic stress. Armed with this evidence, social workers can advocate for changes to policy regarding caseload distribution. Furthermore, these findings give legitimacy to employee requests for employers to put into practice workloads limited. Also, the results can be used to support requests for additional hiring and funding so that caseloads with a high proportion of trauma-exposed client can be minimized.

In addition, social work managers and supervisors can use this information to be deliberate about case allocation practices. If a core duty of a supervisor is to retain skilled professionals, then they should take heed of the study findings. Social work licensing boards could also use study findings to support changes in required continuing education topic areas. If state licensing boards required self-care continuing education courses, then practitioners would be motivated to explore the topic in-depth, review and rehearse self-care strategies that lessen STS reactions, and discuss the ethical implications of unacknowledged STS. Promoting professional development that increases sensitivity to STS and improves awareness of healthy self-care would surely help retain social workers in our profession.

Conclusion
Although this sample has low levels of STS, there is evidence that secondary trauma reactions exist among social workers. Study findings indicate that secondary traumatic stress reactions are influenced by the magnitude of work with traumatized clients (i.e. military service members and veterans) and the level of engagement in self-care activities by the social worker. The essential role of self-care in mitigating the impact of STS is discussed. Further research is needed to explore the experience of a diverse cross-section of social workers that include early career social workers.

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Pediatric oncology social workers’ experience of compassion fatigue.
Authors:
Yi, Jaehee. College of Social Work, University of Utah, Salt Lake City, UT, US
Kim, Jonghee. College of Social Work, University of Utah, Salt Lake City, UT, US, Jonghee.Kim@utah.edu
Akter, Jesmin. College of Social Work, University of Utah, Salt Lake City, UT, US
Molloy, Jennifer K.. College of Social Work, University of Utah, Salt Lake City, UT, US
Kim, Min Ah. Department of Social Welfare, Myongji University, Seoul, Republic of Korea
Frazier, Kristin. Children’s Healthcare of Atlanta, Atlanta, GA, US
Address:
Kim, Jonghee, College of Social Work, University of Utah, Salt Lake City, UT, US, Jonghee.Kim@utah.edu
Source:
Journal of Psychosocial Oncology, Vol 36(6), Nov-Dec, 2018. pp. 667-680.
NLM Title Abbreviation:
J Psychosoc Oncol
Page Count:
14
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
0734-7332 (Print)
1540-7586 (Electronic)
Language:
English
Keywords:
compassion fatigue, social workers, pediatric oncology
Abstract:
Pediatric oncology social workers play an important role in supporting cancer patients and their families as they learn to talk about and cope with the physical and psychological impacts of cancer. As a result, social workers are particularly vulnerable to compassion fatigue and the associated psychological and physical impacts. The purpose of this qualitative study was to understand the experience of compassion fatigue among 27 pediatric oncology social workers. Four main themes emerged throughout the five focus groups: Conditions that contribute to compassion fatigue; the influence of compassion fatigue; coping strategies to alleviate compassion fatigue; and desire for systematic support to prevent compassion fatigue. Our study findings emphasize the importance of developing programs, policies and research geared toward the prevention of compassion fatigue, in addition to coping with symptoms. Further, this study brings attention to the importance of including pediatric oncology social workers in efforts to develop and implement systemic supports. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Neoplasms; *Occupational Stress; *Pediatrics; *Social Workers; *Compassion Fatigue; Social Casework; Test Construction; Oncology
Medical Subject Headings (MeSH):
Adaptation, Psychological; Adult; Child; Compassion Fatigue; Female; Focus Groups; Humans; Male; Medical Oncology; Middle Aged; Neoplasms; Pediatrics; Qualitative Research; Social Workers
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Impaired Professionals (3470)
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Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Focus Group Measure
Methodology:
Empirical Study; Interview; Focus Group; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20181126
Correction Date:
20200611
Copyright:
Taylor & Francis Group, LLC. 2018
Digital Object Identifier:
http://dx.doi.org/10.1080/07347332.2018.1504850
PMID:
30449270
Accession Number:
2018-60074-001
Number of Citations in Source:
32
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Enhancing resilience among providers of trauma-informed care: A curriculum for protection against secondary traumatic stress among non-mental health professionals.
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Authors:
Kerig, Patricia K.. Department of Psychology, University of Utah, Salt Lake City, UT, US, p.kerig@utah.edu
Address:
Kerig, Patricia K., Department of Psychology, University of Utah, Salt Lake City, UT, US, 84112, p.kerig@utah.edu
Source:
Journal of Aggression, Maltreatment & Trauma, Vol 28(5), May-Jun, 2019. pp. 613-630.
NLM Title Abbreviation:
J Aggress Maltreat Trauma
Page Count:
18
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
1092-6771 (Print)
1545-083X (Electronic)
Language:
English
Keywords:
Adolescent, intervention, secondary traumatic stress, trauma-informed care providers, resilience
Abstract:
Although the call to create trauma-informed services for youth has been clearly sounded, a relatively neglected part of this effort is the need to prepare non-mental health professionals to carry out trauma-informed programming in ways that protect them from secondary traumatic stress (STS). To this end, this article introduces Resilience for Trauma-Informed Professionals, a curriculum that introduces participants to techniques designed to promote resilience in the face of exposure to trauma-related material. Based on the existing evidence base regarding risk and protective factors for STS, six core elements targeted by the curriculum are described—appraisals, self-efficacy, emotional awareness, affect regulation, resilience, and prevention—as they are implemented across three stages: pre-exposure preparation, coping in the presence of trauma, and recovery in the aftermath of exposure. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Health Personnel Attitudes; *Resilience (Psychological); *Trauma; *Compassion Fatigue; *Adolescent Health; Trauma-Informed Care
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Grant Sponsorship:
Sponsor: Substance Abuse and Mental Health Services Administration, Center for Trauma Recovery and Juvenile Justice
Grant Number: 1U79SM080044-01
Recipients: Kerig, P. (Prin Inv)
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Feb 26, 2018; Revised: Feb 25, 2018; First Submitted: Oct 8, 2017
Release Date:
20180507
Correction Date:
20200713
Copyright:
Taylor & Francis. 2018
Digital Object Identifier:
http://dx.doi.org/10.1080/10926771.2018.1468373
Accession Number:
2018-21254-001
Number of Citations in Source:
87
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Enhancing Resilience Among Providers of Trauma-Informed Care: A Curriculum for Protection Against Secondary Traumatic Stress Among Non-Mental Health Professionals
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Contents
Defining the boundaries of the construct of secondary traumatic stress
Research on risk and protective factors for STS
Theoretical and empirical foundations of R-TIP
Appraisals and meaning-making
Self-efficacy
Emotional awareness and acceptance
Affect regulation
Resilience
The power of prevention
Outline of the R-TIP curriculum
Future directions
Need for an evidence base
Buy-in and sustainability
Conclusion
References
Full Text
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Although the call to create trauma-informed services for youth has been clearly sounded, a relatively neglected part of this effort is the need to prepare non-mental health professionals to carry out trauma-informed programming in ways that protect them from secondary traumatic stress (STS). To this end, this article introduces Resilience for Trauma-Informed Professionals, a curriculum that introduces participants to techniques designed to promote resilience in the face of exposure to trauma-related material. Based on the existing evidence base regarding risk and protective factors for STS, six core elements targeted by the curriculum are described—appraisals, self-efficacy, emotional awareness, affect regulation, resilience, and prevention—as they are implemented across three stages: pre-exposure preparation, coping in the presence of trauma, and recovery in the aftermath of exposure.

Keywords: Adolescent; intervention; prevention; secondary traumatic stress; trauma

The increasing recognition of the role that trauma exposure plays in many continua of care for troubled youth has led to a clarion call for these systems to become trauma-informed (Listenbee & Torre, [41]; NCTSN Justice Coordinating Committee, [57]). This call has been answered by major initiatives across many contexts in which traumatized young people are served, including child welfare, education, and juvenile justice (e.g., Dierkhising & Branson, [14]; Fraser et al., [23]; Howard & Tener, [29]; Kramer, Sigel, Conners-Burrow, Savary, & Tempel, [40]; Listenbee & Torre, [41]; Olafson, Goldman, & Gonzalez, [61]). One of the hallmarks of these efforts is the call for universal trauma screenings for youth and the training of staff to implement such assessments (Branson, Baetz, Horwitz, & Hoagwood, [ 8]); in addition, many of these initiatives call for the provision of trauma-informed curricula for non-mental health professionals who interact with system-involved youth, such as juvenile detention staff, residential facility workers, and teachers (Ko et al., [39]; Marrow, Benamati, Decker, Griffin, & Lott, [45]; National Child Traumatic Stress Network, [54], [55]).

A caveat deserving consideration, however, is that many of these efforts to create trauma-informed programming expose professionals without Mental Health without training to trauma-related material. This is particularly the case for universal trauma screenings that may be conducted, or simply read, by intake workers in detention and other facilities (Kerig, Ford, & Olafson, [36]). Secondary exposure to trauma also may occur in the context of group interventions that involve youths’ processing of traumatic experiences, some of which are co-led by facility line staff (e.g., DeRosa & Pelcovitz, [13]; Olafson et al., 2016). Although some efforts have been made to acknowledge the importance of helping those who work with traumatized youth to be protected from the potential spillover effects of exposure to others’ trauma, to date, most of the theoretical and empirical literature on this topic focuses on the psychotherapy relationship (Bride, 2007; Craig & Sprang, [11]; Ellwood et al., 2011; Figley, [17]; Harrison & Westwood, 2009; Killian, [38]; Miller & Sprang, 2016; Shapiro et al., 2007) or disaster work (Creamer & Liddle, [12]; Quevillon, Gray, Erickson, Gonzalez, & Jacobs, [66]; Substance Abuse and Mental Health Services Administration, [75]). Notably, these are contexts in which professionals generally receive training in working with trauma-related material, whereas this often is not the case for front-line staff in settings such as justice facilities or schools. Further, where trauma-informed trainings for front-line workers do exist, only a small component addresses the risks associated with secondary trauma exposure (e.g., Marrow et al., [45]).

Consequently, given the salience of the risks associated with secondary trauma exposure, and despite the absence of a mature body of empirical research on the topic, development of a trauma-informed workforce requires the development of strategies for preparing non-mental professionals to carry out such services in ways that protect them from secondary traumatic stress (STS). To this end, this article introduces the underlying concepts and content of Resilience for Trauma-Informed Professionals (R-TIP; Kerig, [35]), a workshop-delivered curriculum designed for non-mental health professionals carrying out trauma-informed practices in a wide variety of contexts—e.g., detention center staff, probation officers, child welfare workers, rape crisis and domestic violence advocates, juvenile defense attorneys, gang intervention workers, teachers, and family violence researchers—that introduces participants to promising techniques for promoting resilience and effective coping in the face of exposure to trauma-related material.

Defining the boundaries of the construct of secondary traumatic stress
A range of terms has been applied to the adverse effects of exposure to others’ trauma, including burnout, vicarious trauma, STS, and compassion fatigue, and the inconsistency with which these terms are used makes integration of the existing literature difficult (Najjar, Davis, Beck-Coon, & Carney Doebbeling, [53]; Newell, Nelson-Gardell, & MacNeil, [58]; Walsh, Mathieu, & Hendricks, [81]). Some authors have suggested that these terms are essentially equivalent with, for example, compassion fatigue being suggested as a less pathologizing label for STS (Figley, [17]; Ludick & Figley, [43]). Other authors propose that the terms represent discrete phenomena that can be meaningfully differentiated from one another (Mathieu, [48]; National Child Traumatic Stress Network Secondary Traumatic Stress Committee, [56]); see Table 1. For example, the term burnout (Maslach, [47]) refers to a general sense of emotional and physical exhaustion that arises when workers perceive low levels of personal control and appreciation; it can occur in any occupation and is not specific to those involving exposure to trauma. In contrast, vicarious trauma (Pearlman & Saakvitne, [64]) refers to profound changes in worldview that can follow from repeated exposure to others’ traumatic experiences. One construct underlying vicarious trauma may be moral injury (Litz et al., [42]), the distress that arises from experiences that shake one’s deeply held moral beliefs. For example, learning about betrayals of trust perpetrated against children by authority figures, religious leaders, or caregivers can lead to a sense of moral injury. In turn, the term compassion fatigue (Figley, [17]) refers to a sense of emotional exhaustion arising from affective engagement with traumatized individuals or the processing of trauma-related information with, as Mathieu ([48]) phrases it, “the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate” (p. 14). In distinction to these terms, STS refers to the presence of posttraumatic symptoms arising from exposure to another’s trauma. STS is now codified in the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, [ 1]) diagnosis of PTSD which, for the first time, acknowledges that trauma exposure may occur indirectly through “repeated or extreme exposure to aversive details” (p. 271) of another’s traumatic experience.

Table 1. Distinctions proposed among the concepts of burnout, vicarious trauma, compassion fatigue, compassion satisfaction, and secondary traumatic stress.

Burnout: Emotional exhaustion and feelings of ineffectiveness due to work-related perceived powerlessness and lack of appreciation
Vicarious trauma: Changes in one’s inner experience or worldview due to empathic engagement with a traumatized person (may include moral injury, the experience of events that transgress deeply held moral and ethical beliefs and expectations)
Compassion fatigue: Feeling of being emotionally “spent” by caring for others without being able to replenish own reserves Compassion satisfaction: Positive feelings deriving from competent performance, engagement with colleagues, and conviction that one’s work makes a meaningful contribution
Secondary traumatic stress: Presence of PTSD symptoms resulting from indirect exposure to others’ trauma
2 Sources: American Psychiatric Association ([ 1]); Figley ([17]); Litz, 2009; Maslach ([47]); Mathieu ([48]); National Child Traumatic Stress Network Secondary Traumatic Stress Workgroup, ([56]); and Pearlman and Saakvitne ([64]).

Several observations led the R-TIP curriculum to focus on the construct of STS. First, over the course of several pilot presentations of the curriculum with diverse constituencies of non-mental health professionals, participants appeared to resonate most strongly to content related to STS. In addition, in the juvenile justice contexts in which R-TIP was first developed, the relevance of STS is suggested by evidence of high rates current symptoms of PTSD among staff (Hatcher, Bride, Oh, King, & Catrett, [28]; Union of Solictor General Employees, [77]). The sources of this posttraumatic stress appear to be threefold: staff members’ past history of trauma; direct exposure to trauma as a function of their work (e.g., witnessing take-downs and restraints, observing violence between youth as well as between youth and staff); and secondary trauma following from learning about interpersonal violence both suffered by and inflicted by youth in their care. For example, participants at R-TIP workshops commonly share feelings of being “haunted” not only by the disturbing abuse histories revealed by the youth with whom they work, but also by stories youth tell of extreme acts of violence they have perpetrated against others. The risks of prior and concurrent trauma exposure are particularly acute in certain contexts; for example, community gang intervention workers are disproportionately either former or current gang members and residents of gang-ridden communities who report extensive personal experience with violence and victimization (Dierkhising & Kerig, [15]).

On the other side of the coin, the constructs of compassion satisfaction (Stamm, [73]) and vicarious resilience (Killian, Hernandez-Wolfe, Engstrom, & Gangsei, [37]) have been proposed as potential antidotes to these negative effects. Compassion satisfaction refers to the experience of energizing and uplifting emotions, perceived self-efficacy, and professional competence related to providing care to others, whereas vicarious resilience refers to positive effects following upon witnessing another’s recovery from trauma, such as increased hopefulness and capacity for emotional engagement. Research also shows that professional training in trauma-informed care is associated with elevations in compassion satisfaction among mental health workers (Sprang, Clark, & Whitt-Woosley, [71]) and that the utilization of evidence-based practices is associated with compassion satisfaction and lower levels of compassion fatigue and burnout among trauma therapists (Craig & Sprang, [11]). These findings suggest that interventions focused on increasing knowledge and providing professionals with effective strategies for responding to trauma can be protective and therefore also helped to inform the development of R-TIP.

Research on risk and protective factors for STS
A number of studies have identified correlates of STS among trauma-exposed professionals, including first responders, child welfare workers, medical staff, and psychotherapists; however, prospective investigations of risk and protective factors are sparse (Molnar et al., [51]). In a recent systematic review of empirical research involving STS and related constructs among mental health professionals, Turgoose and Maddox ([76]) uncovered 32 studies, although most of these were compromised by methodological weaknesses, such as exclusive reliance on cross-sectional methods and sampling bias derived from nonrandom responsivity among those participants motivated to volunteer for participation due to the salience of the issue for their own concerns. Summarizing across studies, the strongest evidence for risk factors increasing the likelihood of STS included participants’ own histories of trauma exposure, especially trauma occurring during childhood. High levels of empathy, particularly the experience of empathic distress in reaction to clients’ trauma, also emerged as a vulnerability across studies. For example, MacRitchie and Leibowitz (2010) found that empathy statistically accounted for the association between previous trauma exposure and STS. In addition, the mere volume of exposure, as indexed by size of caseload and amount of time spent with clients, also emerged as a consistent risk factor across studies, as did lower levels of professional experience in the field. Maladaptive coping strategies, including self-criticism and helpfulness, also conferred risk. In turn, the weight of the evidence regarding gender differences was mixed, with some but not all studies showing higher rates of STS among women.

On the side of resilience, Turgoose and Maddox’s review found that dispositional mindfulness—the tendency to be open to present experience—was associated with lower levels of STS. Compassion satisfaction also emerged as a robust negative correlate of STS. Other variables were measured only in a single study but are suggestive; for example, awareness of one’s own emotional states emerged as a predictor of low STS in Killian’s ([38]) study of clinicians working with trauma survivors. In turn, qualitative data suggest that supervision and debriefing in the aftermath of trauma exposure are viewed as essential by clinicians. As Turgoose and Maddox note, however, the research to date leaves many questions insufficiently addressed. For example, the evidence implicating trauma history as a vulnerability often is not tempered by consideration of whether these issues have been successfully resolved. Resolution and meaning-making in the aftermath of trauma is a keystone of trauma treatment and can be associated with amelioration of its effects (Resick, Monson, & Chard, [67]). For example, two studies of disaster responders have confirmed that it is specifically unresolved past trauma that increases vulnerability to STS (Creamer & Liddle, [12]; Hargrave, Scott, & McDowall, [27]).

These empirical findings are suggestive of potential targets for intervention; however, it is notable that virtually no evidence base yet exists for the techniques that have been proposed to ameliorate STS (Molnar et al., [51]). For example, Bercier and Maynard’s ([ 4]) systematic review of STS interventions uncovered not a single study that met acceptable methodological criteria. Among the studies that do exist, findings generally have been modest and mixed. In particular, although self-care is a virtually ubiquitous feature of STS interventions, some research suggests that trainings focused on self-care do not result in more time spent in these activities, nor do these activities alone result in decreased STS (Bober & Regher, 2006). In contrast, in one of the only randomized controlled trials of an STS intervention, Berger and Gelkopf ([ 5]) found that a psychoeducational curriculum provided to nurses working in war zones was associated with reduced STS in tandem with increased professional self-efficacy. Consequently, additional targets for intervention beyond self-care—such as professional skills and competencies—may be needed to address STS.

Theoretical and empirical foundations of R-TIP
In addition to the empirical research already cited, a rich body of clinical literature on prevention and intervention with STS helped to inform the conceptualization underlying R-TIP (e.g., Baranowksy, [ 3]; Bush, [ 9]; Figley, [17]; Mathieu, [48]; Meyers & Cornille, [49]; Miller & Sprang, [50]; Moran, [52]; Osofsky, [63]; Skovholt & Trotter-Mathison, [69]; Van Dernoot Lipsky, [78]). However, in the absence of a unified theoretical or empirical evidence base for addressing STS specifically, the rationale for R-TIP also was developed in ways that are informed by research and other evidence-based practices for the prevention and treatment of PTSD more generally. Reviewing this literature led to a curriculum focused on six core elements: appraisals, self-efficacy, emotional awareness and acceptance, affect regulation, resilience, and prevention.

Appraisals and meaning-making
Although R-TIP is not a cognitive behavioral psychotherapy, the curriculum draws from the strong empirical evidence regarding the key role of appraisals in the development of posttraumatic stress symptoms (Bovin & Marx, [ 7]; Ehlers & Clark, [16]) and their alleviation (Resick et al., [67]). In an accessible and lay person-friendly way, participants are exposed to the underlying principles of cognitive processing in trauma interventions for adults and youth (Cohen, Mannarino, & Deblinger, [10]; Resick et al., [67]), as well as to the links among appraisals, emotions, and behavior, in order to enable them to better identify unhelpful thoughts that might be keeping them, or colleagues they are debriefing, “stuck” in a trauma story. This module has the additional benefit of demystifying and destigmatizing evidence-based interventions for PTSD, leading a number of participants to request referrals to evidence-based trauma treatment providers or to indicate a new-found willingness to seek psychotherapy for their own distress.

Self-efficacy
Another trauma-linked construct guiding R-TIP is that of self-efficacy, which has been shown to act as a powerful buffer of the association between trauma exposure and primary posttraumatic stress (Nygaard, Johansen, Siqveland, Hussain, & Heir, [59]) as well as STS (Prati, Pietrantoni, & Cicognani, [65]). As suggested by evidence for the salutary effects on trauma clinicians of training in evidence-based methods (Craig & Sprang, 2009) and resulting increased perceived competence (Ortlepp & Friedman, [62]), a prevailing hypothesis informing R-TIP is that prior preparation for exposure to trauma-related material, termed having “tools in our toolbox,” is in itself protective against STS by virtue of increasing professional competence and self-efficacy among participants. To this end, R-TIP goes beyond other curricula that focus on self-care in the aftermath of trauma exposure and strives to help participants to feel prepared in very concrete ways for exposure to trauma-related stories and posttraumatic reactions among the youth they serve, including considering how they would self-regulate and how they would respond to a client in the moment. Handouts and worksheets created for the training explicitly guide non-mental health professionals in how to respond helpfully to youth disclosures and distress without transgressing appropriate boundaries and taking on a psychotherapeutic role.

Emotional awareness and acceptance
Emotional awareness and acceptance is also a key theme in R-TIP. Drawing from Miller and Sprang’s ([70]) conceptual model for addressing STS in clinical supervision, as well as empirical research confirming the protective value of emotional self-awareness (Killian, [38]), R-TIP emphasizes the value of allowing trauma-related thoughts and emotions into consciousness, rather than suppressing or fleeing from them, so as to psychologically metabolize them and titrate their potentially toxic effects. One of the ways R-TIP fosters openness to emotion is through the use of shared humor, which clinical observations suggest can be a powerful method for increasing recognition of one’s own STS (Van Dernoot Lipsky, [78]) as well as offering a potential antidote to its effects (Moran, [52]).

Affect regulation
The centrality of affect regulation in responding to trauma also is a key component of R-TIP. In this regard, R-TIP is heavily influenced by affect regulation-based interventions for traumatized youth, given their emphasis on the positive reciprocal effects of staff remaining regulated, both to help their clients and to maintain their own emotional equilibrium (Ford, [18]; Ford & Blaustein, [19]; Ford & Russo, [22]; Marrow, Knudsen, Olafson, & Bucher, [46]). During moments of high arousal during exposure to trauma-related material, in debriefings afterward, and in subsequent effort to decompress and care for themselves, participants are introduced to strategies for inducing mindfulness and engaging psychophysiological, cognitive, and emotional regulatory processes. Personal observations of the rapidity with which some staff negate and invalidate such strategies (e.g., “I tried that and it doesn’t work;” “I’d feel silly doing that”), and with recognition that “no one size fits all” when it comes to the efficacy and acceptability of mindfulness techniques (Macbeth, [44]), a menu of a wide range of strategies adapted from diverse sources is offered (e.g., Bush, [ 9]; Garland, [24]; Kabat-Zinn, [30]; Macbeth, [44]; Mathieu, [48]; Vo, [80]), as well as the author’s own clinical and personal experience. Further, as an engaging and often humor-infused exercise, participants are invited to share their own creative and unique ways of grounding themselves and reengaging with their personal sources of compassion satisfaction. When coworkers attend the training together, this exercise also helps to build a mutually aware and supportive culture in which participants learn to recognize and foster one another’s self-care strategies, no matter how individually “quirky” those might be.

Resilience
Particularly given concerns in some quarters that the term “secondary traumatic stress” could be seen as pathologizing, the R-TIP curriculum is strength based and emphasizes that its goals are not to identify or cure psychopathology, but rather to enhance participants’ capacities for resilience. Throughout the curriculum, participants are provided opportunities to reflect on and share their individual and collective strengths and to discuss ways those could become more fine-tuned, well-honed, or simply more readily available to be pulled from their “toolboxes.” In keeping with scholarship in the field, resilience in the face of trauma exposure is conceptualized not as a static characteristic an individual possesses but rather as a process of engagement with protective factors in the interaction between the self and the interpersonal environment (Kerig, [34]; Rutter, [68]; Walsh, [82]). Consistent with Grych and colleagues’ (Grych, Hamby, & Banyard, [25]; Hamby, Grych, & Banyard, [26]) resilience portfolio model, three broad domains of protective factors are highlighted in R-TIP: self-regulation, interpersonal strengths, and meaning-making.

The power of prevention
In keeping with pioneering models in the creation of trauma-informed systems (Bloom & Sreedhar, [ 6]), and consistent with recent efforts to promote STS-prevention on an organizational-wide scale (Sprang, Ross, Miller, Blackshear, & Ascienzo, [72]), R-TIP emphasizes that STS is not an individual matter alone. A possible unfortunate and unintended consequence of curricula that focus only on self-care is that participants may mistakenly construe STS as being a consequence of their own personal failure, whether of grit, will, or mental hygiene. The message that prevention of STS requires a change in coworkers’ interrelationships and larger organizational practices, and not just in the self-care repertoires of individual staff members, has resonated strongly with the participants in R-TIP workshops.

Within the R-TIP curriculum, one systemic issue that is addressed concerns the strategies agencies employ for trauma screening. The recommendation that trauma-informed systems implement universal trauma screening often is operationalized as a mandate to elicit youths’ trauma histories which, by asking youth to disclose private and painful events, run the risk of exposing staff who administer or review the results of those screeners to traumatic material (Kerig et al., [36]). However, trauma history measures are only one alternative for establishing the need for trauma-informed services and are perhaps not the most effective. For example, research shows that between 80% and 99% of youth in the juvenile justice system have experienced exposure to at least one traumatic event, but only a small proportion of those evidence significant posttraumatic stress symptoms; thus, trauma histories will not help to triage the subset in need of trauma-specific services (Kerig et al., [36]). Further, in the terminology of forensic risk-needs assessment (Andrews, Bonta, & Hoge, [ 2]; Vincent, Guy, & Grisso, [79]), past history of trauma can be likened to a “static” risk factor in that it is fixed and not amenable to change. Instead, present posttraumatic symptoms can be considered “dynamic” risk factors in that they are likely to affect youth’s behavior and their responses to programming in the here-and-now; moreover, such symptoms are changeable in that they are ameliorated by evidence-based trauma-specific treatments (Ford, Kerig, Desai, & Feierman, [21]). To this end, participants in R-TIP are introduced to screening strategies that offer an alternative to the “archeological” (Ford & Cloitre, 2009, p. 49) process of unearthing past trauma histories by focusing instead on identifying posttraumatic symptoms that are interfering with functioning in the present (Kerig, [32], [33]). By not inquiring about past traumatic events nor the details about them, these posttraumatic symptom-based screening tools have the additional benefits of being non-intrusive for youth and preventative against secondary trauma exposure for staff.

A second prevention target focuses on the strategies staff use when either delivering or receiving a debriefing after trauma exposure. Here, participants are taught techniques derived from low-impact disclosure (LID), a concept originated by Pearlman and Saakvitne ([64]) and elaborated by Mathieu ([48]). LID offers a method to avoid doing harm to others via egregious contagious transmission of trauma-related images through four steps: increasing self-awareness, giving fair warning, obtaining consent, and disclosing thoughtfully by refraining from relaying unnecessarily gruesome details to colleagues during debriefings, particularly with colleagues who are not specifically trained in coping with and responding to such information. Further, consistent with the focus on appraisals in R-TIP, participants are encouraged to consider the relative value of debriefings that are focused less on the trauma “story” (e.g., who did exactly what to whom) and more on the effect of that story on the recipient’s frame of mind (e.g., what does having heard that story signify to the individual about human nature, the world, or the future), with potential resulting traumagenic beliefs (e.g., moral injury, loss of faith, and hopelessness) at the heart of the matter. The development of a supportive culture is encouraged through inviting coworkers to make a commitment to practicing LID with one another, as well as more generally acknowledging STS and responding compassionately to one another’s reactions to trauma-related material.

Third, prevention is addressed by encouraging participants to acknowledge the burden of unrelenting exposure to trauma and to investigate whenever possible opportunities to negotiate with supervisors and administrators for balanced workloads that allow some relief from trauma-related tasks. In this regard, the value of including administrators and supervisors in the training, as well as tailoring specific trainings for them, is emphasized (Dierkhising & Kerig, [15]). Fourth, in what would more accurately be termed secondary prevention, participants are encouraged to develop a personal “dosimeter” (Mathieu, [48]) that registers the early warning signs (e.g., being in the “yellow zone”) that one is just beginning to be affected by STS-related reactions. As in secondary prevention more generally, the benefit of this tool is that it allows the employment of coping strategies early on in the process, when those strategies might be maximally efficacious, and before STS becomes full-blown (e.g., the “red zone”). Moreover, again, the importance of creating a trauma-informed community is emphasized in that participants are encouraged to not depend only on their own insights as to the behaviors that signal they are entering a “yellow zone” of distress, but rather to seek consultation from their coworkers and loved ones as to the signs that those observers are uniquely poised to detect. Not only are others’ observations built into the stress reactions that comprise the “dosimeter,” but participants are encouraged to enlist their coworkers and loved ones as “third eyes” who will promise to offer an alert if they observe signs of stress of which the individual is unaware.

Outline of the R-TIP curriculum
As outlined in Table 2, the R-TIP curriculum addresses three stages in the process of exposure to traumatic material. First, pre-exposure strategies are presented for prevention and protection from the spillover of traumatic stress, including non-intrusive trauma screening and debriefing procedures that protect staff, colleagues, and youth from avoidable secondary trauma exposure, as well as recognition of early signs of emergent STS reactions. Second, for use during moments of trauma exposure, participants are introduced to effective coping techniques, including those that help maintain regulation in the here-and-now in the presence of trauma-related material or traumatized individuals who have become triggered, and strategies for responding helpfully to youth disclosures or distress. Third, the curriculum fosters individual, interpersonal, and systemic strategies that promote recovery in the aftermath of trauma exposure, including identifying and countering unhelpful appraisals, developing a repertoire of effective and accessible self-care practices, developing a team approach to STS in which colleagues act as supports to one another; enhancing more generalized and long-term resilience; and learning to tap into sources of compassion satisfaction and vicarious resilience.

Table 2. Outline of the R-TIP curriculum (Kerig, 2018).

1. Pre-exposure, Prevention, and Protection from Spillover
Introduction to non-intrusive trauma screening techniques focused on clients’ present posttraumatic symptoms rather than details of past traumatic events, through demonstration of specific alternative measures.

Introduction to low-impact disclosure (LID; Mathieu, 2012) to reduce contamination of colleagues and family members during formal or informal debriefings, through didactics and small group practice.

Developing a personal early detection system for the early stages of STS-related reactions onset as a prompt to engage in support-seeking and implementation of self-care, through completing “My Dosimeter” worksheet.

Identifying organizational strategies that are amenable to STS-informed revisions (e.g., workload balance, culture of recognition and responsivity to STS, specialized training for supervisors in trauma-exposure supports, and staff debriefing), through didactics and group discussion.

2. Coping in the presence of trauma
Introduction to strategies for maintaining regulation in the presence of trauma-related material through didactics, “Ways to Engage Inner Balance” handout, and small group practice.

Introduction to strategies for responding in helpful ways to clients who choose to disclose trauma stories through didactics, “Responding to Youth Disclosures” handout, and small group practice.

Strategies for responding in the here-and-now to clients exhibiting posttraumatic symptoms or triggered by trauma reminders through didactics, “Responding to Youth Who Become Triggered” handout, and small group practice.

3. Recovery in the aftermath of trauma exposure
Understanding the role of appraisals in posttraumatic and secondary traumatic reactions and developing strategies to counter them in our own trauma stories and debriefing of colleagues; through didactics and real-life examples of the principles underlying cognitive processing in “unpacking” unhelpful appraisals in trauma narratives.

Developing a culture of mutual support protective against STS among trauma-informed staff and between staff and supervisors, through small group discussion.

Developing repertoires of individualized effective self-care strategies accessible (a) during the work day, (b) during the transition between home and work, and (c) while at home, through completing “STS Prevention Toolkit” worksheet.

Developing a repertoire of longer-term strategies to enhance overall resilience and well-being, through completing “STS Prevention Toolkit” worksheet.

Identifying strategies for tapping into sources of compassion satisfaction, vicarious resilience, and personal meaning in trauma-related work, through “Tapping into Our Compassion Satisfaction” group experiential exercise.

Future directions

Need for an evidence base
As with most curricula for preventing and addressing STS, a major limitation of R-TIP is that its effectiveness has not been subject to rigorous empirical validation. To date, only a small-scale program Assessment is available, in which R-TIP was delivered in the context of a larger trauma-informed training for community gang intervention workers (Dierkhising & Kerig, [15]). Although qualitative feedback from participants in this project was positive overall, the quantitative data obtained on the Professional Quality of Life Scale (ProQOL; Stamm, [74]) showed that, at the pre-test, participants on the whole rated themselves so low on STS and high on compassion satisfaction that floor and ceiling effects prevented the detection of meaningful change; however, participants also offered that the curriculum allowed them to identify symptoms of STS they had misattributed to other sources, thus resulting in higher—but more accurate—ratings of STS after the training. Future research on the effectiveness of R-TIP and other STS-prevention trainings also will benefit from the availability of more refined instruments assessing STS, as well as the protective factors that might buffer against its negative effects, that are currently under development (Sprang, [70]).

Another important question for the future empirical validation of R-TIP will be to determine that it is the conceptually based targets of change in the curriculum that comprise its effective ingredients (Kazdin, [31]). Before organizations invest time and resources in any training, it is important to establish that less time- and resource-expensive nonspecific factors, such as the presence of an engaging presenter, the opportunity for staff to come together in a non-stressful context, or the break from the workday routine, do not result in equally positive results. Therefore, dismantling or process–outcome studies are needed that examine whether it is changes in measurable constructs associated with the six core elements targeted by R-TIP—appraisals, self-efficacy, emotional acceptance, affect regulation, resilience, and preventative practices—that comprise the mechanisms by which the curriculum reduces STS.

Buy-in and sustainability
There are a number of challenges to obtaining buy-in of trauma-informed services in youth-serving agencies. The fact that trauma-informed practices are increasingly being mandated in settings such as juvenile justice (Listenbee & Torre, [41]) would seem to ensure buy-in; however, on the front lines, some express doubts that such obligatory programming is implemented with enthusiasm or fidelity. The terms “flavor of the month” and “crossing another thing off the list” are often heard when staff disclose their candid views about trauma-informed programming during trainings. To the contrary, however, experience to date with offering R-TIP has suggested that staff are appreciative of hearing validation of the strains associated with their work and are eager to learn professional strategies to manage these challenges, beyond simple trauma awareness or self-care. As Molnar et al. ([51]) note, perceived stigma is another potential barrier to participation in STS-related interventions, particularly among non-mental health professionals; however, the accessible and strength-based focus of curricula such as R-TIP may help mitigate such concerns.

Another important issue for future consideration concerns ensuring the sustainability of STS-prevention practices for trauma-informed systems. To this end, R-TIP is intentionally brief, strategic, and cost-effective, and each skill is accompanied by handouts that allow participants to take the curriculum with them at the end of the workshop. Other effective methods to enhance sustainability include forming learning collaboratives to prevent drift, as well as implementing train-the-trainer initiatives, so the ongoing use of the curriculum in each setting is not threatened by staff turnover, which is high in stressful and trauma-pervaded organizations.

Conclusion
In conclusion, R-TIP offers a potentially promising curriculum for guiding non-mental health professionals to carry out trauma-informed programming in ways that protect them from the risks associated with STS. Although not yet empirically validated, the curriculum is informed by research that suggests the importance of addressing six core elements—appraisals, self-efficacy, emotional awareness and acceptance, affect regulation, resilience, and prevention—each of which provides a clear target for intervention, as well as a measurable construct and clearly testable hypothesis to inform future investigations of the mechanisms through which the curriculum achieves its intended beneficial effects.

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~~~~~~~~

By Patricia K. Kerig

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Caring for the caregivers: Assessment of the effect of an eight-week pilot Mindful Self-Compassion (MSC) training program on nurses’ compassion fatigue and resilience.Open Access
Authors:
Delaney, Martin C.. School of Education, University of Aberdeen, Aberdeen, Scotland, martincdelaney@gmail.com
Address:
Delaney, Martin C., martincdelaney@gmail.com
Source:
PLoS ONE, Vol 13(11), Nov 21, 2018. ArtID: e0207261
NLM Title Abbreviation:
PLoS One
Publisher:
US : Public Library of Science
ISSN:
1932-6203 (Electronic)
Language:
English
Keywords:
caregivers, mindful self-compassion, nurses’ compassion fatigue
Abstract:
Background: Nurses vicariously exposed to the suffering of those in their care are at risk of compassion fatigue. Emerging research suggests that self-compassion interventions may provide protective factors and enhance resilience. This pilot study examined the effect of an eight-week Mindful Self-Compassion (MSC) training intervention on nurses’ compassion fatigue and resilience and participants’ lived experience of the effect of the training. Methods: This observational mixed research pilot study adopted an Assessment design framework. It comprised of a single group and evaluated the effects of a pilot MSC intervention by analyzing the pre- and post-change scores in self-compassion, mindfulness, secondary trauma, burnout, compassion satisfaction, and resilience. The sample of the nurses’ (N = 13) written responses to the question, ‘How did you experience the effect of this pilot MSC training?’ were also analyzed. Results: The Pre- to Post- scores of secondary trauma and burnout declined significantly and were negatively associated with self-compassion (r = -.62, p = .02) (r = -.55, p = .05) and mindfulness (r = -.54, p = .05). (r = -.60, p = .03), respectively. Resilience and compassion satisfaction scores increased. All variables demonstrated a large effect size: Mean (M) Cohen’s d = 1.23. The qualitative emergent themes corroborated the quantitative findings and expanded the understanding about how MSC on the job practices enhanced nurses’ coping. Conclusion: This is the first study to examine the effect of a pilot (MSC) training program on nurses’ compassion fatigue and resilience in this new area of research. It provides some preliminary empirical evidence in support of the theorized benefits of self-compassion training for nurses. However, further research, such as a Randomized Control Trial (RCT) with a larger sample size and a longitudinal study, is required to see if the benefits of self-compassion training are sustainable. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Caregivers; *Nurses; *Resilience (Psychological); *Self-Care Skills; *Compassion Fatigue
Medical Subject Headings (MeSH):
Adaptation, Psychological; Burnout, Professional; Caregivers; Compassion Fatigue; Education, Nursing; Empathy; Female; Humans; Mindfulness; Nurses; Pilot Projects; Resilience, Psychological
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Female
Location:
Ireland
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Neff 26-Item Self-Compassion Scale
Frieburg Short Mindfulness Scale
Conor-Davidson Resilience Scale
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Nov 21, 2018; Accepted: Oct 29, 2018; First Submitted: Jan 9, 2018
Release Date:
20191219
Correction Date:
20200702
Copyright:
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.. Martin C. Delaney. 2018
Digital Object Identifier:
http://dx.doi.org/10.1371/journal.pone.0207261
PMID:
30462717
Accession Number:
2018-60808-001
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Caring for the caregivers: Assessment of the effect of an eight-week pilot mindful self-compassion (MSC) training program on nurses’ compassion fatigue and resilience
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Contents
Introduction
Study purpose
Definitions and key concepts
Compassion and self-compassion
Mindfulness and compassion
Method
Study design
Participants
Procedure
The intervention
Measures
Quantitative data analysis
Qualitative data analysis
Data mixing
Results
Quantitative data
Qualitative data
Data mixing
Discussion
Independent variables self-compassion and mindfulness
Associated qualitative emergent themes
Dependent variables: Secondary traumatic stress
Burnout
Compassion satisfaction
Resilience
Emergent theme: Positive mental states
Study limitations and future directions
Conclusions
Supporting information
References
Full Text
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Background: Nurses vicariously exposed to the suffering of those in their care are at risk of compassion fatigue. Emerging research suggests that self-compassion interventions may provide protective factors and enhance resilience. This pilot study examined the effect of an eight-week Mindful Self-Compassion (MSC) training intervention on nurses’ compassion fatigue and resilience and participants’ lived experience of the effect of the training. Methods: This observational mixed research pilot study adopted an Assessment design framework. It comprised of a single group and evaluated the effects of a pilot MSC intervention by analyzing the pre- and post-change scores in self-compassion, mindfulness, secondary trauma, burnout, compassion satisfaction, and resilience. The sample of the nurses’ (N = 13) written responses to the question, “How did you experience the effect of this pilot MSC training?” were also analyzed. Results: The Pre- to Post- scores of secondary trauma and burnout declined significantly and were negatively associated with self-compassion (r = -.62, p = .02) (r = -.55, p = .05) and mindfulness (r = -.54, p = .05). (r = -.60, p = .03), respectively. Resilience and compassion satisfaction scores increased. All variables demonstrated a large effect size: Mean (M) Cohen’s d = 1.23. The qualitative emergent themes corroborated the quantitative findings and expanded the understanding about how MSC on the job practices enhanced nurses’ coping. Conclusion: This is the first study to examine the effect of a pilot (MSC) training program on nurses’ compassion fatigue and resilience in this new area of research. It provides some preliminary empirical evidence in support of the theorized benefits of self-compassion training for nurses. However, further research, such as a Randomized Control Trial (RCT) with a larger sample size and a longitudinal study, is required to see if the benefits of self-compassion training are sustainable.

Keywords: Research Article; Medicine and health sciences; Mental health and psychiatry; Psychological stress; Biology and life sciences; Psychology; Social sciences; People and places; Population groupings; Professions; Medical personnel; Nurses; Health care; Health care providers; Research and analysis methods; Research design; Pilot studies; Diagnostic medicine; Signs and symptoms; Fatigue; Pathology and laboratory medicine; Emotions; Mathematical and statistical techniques; Statistical methods; Regression analysis; Linear regression analysis; Physical sciences; Mathematics; Statistics; Clinical medicine; Clinical trials; Randomized controlled trials; Pharmacology; Drug research and development

Introduction
While empathy and compassion are often seen as two essential qualities in caregiving, continuous exposure to the suffering of others on a daily basis carries a risk of compassion fatigue in nurses [[ 1]]. This can impact a nurse’s professional ability, personal life, and potentially lead to an increase in staff shortages [[ 2]–[ 3]]. Multiple studies have identified that 40–60% of healthcare professionals are challenged by burnout at some stage of their career [[ 3]–[ 4]]. Compassion fatigue (CF) is defined as a state of exhaustion and dysfunction as a consequence of prolonged exposure to suffering and stress [[ 5]]. This research pilot study uses a model that conceptualizes CF as comprising of two main negative aspects secondary traumatic stress and burnout along with the positive aspect of compassion satisfaction which is defined as the fulfillment one gets from being able to do one’s work well. [[ 5]–[ 6]]. There is some consensus that burnout is a response to prolonged exposure to demanding interpersonal circumstances and is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment [[ 6]–[ 7]]. In a healthcare setting, burnout may be experienced by both back office staff and caregivers. Secondary traumatic stress, however, is a consequence of nurses’ and other caregivers’ daily exposure to their clients’ suffering. It comes about as a result of a countertransference of suffering from the clients to nurses as a result of an unconscious attunement to and absorption of the clients’ stresses and trauma. Moreover according to Bride secondary traumatic stress specifically is a phenomenon whereby nurses or other caregivers may become traumatized not by directly experiencing a traumatic event but by indirect exposure to the traumatic events and suffering being experienced by those in their care. .[[ 6], [ 8]–[ 9],[10]].

Emerging research suggests that compassion skills training could serve as an antidote to nurses’ secondary trauma and burnout [[ 4], [ 8]]. A number of studies have examined the role of mindfulness-based interventions (MBis) [[ 2],[11]] and loving kindness meditation interventions (LKMi) for caregivers [[12]]. Additionally, a meta-analysis of the association between self-compassion and psychopathology identified associations between higher self-compassion and lower psychopathology [[13]]. However, a review of the relevant literature till date (till November 2017) found no study that evaluated the effect of a self-compassion intervention (SCi) on nurses’ CF and resilience. The majority of the studies to date were correlational studies, cross-sectional surveys, or reviews of published literature [[ 3]–[ 4], [14]]. Therefore, this pilot study was the first step in gaining some preliminary empirical evidence on the theorized benefits of self-compassion skills training to nurses in a real-world setting.

Kristin Neff and Christopher Germer developed the Mindful Self-Compassion (MSC) intervention to provide participants with a variety of tools to enhance self-compassion and integrate it into their daily lives. They proposed that emerging research indicates a role for explicitly teaching self-compassion skills as a means of enhancing positive psychological health [[15]]. In addition, they suggested that greater self-compassion has been found to predict lower levels of anxiety and depression [[15]]. MSC as a group strengths based positive psychological approach could have potential advantages over the more usual method of dealing with nurses’ challenges in a one to one clinical setting. For example it is preventative rather than reactive and as a group intervention it should prove more cost effective than one to one therapy. Neff and Germer evaluated the effectiveness of their MSC intervention in a pilot study and a randomized controlled trial (RCT) and found that the MSC intervention was successful in enhancing participants’ psychological functioning and that participants also experienced greater life satisfaction and less anxiety and depression. [[16]]

Study purpose
The pilot study sought to gain some preliminary empirical evidence to extend the initial research literature that theorized the benefits of self-compassion skills training to nurses. It chose to do this by assessing the effect of a pilot eight–week SCi in relation to nurses’ compassion fatigue and resilience. As there are no studies to date that examine the effects of a SCi on nurses’ compassion fatigue and resilience, any preliminary empirical evidence gathered may identify possible effects and associations that may be worth following up in subsequent larger studies. As a pilot study, this study is not a hypothesis testing study but a first step in exploring a novel intervention in the real-world setting of a busy university hospital with the goal of providing a preliminary assessment of the benefits of self-compassion skills training to nurses [[17]–[18], [19], [20]].

Definitions and key concepts

Compassion and self-compassion
Compassion can be defined as a basic kindness with a deep awareness of the suffering of oneself and other living things, coupled with the wish and effort to relieve it [[21]]. It is an innate ability, a mental state capable of being enhanced through training [[22]]. Moreover, self–compassion gives one the ability to hold one’s feelings of suffering with a sense of warmth, connection, and concern, rather than reacting with self-criticism and self-judgment. It is a response that reverses the more usual reactions of avoidance and suppression of suffering [[23]]. Neff [[24]] conceptualizes self-compassion by contrasting its three aspects with three opposing mental states, as follows:

1 Self-kindness: The ability to treat oneself with care and understanding rather than being harsh, judgmental, and self-critical.
A sense of common humanity: Recognizing that imperfection is a shared aspect of human experience rather than feeling isolated by one’s failures.
Mindfulness: Holding one’s painful thoughts and feelings in a balanced perspective rather than avoiding them or exaggerating the dramatic storyline of one’s suffering.
Mindfulness and compassion
According to Nairn [[25]], two aspects of mindfulness are a knowledge of what is happening in the present moment coupled with an attitude of non-preference to whatever arises in our field of awareness. However, mindfulness and compassion are seen as separate processes that need to be explicitly cultivated in their own ways though they have overlapping but quite different effects on the brain [[22]]. Both mindfulness and compassion involve moving toward discomfort or pain with an accepting rather than a conditioned reactive stance. However, the differences between the two are further clarified by Neff and Dahm [[26]] who stated that while mindfulness involves a balanced awareness of negative thoughts and feelings with equanimity, compassion has a broader scope that includes the elements of kindness and common humanity combined with the actions of actively soothing and comforting oneself or others. Like mindfulness, compassion training has a long tradition in Buddhist practice. Neale has compared the process of cultivating compassion through training to Wolpe’s theory of reciprocal inhibition [[27]]. This theory proposes that repeated practice establishes a desired attitude or behavior in direct antithesis to the stress response of flight, fight, or freeze when confronted with anxiety provoking stimuli. Reciprocal inhibition, according to Neale [[27]], is called pratipakha bhavanam in Sanskrit, meaning the cultivation of an opposing thought. From this perspective, training nurses to enhance their attitudes of self-compassion can be seen as an antidote to self-critical attitudes that can lead to the subordination of their own needs and an over-identification with patient outcomes.

Consequently, the study expected that nurses who attended a pilot eight-week MSCi would show enhanced internal resources of self-compassion and mindfulness and that these enhanced internal resources would be associated with a reduction in both negative aspects of compassion fatigue secondary traumatic stress and burnout, while also being associated with increased resilience and compassion satisfaction. Moreover, as a new area of investigation, the study examined nurses’ lived experience of participating in this pilot MSCi. The study was carried out in the Health Service Executive (HSE) of the Irish National Health Service at a university hospital in the west of Ireland.

Method

Study design
This observational pilot study adopted an Assessment research approach following STROBE guidelines [[28]]. The study had a single group Assessment design that used mixed research methods. A pilot study, according to Thabane et.al., has the possibility of finding preliminary empirical evidence that could inform decisions on the need for larger scale studies [[17]]. As a new area of investigation, the study combined a pragmatic stance with mixed research methods [[29]–[30],[31]]. This allowed for a corroboration of results between the two data sets, gave a richer understanding of participants’ experience of the intervention, allowed for elaboration of the results beyond what could be known with the use of self report instruments alone, and enhanced the interpretation of the findings [[32]]. The mixed research framework was a partially mixed, concurrent design with a dominant quantitative phase [[32]]. The quantitative phase consisted of the calculation of descriptive and inferential statistics. The qualitative phase used a phenomenological approach based on Interpretative Phenomenological Analysis (IPA) [[33]–[34]]. The mixed methods phase, including data transformation and integration of the two data sets, followed the guidance of Leech and Onwuegbuzie whereby the qualitative data was quantitated and combined with quantitative data to form a coherent whole data set [[32]]. This design choice provided the best opportunity to answer the research questions in the context in which the study was taking place.

Participants
Participants were all female nurses (n = 18). However, five participants did not complete the full eight-weeks MSC training, so the final sample size was n = 13. The sample size was just in excess of the sample size of 12 that is proposed for pilot studies by Julious, and by Belle, and also by the Royal College of Surgeons Ireland (RCSI) Guide for pilot studies [[35]–[36], [37]].

Procedure
Prior to the commencement of the study, the study topic was reviewed and approved by the Irish Health Service Executive (HSE) regional ethics committee (REC) and the University of Aberdeen, where it was submitted as part of the completion of the MSc degree in mindfulness, compassion, and insight studies.

In order to have a varied sample a poster advertisement was broadcast electronically to each area of the hospital. After an information evening, participants were self-selected and completed informed consent forms.

The sample was representative with participants coming from across a range of the hospital’s disciplines including Cancer Care, Cardiology, Maternity, Midwifery, Intensive Care, and Urology. The sample of participants was also representative in relation to ages from 30< to >60 years and, likewise, experience pertaining to the number of years working in nursing from 10< to >31 years. The mean age of the sample was M = 44 years, and participants’ mean years of having worked as nurses was M = 25. Particularly relevant to this study was that 70% of the nurses in the sample had worked as nurses between 21–40 years, and, therefore, would have had exposure to secondary traumatic stress for a longer period of time than, for example, students or trainee nurses. None of the participants had any previous meditation experience.

Subsequently, participants attended a pilot eight-week MSCi that took place weekly during normal working hours and during times suitable for both day and night duty staff. All participants completed pre- and post-intervention measures on mindfulness, self-compassion, resilience, and compassion fatigue. Additionally exploratory qualitative data was gathered on week eight of the MSCi in a twin approach that combined a brief 40-minute focus group discussion and participants written responses to the question “How did you experience the effects of this Pilot (MSC) training?” [[38]–[39]].

The intervention
This generic eight-week training teaches core principles and practices that enable participants to respond to difficult moments in their lives with kindness, care, and understanding. Participants attended a two-and-a-half hour training session each week and also participated in a half-day retreat. The focus of this MSC program was on helping participants develop self-compassion, with a secondary emphasis on mindfulness. In addition to weekly training sessions, participants were encouraged to practice on a daily basis and received four practice CDs of formal practices and informal practices that they could use on the job. The core practices of MSC include Mindfulness Meditation (MM), Loving Kindness Meditation (LKM), and Compassion Meditation (CM). A meditation session took place on each week of the course. The intervention teacher was a trained MSC teacher with the Center for Mindful Self-compassion (CMSC) and a fully accredited therapist/mental health professional in private practice, having previously worked in the Irish Health Service Executive (HSE) Employee Helpance Program (EAP). The choice of an eight–week MSC program is based on the fact that the majority of the evidence supporting the efficacy of mindfulness training is predominately based on the investigation of eight-week interventions [[40]]. In addition the eight-week MSC program is a manualized intervention, which will allow for repeatability and better comparisons with future research [[41]].

Measures
Pre- and post-intervention quantitative data was gathered using the following standardized self-report instruments: The Neff Self–Compassion Scale 26 item, the Frieburg Short Mindfulness Scale, ProQOL Professional Quality of Life Scale, and Conor-Davidson Resilience Scale 25 Item.[[42]–[43], [44],[ 5]].

The Neff 26-item Self-compassion scale was developed to measure both the negative and positive aspects of the three main components of self-compassion: self-kindness versus self-judgment, common humanity versus isolation, and mindfulness versus over-identification. This is based on Neff’s conceptualization of self-compassion, which was used in this study [[24]]. The internal consistency of the Neff 26 Item Self-compassion scale was Cronbach’s α = .97 [[42]].

The Freiburg Mindfulness inventory, a 14-item short version, was developed to measure mindfulness in people with no background in mindfulness or meditation and, for that reason, was appropriate for inclusion in this study. The internal consistency of the Freiburg Mindfulness Inventory was Cronbach’s α = .79 [[43]].

ProQOL Version 5 Professional Quality of Life Scale: Compassion Satisfaction and Fatigue Version [[ 5]]: ProQOL measures both the negative and positive effects of helping people who experience suffering and trauma. The ProQOL has sub-scales for compassion satisfaction, burnout, and the secondary traumatic stress associated with caregiving. The measure has been in use since 1995. Several revisions have been brought about in this measure with ProQOL 5 being the current version. The scales are:

Compassion Satisfaction: This is about the fulfillment one derives from being able to do one’s work well. For example, one may feel like it is a pleasure to help others through one’s work. The internal consistency of the ProQOL Compassion Satisfaction scale was Cronbach’s α = . 87.

Burnout: From the research perspective, this is one of the elements of compassion fatigue (CF). It is associated with feelings of hopelessness and difficulties in dealing with work or in effectively doing one’s job. The internal consistency of the ProQOL Burnout Scale was Cronbach’s α = .72.

Secondary Traumatic Stress: The second component of compassion fatigue is work-related secondary exposure to extremely or traumatically stressful events. The internal consistency of the Pro QOL Secondary Traumatic stress scale was Cronbach’s α = .80.The three scales cannot be combined to give an overall compassion fatigue score. However, it is designed to measure both the positive and negative effects of being a caregiver, which made these scales very relevant to this study.

Connor-Davidson Resilience Scale 25 item (CD-RISC 25) is designed to measure a person’s ability to cope with stress and adversity. It is based on the definition of resilience as the ability to adapt well, overcome adversity, and even thrive in the face of adversity. The fact that this scale was developed to assess the positive effects of treatment for stress made it relevant in assessing the effects of this study’s intervention on participants’ resilience. The internal consistency of the CD-RISC 25 was Cronbach’s α = .89 [[44]].

A summary of the tools used along with their reliability and validity is shown in Table 1 below.

Table 1: Summarizing the measures used with their reliability and validity.

Scale Cronbach Alpha Validity
Neff. 26 item Self-Compassion Scale a = .97 Factor Analysis results support a six factor model. Positive correlations with instruments measuring similar constructs
6 Factor Sub-scales
Self-kindness a = .79
Self-judgement a = .74
Common humanity a = .72
Isolation a = .69
Mindfulness a = .85
Over-Identification a = .72
Frieburg Short Mindfulness Scale a = .79 Positive Correlations between this and other instruments measuring mindfulness across a multitude of samples
Proqul Professional Quality of Life Scale
There is good construct validity with over 200 published papers.Nearly half of the 100 published research papers on compassion fatigue and secondary traumatic stress have utilised this scale
Sub-scales The sub-scales cannot be combined. The three scales measures separate constructs
Compassion Satisfaction a = .87
Burnout a = .72
Secondary Traumatic Stress a = .80
Connor—Davidson Resilience Scale 25 Item a = .89 Positive correlation with instruments measuring similar constructs. r = .82
The measures used in the study were all relevant to the studies’ conceptualizations and also relevant to the sample. For example the ProQol measure corresponded to the studies conceptualization of compassion fatigue, and the Frieburg Short Mindfulness Scale was appropriate for participants with no previous meditation experience. According to Simmons and Lehmann all social science instruments have a degree of error however as shown below all the measures chosen for this study had high levels of reliability and therefore less error. The reliability of the measures was characterized by good internal consistency that ranged from cronbach alpha a = .72 for burnout to cronbach alpha a = . 97 for self-compassion. Likewise the measures have demonstrated high validity with positive correlations with other instruments measuring similar constructs. [[45]]

Consequently all the measures used were relevant to the study and had high levels of reliability and validity.

Quantitative data analysis
Descriptive Statistics were calculated including the means and standard deviation for all variables pre- and post-intervention and Cohen d to measure effect size. Inferential statistics were used to examine the relationships between independent and dependent variables. Data was plotted into scatter plots and the following inferential statistics were used: Pearson’s correlation represented by r = to measure the strength and direction of associations between independent variables, self-compassion and mindfulness and the dependent variables, secondary traumatic stress, burnout, compassion satisfaction, and resilience. Linear regression was used to calculate the extent to which the variance in the dependent variables was attributable to the independent variables, represented by R2. P values are inserted for the benefit of the reader and not in an attempt at hypothesis testing [[46]–[47],[48]].

Qualitative data analysis
A phenomenological approach based on interpretative phenomenological analysis (IPA) was used in order to gain an understanding of the group’s shared lived experience of participating in this pilot MSCi. IPA is concerned with the subjective reports of individuals rather than the formulation of objective accounts. There are dual aspects to IPA: the reflections of the participants and the interpretative analysis of the researcher [[33]–[34]]. So, in order to gain a deeper understanding of what participating in this pilot program meant for the group, a brief 40-minute focus group session was held on completion of the intervention. This consisted of a group discussion among the participants on the question, “How did you experience the effects of this pilot (MSC) training?” During the group discussion, the nurses shared reflections and perspectives on their experiences. The eight-week MSC program contained a number of guided reflection exercises to help participants gain a deeper insight into their own experience. Likewise, at the end of the focus group discussion, participants were invited to again reflect on the question, “How did you experience the effects of this pilot (MSC) training?” They then wrote down what they discovered, and the written responses gathered in this way was the source of the qualitative data. Subsequently, participants’ written reports of their lived experience were subject to a subjective and reflective interpretation by the researcher. Themes that emerged directly from the data were initially coded and categorized into broad themes and were recoded into more specific emergent themes after continuous reading. Magnitude Coding was used to indicate the frequency and importance of the emerging themes and to facilitate qualitative data mixing with the quantitative data [[38]–[39]].

Data mixing
Percentile rank was calculated on the frequency of participants’ responses in relation to each of the qualitative emergent themes to denote the importance of each emergent theme, on the following basis: 3 = High, based on whether they were on or above 75 percentile, 2 = Medium, between 25–74 percentile, and 1 = Low, below 25 percentile. These quantitated qualitative results were then combined with the quantitative results, resulting in the formation of a combined data set. This data mixing facilitated the corroboration of the results from individual data sets. Furthermore, data mixing also facilitated further insights from the results than those that would have been gained with the use of pre-determined variables alone. It also enabled elaboration on the issues arising from combining data [[29], [39]].

Results

Quantitative data
A summary of the main quantitative findings pre–to- post the MSC intervention are shown in Table 2 below. It shows the trends for the independent variables self-compassion and mindfulness and the dependent variables secondary traumatic stress, burnout, compassion satisfaction, and resilience.

Table 2: Summary of the group’s pre- and post-intervention mean scores and effect size using cohen’s d.

Variables Pre. Mean S.D Post.Mean S.D Effect Size Cohen d 95% Confidence Interval Cohen d
Self-compassion 2.87 0.67 3.57 0.38 1.28 [0.1–2.48]
Mindfulness 33.92 6.56 42.00 4.86 1.40 [0.19–2.61]
Secondary Traumatic Stress 27.23 4.10 23.84 4.21 0.82 [-1.9–0.32]
Burnout 29.07 4.34 23.07 3.35 1.55 [-2.79–0.31]
Compassion Satisfaction 37.92 3.45 41.00 3.94 0.83 [-0.30–1.97]
Resilience 67.61 8.79 80.30 8.08 1.50 [0.27–2.73]
The analysis of the quantitative data indicated that post intervention scores on the self-compassion, mindfulness, compassion satisfaction and resilience scales were increased. Moreover the groups’ reported scores on the scales representing the two negative aspects of compassion fatigue, secondary traumatic stress and burnout both showed decreases. Effect size Cohen d for all the variables was large between d = .82 [CI -1.9–0.32] to d = 1.5[CI 0.27–2.73] in accordance with Cohen table for the interpretation of effect size. Mean effect size was (M) d = 1.23. [[46]–[47]].

Overall participants’ reported scores showed an increase for self-compassion, mindfulness, compassion satisfaction and resilience. Whereas reported scores in both of the negative aspects of compassion fatigue secondary traumatic stress and burnout decreased.

The analysis shown in Table 3 below reveals the strength and direction of the relationship between self-compassion and secondary traumatic Stress, burnout, compassion satisfaction, and resilience.

Table 3: Correlation analysis using pearson correlation showing the strength and direction of the relationship between self-compassion and secondary traumatic stress, burnout, compassion satisfaction, and resilience.

Variables Pearson Correlationr = P-value=
Secondary Traumatic Stress -0.62 0.02
Burnout -0.55 0.05
Compassion Satisfaction -0.19 0.52
Resilience +0.27 0.37
1 Note. The guidance used for interpreting the Pearson’s correlation was: Small = ± .1 to .29, Medium ± .3 to .49, and large ± .5 to 1.0 [[48]]

There was a strong negative association between participants’ reported scores of self-compassion and both negative aspects of compassion fatigue, secondary traumatic stress r = -0.62 and burnout r = 0.55 respectively. Of particular interest is the fact there was just a small positive association between self-compassion and compassion satisfaction and resilience. However this was a pilot study with a small sample size. A study with a larger sample size may for example find that an association of r = 0.27 between self-compassion and resilience might become significant.

Self-compassion had a negative association with both negative aspects of compassion fatigue secondary traumatic stress and burnout. However the association of self-compassion with compassion satisfaction and resilience requires further investigation.

The strength and direction of the relationship between mindfulness and secondary traumatic Stress, burnout, compassion satisfaction, and resilience can be seen in Table 4 below.

Table 4: Correlation analysis using pearson correlation showing the strength and direction of the relationship between mindfulness and secondary traumatic stress, burnout, compassion satisfaction, and resilience.

Variables Pearson Correlationr = P-value=
Secondary Traumatic Stress -0.54 0.05
Burnout -0.60 0.03
Compassion- Satisfaction -0.25 0.41
Resilience +0.66 0.01
2 Note. The guidance used for interpreting the Pearson’s correlation was: Small = ±. .1 to .29, Medium ± .3 to .49, and Large ± .5 to 1.0 [[48]]

The results indicated a strong negative association between participants’ reported enhanced mindfulness and secondary traumatic stress and burnout, wherein with an increase in mindfulness, there was a decrease in secondary traumatic stress and burnout. These reported results also show a large positive association between mindfulness and resilience r = 0.66. However, once again, there was no statistically significant relationship between mindfulness and compassion satisfaction with a p value of .41

Mindfulness had a negative association with both secondary traumatic stress and burnout. While there was a large positive association between mindfulness and resilience once more further investigation is required on the association between mindfulness and compassion satisfaction.

A summary of simple linear regression showing how the dependent variables were associated with self-compassion is presented in Table 5 below.

Table 5: A Summary of simple linear regression showing how the dependent variables were associated with self-compassion.

Variables Coefficient of DeterminationR2 β F p-level
Secondary Traumatic Stress .39 -6.77 6.9 .02
Burnout .30 -4,73 4.66 .05
Compassion Satisfaction .04 -1.98 .43 .52
Resilience .07 5.6 .87 0.37
The results indicated a negative trend a decrease in reported secondary traumatic stress and burnout as self-compassion increased. Reported enhanced self-compassion was a predictor of reduced secondary traumatic stress β = -6.77 and burnout β = -4.73 respectively. However, once more self-compassion had no statistically significant association with either compassion satisfaction or resilience.

Reported enhanced self-compassion was a predictor of reduced secondary traumatic stress and burnout.

However the association between self-compassion and compassion satisfaction and resilience requires further investigation.

A summary of simple linear regression describing how the dependent variables were associated with mindfulness is shown in Table 6 below.

Table 6: A Summary of linear regression showing how the dependent variables were associated with mindfulness.

Variable Coefficient of DeterminationR2 β F p-level
Secondary Traumatic Stress .30 -.47 4.62 .05
Burnout .36 -.42 6.28 .03
Compassion Satisfaction .06 -.2 .72 .41
Resilience .44 1.09 8.47 0.01
These results indicated a negative trend whereby as the groups’ reported score in mindfulness increased, there was a decrease in reported group scores for secondary traumatic stress and burnout. Moreover enhanced mindfulness was a predictor of reduced secondary traumatic stress β = -.47 and also burnout β = -.42. Conversely the increased group reported score for mindfulness was predictor of a large increase in enhanced resilience β = 1.09. However once again there was no statistically significant association with compassion satisfaction, indicating again that this requires further investigation.

Reported enhanced mindfulness was a predictor of reduced secondary traumatic stress and burnout and enhanced resilience. However the association between mindfulness and compassion satisfaction requires further investigation.

Qualitative data
Analysis of the exploratory qualitative data and the ranking of the emergent themes according to their importance is shown in Table 7 and Fig 1 below.

Table 7: Showing the emergent themes ranked according to their importance.

Emergent Themes Importance of Emergent Themesbased on Participants’ Responses
Positive Mental States 3
Enhanced Coping 3
Acceptance 2
Mindful Awareness 2
Less Self-critical 2
Reduced Stress 1
Difficulty Practicing 1
3 Note. Percentile rank was calculated on the frequency of participants’ responses associated with each of the emergent themes to denote the importance of each emergent theme, on the following basis: 3 = High, based on whether it was on or above 75 percentile, 2 = Medium, between 25–75 percentile, and 1 = Low, below 25 percentile [[39]].

The three medium ranked emergent themes of Acceptance, Mindful Awareness, and Less Self-Critical, could be seen to represent aspects of participants’ enhanced skills of self-compassion and mindfulness. The two highest ranked emergent themes of Positive Mental States, Enhanced Coping along with one of the low ranked emergent theme Reduced Stress may be associated with these enhanced skills. Interestingly even though none of the nurse participants’ had any previous meditation experience the emergent theme Difficulty Practicing ranked as of low importance.

Emergent themes can be viewed as being associated with aspects of participants’ enhanced skills of self-compassion and mindfulness and also associated with participants’ improved positive affect and coping skills.

Fig 1 below shows the relationship between emergent themes and an example of participants’ responses to the focus group question, “How did you experience the effect of this pilot MSC training?”

Data mixing
Qualitative and Quantitative Data was combined in Tables 8 and 9 below, allowing for a corroboration and elaboration of the results.

Table 8: The emergent themes associated with their nearest variable.

Emergent Theme Independent Variable Dependent variable
Mindful Awareness Mindfulness
Acceptance 1.Mindfulness & 2.Selfcompassion
Less Self-critical Self-compassion
Enhanced coping Resilience
Reduced stress Secondary Traumatic Stress & Burnout
Positive Mental states None None
Difficulty Practicing None None
Table 9: Combined results of emergent themes and associated variables pre- and post-intervention scores and effect size.

Associated Emergent theme ImportanceOf Theme Variable Pre. Post. Effect Size 95%Cohen’s d C.I.
Less Self-critical 2 Self-compassion 2.87 3.57 1.28 [0.1–2.48]
Mindful Awareness 2 Mindfulness 33.92 42 1.40 [0.19–2.61]
Acceptance 2 1. Self-compassion2. Mindfulness 2.8733.92 3.5742 1.28 [0.1–2.48]1.40 [0.19–2.61]
Reduced Stress 1 Secondary Traumatic Stress 27.23 23.84 .82 [-1.9–0.32]
Reduced Stress 1 Burnout 29.07 23.07 1.55 [-2.79–0.32]
None 0 Compassion Satisfaction 37.92 41 .83 [-0.33–1.97]
Enhanced Coping 3 Resilience 67.61 80.30 1.5 [0.27–2.73]
Positive Mental States 3 None
DifficultyPracticing 1 None
The outcome of combining the emergent themes with their nearest corresponding variable is shown in Table 8 below.

The majority of the emergent themes could be seen to be associated with a pre-determined variable.

The exception being Difficulty Practicing which was of low importance and also Positive Mental States which was of high importance. While Positive Mental States was not associated with a pre-determined variable this finding does concur with the findings of Neff et al., that training in self-compassion was associated with increased happiness optimism and positive affect.

The emergent themes were closely associated with the pre-determined variables. The main exception Positive Mental States concurred with the findings of Neff et al., in a study that examined self-compassion in relation to positive psychological functioning. [50]

The combined quantitative and qualitative results are shown in in Table 9 below.

The qualitative data results corroborated the quantitative finding. Generally the importance of emergent themes and effect size were related in that a theme’s ranking of importance was associated with the relevant effect size. For example Enhanced Coping was of high importance and was associated with Resilience the variable with one of the largest effect size Cohen d = 1.5 [C. I. 0.27–2.73]. However the other emergent theme of high importance Positive Mental States was not associated with a pre–determined variable. Nevertheless, the Positive Mental States reported by participants could be expected to have an impact on Compassion Satisfaction, the fulfillment one gets from being able to help others through one’s work. Once more this is an issue requiring further examination.

The combined data set demonstrated that the exploratory qualitative data corroborated the quantitative findings.

Discussion

Independent variables self-compassion and mindfulness
This study sought to find some preliminary evidence in a real-world setting of a busy university hospital in relation to the theorized benefits of self-compassion training to nurses [[ 6]–[ 7]]. This was approached by examining the effects of a pilot eight-week MSCi on nurses’ compassion fatigue and resilience. The results suggested that this pilot MSCi was associated with participants’ reported enhanced capacities of self-compassion and mindfulness. The group’s (.70) increase on the self-compassion scale (SCS) and a 8.08 increase on the mindfulness scale with a large effect size (d = 1.28 95% C.I [.0.1–2.48] and 1.40 95% CI [.0.19–2.61]), respectively, concurs with Neff and Germer’s [[16]] randomized controlled trial (RCT) of MSC where they also found a large effect size in both self-compassion and mindfulness Cohen’s d = 1.60 and .60, respectively. In comparison, they quoted three studies on Mindfulness Based Stress Reduction (MBSR) [[51]–[52], [53]] that yielded an average effect size of d = . 54 increase on the SCS. An interesting difference between this study and the Neff and Germer’s RCT is the reversal of increased scores and effect size for self-compassion and mindfulness. A possible explanation is the very different samples. Neff and Germer stated that in their sample, 81% of participants had previous meditation experience, while in this study, none of the nurses had any previous meditation experience. [[16]]

Associated qualitative emergent themes
Additionally, the quantitative results were supported by the qualitative analysis of participants’ responses to the focus group question, “How did you experience the effects of this Pilot MSC training?” Emergent themes closely associated with self-compassion and mindful awareness both ranked as having medium importance. Likewise acceptance also ranked as having medium importance. Acceptance is more often seen as an aspect of mindfulness [[25], [54]]. But Baer et al. [[55]] expanded the view of acceptance to incorporate both non-reactivity and non-judgment. Two of the six components of self-compassion, according to Neff [[24]], are the positive aspects of self-kindness rather than a negative reactivity of being harsh, judgmental, and self-critical. Therefore, from this perspective, acceptance can be seen as a meeting point between mindfulness and self-compassion. It indeed features in all of the core practices taught in MSC. Accordingly, the results from both quantitative measures and the qualitative analysis suggested that this pilot MSCi was associated with an enhancement of the nurses’ capacities of self-compassion and mindfulness.

Dependent variables: Secondary traumatic stress
Secondary traumatic stress and burnout are seen as two critical aspects of compassion fatigue that are related to caregivers’ psychological problems [[ 5], [ 9]]. Secondary traumatic stress is defined as the stress resulting from helping or wanting to help a traumatized or suffering person [[ 6]]. There was a significant reduction in nurses’ baseline score for secondary traumatic stress of 3.39 from pre (M = 27.23) to a post score of (M = 23.84) representing a large effect size of d = .82 95% CI [-1.9–0.32]. This can be compared with Potter et al. [[56]], who evaluated a five-week compassion fatigue resiliency program for oncology nurses (n = 13) and reported a 2.15 reduction in secondary traumatic stress. While no other comparable empirical studies were found till date (November 2017), this concurred with the theorized benefits that proposed that self-compassion may be a beneficial protective factor in caregivers’ compassion fatigue [[ 3],[ 8]]. The findings supplement these theories with some preliminary empirical evidence. As both self-compassion and mindfulness scores increased, secondary traumatic stress decreased, showing a strong negative association r = -.62 p <0.02 and r = -.54 p<0.05, respectively. Moreover, simple linear regression showed that the variance in self-compassion accounted for 39% (R2 = .39) of the variance in nurses’ secondary traumatic stress, while the variance in mindfulness accounted for almost 30% (R2 = .30) of the variance in secondary traumatic stress. This demonstrates that both self-compassion and mindfulness contributed to a significant reduction in nurses’ secondary traumatic stress. Additionally, participants’ increased capacities of both self-compassion and mindfulness were predictors of reduced traumatic stress, as represented by β = -6.77 and β = -.47, respectively. Participants’ responses in the qualitative data supported the quantitative data with two emergent themes: Enhanced Coping and Reduced Stress ranked as high importance and low importance, respectively.

Burnout
As stated above, burnout is defined as a response to prolonged exposure to demanding interpersonal situations and is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment [[ 7]]. The study found a significant reduction of 6 in participants’ baseline burnout score from pre M = 29.07 to post M = 23.07, again representing a large effect size, Cohen’s d = 1.55, 95% CI. [-2.79–0.32]. This is compared with Potter et al. [[56]], who reported a reduction in oncology nurses’ burnout of .85 (pre, M = 23.46 to post M = 22.61). Once again, no comparable studies were found (November 2017) for further comparisons. However, this study identified negative associations between self-compassion and burnout, r = -0.55, and mindfulness and burnout, r = -0.60. Similarly, both enhanced self-compassion and mindfulness were predictors of reduced burnout, as represented by β = -4.73 and β = 0.41, respectively. Likewise, simple linear regression identified that self-compassion accounted for 30% of the variance in burnout (R2 = . .30) and mindfulness accounted for 36% of the variance in burnout (R2 = .36). It is noteworthy that the combined reduction in both aspects of compassion fatigue had an average effect size of Cohen’s d = 1.18, almost double the effect size of d = . .65 reported for various forms of therapy in a meta-analysis study, by Cuijpers et.al. [[57]]. Qualitative data once more supported the quantitative results. Two emergent themes, Enhanced Coping and Less Stressed were indicators of participants’ reduced emotional exhaustion and were ranked as high and low importance, respectively.

Compassion satisfaction
Compassion satisfaction is defined as the fulfillment one derives from being able to do one’s work well and should be included in any assessment of nurses’ professional quality of life, according to

Stamm [[ 5]]. However, no statistically significant association was found between self-compassion or mindfulness and compassion satisfaction. But participants’ score did show a positive change from pre mean score (M = 37.92) to post mean score (M = 41), indicating an increase in compassion satisfaction of 3.95 with a large effect size Cohen’s d = .83 95% CI. [-0.33–1.97]. Likewise, Potter et al. found no statistically significant association between a compassion fatigue intervention and oncology nurses’ compassion satisfaction by [[56]]. One possible explanation of nurses’ increased compassion satisfaction in this study is the Hawthorne Effect, a psychological phenomenon that produces an improvement in human behavior or performance, as a result of increased attention from superiors, clients, or colleagues [[58]]. However, while no association was found between the pre-defined variables, qualitative results may give further insight into nurses’ increased compassion satisfaction. For example, it may be associated with the two highest ranked emergent themes Positive Mental States and Enhanced coping. This is obviously an issue that requires further examination in the future.

Resilience
Resilience results showed a large effect size of Cohen’s d = 1.5 95% CI [.0.27–2.73]. The nurses’ pre-intervention resilience score of M = 67.61 was well below the mean (M = 80.4), found in the original report of a US general population sample by Connor and Davidson [[44]]. However, participants’ post mean score (M = 80.30) brought them into line with the general population norms. The results also demonstrated a strong positive association between the mindfulness aspect of this pilot MSCi and resilience (r = .66). In comparison, a survey of n = 45, Medicine Pediatric Residents [[ 4]] found mindfulness to have a moderate association with resilience (r = .38). Simple regression found that participants’ increased mindfulness explained a significant proportion of the variance in resilience (R2 = .44) and was also a predictor of increased resilience (β = 1.09 p = .01). Unexpectedly, however, no statistically significant association was found between participants’ self-compassion scores and resilience. This may be due to the small sample size (N = 13) and an association of r = . 27, may become significant in a larger sample. Significantly, a study by pediatric residents [[ 4]] showed a moderate positive association between self-compassion and resilience (n = 45, r = .37). However, it used a different resilience measure [[59]]. This is an issue that bears further investigation.

In relation to resilience, the qualitative results supported these quantitative findings. Resilience, according to Connor and Davidson, embodies personal qualities that enable one to thrive in the face of adversity and may be viewed as a stress coping ability [[44]]. The emergent theme Enhanced Coping was ranked as having high importance. Furthermore, additional details regarding this result emerged on an examination of the participants’ responses. Noteworthy is the fact that 80% of the nurses’ responses associated with this emergent theme related to their use of informal MSC practices on the job. For example, “Informal practice in work allows me to step back from a situation”, “Practice is helpful in work”, “Practice in work made me less exhausted than I would normally be.” This evidence suggested that these practices provided protective factors that could be used during the caregiving process rather than just after the event’s self-care strategies. However, further research is required to fully understand the mechanisms involved in these preliminary positive outcomes.

Emergent theme: Positive mental states
Overall, the qualitative data in addition to a corroboration of the quantitative results gave a deeper understanding of participants’ lived experience of the effects of this pilot MSCi than what would have been achieved with the use of standard self-report instruments alone. Noteworthy is the fact that one of the two emergent themes ranked as having high importance was Positive Mental States. While not linked to any particular pre-defined variable, this qualitative result is in line with Cayoun who saw that a further benefit of training in positive mental attitudes, such as compassion, is that it creates the circumstance for the co-emergence of Positive Mental States. Co-emergence, according to Cayoun simply means two or more things emerging at the same time [[60]]. Therefore, training in compassion can be seen as creating the conditions that may lead to the co-emergence of other Positive Mental States. Furthermore, according to Hanson a repetition of the experience of Positive Mental States can lead to the cultivation of positive mental traits [[61]].

An association between LKM and CM and Positive Mental States has also been found in a number of previous studies. Self-compassion predicted significant variance in positive psychological health and strengths and was associated with happiness, optimism, and a positive effect, in a study by Neff et al. [[50]].Likewise Frederickson proposes that, positive emotions can broaden an individual’s momentary thought-action repertoire toward specific actions, in contrast to negative emotions that have a narrow focus, usually on survival involving flight, fight, or freeze reactions. By broadening the momentary thought-action repertoire, positive emotions loosened the hold of negative emotions [[62]–[63]].

Study limitations and future directions
This pilot study included a small sample size (N = 13) and lacked a control group. These factors limited the extent to which the findings can be generalized, and although all variables had a large effect size, the study did not have a longitudinal phase to see if gains were maintained. However, to gain some preliminary insight into the practical significance of a SCi for nurses, this pilot study adopted a pragmatic approach. By evaluating a pilot MSCi using mixed research, the study was able to corroborate the results of both quantitative and qualitative data. Furthermore, the use of qualitative data enabled a greater insight into the benefits of on the job informal MSC practices to nurses.

Consequently, this pilot study, for the first time, obtained some preliminary empirical evidence in support of the theories that suggest that a SCi may benefit nurses in relation to compassion, fatigue, and resilience. Likewise, this pilot study, which involved a preliminary assessment of the benefits of a SCi to nurses, suggests that it is a promising area for future study. Further work required include an RCT with a larger sample size of nurses and an RCT with a larger sample size of other professional caregivers, such as social workers and clinicians. A longitudinal study would be beneficial to see if gains are maintained. In addition, it would be interesting to further examine the unexpected findings of this study, the association between self-compassion and resilience, and the role of self-compassion training in promoting caregivers’ Positive Mental States and their association with perceived benefits.

Conclusions
This is the first study to examine the suggested theoretical benefits of a self-compassion intervention on nurses’ compassion fatigue and resilience. This observational pilot study is limited, in generalization, due to the small sample size and a lack of a control group. However, by evaluating the effects of a pilot Mindful Self-compassion Intervention for nurses using a mixed research approach, it has, for the first time, provided some preliminary empirical evidence of the practical significance of a SCi in providing nurses with on the job protective factors against compassion fatigue and for significantly enhancing their resilience. Moreover, the qualitative results suggested that training nurses in positive attitudes of love, kindness, and compassion may be associated with the co-emergent Positive Mental States that were reported.

Supporting information
S1 Table. Quantitative data scores. (DOCX)

S2 Table. Quantitative data scores. (DOCX)

S3 Table. Quantitative data scores. (DOCX)

S4 Table. Qualitative data coding. (DOCX)

S5 Table. Qualitative data coding. (DOCX)

DIAGRAM: Fig 1: Dialogue map of the emergent themes and a sample of participants’ responses [ 49 ].

A research project presented in partial fulfillment of the requirements for the degree of MSc in Mindfulness Compassion and Insight Studies at the School of Education University of Aberdeen Scotland. Firstly I would like to thank all the nurses who participated in the study and who generously shared their experience of their practice. In particular I would like to thank M/s Colette Cowan, Group Chief Executive Officer, M/s Jean Kelly Director of Nursing and Midwifery, and M/s Mary Moggan Nursing Administration, whose support made this project possible, I would like also to thank M/s Sarah Kearns of the University of Aberdeen for her guidance and support throughout the project, and finally Mr. Richard Bruton whose good counsel was always helpful.

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The family caregiver experience – examining the positive and negative aspects of compassion satisfaction and compassion fatigue as caregiving outcomes.
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Authors:
Lynch, Susan H.. School of Nursing, University of North Carolina Charlotte, Charlotte, NC, US, slynch16@uncc.edu
Shuster, Geoff. College of Nursing, University of New Mexico, Albuquerque, NM, US
Lobo, Marie L.. College of Nursing, University of New Mexico, Albuquerque, NM, US
Address:
Lynch, Susan H., slynch16@uncc.edu
Source:
Aging & Mental Health, Vol 22(11), Nov, 2018. pp. 1424-1431.
NLM Title Abbreviation:
Aging Ment Health
Page Count:
8
Publisher:
United Kingdom : Taylor & Francis
ISSN:
1360-7863 (Print)
1364-6915 (Electronic)
Language:
English
Keywords:
compassion fatigue, caregiver burden, compassion satisfaction, family caregiver
Abstract:
Objectives: Caregiving results in both positive and negative outcomes for caregivers. The purpose of this study was to examine compassion fatigue and compassion satisfaction in family caregivers. Methods: Using a cross sectional descriptive survey design with a convenience sample, 168 family caregivers of individuals with chronic illness completed a web-based survey. Measures included a demographic questionnaire, Caregiver Burden Interview, Brief COPE inventory and Professional Quality of Life (ProQOL). Results: The majority of participants (71%) reported high levels of caregiver burden, moderate to low levels of the compassion fatigue concepts of burnout (59.5%) and secondary traumatic stress (STS) (50%), and moderate levels of compassion satisfaction (82.7%). Regression analyses showed that caregiver burden, time caregiving, coping, social support, and caregiving demands explained a total variance of 57.1%, F(11,119) = 14.398, p < .00 in burnout and a total variance of 56%, F(11, 119) = 13.64, p < .00 in STS. Specifically, behavioral disengagement is a predicator that may indicate early compassion fatigue. Conclusion: Findings suggest that despite high caregiver burden and moderate compassion fatigue, family caregivers are able to provide care and find satisfaction in the role. This study supports the use of compassion fatigue and compassion satisfaction as alternative or additional outcomes to consider in future research. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Caregiver Burden; *Quality of Life; *Satisfaction; *Compassion Fatigue; *Caregiving
Medical Subject Headings (MeSH):
Adult; Aged; Caregivers; Chronic Disease; Compassion Fatigue; Cost of Illness; Cross-Sectional Studies; Empathy; Family; Female; Humans; Male; Middle Aged; Personal Satisfaction; Social Support
PsycInfo Classification:
Home Care & Hospice (3375)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Very Old (85 yrs & older)
Tests & Measures:
Caregiver Burden Interview
Professional Quality of Life
Brief COPE Inventory DOI: 10.1037/t04102-000
Grant Sponsorship:
Sponsor: Sigma Theta Tau, Gamma Iota Chapter
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jul 29, 2017; First Submitted: Jan 30, 2017
Release Date:
20190225
Correction Date:
20200713
Copyright:
Informa UK Limited, trading as Taylor & Francis Group. 2017
Digital Object Identifier:
http://dx.doi.org/10.1080/13607863.2017.1364344
PMID:
28812375
Accession Number:
2019-07026-004
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34
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The family caregiver experience – examining the positive and negative aspects of compassion satisfaction and compassion fatigue as caregiving outcomes
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Contents
Problem
Methods
Design and setting
Sample
Measures
Results
Level of compassion fatigue
Relationship with caregiver burden
Demographic differences
Predicting compassion fatigue and compassion satisfaction
Discussion
Compassion fatigue
Caregiver burden and compassion fatigue
Caregiver factors
Predicting compassion fatigue
Predicting compassion satisfaction
Limitations
Conclusion
Acknowledgments
Disclosure statement
References
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Objectives: Caregiving results in both positive and negative outcomes for caregivers. The purpose of this study was to examine compassion fatigue and compassion satisfaction in family caregivers. Methods: Using a cross sectional descriptive survey design with a convenience sample, 168 family caregivers of individuals with chronic illness completed a web-based survey. Measures included a demographic questionnaire, Caregiver Burden Interview, Brief COPE inventory and Professional Quality of Life (ProQOL). Results: The majority of participants (71%) reported high levels of caregiver burden, moderate to low levels of the compassion fatigue concepts of burnout (59.5%) and secondary traumatic stress (STS) (50%), and moderate levels of compassion satisfaction (82.7%). Regression analyses showed that caregiver burden, time caregiving, coping, social support, and caregiving demands explained a total variance of 57.1%, F(11,119) = 14.398, p <.00 in burnout and a total variance of 56%, F(11, 119) = 13.64, p <.00 in STS. Specifically, behavioral disengagement is a predicator that may indicate early compassion fatigue. Conclusion: Findings suggest that despite high caregiver burden and moderate compassion fatigue, family caregivers are able to provide care and find satisfaction in the role. This study supports the use of compassion fatigue and compassion satisfaction as alternative or additional outcomes to consider in future research.

Keywords: Compassion fatigue; caregiver burden; compassion satisfaction; family caregiver

Problem
Individuals significantly contribute to the provision of health care for their family members. In 2015, approximately 43.5 million people in the United States provided unpaid care to an adult or child in the prior 12 months (National Alliance for Caregiving & AARP, 2015). As increased health care costs prompt earlier transitions to home, families will continue to serve a primary caregiving role for family members with chronic disease at a substantial estimated at $450 billion (Feinberg, Reinhard, Houser, & Chouta, 2011).

Family members provide care that is often unpredictable, creating stress that can result in the negative outcomes. Although much research exists regarding the burdens caregivers face and interventions aimed at reducing those burdens, this research mainly accounts for the negative aspects of the caregiving experience. Caregiver burden has been a concept of interest to researchers but provides a perspective that is limited in scope due to its conceptual lack of clarity (Bastawrous, 2013) and its incomplete view of the experience by focusing on only negative outcomes. Positive outcomes, such as enhanced health, improved well-being, personal growth (Jones, Winslow, Lee, Burns, & Zhang, 2011) satisfaction, sense of fulfillment, and feeling good about caring (Greenwood, Mackenzie, Cloud, & Wilson, 2008) also exist in the caregiving experience. Therefore, current research is often polarized, focused on the positive or negative aspects of caregiving. To better understand the family caregiver experience and empower caregivers to continue to provide care to chronically ill individuals, it is necessary to examine both the positive and negative aspects simultaneously.

Compassion fatigue is an alternative concept to caregiver burden that may better represent the family caregiver experience. Although compassion fatigue is similar to caregiver burden in that it represents the negative outcomes associated with caregiving, the concept is not viewed in isolation, but in relation with the positive outcomes that also result. According to Stamm (2010), the caregiving experience consists of both the concept of compassion fatigue that includes components of burnout and secondary traumatization and the positive outcome of compassion satisfaction. Although the concept is most often associated with professionals, recently, the concept has been applied to family caregivers (Day & Anderson, 2011; Lynch & Lobo, 2012; McHolm, 2006; Perry, Dalton, & Edwards, 2010). As a result, compassion fatigue in family caregivers ‘occurs when a caregiving relationship founded on empathy potentially results in a deep psychological response to stress that ultimately progresses to physical, psychological, spiritual, and social exhaustion’ (Lynch & Lobo, 2012, p. 2128).

Methods

Design and setting
The purpose of this study was to examine the concepts of compassion fatigue and compassion satisfaction among family caregivers using a cross sectional descriptive survey design with a convenience sample. Pearlin’s stress process model (Pearlin, Lieberman, Menaghan, & Mullan, 1981) was used as a theoretical framework to examine study concepts in relation to stressors, appraisal of stress, mediators and outcomes. Study concepts impacting caregiving outcomes were derived from the model and included background context factors, caregiving demands as stressors, caregiver burden as appraisal of stress, social support, and coping as mediators, and compassion fatigue and compassion satisfaction as outcomes. The following four research questions guided the study:

What is the level of compassion fatigue and compassion satisfaction in family caregivers?
What is the relationship between caregiver burden and compassion fatigue?
Do background context factors (age, gender, ethnicity, employment status, caregiver education, caregiver relationship, income) contribute to differences in compassion fatigue scores?
Do caregiving demands, length of time caregiving, social support, coping, and caregiver burden contribute to the prediction of compassion fatigue and compassion satisfaction in family caregivers?
In addition to the web based survey, a secondary method of a paper survey was available due to the possibility of some family caregivers either not being comfortable with the technology or not having access to a computer/internet. The risk of harm to subjects in this study was minimal because the survey was anonymous and participant answers were not associated with email addresses. Human research protection approvals and informed consent from participants were obtained.

Sample
A convenience sampling strategy was used to find caregivers who provided care to a family member with a chronic illness. Participants were recruited from agencies including a family caregiver support program serving a large metropolitan county, a hospice and palliative care organization, and a statewide Amyotrophic Lateral Sclerosis (ALS) Association and Multiple Sclerosis Society. A power analysis was conducted a priori using G*Power Version 3.1.2 (Faul, Erdfelder, Lang, & Buchner, 2007). A minimum sample of 159 was needed for all planned statistical tests with a p <.05, power of.80 and a medium effect size. Inclusion criteria included those participants who identified themselves as family caregivers, 18 years of age or older and provided care for an adult diagnosed with a chronic disease. Participants were able to comprehend enough English so that they could understand the benefits and risks associated with the study, provided consent to participate in the study, and completed the study instruments. Participants were excluded if they identified themselves as caregivers of those with acute illnesses and care provided was anticipated for a duration of less than 1 month.

Measures
The study was guided using Pearlin’s stress process model (Pearlin et al., 1981) where background context factors (demographics), stressors (caregiving demands), appraisal of stress (caregiver burden), and mediators (social support and coping) contribute to caregiving outcomes (compassion fatigue and compassion satisfaction). The survey included four measures; demographic questionnaire, Zarit Caregiver Burden Interview (ZBI), Brief COPE inventory and Professional Quality of Life (ProQOL). Instruments were selected based on reported reliability and validity data, plus the need to consider the length of the survey due to the potential of survey burden.

Demographic factors of the family caregiver including age, gender, ethnicity, employment status, education level, relationship to the care recipient, income, caregiving demands, caregiver experience characteristics, and length of time caregiving were collected from all participants.

The variables of coping and social support were measured using the Brief COPE (Coping Orientations to Problems Experienced) scale. The Brief COPE scale is a 28-item self-report scale that consists of 14 subscales that measure various dimensions of coping including active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, using instrumental support, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. Each subscale contains 2 distinct items that measure the specific dimension of coping identified. Reliability of the 14 subscales of the Brief COPE ranged with Cronbach alpha coefficients ranging 0.50 (venting) to 0.90 (substance use). Carver (1997) indicated that the instrument does not need to be used in its entirety; selected subscales can be used individually for specific consideration in research. For this study, all subscales were used.

Caregiver burden was measured using the Zarit Caregiver Burden Interview (ZBI). It is a commonly used caregiver burden instrument in caregiver research. The 22-item scale can be self-administered. Scoring ranges from 0-4 with higher ratings indicating greater caregiver burden (Knight, Fox, & Chou, 2000). Reliability of the instrument used in multiple studies (Harkness & Tranmer, 2007; Knight et al., 2000) found the range of Cronbach’s alpha to be 0.88-0.92.

Compassion fatigue and compassion satisfaction were measured using the ProQOL. The scale consists of three subscales; compassion satisfaction, burnout, and secondary traumatic stress (STS). Burnout and STS represent the two components of compassion fatigue (Stamm, 2010). Stamm (2010) described compassion satisfaction as the positive feelings or pleasure that result from caregiving. Whereas, burnout is viewed as feelings of exhaustion, frustration, anger, and depression with STS conceptualized as a secondary exposure to traumatically stressful events that results in fear, intrusive images, and sleep disturbances. Stamm (2010) reported that the subscale of compassion satisfaction had an alpha reliability of 0.88, with the burnout subscale as 0.75 and STS subscale as 0.81. Although no composite score exists for the entire scale, each subscale has defined cut scores that contribute to identifying high, average/moderate, or low levels of compassion satisfaction, burnout, and STS.

Results
Data from the web based survey platform Qualtrics was directly exported to SPSS for analysis. Additional cases that were mailed (n = 5) to the researcher were added to the data file. Data were then screened to determine the total number of respondents for the study were N = 168. The demographic characteristics of the total sample are presented in Table 1 and the caregiving experience characteristics are presented in Table 2. Overall, family caregivers who participated in the study were predominantly female (n = 121, 72%), White (n = 130, 77%) with an age range of 19-87 years (M = 57.94, SD = 14.3). Family caregivers reported time spent caregiving ranged from 1 to 25 years (M = 7.04, SD = 5.42) with an average of 50 h per week. Most of the sample were spouses (n = 84, 50%), characterized their own health as good (n = 100, 59.5%) and identified their caregiving experiences as resulting in both positive and negative feelings (n = 145, 86.3%). Family caregivers also reported on the care recipients’ medical diagnoses. Caregivers reported Multiple sclerosis (n = 65; 48%) and dementia or Alzheimer’s disease (n = 49; 36%) as the most common diagnoses; followed by depression (n = 24; 18%), diabetes (n = 20; 15%), cardiac disease (n = 19; 14%), musculoskeletal disorders (n = 17; 13%) and stroke (n = 15; 11%).

Caregiver demographics.

Family caregiver (n = 168)
Characteristic M SD
Age 57.94 14.32
n %
Gender
 Male 42 25
 Female 121 72
 Not reported 5 3.0
Ethnicity
 White 130 77.4
 Black or African-American 22 13.1
 Asian 1 .6
 Two or more races 5 3.0
 Prefer not to report 2 1.2
 Not reported 3 3
Education
 High school 16 9.5
 Some college or associates degree 53 31.5
 Bachelors 43 25.6
 Advanced degree 49 29.2
 Not reported 7 4.2
Income
 Less than $15,000 7 4.2
 $15,000-$29,999 23 13.7
 $30,000-49,999 26 15.5
 $50,000-$74,999 32 19.0
 $75,000-$99,999 18 10.7
 $100,000 or more 32 19.0
 Prefer not to report 24 14.3
 Not reported 6 3.6
Employment
 Full time 59 36.2
 Part time 23 13.7
 Not working 16 9.5
 Retired 63 37.5
 Disabled 2 1.2
 Not reported 5 3.0
Relationship to care recipient
 Spouse 84 50
 Child 35 20.8
 Other family member 47 28
 Friend or neighbor 2 1.2
Caregiving experience characteristics.

Family caregiver (n = 168)
Characteristic M (range) SD
Years caregiving 7.04 (1-25) 5.42
Hours per week caregiving 50.32 (1-168) 53.62
n %
Feelings experienced caregiving
 Positive 19 11.3
 Negative 4 2.4
 Both positive and negative 145 86.3
Description of own health
 Excellent 38 22.6
 Good 100 59.5
 Fair 24 14.3
 Poor 6 3.6
Major health issues for caregiver
 None 65 38.7
 M-S (arthritis, osteoporosis) 35 20.8
 Depression 23 13.7
 Diabetes 22 13.1
 Stroke/HTN 21 12.5
This sample compared similarly to national estimates from the National Alliance for Caregiving and AARP (2015) regarding age, gender, race, and the care provided (ADL, IADL, complex). However, this sample overall provided care for a longer duration of time (7.04 years compared to 5.6 years) and provided more hours of care per week (50.32 h per week compared to 24 h). This may be attributed to over a 1/3 of the care recipients receiving hospice care (36%).

Level of compassion fatigue
Compassion fatigue and compassion satisfaction were measured with the ProQOL version 5 (Stamm, 2009). In this study each subscale, burnout, STS, and compassion satisfaction demonstrated good reliability with a Cronbach alpha coefficient of 0.90 on the compassion satisfaction subscale, 0.78 on the burnout subscale and 0.82 on the STS subscale. A summary of results are reported in Table 3. The majority of the sample, had a moderate level of compassion satisfaction (n = 139, 82.7%) with moderate levels of compassion fatigue, represented by the burnout (n = 100, 59.5%) and STS (n = 84, 50%) subscales. It is important to note that very few participants scored low on compassion satisfaction (n = 5, 3%) and no participant scored high on burnout or STS.

ProQOL results.

95% Confidence interval
Subscale M (SD) Lower Upper Level Frequency (n) Percent (%)
CS 34.18 (7.30) 33.07 35.29 Low (≤22) 5 3
Average (23-42) 139 82.7
High (43+) 24 14.3
BO 24.47 (6.43) 23.49 25.45 Low (≤22) 68 40.5
Average (23-41) 100 59.5
High (42+) 0 0
STS 22.16 (6.94) 21.10 23.21 Low (≤22) 84 50
Average (23-41) 84 50
High (42+) 0 0
Relationship with caregiver burden
The relationship between caregiver burden and compassion fatigue was examined with the ZBI (Zarit, Reever, & Bach-Peterson, 1980) and the ProQOL instruments (Stamm, 2009). In this study, the Cronbach alpha coefficient of the ZBI was 0.89, similar to reported reliability. Schreiner, Morimoto, Arai, and Zarit (2006) identified a cut off score of 25, indicating that those with scores of 25 or less had low burden and those with scores greater than 25 had high burden and needed additional assessment and intervention. Using these cut points, 71% reported high levels of burden indicating a need for further Assessment.

To explore the relationships, a Pearson product-moment correlation coefficient was conducted. Preliminary analyses revealed no violation of assumptions. There was a strong positive relationship between caregiver burden and compassion fatigue as represented by burnout and STS. Results between caregiver burden and burnout showed that higher levels of caregiver burden were positively associated with higher levels of burnout, r =.677, n = 168, p <.000. Similar results were found between caregiver burden and STS, r =.669, n = 168, p <.000. In addition, a small negative association was found between caregiver burden and compassion satisfaction, r = −.229, n = 168, p <.003 with a 5% shared variance.

Using the cut scores identified by Schreiner et al. (2006) for low and high caregiver burden, an independent t-test was performed to determine whether there were differences in burnout, STS, and compassion satisfaction for caregiver burden. Those with low burden scores of 25 or less were compared to those with burden scores higher than 25. Significant differences were found in relationship to all subscales of the ProQOL; compassion satisfaction, burnout and STS. Higher compassion fatigue scores were associated with higher caregiver burden scores and higher compassion satisfaction was associated with lower caregiver burden scores.

Demographic differences
Demographic factors of age, gender, ethnicity, employment status, caregiver education, caregiver relationship, income were examined to determine if differences in compassion fatigue scores existed. Significant results were found for gender, age, employment, and income. However, post hoc analysis of employment and income group differences were inclusive. Regarding gender, independent sample t-tests were conducted to compare the scores on the ProQOL subscales. Significant differences were found in burnout for males (M = 22.53, SD = 7.13) and females (M = 25.16, SD = 5.99; t (161) = −2.332, p =.021, two tailed) and STS for males (M = 19.395, SD = 6.68) and females (M = 23.04, SD = 6.73; t (161) = −3.026, p =.003, two tailed).

There were a wide distribution in ages from 19 to 87 years (M = 57.94, SD = 14.3). As such, age was dichotomized into 2 groups based on percentiles. Significant differences in age were only found in the compassion satisfaction subscale between Group 1, less than 59 years, (M = 35.42, SD = 7.54) and Group 2, greater than 60 years (M = 32.90, SD = 6.71; t (135) = −2.061, p =.041, two tailed). Those greater than 60 years reported more compassion satisfaction than the lower age group.

Predicting compassion fatigue and compassion satisfaction
Hierarchical regression was used to assess whether caregiving demands, length of time caregiving, social support, coping, and caregiver burden contributed to the prediction of compassion fatigue in family caregivers after controlling for the influence of age, gender, and caregiver health. Variables in the model were selected based on previous research, Pearlin’s stress model, and the correlation matrix of coping patterns with burnout and STS (Table 4). Those that revealed a positive correlation (r >.30) with both burnout and STS were considered and entered into the regression. Caregiving demands were measured as the total number of ADL, IADL, and complex clinical tasks performed. The length of time caregiving was represented by the number of hours per week spent caregiving.

Pearson product-moment correlation between Brief COPE and ProQOL subscales.

Scale 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
(1) CS –
(2) BO −.443** –
(3) STS −.107 .709** –
(4) Transformed STS −.114 .711** .996** –
(5) Self-distraction .045 .221** .337** .348** –
(6) Active coping .238** −.015 .163* .159* .218** –
(7) Denial −.138 .390** .347** .330** −.021 −.011 –
(8) Subst. abuse −.043 .224** .209** .204** .053 −.022 .227** –
(9) Emotional support .183* −.004 .139 .138 .299** .335** .061 .109 –
(10) Instrum. support .135 .092 .197* .186* .279** .391** .070 −.034 .709** –
(11) Behavioral disengagement −.287** .381** .381** .380** .152* −.052 .343** .188* −.094 −.090 –
(12) Venting −.068 .276** .260** .262** .248** .203** .185* .201** .417** .406** .198* –
(13) Positive reframing .283** −.171* .047 .054 .239** .374** −.124 −.056 .196* .160* −.186* .027 –
(14) Planning .079 .124 .328** .325** .172* .610** .136 −.041 .398** .504** .080 .334** .318** –
(15) Humor .190* .065 .113 .117 .198* .186* .040 .034 .211** .258** .014 .245** .245** .264** –
(16) Acceptance .235** −.095 .048 .064 .312** .275** −.243** −.099 .257** .208** −.154* .103 .270** .188* .205** –
(17) Religion .131 −.062 .192* .198* .000 .086 .113 −.169* −.197* .219** −.055 −.016 .186* .152* −.065 .102 –
(18) Self-blame −.158* .401** .421** .417** .240** .141 .241** .048 .031 .108 .435** .274** .055 .218** .167* .011 −.030 –
1 * p<.05; ** p<.000

Regression analyses were conducted with both burnout and STS subscales of the compassion fatigue instrument. Preliminary analyses were conducted to ensure no violation of assumptions. In each regression analyses age, gender, and caregiver health were entered in Step 1 and caregiving demands, length of time caregiving, social support, coping and caregiver burden were entered in Step 2. For burnout (Table 5), model 1 explained 9% of the variance. The total variance explained after Step 2 by the model was 57.1%, F (11, 119) = 14.398, p <.000. In the final model, two predictors were significant including caregiver burden (beta =.535, p <.000) and the coping pattern of behavioral disengagement (beta =.175, p =.019). Caregiver burden uniquely explained 17% of the variance with behavioral disengagement explaining 2% of the variance.

Hierarchical regression: burnout.

Model summary
Change statistics
Model R R square Adjusted R square Std. error of the estimate R square change F change df1 df2 Sig. F change
1 .300 .090 .068 6.20629 .090 4.179 3 127 .007
2 .756 .571 .531 4.40189 .481 16.682 8 119 .000
For the STS regression analysis (Table 6), Step 1 explained 17% of the variance. After Step 2, the total variance explained by the model was 56%, F (11, 119) = 13.64, p <.000. In the final model, two predictors were significant including caregiver burden (beta =.519, p <.000), and caregiver health (beta =.261, p <.000). Caregiver burden uniquely explained 16% of the variance with caregiver health explaining 6% of the variance.

Hierarchical regression: secondary traumatic stress.

Model summary
Change statistics
Model R R square Adjusted R square Std. error of the estimate R square change F change df1 df2 Sig. F change
1 .414 .172 .152 .68809 .172 8.778 3 127 .000
2 .747 .558 .517 .51943 .386 12.983 8 119 .000
In the final regression model for compassion satisfaction (Table 7), Step 1 was not significant, p =.292. After entering caregiving demands, length of time caregiving, social support, coping and caregiver burden at Step 2, model 2 was significant and the total variance explained by the model was 22.7%, F (11, 119) = 2.97, p =.002. In the final model, three predictors were significant including caregiving demands (beta =.272, p =.008), caregiver burden (beta = −.247, p =.019), and coping pattern of behavioral disengagement (beta = −.208, p =.038). Caregiving demands uniquely explained 5% of the variance, caregiver burden uniquely explained 4% of the variance, and behavioral disengagement uniquely explained 3% of the variance.

Hierarchical regression: compassion satisfaction.

Model summary
Change statistics
Model R R square Adjusted R square Std. error of the estimate R square change F change df1 df2 Sig. F change
1 .170 .029 .006 7.28355 .029 1.256 3 127 .292
2 .464 .215 .143 6.76353 .186 3.535 8 119 .001
Discussion

Compassion fatigue
The level of compassion fatigue and compassion satisfaction according to Stamm (2010) is interpreted as low, average/moderate, or high. As there have been no published studies using the ProQOL-V with family caregivers; consequently, these results are exploratory. In this study, the level of compassion fatigue and compassion satisfaction in family caregivers revealed that the majority of participants reported moderate levels of compassion satisfaction and burnout, with equally divided low and moderate levels of STS. These results support the qualitative results of Perry et al. (2010) and Ward-Griffin, St-Amant, and Brown (2011) who indicated that compassion fatigue existed in family caregivers and the concept can be applied to informal caregivers (Day & Anderson, 2011). Typically, those who scored high on burnout in combination with any other score on the subscales are individuals at-risk (Stamm, 2010). This sample exhibited moderate to high satisfaction, with low to moderate burnout and STS. Even though this may not be classified as at-risk, concern exists since situational change can impact resultant compassion fatigue and compassion satisfaction. Therefore an opportunity for improvement exists; for caregivers to increase the level of compassion satisfaction and reduce the levels of burnout and STS.

Caregiver burden and compassion fatigue
Important to the caregiver experience is the long standing relationship between caregiver and care recipient. Caregiver burden is often conceptualized based on the impact the performed tasks have on caregiver, whereas, compassion fatigue is a concept in which the empathetic relationship between the caregiver and care recipient is foundational to resultant outcomes. The majority of participants in this study (71%) reported high levels of caregiver burden compared to 30% in national estimates (National Alliance for Caregiving & AARP, 2009). This discrepancy may be due to multiple instruments used to measure caregiver burden, the various reported cut scores using the Caregiver Burden Interview, or sample characteristics. One sample characteristic to consider may be that 37% of participants indicated the receipt of hospice services and thus cared for relatives at end of life. Therefore, high caregiver burden would be expected.

This study found that strong positive relationships existed between caregiver burden and both burnout and STS. This is not surprising as the three concepts represent the negative aspects of caregiving. Interestingly, there was a small negative relationship between caregiver burden and compassion satisfaction whereas, a stronger negative relationship existed between burnout and compassion satisfaction. This supports literature that caregiver burden can exist without impacting caregiving satisfaction (Andren & Elmstahl, 2005). Secondly, since the ProQOL consists of three separate subscales with no composite scale score, relationships between the subscales are relevant indicating that the strong negative association between compassion satisfaction and burnout provides support that compassion satisfaction may be protective for burnout as literature suggested (Day & Anderson, 2011; Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010; Yoder, 2010). Finally, group differences between low and high caregiver burden with compassion fatigue and compassion satisfaction indicated that those with higher caregiver burden had higher burnout and STS, and those with lower caregiver burden had higher compassion satisfaction. In addition, the high level of caregiver burden combined with the moderate to low level of burnout and STS indicated a relationship exists between the concepts. These findings support the position that caregiver burden and compassion fatigue are related but distinct concepts.

Caregiver factors
The stress process model (Pearlin et al., 1981) indicated that characteristics of the caregiver can influence the intensity of stress. Therefore, this research explored how demographic factors (age, gender, ethnicity, employment status, caregiver education, caregiver relationship, income) contributed to differences in compassion fatigue scores.

Regarding the negative outcomes of compassion fatigue, findings revealed that gender, employment, income, number of hours per week caregiving, and caregiver health contributed to significant differences in compassion fatigue scores. In this study, women (72%) accounted for the majority of the sample and women reported higher levels of burnout and STS. This may be indicative of women’s multiple demands as they are increasingly employed outside the home and continue to provide the majority of family caregiving. Although not significant, men (M = 35.19, SD = 7.14) reported more compassion satisfaction than women (M = 33.86, SD = 7.00) in this study, therefore, adding to the support that compassion satisfaction is protective of burnout and STS.

Length of time caregiving was a variable of interest since it has been proposed that cumulative stress from years of caregiving may result in more negative outcomes such as caregiver burden and compassion fatigue (Bainbridge, Krueger, Lohfeld, & Brazil, 2009; Coetzee & Klopper, 2010; Figley, 1995, 2002; Savundranayagam, Montgomery, & Kosloski, 2011). Results in this study indicated that it was not the total number of years of caregiving that contributed to differences in compassion fatigue, but the number of hours per week; suggesting that intensity rather than duration accounted for the major difference in this population. Results found that those providing care for more than 25 h per week had significantly more burnout and STS than those working less hours.

These findings support the assertion from the National Alliance and AARP report (2015) that those providing a higher number of hours per week are a vulnerable population. Therefore, additional variables that may better reflect prolonged exposure and cumulative stress over time should be examined. Identifying factors that contribute to the perception of increased stress and burden need to be explored to determine if specific characteristics or situations in caregiving may explain this finding.

In contrast, age was the only caregiver characteristic that resulted in significant differences for compassion satisfaction. The study found that those over 60 years of age reported more satisfaction with caregiving than the younger group. Plausible explanations for this finding could be related to the established relationship between the caregiver and care recipient, factors that contributed to the caregiver assuming this role, living arrangements, or competing demands for the caregiver.

Predicting compassion fatigue
Caregiver burden and behavioral disengagement were two variables found to significantly contribute to the prediction of burnout, whereas, caregiver burden and caregiver health contributed to the prediction of STS. Caregiver burden was the largest predictor of both burnout and STS. Interestingly, those who used disengagement as a coping mechanism are more likely to exhibit higher levels of burnout. This supports Figley’s (2002) model that stated disengagement contributed to the development of compassion fatigue and may be an indicator of early compassion fatigue.

Caregiver health also contributed to the STS model indicating that those who rated their health as fair or poor reported more STS than those who characterized their health as good or excellent. As STS reflects the caregivers’ own fear and emotions felt when they help or want to help a suffering person (Figley, 1995), caregivers who are in poor health themselves may be at higher risk when they cumulatively experience negative feelings related to both their own health and the family members’ suffering. This finding is congruent with Zarit, Femia, Kim, and Whitlach (2010)) findings related to caregiver health influencing caregiver outcomes.

Predicting compassion satisfaction
The study found that the coping pattern of behavioral disengagement, caregiver burden, and caregiving demands contributed to the prediction of compassion satisfaction. Both behavioral disengagement and caregiver burden were negatively associated with compassion satisfaction suggesting that those who used behavioral disengagement and exhibited more caregiver burden had less compassion satisfaction. Interestingly, the total number of caregiving demands or tasks performed during caregiving was positively associated with compassion satisfaction. Although a small correlation, this suggests that caregivers receive satisfaction from the caregiving duties they perform.

Limitations
Several limitations of this study including the cross sectional design, unknown influence of other variables, selection bias, and the recruitment and sampling strategy affected the generalizability of results. The cross-sectional design examined family caregivers at one point in time that may not accurately reflect the concepts under study. This is an accepted limitation due to the design of the study.

Secondly, other variables that were not examined in this study need to be explored. The quality of the relationship between the caregiver and care recipient may have influenced the results. Feelings of obligation to provide care for a family member or a past poor relationship with the care recipient as Wuest (2001) described may influence positive or negative caregiving outcomes. In addition, unreported psychological problems such as depression or other medical conditions may not have been reported which could have contributed to study results.

Another limitation considered is related to selection bias of the family caregivers who participated in the study. Since the majority of participants had some college education and the sample lacked representation of all ethnic groups, it is unclear how these variables influenced the findings. Also, since the survey was web based, access may have been limited. In addition, it is noted that participants self-selected to participate in the study. Since the results found low to moderate burnout and STS, it may be that participants who had higher levels did not participate in the study due to lack of time or energy to participate in any extra activity.

Finally, an accurate response rate was difficult to calculate due to one agency using a global client list of family and friends who may not have been actual caregivers and the addition of a snowball sampling strategy to achieve sample size needed to adequately power the study.

Conclusion
In an effort to understand the caregivers’ experience and provide services that continue to allow the caregiver to provide care to their loved one, health care systems must develop processes to assess and support family caregivers. Individual assessment recognizing those caregivers providing a high number of caregiving hours per week as a vulnerable population and the identification of caregiving patterns consisting of both positive and negative aspects can be used as strategies to lead to individualized intervention development. Overall, better understanding of caregiver characteristics and the caregiving experience can aid the healthcare professional to develop individualized interventions that may have a lowering effect on compassion fatigue and increase overall satisfaction.

Theoretically, this study provides support for the use of compassion fatigue and compassion satisfaction compared to caregiver burden when examining the family caregiver experience. First, it is important to note that participants (86%) indicated that they experienced both positive and negative feelings related to caregiving. Very few (2.4%) reported that they had only experienced negative feelings in relationship to caregiving. In addition, the ProQOL scores of moderate to high compassion satisfaction and moderate to low compassion fatigue support the idea that family caregivers experience both positive and negative outcomes from the caregiving.

Furthermore, results indicated that those with higher compassion satisfaction had lower levels of burnout, therefore indicating that compassion satisfaction may be viewed as a protective mechanism. Therefore, arguments could be made that compassion satisfaction is an appraisal of the caregiving stress, not a caregiving outcome. Supporting this finding, Morrison (1999) reported that studies supported the view that the caregivers’ appraisal of stressors and availability of resources buffered the effects of the stressors, and later suggested that positive consequences of caregiving could do the same, making a connection between appraisal and positive outcomes. Jones et al. (2011) and Greenwood et al. (2008) reported positive outcomes in relation to caregiving, thus supporting the premise that compassion satisfaction could be viewed as an appraisal of stress or outcome. Conversely, results indicated limited support for compassion satisfaction as being protective of caregiver burden since only small, negatively correlated relationship existed. This provides support for Figley’s (2002) compassion fatigue model, and the positions posed by Bastawrous (2013) and Pearlin, Mullan, Semple, and Skaff (1990) that caregiver burden should be viewed as a stressor or an appraisal of stress resulting in caregiving outcomes (Chronister & Chan, 2006; Fletcher et al., 2012). This analysis may indicate that compassion satisfaction and its relationship to compassion fatigue may better gauge when a caregiver approaches the inability to provide care for their family member. As a result, future research and interventions aimed to increase compassion satisfaction and reduce caregiver burden may therefore prevent and treat compassion fatigue.

Overall, the results of this study found that caregivers exhibited a high level of burden while providing care, functioning in other roles, and perceiving themselves in good health. Although various characteristics impacted the level of compassion fatigue and compassion satisfaction, the results pointed to characteristics of an at-risk family caregiver: female, retired, perceive themselves in fair to poor health, perform over 25 h of care per week, and exhibit signs of disengagement. The intensity of the caregiving relationship seems more important compared to the duration. Although burdened, this population reported low to moderate burnout and STS, while experiencing moderate to high compassion satisfaction leading to the supposition that compassion satisfaction may be protective of burnout.

Therefore, these findings suggest that despite high caregiver burden family caregivers are able provide care for their family members and find satisfaction in that role. Caregiver burden thus is appraisal of the caregiver stress, however, is limited in its usefulness as a caregiver outcome. This study supports the use of compassion fatigue and compassion satisfaction as alternative caregiving outcomes to better reflect the family caregiver experience. Even though caregiver burden is an important factor, behavioral disengagement as a key predictor for compassion fatigue adds to the caregiving literature and may indicate when caregiver burden becomes too much for the caregiver to handle and thus alert the health care provider to elicit immediate intervention.

As limited previous evidence existed related to compassion fatigue in family caregivers, the results of this study are preliminary and can direct future research to further explore compassion fatigue and compassion satisfaction in family caregivers with the goal to better understand the family caregiver experience. In addition, assessment strategies aimed to identify early behavioral disengagement plus interventional research aimed to reduce the negative outcomes of compassion fatigue and increase the positive aspects of compassion satisfaction can be designed so that family caregivers can continue to provide the high quality care their family members need.

Acknowledgments
The authors would like to thank Dr. Emily Haozous and Dr. Diana Rowan for their contributions to this work. Also we would like to thank the Gamma Iota Chapter of Sigma Theta Tau and Elinor Caddell for providing financial support for this study.

Disclosure statement
No potential conflict of interest was reported by the authors.

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~~~~~~~~

By Susan H. Lynch; Geoff Shuster and Marie L. Lobo

This article is copyrighted. All rights reserved. Source: Aging & Mental Health

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Interventions for occupational stress and compassion fatigue in animal care professionals—A systematic review.
Authors:
Rohlf, Vanessa I.. School of Counselling, Australian College of Applied Psychology, Melbourne, VIC, Australia, virohlf@gmail.com
Address:
Rohlf, Vanessa I., PO BOX 2567, Gladstone Park, VIC, Australia, virohlf@gmail.com
Source:
Traumatology, Vol 24(3), Sep, 2018. pp. 186-192.
NLM Title Abbreviation:
Traumatology (Tallahass Fla)
Page Count:
7
Publisher:
US : Educational Publishing Foundation
Other Journal Titles:
Traumatology: An International Journal
Other Publishers:
US : Academy of Traumatology
US : Green Cross Project
US : Sage Publications
ISSN:
1085-9373 (Electronic)
Language:
English
Keywords:
burnout, secondary traumatic stress, compassion fatigue, animal care professionals
Abstract:
The work associated with caring for suffering and traumatized animals leaves many animal care professionals vulnerable to occupational stress and compassion fatigue. Given the number of negative outcomes these conditions have for the workplace and the individual, the availability of effective therapeutic interventions is extremely important. It was, therefore, the aim of this article to conduct a systematic literature review on intervention programs for occupational stress and compassion fatigue in animal care professionals for the purpose of providing best practice guidelines. The review found that although occupational stress is highly prevalent in the animal care profession, only 4 articles evaluating therapeutic interventions in this population were identified. This small number, combined with the variability in design and outcome measures of the articles, made best practice recommendations on the basis of this review difficult. The author recommends that administrators and/or managers within the animal care profession and mental health professionals wishing to implement therapeutic interventions borrow from research conducted in other areas until a strong research base in the animal care profession is established. A review of occupational stress interventions in the human care profession revealed that cognitive–behavioral techniques, including mindfulness-based approaches, are the most frequently cited approaches for therapeutic interventions in this population. Programs incorporating psychoeducation, coping skills training, and relaxation within a cognitive–behavioral framework with possible mindfulness-based approaches may, therefore, offer mental health professionals, administrators, and/or managers in the animal care profession a useful starting point with which to base future interventions. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Interspecies Interaction; *Occupational Stress; *Post-Traumatic Stress; *Compassion Fatigue; Veterinary Medicine
PsycInfo Classification:
Personnel Attitudes & Job Satisfaction (3650)
Population:
Human
Methodology:
Literature Review; Systematic Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Mar 5, 2018; Accepted: Nov 28, 2017; Revised: Nov 15, 2017; First Submitted: Jun 29, 2017
Release Date:
20180305
Correction Date:
20180830
Copyright:
American Psychological Association. 2018
Digital Object Identifier:
http://dx.doi.org/10.1037/trm0000144
Accession Number:
2018-09296-001
Number of Citations in Source:
52
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Interventions for Occupational Stress and Compassion Fatigue in Animal Care Professionals—A Systematic Review
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✖
Contents
Method
Eligibility Criteria
Information Sources
Search
Study Selection
Data Collection and Assessment
Results
Study Selection
Study Characteristics
Discussion
References
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By: Vanessa I. Rohlf
School of Counselling, Australian College of Applied Psychology, Melbourne, Victoria, Australia ;
Acknowledgement: Vanessa I. Rohlf is now at School of Social Sciences, Monash University, Caulfield, Victoria, Australia.

This work was submitted in partial fulfilment of a Master’s in Counselling and Psychotherapy at the Australian College of Applied Psychology.

Animal care professionals in veterinary, animal shelter and control sectors are considered at risk for a number of stress-related conditions brought on by their work (Scotney, McLaughlin, & Keates, 2015). It is recognized that occupational roles within these professions are diverse. For example, a veterinarian primarily examines, diagnoses, and provides medical treatment to animals, whereas those working in animal control investigate cases of animal cruelty, provide responsible animal ownership education, and rehome or reunite lost and abandoned animals. However, these professionals all provide care to animals and are all exposed to trauma as part of their work.

Caring for sick, injured and dying animals, exposure to cases of animal cruelty (e.g., neglect and abuse), together with consoling traumatized and grieving owners, can have negative effects on the well being of animal care professionals (Bartram, Yadegarfar, & Baldwin, 2009; Deacon & Brough, 2017; Platt, Hawton, Simkin & Mellanby, 2012; Reeve, Rogelberg, Spitzmuller, & Digiacomo, 2005; Rohlf & Bennett, 2005). These stressful work conditions are compounded in some workplaces where resources are limited, employees are expected to work long hours, and staff feel isolated or unsupported (Black, Winefield, & Chur-Hansen, 2011; Schabram & Maitlis, 2017).

The euthanasia of animals can also be particularly distressing for animal care professionals. Many animal care professionals, including veterinarians, veterinary nurses, and animal shelter workers, choose their occupation because of their love for animals and a desire to help them, yet part of their job also requires that they participate in the killing of these animals (Rohlf & Bennett, 2005). Many animals are euthanized at veterinary clinics and animal shelters because they are sick, for behavioral reasons, or because they are unwanted (Rohlf & Bennett, 2005). This element of the job causes moral stress, a particular form of stress resulting from performing a behavior that is in conflict with what one believes they ought to do (Crane, Phillips, & Karin, 2015; Rollin, 2011).

Performing euthanasia has also been linked to traumatic stress symptoms, including intrusive thoughts and images, avoidance of reminders of the event, emotional numbing, irritability, and difficulty concentrating (Rohlf & Bennett, 2005; White & Shawhan, 1996). This phenomenon has been described as a unique form of posttraumatic stress called perpetration-induced traumatic stress (PITS; MacNair, 2002, 2015). PITS is a form of posttraumatic stress where the trauma symptoms are caused by participation in the traumatic event(s) (MacNair, 2002, p. 215). PITS is not unique to animal care professionals and has been identified in other occupational contexts, including war veterans (MacNair, 2002), police officers (Loo, 1986), and personnel working in animal slaughterhouses (Dillard, 2009).

Participation in euthanasia, however, does not always lead to stress outcomes. Rohlf and Bennett (2005) found that only 50% of animal care professionals reported trauma symptoms related to their exposure to euthanasia and none met clinical levels of posttraumatic stress. Whether the decision is consistent with the individuals’ beliefs in what ought to be done (Rollin, 2011), level of concern over animal death (Rohlf & Bennett, 2005), level of training, and the degree to which the decision to euthanize is a shared decision and supported by protocol (Von Dietze & Gardner, 2014) may, altogether, influence the emotional response to euthanasia.

Despite this, animal care workers consistently report high levels of exhaustion, sadness, sleep difficulties, and feelings of guilt and anger resulting from their work (Black et al., 2011; Moore, Coe, Adams, Conlon, & Sargeant, 2014; Reeve et al., 2005; Scotney et al., 2015; White & Shawhan, 1996). These symptoms have collectively been referred to, by some researchers, as compassion fatigue (Figley & Roop, 2006). The concept of compassion fatigue was first introduced by Joinson (1992), who described the condition as a unique form of burnout affecting professional caregivers. Later, Figley (2002) used the term to describe secondary traumatic stress reactions in caregivers resulting from their prolonged exposure to the stress associated with helping or wanting to help victims of trauma. According to Figley (2002) and Figley and Roop (2006), secondary traumatic stress resulted in preoccupation with the victim or patient and the manifestation of posttraumatic stress symptoms, including avoidance, numbing, and reexperiencing the traumatic event.

More recently, efforts have been made to conceptually clarify the term compassion fatigue (Coetzee & Klopper, 2010 ). Coetzee and Klopper (2010) conducted a concept analysis of compassion fatigue using literature sources from the human health care field, including psychology, medicine, and nursing. On the basis of this analysis, the authors define compassion fatigue as “. . .the final result of a progressive and cumulative process that evolves from compassion stress after a period of unrelieved compassion discomfort, which is caused by prolonged, continuous, and intense contact with patients, the use of self, and exposure to stress” (Coetzee & Klopper, 2010, p. 239). Literature sources relating to animal health care were, however, excluded from this analysis. Whether this definition equally applies to animal care professions needs to be established.

Although recent efforts have been made to clarify the term compassion fatigue, determining incidence rates of this type of caregiver stress, as well as risk and protective factors for the condition, has been difficult due to the inconsistent usage of the terms associated with compassion fatigue, namely, traumatic stress and burnout. The terms compassion fatigue, burnout, and secondary trauma are used in the literature interchangeably (Boscarino, Figley, & Adams, 2004; Huggard & Huggard, 2008; Newell & MacNeil, 2010). Compassion fatigue has also been used interchangeably with an additional term called vicarious trauma (Huggard & Huggard, 2008; Newell & MacNeil, 2010; Overfield, 2012). Vicarious trauma refers to cognitive changes in caregivers who work with trauma survivors that result from bearing witness to or hearing accounts of the traumatic event from survivors (Pearlman & Mac Ian, 1995). For example, therapists have reported changes in their views of the self, the world, and others as a result of their work with trauma survivors (Pearlman & Mac Ian, 1995). Despite these inconsistencies in the usage of the term compassion fatigue, and the associated limitations in identifying trajectories of the condition, there is little doubt that animal care professionals experience significant levels of stress from their work (Scotney et al., 2015).

This occupational stress is associated with a number of negative outcomes for the workplace and the individual. In animal care professionals, workplace stress has been linked to intentions to leave (Kimber & Gardner, 2016), staff turnover (Anderson, Brandt, Lord, & Miles, 2013), accidents at work, and car accidents (Trimpop, Kirkcaldy, Athanasou, & Cooper, 2000). Further to this, occupational stress can exacerbate the development of mental health disorders, including anxiety and depression, and contribute to an increased risk of suicide (Bartram & Baldwin, 2010; Bartram et al., 2009; Tiesman et al., 2015). Together, these negative implications make the availability of effective therapeutic interventions in the animal care profession critically important. It is, therefore, the aim of this article to review the literature on therapeutic programs for occupational stress in animal care professionals. These findings will inform best practice guidelines for administrators and/or managers in the animal care profession and mental health professionals working with this population.

Method

The study was conducted with reference to the Preferred Reporting Systems for Systematic Reviews and Meta-Analyses statement for transparent reporting of systematic reviews (Liberati et al., 2009; Moher, Liberati, Tetzlaff, & Altman, 2009).

Eligibility Criteria
Studies were eligible for inclusion if they investigated intervention programs for occupational stress, vicarious trauma, compassion fatigue, secondary trauma, burnout, or PITS in the animal care profession, including veterinary clinics, humane societies, animal welfare shelters, pounds, or rescue organizations. Qualitative, quantitative, and mixed-method designs were eligible for inclusion. Peer-reviewed journal articles, conference papers, and dissertations were included in the review. No publication date restrictions were enforced and articles were restricted to the English language.

Information Sources
Studies were identified by searching the following electronic databases between January 17, 2017 and January 24, 2017 and between February 16 and February 23, 2017: PsycINFO, OvidMEDLINE, Web of Science, and ProQuest. This was accompanied by a search on Google Scholar and by scanning through the reference lists from each of the studies selected. The author also e-mailed three researchers, who had presented conference papers on occupational stress interventions for animal care professionals, and asked if they had peer-reviewed articles that were published, submitted, or in press. Three researchers of the articles included in this review were also contacted for additional information on their treatment protocol.

Search
The search terms included the following: animal shelter OR veterinary clinic OR animal care professionals OR animal shelter workers OR veterinarian OR animal technician OR veterinary nurse OR veterinary support staff OR animal control AND occupational stress OR compassion fatigue OR secondary trauma OR vicarious trauma OR burnout OR traumatic stress OR job stress OR stress management OR moral stress OR workplace stress.

Study Selection
The title and the abstract of all articles found from the search strategy described were evaluated. Those that appeared to fulfil the eligibility criteria were read in full. Articles that investigated the incidence, risk, and protective factors related to occupational stress outcomes were excluded from the study. Articles that described occupational stress, coping mechanisms, and management strategies but did not formally evaluate an intervention were also excluded.

Data Collection and Assessment
The author collated the articles and reviewed them to determine whether they fulfilled the selection criteria. Eligible studies were not evaluated for indicators of study quality using scales of assessment due to the variability of study designs. For example, one study was qualitative in design and, of the three quantitative studies, only one study included a control group. Further, quantitative studies varied in terms of the outcome measures used, making meaningful comparisons difficult. For these reasons, assessment of bias and meta-analysis could not be conducted.

Results

Study Selection
The database search identified 161 articles for preliminary screening, eight of which were selected after reading the title and abstracts. Five of these were excluded from analysis because they were either duplicates or, upon further inspection, were found to not meet the selection criteria. An additional article, a dissertation, was located via an additional Google Scholar search. This procedure left four studies for full review.

Study Characteristics
Three articles that were located were peer-reviewed journal articles and one article was a dissertation. Large variation was found in research design, recruitment methods, and data analyses among the four studies. Three studies were quantitative and one was qualitative. The studies were also conducted in a number of different regions and on different sectors of the animal care profession. Two studies were conducted in the United States, one in India, and one in Canada. Two of the studies recruited individuals from the veterinary sector, one recruited participants from an animal shelter, and the fourth article recruited a mixture of animal care professionals. Sample size, type of intervention, duration, and outcomes for the three quantitative studies are summarized in Table 1.

trm-24-3-186-tbl1a.gifA Summary of Study Characteristics and Results Pertaining to the Four Quantitative Studies

The first study was conducted in the United States and evaluated the impact of a stress management therapeutic program on a small sample of five veterinarians recruited from an emergency clinic (Wessels, 1982). Five veterinarians from a similar clinic in the same area were used as a control group. The program consisted of 3-hr weekly sessions for 5 weeks and covered topics such as the importance of the human–animal bond, self-awareness, and relational skills building. These were covered using a combination of experience-based learning through role-plays, personal reflection, and didactic presentation. Veterinary clinicians from both the control group and the treatment group completed the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970 as cited in Wessels, 1982), and empathy was measured through videotaped simulated interactions between the participants and a pet owner (actor). These videos were scored by an assessor blind to the experiment using the Carkhuff Empathic Understanding Scale (Carkhuff, 1969 as cited in Wessels, 1982). These outcomes are relevant to occupational stress in this population due to the demonstrated links between increased perceived stress, burnout, and reduced empathy (Passalacqua & Segrin, 2012) and between occupational stress and anxiety (Bartram et al., 2009). The results revealed a significant increase in empathy ratings toward the client (actor) over time, pre- and posttreatment, and between the control and the treatment group. No significant differences in anxiety ratings were found.

The second study was also conducted in the United States and evaluated a compassion fatigue therapeutic program for animal care professionals (Rank, Zaparanick, & Gentry, 2009). This sample of 57 participants comprised individuals from veterinary medicine, animal shelters, and other settings, including animal rehabilitation, animal sanctuaries, and pet stores. The program consisted of three modules. Module 1 consisted of a 2-day workshop following a manual-based treatment protocol. Rank et al. (2009) did not describe the content of this protocol and the author was unable to retrieve a copy of the manual. Module 2 was conducted online and included PowerPoint presentations and quizzes testing for participants’ comprehension of traumatic stress, burnout, grief and loss, and therapeutic interventions. Participants were also asked to create their own self-care plans as part of this module. The third module consisted of a review component and discussion of issues experienced since the preceding module. Due to a dropout rate of 77% from the first module to the second and third modules, most of the reported Assessments referred to the first module. Levels of compassion fatigue (burnout and secondary trauma) and compassion satisfaction (satisfaction received from caring for others) were measured using the Professional Quality of Life Scale (revised from Stamm, 2002). State and trait anxiety was measured using the State–Trait Anxiety Inventory for Adults Form Y (Spielberger, Gorsuch, & Lushene, 1983 as cited in Rank et al., 2009). A measure of trauma recovery called the Trauma Recovery Scale was also used in the Assessment (Gentry & Baranowski, 1999 as cited in Rank et al., 2009). Results comparing scores before and after participation in Module 1 revealed significant decreases in compassion fatigue (secondary trauma and burnout) and significant increases in levels of compassion satisfaction. Follow-up from this sample 6 months after the program revealed the benefits achieved from the program were maintained, but no data were provided to support this finding.

The third study was conducted in India and investigated the effectiveness of the Art of Living program on decreasing levels of organizational role stress and burnout on a sample of 382 veterinarians and veterinary support staff (Soni et al. 2015). The program ran for 5 consecutive days and covered the topics of yoga, breathing techniques, and meditation. Results revealed significant decreases in levels of burnout, as measured by the Maslach Burnout Inventory—General Survey (Maslach, Jackson, & Leiter, 1986) and the Organizational Role Stress Scale (Pareek, 1983 as cited in Soni et al., 2015).

The fourth study was qualitative in design and consisted of a convenience sample of five participants recruited from an animal shelter in Canada (Unsworth, Rogelberg, & Bonilla, 2010). As part of the intervention, participants were asked to write about their feelings on euthanasia and work-related stress every 3 days for 2 weeks. Unstructured interviews with the participants demonstrated positive effects of this form of expressive writing. The expressive writing appeared to have had a cathartic effect on participants, as they reported increased levels of insight, reduced levels of stress, and greater sense of self-awareness.

Discussion

The aim of this article was to conduct a systematic review on intervention programs for occupational stress in animal care professionals to provide best practice guidelines for administrators and/or managers and mental health professionals working with this population. The present review found that although occupational stress is prevalent in the animal care profession, very little research documenting the effectiveness of intervention programs exists for this population. Only four articles, one of which was a dissertation, could be found. Further to this, the variability in design and outcome measures makes meaningful comparisons and best practice recommendations on the basis of these findings difficult.

An additional limitation to providing best practice guidelines based on these studies is that very few employed control groups or follow-ups in their Assessment. The one study that did employ a control group did not use random assignment. This makes it difficult to determine if the demonstrated treatment effects were due to the treatment or a preexisting difference in the groups in terms of motivation levels, demographics, or the workplace context. Further, only one study included a follow-up component to the Assessment, so, for the remaining studies, whether the changes observed in levels of burnout, anxiety, and stress were lasting changes is not known. Incomplete reporting of the research results, and the details of some of the therapeutic programs, also adds to the difficulties in providing best practice guidelines on the basis of these studies.

With these caveats in mind, there does appear to be preliminary evidence that occupational stress therapeutic intervention programs for animal care professionals are beneficial, with reduced levels of burnout, anxiety, and stress being reported. These programs focus on psychoeducation and improving individual resources and coping skills through the development of relational skills, relaxation techniques, self-awareness, and reflection (Rank et al., 2009; Soni et al., 2015; Unsworth et al., 2010). There is, however, a clear need to develop additional interventions and evaluate these using controlled and, ideally, randomized research designs with follow-ups. Assessments of these interventions should include detailed reports of the contents of the program (including the type of therapeutic orientation) and comprehensive reporting of the results and replications on a range of occupational roles within the animal care profession. Demographic details of the participants should also be recorded and included in the analysis to determine whether programs work for some individuals better than others.

Until empirically supported interventions become available, it would be prudent for administrators and/or managers and mental health professionals working in the animal care profession to borrow from research conducted in other occupational sectors where the empirical research is further developed. Although a comprehensive literature review of occupational stress interventions in other workplaces is beyond the scope of this article, a number of comments can be made.

A brief review of current interventions for workplace stress, compassion fatigue, burnout, and trauma revealed similar reductions in workplace stress across a range of industries (McLeod, 2010). McLeod (2010) found that many programs varied in the type of therapeutic orientation, with psychodynamic, cognitive–behavioral, and client-centered approaches demonstrating equivalent improvements in employee well-being and reductions in stress. These findings have also been supported by others who have found equivalence in effectiveness across therapeutic orientations (Messer & Wampold, 2002).

Despite this noted equivalence across orientations, after narrowing the search to populations involved in human care (including police officers, nurses, and physicians), a group also exposed to trauma and suffering, the most frequently utilized orientation was cognitive–behavioral therapy or those based on cognitive–behavioral techniques, including mindfulness-based approaches (Regehr, Glancy, Pitts, & LeBlanc, 2014; West, Dyrbye, Erwin, & Shanafelt, 2016). These interventions were linked with significant reductions in stress (Ruotsalainen, Serra, Marine, & Verbeek, 2008), anxiety levels (Regehr et al., 2014), and burnout (Ruotsalainen et al., 2008; West et al., 2016).

This overrepresentation of cognitive–behavioral techniques may not, however, indicate that this therapeutic orientation is better suited to organizational stress in care professions; rather, it may be reflective of the overall dominance of cognitive–behavioral techniques in the research literature (Gaudiano, 2008). Approaches using psychodynamic approaches, for example, have demonstrated positive results for the treatment of trauma in police officers (Gersons, Carlier, Lamberts, & van der Kolk, 2000). Additional interventions not aligned with a specific orientation were also beneficial for employees, and these included coping skills training, relaxation techniques, and psychoeducation (Nowrouzi et al., 2015; Regehr et al., 2014; Ruotsalainen et al., 2008; West et al., 2016). Psychoeducation, with the exception of music therapy (Hilliard, 2006), was the predominant form of intervention for compassion fatigue (Flarity, Gentry, & Mesnikoff, 2013; Meadors & Lamson, 2008; Potter et al., 2013).

In summary, this systematic review found that, despite the prevalence of occupational stress in animal care professionals, and the documented negative impacts on individual and workplace well-being, very little research documenting the effectiveness of therapeutic interventions in this population exists. Recommendations for best practice on the basis of these limited studies can, therefore, not be made. A brief review of the literature on therapeutic interventions in other occupational groups suggests those interventions that address psychoeducation, coping skills, and relaxation techniques are useful strategies for addressing compassion fatigue (burnout and secondary trauma) and other forms of occupational stress.

In terms of therapeutic orientations, there appears to be no strong evidence supporting one approach over another. Interventions using person-centered, psychodynamic, and cognitive–behavioral therapies have all been equally linked to therapeutic benefits. Cognitive–behavioral techniques, including mindfulness-based approaches, are the most frequently cited approach for therapeutic interventions addressing occupational stress in human care professionals. Programs that aim to incorporate psychoeducation, coping skills training, and relaxation within a cognitive–behavioral orientation with possible mindfulness-based approaches may, therefore, offer mental health professionals and manager/administrators in the animal care profession a useful starting point with which to base future interventions. What remains clear from this review is the urgent and critical need for further research evaluating interventions for animal care professionals, so that best practice guidelines can be made.

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Submitted: June 29, 2017 Revised: November 15, 2017 Accepted: November 28, 2017

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Source: Traumatology. Vol. 24. (3), Sep, 2018 pp. 186-192)
Accession Number: 2018-09296-001
Digital Object Identifier: 10.1037/trm0000144

Result List Refine Search PrevResult 40 of 68 Next
Mental health nurse’s exposure to workplace violence leads to job stress, which leads to reduced professional quality of life.Open Access
Authors:
Itzhaki, Michal. Nursing Department, School of Health Professions, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Bluvstein, Irit. Nursing Department, School of Health Professions, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Peles Bortz, Anat. Sheba Medical Center, Ramat Gan, Israel
Kostistky, Hava. Sha’ar Menashe Mental Health Center, Emeq Hefer, Israel
Bar Noy, Dor. Sha’ar Menashe Mental Health Center, Emeq Hefer, Israel
Filshtinsky, Vivian. Sha’ar Menashe Mental Health Center, Emeq Hefer, Israel
Theilla, Miriam. Nursing Department, School of Health Professions, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel, miriamt@post.tau.ac.il
Address:
Theilla, Miriam, miriamt@post.tau.ac.il
Source:
Frontiers in Psychiatry, Vol 9, Feb 27, 2018. ArtID: 59
NLM Title Abbreviation:
Front Psychiatry
Publisher:
Switzerland : Frontiers Media S.A.
Other Publishers:
Switzerland : Frontiers Research Foundation
ISSN:
1664-0640 (Electronic)
Language:
English
Keywords:
workplace violence, professional quality of life, job stress, mental health nurses, compassion satisfaction, compassion fatigue
Abstract:
Professional quality of life (ProQOL) reflects how individuals feel about their work as helpers. Psychiatric ward nurses cope with significant psychological and physical challenges, including exposure to verbal and physical violence. This study was based on two aspects of ProQOL, the positive compassion satisfaction, and the negative compassion fatigue, with the aim of investigating the relation of ProQOL to job stress and violence exposure at a large mental health center. Data were collected from 114 mental health nurses (49/63 M/F) who completed a self-administered questionnaire examining violence exposure, ProQOL, and job stress. The results showed that during the last year, almost all nurses (88.6%) experienced verbal violence, and more than half (56.1%) experienced physical violence. Only 2.6% experienced no violence. ProQOL was not associated with violence exposure but was reduced by work stress and by previous exposure to violence; nurses who perceived their work as more stressful had lower satisfaction from their work. In conclusion, although most mental health nurses are exposed to physical and verbal violence, their ProQOL is more related to job stress than to workplace violence (WPV). Hospital managements should conduct work stress reduction intervention programs and promote strategizes to reduce WPV. Further exploration of (a) factors affecting ProQOL and (b) the effect of violence coping workshops on ProQOL is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Occupational Stress; *Quality of Work Life; *Satisfaction; *Workplace Violence; *Compassion Fatigue; Psychiatric Nurses
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Israel
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Methodology:
Empirical Study; Longitudinal Study; Retrospective Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Feb 27, 2018; Accepted: Feb 12, 2018; First Submitted: Jan 2, 2018
Release Date:
20181015
Copyright:
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.. Itzhaki, Bluvstein, Peles Bortz, Kostistky, Bar Noy, Filshtinsky and Theilla. 2018
Digital Object Identifier:
http://dx.doi.org/10.3389/fpsyt.2018.00059
PMID:
29535652
Accession Number:
2018-09851-001
Number of Citations in Source:
45
Result List Refine Search PrevResult 41 of 68 Next
Crimes against caring: Exploring the risk of secondary traumatic stress, burnout, and compassion satisfaction among child exploitation investigators.
Authors:
Brady, Patrick Q.. Department of Criminology, University of West Georgia, Carrollton, GA, US, patbrady@shsu.edu
Address:
Brady, Patrick Q., Department of Criminology, University of West Georgia, Pafford Social Science Building, Carrollton, GA, US, 30118, patbrady@shsu.edu
Source:
Journal of Police and Criminal Psychology, Vol 32(4), Dec, 2017. pp. 305-318.
Page Count:
14
Publisher:
Germany : Springer
ISSN:
0882-0783 (Print)
1936-6469 (Electronic)
Language:
English
Keywords:
secondary traumatic stress, burnout, compassion satisfaction, child exploitation, criminal investigation
Abstract:
Secondary traumatic stress (STS) and burnout are debilitating occupational hazards that inhibit helping professional’s overall well-being. Much of the extant scholarship on this topic has focused on mental health and child welfare workers and not law enforcement officials who investigate Internet child exploitation. This study used data from 433 Internet Crimes Against Children (ICAC) Task Force personnel to explore the impact of individual and work-related factors associated with the risk of STS, burnout, and compassion satisfaction. Findings indicated that nearly one in four ICAC personnel exhibited low compassion satisfaction and high levels of STS and burnout. Individual-level protective factors for increasing compassion satisfaction and mitigating symptoms of STS and burnout included having a strong social support system outside of work and the frequent use of positive coping mechanisms. Work-related risk factors such as frequent indirect exposure to disturbing materials, low organizational support, and frequently feeling overwhelmed at work were all associated with higher STS and burnout and lower levels of compassion satisfaction. Policy implications and future avenues of research are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Occupational Stress; *Stress; *Sympathy; *Compassion Fatigue; Child Welfare
PsycInfo Classification:
Personnel Attitudes & Job Satisfaction (3650)
Population:
Human
Male
Female
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Self-Care Practices Questionnaire
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Dec 9, 2016
Release Date:
20161215
Correction Date:
20180405
Copyright:
Society for Police and Criminal Psychology. 2016
Digital Object Identifier:
http://dx.doi.org/10.1007/s11896-016-9223-8
Accession Number:
2016-60159-001
Number of Citations in Source:
75
Result List Refine Search PrevResult 42 of 68 Next
Exploring wellness of wildlife carers in New Zealand: A descriptive study.
Authors:
Yeung, Polly. School of Social Work, Massey University, Palmerston North, New Zealand, p.yeung@massey.ac.nz
White, Bridey. Wildbase, Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Palmerston North, New Zealand
Chilvers, B. Louise. Wildbase, Institute of Veterinary, Animal and Biomedical Sciences, Massey University, Palmerston North, New Zealand
Address:
Yeung, Polly, School of Social Work, Massey University, PO Box 11-222, Palmerston North, New Zealand, 4442, p.yeung@massey.ac.nz
Source:
Anthrozoös, Vol 30(4), Oct, 2017. pp. 549-563.
NLM Title Abbreviation:
Anthrozoos
Page Count:
15
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Journal of the Delta Society
Other Publishers:
United Kingdom : Berg Publishers
United Kingdom : Bloomsbury Publishing
US : Purdue University Press
ISSN:
0892-7936 (Print)
1753-0377 (Electronic)
Language:
English
Keywords:
compassion fatigue, compassion satisfaction, cross-sectional survey, quality of life, wellbeing
Abstract:
The rescue and care of vulnerable wildlife is rewarding. Most people involved in animal rescue have a strong commitment to service but the work can be profoundly challenging. The ability to know and respond appropriately to an animal’s needs depends on the professional skills and knowledge of wildlife carers. In the face of unrelenting suffering and countless numbers of animals in need, there are multiple stressors, vulnerabilities, and barriers that can undermine carers’ wellbeing and put them at risk of compassion fatigue. The balance between compassion satisfaction and compassion fatigue is considered professional quality of life. The aim of this study was to provide a preliminary understanding of the potential for compassion satisfaction and the risk of compassion fatigue among wildlife carers within New Zealand. Thirty wildlife carers voluntarily completed a self-report survey, which included questions on socio-demographics, self-perceived quality of life (EUROHIS-QOL), professional quality of life (ProQOL), job satisfaction, motivation for ongoing work in wildlife rehabilitation, and coping mechanisms. We found that there were significant differences in compassion satisfaction and compassion fatigue on the basis of age, gender, financial capability, and years of experience. Overall, this sample showed high levels of compassion satisfaction and low levels of compassion fatigue. Understanding the elements of professional quality of life can have a positive effect on work environment. These results may provide clues to help identify wildlife carers’ strengths for compassion satisfaction and vulnerabilities to compassion fatigue, and to help develop strategies to improve their professional quality of life. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Environment; *Professional Personnel; *Quality of Life; *Well Being; *Compassion Fatigue; Suffering
PsycInfo Classification:
Environmental Issues & Attitudes (4070)
Population:
Human
Male
Female
Location:
New Zealand
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Reasons for Ongoing Work in Wildlife Rehabilitation Scale
How to Deal With Inevitable or Euthanized Deaths Measure
Professional Quality of Life Scale DOI: 10.1037/t05192-000
EUROHIS–Quality of Life 8-item Index DOI: 10.1037/t64016-000
Job Satisfaction Questionnaire
Life Satisfaction Scale
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20180416
Copyright:
ISAZ. 2017
Digital Object Identifier:
http://dx.doi.org/10.1080/08927936.2017.1370213
Accession Number:
2017-55820-002
Number of Citations in Source:
54
Result List Refine Search PrevResult 43 of 68 Next
Preventing, managing and treating compassion fatigue.Open Access
Authors:
Vu, Francis. Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland, francis.vu@chuv.ch
Bodenmann, Patrick. Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
Address:
Vu, Francis, Policlinique Medicale Universitaire (PMU), Rue du Bugnon 44, CH-1011, Lausanne, Switzerland, francis.vu@chuv.ch
Source:
Swiss Archives of Neurology, Psychiatry and Psychotherapy, Vol 168(8), 2017. pp. 224-231.
Page Count:
8
Publisher:
Switzerland : Schwabe & Co
Other Journal Titles:
Schweizer Archiv für Neurologie und Psychiatrie; Schweizer Archiv für Neurologie, Neurochirurgie und Psychiatrie
ISSN:
2297-6981 (Print)
2297-7007 (Electronic)
Language:
English
Keywords:
compassion fatigue, (self-)awareness, occupational hazards, coping, resiliency
Abstract:
In the helping and social professions, professionals are usually expected to use compassion and empathy when engaging with traumatised and suffering individuals, although that it may require a ‘cost of caring’. In the literature, the psychological and physical negative effects resulting from such an empathic and compassionate engagement is referred as ‘compassion fatigue’. Over the last two decades, a rising number of interventions to mitigate the risks of compassion fatigue have been advocated in the literature. The main purpose of this article is to provide a critical appraisal and review of the existing recommendations to combat compassion fatigue. A systematic review of the literature shows that compassion fatigue can be combated among helping and social organisations and professionals, which requires increasing their (self-)awareness of occupational hazards through education, debriefings and supervisions, and equipping them with adequate knowledge and skills that will enhance their coping and resiliency resources. It also requires developing and nurturing self-care and self-management strategies, and promoting organisational and structural changes that will mitigate work environment constraints. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Compassion Fatigue; Management; Prevention; Treatment
PsycInfo Classification:
Working Conditions & Industrial Safety (3670)
Population:
Human
Methodology:
Literature Review; Systematic Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20180122
Accession Number:
2018-00446-001
Result List Refine Search PrevResult 44 of 68 Next
Vicarious trauma, social media and recovery in Hong Kong.
Authors:
Turnbull, Margo, ORCID 0000-0002-9094-6814 . International Research Centre for the Advancement of Health Communication, Hong Kong Polytechnic University, Hong Kong, margo.turnbull@polyu.edu.hk
Watson, Bernadette. International Research Centre for the Advancement of Health Communication, Hong Kong Polytechnic University, Hong Kong
Jin, Ying. International Research Centre for the Advancement of Health Communication, Hong Kong Polytechnic University, Hong Kong
Lok, Beatrice. Department of English, Hong Kong Polytechnic University, Hong Kong
Sanderson, Alexandra. Department of Applied Social Sciences, Hong Kong Polytechnic University, Hong Kong
Address:
Turnbull, Margo, margo.turnbull@polyu.edu.hk
Source:
Asian Journal of Psychiatry, Vol 51, Jun, 2020. ArtID: 102032
NLM Title Abbreviation:
Asian J Psychiatr
Publisher:
Netherlands : Elsevier Science
ISSN:
1876-2018 (Print)
1876-2026 (Electronic)
Language:
English
Keywords:
vicarious trauma, social media, mental health, novel coronavirus
Abstract:
There have been broad calls in Hong Kong for greater investment in mental health but as yet little data has been gathered from those affected which can help design community-level interventions. A multi-method research study was conducted in the weeks immediately following these events at PolyU. Participants completed an anxiety scale and participated in interviews which included questions focused on community-level recovery. Interviews were conducted in English, Cantonese or Mandarin Chinese depending on individual preference. This article presents preliminary analysis of the data highlighting three important themes that warrant further investigation in relation to community-level recovery following large scale disruption such as social unrest and population health emergencies. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Letter
Subjects:
*Mental Health; *Social Issues; *Trauma; *Vicarious Experiences; *Preventive Mental Health Services; Coping Behavior; Social Media
Medical Subject Headings (MeSH):
Compassion Fatigue; Hong Kong; Humans; Social Media
PsycInfo Classification:
Health & Mental Health Treatment & Prevention (3300)
Population:
Human
Location:
Hong Kong
Age Group:
Adulthood (18 yrs & older)
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Submitted: Mar 17, 2020
Release Date:
20210729
Copyright:
All rights reserved.. Elsevier B.V.. 2020
Digital Object Identifier:
http://dx.doi.org/10.1016/j.ajp.2020.102032
PMID:
32302961
Accession Number:
2020-62647-001
Number of Citations in Source:
9
Prevalence and predictors of compassion fatigue, burnout and compassion satisfaction among oncology nurses: A cross-sectional survey.
Authors:
Yu, Hairong. School of Nursing, Second Military Medical University, Shanghai, China, yhr900926@126.com
Jiang, Anli. School of Nursing, Second Military Medical University, Shanghai, China, alj1018@aliyun.com
Shen, Jie. School of Nursing, Second Military Medical University, Shanghai, China, shenjie0801@126.com
Address:
Jiang, Anli, School of Nursing, Second Military Medical University, No. 800, Xiangyin Road, Yangpu District, Shanghai, China, alj1018@aliyun.com
Source:
International Journal of Nursing Studies, Vol 57, May, 2016. pp. 28-38.
NLM Title Abbreviation:
Int J Nurs Stud
Page Count:
11
Publisher:
Netherlands : Elsevier Science
ISSN:
0020-7489 (Print)
1873-491X (Electronic)
Language:
English
Keywords:
Burnout, Compassion fatigue, Compassion satisfaction, Cross-sectional survey, Oncology nurses, Predictors
Abstract:
Background: cancer is a leading cause of death worldwide. Given the complexity of caring work, recent studies have focused on the professional quality of life of oncology nurses. China, the world’s largest developing country, faces heavy burdens of care for cancer patients. Chinese oncology nurses may be encountering the negative side of their professional life. However, studies in this field are scarce, and little is known about the prevalence and predictors of oncology nurses’ professional quality of life. Objectives: To describe and explore the prevalence of predictors of professional quality of life (compassion fatigue, burnout and compassion satisfaction) among Chinese oncology nurses under the guidance of two theoretical models. Design: A cross-sectional design with a survey. Settings: Ten tertiary hospitals and five secondary hospitals in Shanghai, China. Participants: A convenience and cluster sample of 669 oncology nurses was used. All of the nurses worked in oncology departments and had over 1 year of oncology nursing experience. Of the selected nurses, 650 returned valid questionnaires that were used for statistical analyses. Methods: The participants completed the demographic and work-related questionnaire, the Chinese version of the Professional Quality of Life Scale for Nurses, the Chinese version of the Jefferson Scales of Empathy, the Simplified Coping Style Questionnaire, the Perceived Social Support Scale, and the Chinese Big Five Personality Inventory brief version. Descriptive statistics, t-tests, one-way analysis of variance, simple and multiple linear regressions were used to determine the predictors of the main research variables. Results: Higher compassion fatigue and burnout were found among oncology nurses who had more years of nursing experience, worked in secondary hospitals and adopted passive coping styles. Cognitive empathy, training and support from organizations were identified as significant protectors, and ‘perspective taking’ was the strongest predictor of compassion satisfaction, explaining 23.0% of the variance. Personality traits of openness and conscientiousness were positively associated with compassion satisfaction, while neuroticism was a negative predictor, accounting for 24.2% and 19.8% of the variance in compassion fatigue and burnout, respectively. Conclusions: Oncology care has unique features, and oncology nurses may suffer from more work-related stressors compared with other types of nurses. Various predictors can influence the professional quality of life, and some of these should be considered in the Chinese nursing context. The results may provide clues to help nurse administrators identify oncology nurses’ vulnerability to compassion fatigue and burnout and develop comprehensive strategies to improve their professional quality of life. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Nurses; *Occupational Stress; *Oncology; *Compassion Fatigue; Satisfaction
Medical Subject Headings (MeSH):
Adult; Burnout, Professional; Compassion Fatigue; Cross-Sectional Studies; Female; Humans; Job Satisfaction; Male; Middle Aged; Oncology Nursing; Prevalence
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
China
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Professional Quality of Life Scale-Chinese Version
Jefferson Scale of Empathy-Chinese Version
Chinese Big Five Personality Inventory Brief Version
Simplified Coping Style Questionnaire
Perceived Social Support Scale-Chinese Version
Grant Sponsorship:
Sponsor: Second Military Medical University, Graduate School, China
Other Details: Doctorate Innovative Fund
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jan 27, 2016; Revised: Jan 23, 2016; First Submitted: Sep 2, 2015
Release Date:
20160505
Correction Date:
20170928
Copyright:
All rights reserved.. Elsevier Ltd.. 2016
Digital Object Identifier:
http://dx.doi.org/10.1016/j.ijnurstu.2016.01.012
PMID:
27045562
Accession Number:
2016-17106-004
Number of Citations in Source:
52
Prevalence and predictors of compassion fatigue, burnout and compassion satisfaction among oncology nurses: A cross-sectional survey.
Authors:
Yu, Hairong. School of Nursing, Second Military Medical University, Shanghai, China, yhr900926@126.com
Jiang, Anli. School of Nursing, Second Military Medical University, Shanghai, China, alj1018@aliyun.com
Shen, Jie. School of Nursing, Second Military Medical University, Shanghai, China, shenjie0801@126.com
Address:
Jiang, Anli, School of Nursing, Second Military Medical University, No. 800, Xiangyin Road, Yangpu District, Shanghai, China, alj1018@aliyun.com
Source:
International Journal of Nursing Studies, Vol 57, May, 2016. pp. 28-38.
NLM Title Abbreviation:
Int J Nurs Stud
Page Count:
11
Publisher:
Netherlands : Elsevier Science
ISSN:
0020-7489 (Print)
1873-491X (Electronic)
Language:
English
Keywords:
Burnout, Compassion fatigue, Compassion satisfaction, Cross-sectional survey, Oncology nurses, Predictors
Abstract:
Background: cancer is a leading cause of death worldwide. Given the complexity of caring work, recent studies have focused on the professional quality of life of oncology nurses. China, the world’s largest developing country, faces heavy burdens of care for cancer patients. Chinese oncology nurses may be encountering the negative side of their professional life. However, studies in this field are scarce, and little is known about the prevalence and predictors of oncology nurses’ professional quality of life. Objectives: To describe and explore the prevalence of predictors of professional quality of life (compassion fatigue, burnout and compassion satisfaction) among Chinese oncology nurses under the guidance of two theoretical models. Design: A cross-sectional design with a survey. Settings: Ten tertiary hospitals and five secondary hospitals in Shanghai, China. Participants: A convenience and cluster sample of 669 oncology nurses was used. All of the nurses worked in oncology departments and had over 1 year of oncology nursing experience. Of the selected nurses, 650 returned valid questionnaires that were used for statistical analyses. Methods: The participants completed the demographic and work-related questionnaire, the Chinese version of the Professional Quality of Life Scale for Nurses, the Chinese version of the Jefferson Scales of Empathy, the Simplified Coping Style Questionnaire, the Perceived Social Support Scale, and the Chinese Big Five Personality Inventory brief version. Descriptive statistics, t-tests, one-way analysis of variance, simple and multiple linear regressions were used to determine the predictors of the main research variables. Results: Higher compassion fatigue and burnout were found among oncology nurses who had more years of nursing experience, worked in secondary hospitals and adopted passive coping styles. Cognitive empathy, training and support from organizations were identified as significant protectors, and ‘perspective taking’ was the strongest predictor of compassion satisfaction, explaining 23.0% of the variance. Personality traits of openness and conscientiousness were positively associated with compassion satisfaction, while neuroticism was a negative predictor, accounting for 24.2% and 19.8% of the variance in compassion fatigue and burnout, respectively. Conclusions: Oncology care has unique features, and oncology nurses may suffer from more work-related stressors compared with other types of nurses. Various predictors can influence the professional quality of life, and some of these should be considered in the Chinese nursing context. The results may provide clues to help nurse administrators identify oncology nurses’ vulnerability to compassion fatigue and burnout and develop comprehensive strategies to improve their professional quality of life. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Nurses; *Occupational Stress; *Oncology; *Compassion Fatigue; Satisfaction
Medical Subject Headings (MeSH):
Adult; Burnout, Professional; Compassion Fatigue; Cross-Sectional Studies; Female; Humans; Job Satisfaction; Male; Middle Aged; Oncology Nursing; Prevalence
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
China
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Professional Quality of Life Scale-Chinese Version
Jefferson Scale of Empathy-Chinese Version
Chinese Big Five Personality Inventory Brief Version
Simplified Coping Style Questionnaire
Perceived Social Support Scale-Chinese Version
Grant Sponsorship:
Sponsor: Second Military Medical University, Graduate School, China
Other Details: Doctorate Innovative Fund
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jan 27, 2016; Revised: Jan 23, 2016; First Submitted: Sep 2, 2015
Release Date:
20160505
Correction Date:
20170928
Copyright:
All rights reserved.. Elsevier Ltd.. 2016
Digital Object Identifier:
http://dx.doi.org/10.1016/j.ijnurstu.2016.01.012
PMID:
27045562
Accession Number:
2016-17106-004
Number of Citations in Source:
52
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Risk and protective factors for secondary traumatic stress and burnout among home visitors.
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Authors:
Begic, Sandina. Center for Health Policy, Boise State University, Boise, ID, US
Weaver, Jennifer M.. Department of Psychological Science, Boise State University, Boise, ID, US, jenniferweaver@boisestate.edu
McDonald, Theodore W.. Department of Psychological Science, Boise State University, Boise, ID, US
Address:
Weaver, Jennifer M., Department of Psychological Science, Boise State University, 1910 University Dr., Boise, ID, US, 83725, jenniferweaver@boisestate.edu
Source:
Journal of Human Behavior in the Social Environment, Vol 29(1), Jan, 2019. pp. 137-159.
NLM Title Abbreviation:
J Hum Behav Soc Environ
Page Count:
23
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Haworth Press
ISSN:
1091-1359 (Print)
1540-3556 (Electronic)
Language:
English
Keywords:
Secondary traumatic stress, home visitors, burnout
Abstract:
The overarching goal of this study was to understand the context of home visitor secondary traumatic stress and burnout, and how this might affect intention to quit among home visitors, particularly focusing on potential risk factors and supportive strategies identified by the home visitors. All home visitors providing services in the state in which the research was conducted (N = 27) completed a structured interview and a quantitative survey at two time points, 6 months apart. Results indicated that more than two-thirds of the home visitors experienced either medium or high levels of secondary traumatic stress and burnout over the course of the study. Approximately one quarter of home visitors indicated thinking of leaving their present positio. Qualitative data indicated that risk factors associated with burnout included those related to both direct and non-direct services. Risk factors associated with secondary traumatic stress included traumatic stress of families, inability to recognize one’s own experiences of secondary traumatic stress, and unhealthy work culture. In terms of protective factors, home visitors strongly emphasized the importance of having a supportive supervisor who they could trust and communicate with openly. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Occupational Stress; *Protective Factors; *Risk Factors; *Compassion Fatigue
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
ProQOL Scale
Supervisory Working Alliance Inventory-Trainee
Work-Life Support Index
Satisfaction With Employment Situation Scale
Workplace Scale DOI: 10.1037/t59638-000
Coping Humor Scale DOI: 10.1037/t08093-000
Grant Sponsorship:
Sponsor: Idaho Department of Health and Welfare, US
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20191118
Copyright:
Taylor & Francis Group, LLC. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/10911359.2018.1496051
Accession Number:
2019-01058-013
Images:
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Risk and protective factors for secondary traumatic stress and burnout among home visitors
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✖
Contents
STS, burnout, and intention to quit
Risk and protective factors for home visitors
Reflective supervision
Workplace supportiveness
Humor
Current study
Method
Participants and data collection timeline
Measures
STS and burnout
Intention to quit
Reflective supervision
Supervisor’s supportiveness
Supportive work-life policies
Humor
Length of time working with MIECHV families
Percentage of families with high or special needs
Satisfaction with employment situation
Interview protocol
Data analysis
Results
Levels of STS, burnout, and turnover intentions
Factors associated with STS, burnout and turnover intentions
Home visitor’s perceptions of risk factors
Risk factors associated with STS
Risk factors associated with burnout
Risk factors associated with direct services
Risk factors associated with aspects of home visiting other than direct services
Intention to quit
Home visitors’ perceptions of protective factors
Supportive supervisor and RS
Supportive work-life policies
Coping strategies and use of humor
Discussion
Study limitations and future directions
Conclusions and recommendations
References
Full Text
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The overarching goal of this study was to understand the context of home visitor secondary traumatic stress and burnout, and how this might affect intention to quit among home visitors, particularly focusing on potential risk factors and supportive strategies identified by the home visitors. All home visitors providing services in the state in which the research was conducted (N = 27) completed a structured interview and a quantitative survey at two time points, 6 months apart. Results indicated that more than two-thirds of the home visitors experienced either medium or high levels of secondary traumatic stress and burnout over the course of the study. Approximately one quarter of home visitors indicated thinking of leaving their present positio. Qualitative data indicated that risk factors associated with burnout included those related to both direct and non-direct services. Risk factors associated with secondary traumatic stress included traumatic stress of families, inability to recognize one’s own experiences of secondary traumatic stress, and unhealthy work culture. In terms of protective factors, home visitors strongly emphasized the importance of having a supportive supervisor who they could trust and communicate with openly.

Keywords: Secondary traumatic stress; home visitors; burnout

Home visiting programs have existed in the United States for many years; the earliest documented home visiting services were offered at least 130 years ago (Charity Organization Society, 1883; cited in Sweet & Appelbaum, 2004; see also Wasik, 1993). Yet, it was not until the 1980s that rigorous Assessments of the benefits of home visiting programs began to surface (e.g., Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds, Henderson, Tatelbaum, & Chamberlin, 1986). In 2010, home visiting programs serving pregnant women and new mothers and their children were significantly expanded through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program funded through the Patient Protection and Affordable Care Act (PPACA, 2010) (Adirim & Supplee, 2013). Consequently, hundreds if not thousands of new home visitors have likely been hired throughout the country (Adirim & Supplee, 2013).

The training of home visitors can be extensive and costly (Azzi-Lessing, 2011), making retention a key issue for local implementing agencies (LIAs). For a variety of reasons, including relatively poor compensation, working with highly stressed families, and high demands with few resources, turnover tends to be high among home visitors (Gill et al., 2007; Lee et al., 2013; Wasik, 1993). Some factors causing the high turnover are believed to be secondary traumatic stress (STS) incurred by working with traumatized families (Osofsky, 2009) and burnout from emotional exhaustion (e.g., Gill et al., 2007; Lee et al., 2013). In this exploratory study, we utilized a mixed methods approach to document the prevalence of STS, burnout, and intention to leave one’s job among home visitors providing MIECHV-funded services in one Northwest state over the course of 6 months and to identify aspects of the position that may act as risk or protective factors for these workers.

STS, burnout, and intention to quit
Also called compassion fatigue or vicarious stress (Bride, Radey, & Figley, 2007; Jenkins & Baird, 2002), STS is described as a common result of working with traumatized others, and has been documented in therapists, social workers, first responders, nurses, and others in helping professions—including home visitors (Beck, 2011; Boscarino, Figley, & Adams, 2004; Cornille & Meyers, 1999; Figley, 1995; Lee et al., 2013). It has been maintained that because people in human service professions work so closely with traumatized others, they come to share much the same burdens from the trauma as the traumatized victims themselves (Bride et al., 2007). Osofsky (2009) argued that those who work with traumatized infants and children may be particularly at risk for STS, as they may feel compelled to “rescue” the infant or child to protect him or her from traumatic circumstances, a feeling that may ultimately increase the likelihood that the person experiencing STS withdraws from the case or leaves his or her position.

Often linked to STS but conceptually distinct, burnout has been studied intensively in the organizational, social science, and health science literatures. Characterized by an enduring emotional response to chronic stressors in a professional setting, burnout is conceptualized as having three dimensions: exhaustion (emotional, physical, or both), inefficiency (also known as professional efficacy), and cynicism (also known as depersonalization) (Lee et al., 2013; Schaufeli & Bakker, 2004). In the context of home visiting, burnout has been reported to be caused by job and role strain, workload and time pressure, and lack of supervisory support (Lee et al., 2013). Like STS, burnout is understood to affect professionals’ intention to leave their jobs and turnover (Leiter & Maslach, 2009; Linzer et al., 2015; Schaufeli & Bakker, 2004).

Studies on home visiting have consistently reported turnover rates to be high (e.g., Korfmacher, O’Brien, Hiatt, & Olds, 1999; Wasik, 1993; Wasik & Roberts, 1994). Exactly how staff turnover affects service delivery is not known (Gill et al., 2007), however, at the very least, it likely incurs cost to the LIA (through recruitment and training expenses) and some disruption in services to families assigned to home visitors who quit or are otherwise terminated. The literature seems surprisingly sparse on the factors that influence home visitors’ intentions to leave their organizations (turnover intentions) or to actually leave those organizations.

Risk and protective factors for home visitors
In addition to documenting the prevalence of STS and burnout among this population of home visitors, we also sought to understand the risk and protective factors these workers experienced as part of their job. With regard to risk factors, we explored several potential characteristics of the job, the families, and the home visitors themselves that may serve to exacerbate or differentiate home visitors’ experience of STS, burnout, and intention to quit. In terms of protective factors, our attention was particularly focused around the workplace environment. Although there is a growing body of research on STS and burnout among workers in the human services field (e.g., Boyas & Wind, 2010; Leiter, Gascon, & Martinez-Jarreta, 2010; Lizano & Mor Barak, 2012), there is a lack of research on protective factors that may mitigate risks for STS and burnout (Gupta, Paterson, Lysaght, & Von Zweck, 2012; Halbesleben & Buckley, 2004; Herbert & Dudley, 2009) and just how these protective factors may vary across different groups of workers (Boyas, Wind, & Ruiz, 2015; Green, Albanese, Shapiro, & Aarons, 2014). Because working in the home visiting field often means working with high-need families while being relatively poorly compensated and having limited resources, it seemed imperative to understand whether and to what extent a supportive work environment may act as a protective factor that could mitigate the prevalence of STS and burnout.

Reflective supervision
Reflective supervision (RS) is considered by many to be an integral part of interventionist work (Minnesota Association for Infant & Early Childhood Mental Health, n.d.; Paulsen, Boller, Hallgren, & Esposito, 2010; Watson, Neilsen Gatti, Cox, Harrison, & Hennes, 2014). There is a growing literature that suggests that RS may have a positive effect on job satisfaction and job stress among early childhood workforce, such that interventionists who receive regular RS experience a reduction in job-related stress (Watson & Neilsen Gatti, 2012; Watson et al., 2014). We specifically queried home visitors about their experiences with RS to determine whether they felt it to be a helpful exercise that mitigated the negative effects of working with high-need families.

Workplace supportiveness
Firth, Mellor, Moore, and Loquet (2004) have found that supervisor support can reduce job stress and intention to leave one’s job among workers in the service industry. In recent years, several studies have examined how perceived support from one’s supervisor may mediate the prevalence of STS, burnout, and intention to leave one’s job among human services workers (Boyas, Wind, & Kang, 2012; Firth et al., 2004; Lee et al., 2013; Leiter et al., 2010; Swanson & Power, 2001; Yoo, 2002). However, to our knowledge, there are no studies that have explored whether and exactly how perceived support from one’s supervisor may act as a potential protective factor among individuals working in the home visiting field.

Humor
In preliminary, anecdotal conversations with home visitors, the importance of humor in the workplace was frequently emphasized as a mechanism for dealing with daily work stressors such as working with families with high needs and balancing the desire to help while maintaining professional boundaries. Indeed, the positive effects of humor on job satisfaction and wellbeing (Martin, 1996; Mesmer-Magnus, Glew, & Viswesvaran, 2012), including burnout (e.g., Abel, 2002; Gupta et al., 2012; Talbot, 2010), are well documented. We are, however, not aware of studies examining how humor may act as a protective factor among home visitors.

Current study
The overarching goal of this study was to understand the context of home visitor STS and burnout, and how this might affect home visitors’ intention to quit, particularly focusing on potential risk factors and supportive strategies identified by the home visitors themselves:

What are the levels of STS, burnout, and intention to quit one’s job in this population of home visitors? This question was explored through the use of qualitative data.
How do factors related to the families (percent of families with high needs on one’s caseload and caseload size), satisfaction with the workplace (pay, resources, institutional culture, supportive work policies), the supervisor (quality of RS, supportive supervisor, perceived supervisor’s sense of humor), and the home visitors themselves (sense of humor) relate to home visitors’ reports of STS, burnout, or intention to quit? This question was explored through the use of quantitative data.
What are home visitors’ perceptions of risk factors and how do these relate to STS and burnout? This research question was explored through qualitative data.
How do workplace supportiveness, RS, and use of humor act to mitigate the negative effects of working in a high stress profession? This research question was explored through qualitative data.
To address these questions, we collected data at two time points, 6 months apart, from all eligible home visitors situated within 10 different LIAs.

Method

Participants and data collection timeline
Sampling was not utilized in this study due to the small size of the home visiting program in the state in which it was completed. All 27 eligible home visitors were invited to participate. Their characteristics are presented in Table 1. No incentives for participation were offered. All data collection procedures were approved by the authors’ institutional review board. Quantitative data were collected in December 2015 (Time 1) and July 2016 (Time 2). Qualitative interviews were completed in November-December 2015 (Time 1) and May-June 2016 (Time 2).

Home visitor characteristics.

Model
Variable n Nurse Family Partnership (NFP) n Parents as Teachers (PAT) n Early Head Start (EHS) Total N
Eligible Participants T1 6 16 5 27
Completed Survey at T1 6 10 4 20
Completed T1 Interview 6 16 5 27
Education Level T1
< Bachelor’s Degree 1 0 1 2
Bachelor’s Degree 5 8 2 15
Master’s Degree 0 2 1 3
Eligible Participants T2 5 15 3 23a
Completed Survey at T2 5 14 3 22
Completed T2 Interview 6 15 5 26
Education Level T2
< Bachelor’s Degree 1 2 0 3
Bachelor’s Degree 4 10 1 15
Master’s Degree 0 2 2 4
Note: a One home visitor who completed the interview at the second data collection point was no longer employed at the time the survey was administered for the second time. Two Time 2 interviews were completed in March 2016, shortly after two home visitors who had stopped working with MIECHV families between the first and the second data collection time points quit their jobs (the results of these two interviews are discussed together with all other interviews completed at Time 2).
Measures
The quantitative measurements of the key constructs were collected using the following instruments. All surveys were administered via an online survey platform (Qualtrics).

STS and burnout
STS and burnout were measured using the ProQOL scale (Stamm, 2010). The STS and Burnout subscales of the ProQOL include 10 items each with responses scored on a 5-point scale ranging from 1 = Never to 5 = Very often. Following the tool developer guide, the raw STS and burnout scores were converted to t-scores and coded following the tool-specific guidelines as low (less than or equal to 43), medium (between 44 and 56), or high (57 or above). The Cronbach’s alpha for the STS scale was 0.90 and for the Burnout scale it was 0.80.

Intention to quit
Intention to Quit was measured with a two-item scale from the organizational literature (Firth et al., 2004). The first item, using a 5-point scale ranging from 1 = Rarely or Never to 5 = Very often, asks, “How often do you think of leaving your present job?” The second item, using a 5-point scale ranging from 1 = Very unlikely to 5 = Very likely, asks, “How likely are you to look for a new job within the next year?” (Cronbach’s alpha = 0.86).

Reflective supervision
RS was measured using the Supervisory Working Alliance Inventory-Trainee (SWAI-T) (Efstation, Patton, & Kardash, 1990). It contains 19 items on two scales (Rapport [12 items] and Client Focus [7 items]) rated on a 7-point scale ranging from 1 = Almost never to 7 = Almost always. It includes items such as, “I feel comfortable working with my supervisor,” and “My supervisor helps me talk freely in our sessions.” Alpha reliability coefficients were 0.97 for the Rapport scale and 0.95 for the Client Focus scale.

Supervisor’s supportiveness
Perceived support from one’s supervisor was measured with a subscale of the Workplace Scale consisting of three items rated on a 5-point scale ranging from 0 = Not at all to 4 = Very much (Firth et al., 2004). It addresses the degree to which one’s supervisor goes out of her way to support the home visitor, the ease with which the home visitor can talk about job-related problems with her supervisor, and the level to which the home visitor can rely on her supervisor when things get tough at work (Cronbach’s alpha = 0.87).

Supportive work-life policies
Perceived supportive work-life policies was measured with a single item rated on a 5-point agreement scale (low to high), adopted from the Work-Life Support Index (Civian, Richman, Shannon, Sandee, & Brennan, 2008). This item asks whether an individual’s organization has policies that are supportive of personal family responsibilities.

Humor
Home visitors’ use of humor was measured with the Coping Humor Scale (Avolio, Howell, & Sosik, 1999) that consists of five items rated on a 4-point agreement scale (low to high). This scale includes self-descriptive statements such as “I often lose my sense of humor when I’m having problems” (Cronbach’s alpha = 0.79).

Perceived sense of humor of the supervisor was measured with a 5-item scale (Avolio et al., 1999), rated on a 4-point scale (0 = Not at all to 4 = Frequently, if not always). Items include queries about supervisor’s use of humor in stressful situation (Cronbach’s alpha = .90).

Length of time working with MIECHV families
Length of time home visitors spent working with MIECHV families at the time of survey completion was measured with a single open-ended item asking them to indicate the length of time working with MIECHV families.

Percentage of families with high or special needs
Percentage of families with high or special needs was measured with a single open-ended item asking home visitors to indicate what percentage of families on their current caseload were families with high or special needs.

Satisfaction with employment situation
Home visitors’ satisfaction with their employment circumstances was measured with four items rated on a 7-point satisfaction scale (low to high) developed by the researchers. These items measured their satisfaction with pay, caseload size, availability of resources, and the overall institutional culture at the workplace.

Interview protocol
The qualitative data were collected in in-depth semi-structured individual interviews (for interview protocol see Appendix A). Nearly all topics that were measured using the quantitative tools described above were also explored in individual interviews. Two primary topical categories that were explored in these interviews were: i) potential risk factors for STS, burnout, or both (including caseload size, geographic region, and percentage of families served with high or special needs), and ii) potential protective factors that may lower the risk of experiencing STS, burnout or both (including RS, perceived support from one’s supervisor, perceived supportive work-life policies, perceived job flexibility, use of humor by the home visitor, and perceived sense of humor of the supervisor, among others).

Data analysis
All quantitative data were entered into SPSS and subjected to simple statistical analysis to document the prevalence of the three key constructs and factors associated with each.

The qualitative data gathered through personal interviews were analyzed using the framework method of analysis (Gale, Heath, Cameron, Rashid, & Redwood, 2013). Once transcribed, each interview was organized and manually coded for preset and emerging themes by at least two members of the research team to increase analytical rigor. The coded data were then used to start mapping emerging patterns in home visitors’ experience of STS and burnout. Due to the small sample size, the research team determined that ascribing quotes to individual home visitors may compromise their anonymity. Thus, instead of creating a list of individual home visitors, assigning a pseudonym to each, and identifying which quote came from which home visitor, the researchers used the more general language such as “one home visitor.”

Results

Levels of STS, burnout, and turnover intentions
Preliminary analyses suggested no statistical differences between the Time 1 and Time 2 survey data, so we present them here in a combined fashion. Analyses of the survey data were undertaken to determine the levels of STS, burnout and intention to quit. Descriptive results are presented in Table 2. We also report, in Table 3, the percentages of home visitors who could be classified as having low, medium or high levels of STS and burnout, which indicate that more than two-thirds experienced either medium or high levels of STS (69.0%) and burnout (73.8%).

Levels of secondary traumatic stress, burnout, and intention to quit.

Construct M SD Range
Secondary Traumatic Stress 49.88a 10.00 41.00 (38.00 – 79.00)
Burnout 50.05a 9.87 41.00 (32.00 – 73.00)
Intention to quit 2.33b 1.37 4.00 (1.00 – 5.00)
Note: a scores reflected as t-scores. b Computed as the mean of two items, answered on a 5-point scale from 1 = very unlikely to 5 = very likely.
Percentage of participants with low, medium and high levels of secondary traumatic stress (STS) and burnout.

Level
Measure Low Medium High
STS 31.0 47.6 21.4
Burnout 26.2 40.5 33.3
When asked how often, if ever, they thought of leaving their present position, almost half of the home visitors selected rarely or never as their response (47.6%), with nearly 29.0% indicating having such thoughts occasionally (19.0%) or sometimes (9.5%). Just under one-quarter indicated thinking about leaving their present position fairly (14.3%) or very (9.5%) often. A majority (52.4%) of the home visitors reported being very unlikely (40.5%) or unlikely (11.9%) to look for a new job within the next year and approximately one-fifth expressed being likely (2.4%) or very likely (19.0%) to do so; the remaining respondents (26.2%) indicated being unsure about looking for a new job within the next year. On average, the home visitors expected to work six-and-a-half years for their present organization (ranging from zero to 35 years).

Factors associated with STS, burnout and turnover intentions
We examined whether factors related to the families, satisfaction with the workplace, the supervisor, and the home visitors themselves were associated with home visitors’ reports of STS, burnout, and intention to quit. Descriptive statistics and correlations for these variables are presented in Table 4. Results suggest that home visitors who had worked with MIECHV families for a longer length of time had higher levels of STS, burnout and intention to quit. Also negatively related to these outcomes were the home visitors’ satisfaction with pay and the institutional culture. The home visitors’ perceptions of their relationship with their supervisor, including the supervisor’s sense of humor, were also consistently related to STS, burnout and intention to quit.

Factors associated with home visitor’s secondary traumatic stress, burnout and intention to quit.

Construct M SD Correlation with Secondary Traumatic Stress Correlation with Burnout Correlation with Intention to Quit
Length of time working with MIECHV families 17.71 12.14 .58*** .56*** .35*
Satisfaction with caseload size 4.30 1.18 .07 .14 −.25
Percentage of families with high or special needs 62.29 27.32 .01 −.13 .14
Satisfaction with pay 4.27 1.45 −.44** −.39* −.50**
Satisfaction with availability of resources 5.24 1.40 −.30† −.29† −.14
Satisfaction with institutional culture 5.27 1.59 −.56** −.54** −.49**
Supervisory Working Alliance Inventory—Rapport 6.10 1.14 −.29† −.38* −.31*
Supervisory Working Alliance Inventory—Client Focus 5.66 1.34 −.33* −.40** −.32*
Supportive supervisor 3.56 .65 −.31* −.39* −.25
Supportive work policies 4.05 1.21 −.07 .12 .12
Home visitor’s use of humor 2.89 .27 .25 .13 .23
Perceived supervisor’s sense of humor 2.80 .81 −.46** −.50** −.11
Home visitor’s perceptions of risk factors
To address our third research question, we next turned to the qualitative interview data to examine what risk factors home visitors themselves identified in their daily work, and how they perceived these risk factors to relate to STS, burnout and intention to quit.

Risk factors associated with STS
In speaking of STS, home visitors often expressed having difficulties coping with so-called ‘normalized’ trauma, encountered frequently in their work with families. Many felt that some families accepted traumatic experiences as “just part of life,” internalizing them to such an extent that living in “this culture of abuse,” to borrow from one home visitor, simply became a part of their personal culture. Clearly struggling with accepting this notion, one home visitor stated:

I definitely have had some clients tell me some fairly traumatic things that have happened to them, kind of the sad part with some of the clients though is that to them it’s very nonchalant, like, “Oh yeah, I was abused.” or “Oh yeah my foster dad used to molest us.” Stuff like that to them is like, “Yeah, that just happens.”… And for us it’s kind of hard to think that to them that’s normal behavior. Or that my boyfriends used to hit me and that’s just how things were.

Accepting that some clients experienced emotional or physical abuse within their relationships as something that is “not a big deal” was difficult for many to process without being personally affected. One home visitor noted how “hard” it was to process “that people have to live with trauma,” thinking that “they’ve always had ‘normal’ relationships.” Several home visitors struggled connecting with or “reaching” families due to the severity of their traumas. Describing how challenging it was for her to witness what a young mother had to deal with on a regular basis, one home visitor verbalized her emotional struggle by explaining:

Sometimes I cry on the drive home. It’s hard that people have to live with that kind of trauma. They think they’ve always had ‘normal’ relationships or write things off as him being [of a particular cultural background] or just like their dads but really it is abuse. So that culture of abuse is hard.

In speaking of risk factors and STS, the home visitors’ inability to recognize changes in their own emotional and physical wellbeing stemming from their work emerged as a significant factor. As one home visitor explained, “I would be the type of person that would be the last to know that I was experiencing secondary trauma. I’m not really good at recognizing that in myself.”

Paralleling the survey results, several home visitors also discussed how their ability to process the trauma of the families was affected by the lack of adequate RS, an unsupportive supervisor who was unwilling or unable to acknowledge that the home visitor was experiencing vicarious trauma, or unhealthy work climate. Noting how she often felt isolated and unsupported by her supervisor, one home visitor described the effect the unhealthy work environment had on her, “I’m so tired of arguments, and I’m so tired of fighting. I just, and I rack my brain over how I contribute to it, what should I do, and I think, I’m just not gonna talk to anybody.”

The absence of adequate RS was noted as a risk factor by several home visitors, particularly those whose RS provider was also their administrative supervisor. They felt cautious about sharing any negative emotions they may experience in response to their work with high-need families because they feared that sharing such emotions in a RS session could spill over into their performance Assessment at the administrative level. It also became apparent that the RS sessions were not always fully utilized as intended (in some cases these sessions were used more for case management purposes, not as genuine reflection), which is most likely due to the fact that the person who was responsible for RS also acted as the administrative supervisor.

Risk factors associated with burnout
Because the home visitors frequently expressed a dichotomy between direct services and all other aspects of home visiting, the risk factors and stressors associated with burnout were grouped accordingly.

Risk factors associated with direct services
The risk factors named with some frequency included caseload size, family characteristics and lack of family buy-in and follow-through.

Contrary to expectations, very few home visitors felt that their caseload size was too large or overwhelming. In fact, the vast majority felt that it was just right, several noting that having a sufficiently large caseload size was good because it kept them busy. One home visitor even stated that she liked carrying a larger caseload because it kept her from thinking about other families. Overall, caseload size on its own was not perceived as a major risk factor; however, having a large caseload size with families with complex, high, or multiple needs was identified as something that could be emotionally taxing and lead to burnout. One home visitor elucidated:

I did have one family that had diagnosed mental illness. Kids weren’t hers, they were her fiancés who was still married to the ex-wife and there was a lot of “Oh, my gosh – you know, how do we deal with this?” Do you call this person mom? And so, that was the family where the kids went back to mom. So, she was just really hard to work with because there were people in and out of the house all the time, stealing things. Her husband was picking up people on the side of the road…bringing them to their house to live because they didn’t have anywhere to live… It was kind of scary for those kids…I would come back and go “what am I going to do? How do we change their perception of safety and what’s important?” So, that was kind of overwhelming.

The importance of having a healthy balance between high need and more functional families, especially if carrying a full caseload, was repeatedly stressed. The home visitors explained that high need families typically demand more time, resources, and creative thinking on the part of the home visitor while simultaneously trying to complete the planned activities.

Another major stressor associated with direct services that can lead to the experience of burnout among home visitors was the perceived lack of family buy-in and follow-through. Most home visitors discussed how working with families that lacked motivation to make changes in their lives and the lives of their children was very frustrating. In the words of one home visitor:

[T]hey kind of depend more on you as an educator to bring them up and raise them to, um, to raise their children correctly and to have those opportunities so I have some families that are not really interested in coming out of that situation and it’s kind of hard for me to pull them out if they don’t want to be pulled out. So some of the challenges are making sure that I’m providing all the tools that they need to survive or to become independent and some of the families that I have, it’s kind of hard because they’re not interested or they’re not, um, trying hard enough.

The home visitors frequently discussed how rewarding and satisfying it was to see progress in families. They felt that all their hard work was worthwhile if the families made even the smallest progress to better their lives and the lives of their children. Because this intrinsic reward appeared to be a major motivator for so many home visitors, having families who were showing little to no interest in bettering their lives was experienced as particularly demoralizing.

Risk factors associated with aspects of home visiting other than direct services
Most home visitors experienced providing direct services to families as the most enjoyable part of their work. While recognizing that their duties cannot be limited to direct services only, they often felt overwhelmed and burned out by other aspects of home visiting, including completing paperwork, attending meetings and trainings, and engaging in outreach and recruitment-related activities. One home visitor illustratively used the term “paperwork burnout” to explain how her experience of burnout was related to ancillary activities, and added, “but as far as working with the families, not so much.” Although most home visitors expressed a need for topic-specific training in areas related to mental health and domestic violence, among others, they were not happy about being required to attend meetings and trainings they did not perceive to be particularly useful.

Model-specific requirements, including collecting an overwhelming amount of data and completing the expected number of home visits, were experienced as unrealistic. The home visitors felt that funders and model developers placed more importance on form completion and data collection than meeting the needs of the families. As one home visitor explained:

I think another thing that I probably get conflicted with is the data. Are we helping the families or are we helping [funders’] research? Like, I’m conflicted between that sometimes, and [supervisor] always has to remind me, “If we want our money we have to help the research.” And I’m thinking if we don’t help the families the research isn’t gonna look good at all. It’s not gonna show improvement. So I’m just conflicted there.

A major risk factor identified by a number of the home visitors was related to several aspects of the work culture, including a sense of isolation expressed by members of home visiting teams housed within a larger organization, disconnect due to a lack of communication with upper management, and the supervisor’s lack of understanding of home visiting. In fact, two of the three home visitors who terminated their employment between the first and the second interview clearly articulated that they decided to leave because they felt unsupported, alienated, and generally misunderstood by both their direct supervisor and upper management.

Intention to quit
When asked what factors would lead them to consider quitting their job, the home visitors frequently discussed negative changes in work culture, unsupportive supervisors and co-workers, low pay, poor benefits including reduced flexibility, and compromised professional efficacy and interests. One home visitor detailed her experience with high-needs families and programmatic demands as a reason to contemplate quitting her job:

Yeah, um, sometimes it is really hard to come into work, and usually it’s on a week where my families have been really high need, or there’s been a lot going on just in the program in general. Um, but it never gets past the thinking stage or, ‘Oh God, why do I have to go to work today?’ stage.

Interestingly, whereas only two home visitors identified concerns about their caseload size becoming unmanageable as a hypothetical factor that might lead them to think about leaving their position, a number of home visitors reported that overwhelming ancillary activities such as planning and paperwork could lead them to consider quitting their job.

Home visitors’ perceptions of protective factors
Home visitors commented extensively on the factors that helped to mitigate the negative effects of working in a high stress profession. They emphasized the importance of having a supportive supervisor, which often included having opportunities for RS and the use of humor.

Supportive supervisor and RS
The home visitors strongly emphasized the importance of having a supportive supervisor with whom they can communicate openly without worrying whether what they say could lead to penalties, particularly in those programs in which the administrative supervisor and the RS provider were the same person. In situations in which the supervisor was able to create a work environment that felt comfortable, having the same person provide both types of supervision was not perceived as a concern (still most home visitors noted that having periodic RS with a neutral RS provider, preferably a mental health specialist, would be desired). One home visitor who reported experiencing burnout remarked:

The stresses with the clients are going to ebb and flow continually, but if I were to feel really supported and nurtured, that would help offset that. That makes a big difference on how you can handle that or not, whether you can just try to take care of yourself and feel like you’re taken care of here too, or whether you just reach a breaking point.

Conversely, those home visitors who reported feeling well supported by their supervisor and other coworkers were much more likely to report low levels of STS and burnout. Indeed, most home visitors came to appreciate the value of RS, when performed well, in allowing them to be more reflective in their work with the families, gaining a different perspective on a situation that initially seemed overwhelming, reducing feelings of isolation, and helping with processing their own emotions related to both professional and personal life. In the words of one home visitor:

I think [RS] is almost required to be able to work with the high needs clientele that we do work with…to have an ability to talk through the stuff that’s really stressful. Just like any other emotion. You bottle it up and it doesn’t work. If you bottle up what you’re stressed out about with a family, you end up not being as effective in dealing internally as well as with the family. Yeah, I definitely think it’s a requirement.

Although formal RS was mostly experienced as beneficial, the real value of reflective practices was experienced during informal reflective sessions with other members of the team (the RS provider, the administrative supervisor, or other home visitors), which typically occurred right after a difficult visit. Home visitors experienced these sessions as more valuable than the formal RS because they occurred more frequently and at times when they really needed them.

Supportive work-life policies
Supportive work-life policies named with some frequency included flexibility, “open door” policy, availability of work-related resources including a work phone, benefits, the ability to work part-time if desired, no-overtime policy, and sufficient time allowed to build up one’s caseload.

Flexibility was perhaps the most important work-life policy, particularly for those home visitors who had children themselves. Some even named this as one of the key reasons they stayed in their jobs in spite of poor pay and high level of stress. They appreciated the ability to flex their schedules, attend their children’s school events and doctor’s visits when needed, without experiencing penalties. Flexibility was offered by all LIAs, with an understanding that the home visitors could flex their schedules as long as their work performance did not suffer.

Generous benefits, including paid leave, personal days off, and sick leave were also important because they offered home visitors a sense of having adequate resources to maintain a healthy work-life balance. Some home visitors valued the ability to work less than full time, with a few considering leaving their jobs because of the inability to work part time. Some LIAs had a firm policy preventing home visitors from working overtime, a policy that may help minimize burnout caused by working evenings or weekends and spending too much time away from home.

Coping strategies and use of humor
In addition to these protective factors, the home visitors named several coping strategies and self-care tactics they used to manage the stress of working in the home visiting field including teaching oneself to compartmentalize, setting boundaries, using humor to deal with challenging situations, and using drive time to decompress.

Teaching oneself to compartmentalize was mentioned as a key coping strategy the home visitors used in response to recognizing that they were experiencing signs and symptoms of STS or burnout, such as withdrawing, not being fully present with family members, and engaging in unhealthy eating habits. One home visitor shared that she had to actually tell her work to stay at work in order not to take it home, “You stay here until tomorrow, I’m going home.” She explained how “saying that out loud and going home” made the burden feel “a little lighter.” Another coping strategy, setting boundaries, was something that a number of home visitors struggled with even though they fully recognized the importance of setting clear boundaries in managing stress. One home visitor noted that she was finally able to “take a step back and realize that anything [she does] for [the families] is better than what they were getting before.”

Many home visitors reported using humor as a coping strategy to relieve the stress of working with families with complex needs, with some explaining that it frequently came down to either crying or laughing. They also noted the importance of having a supervisor and coworkers who appreciate the use of humor to lighten a difficult situation. As one home visitor explained:

That is one of the fun things about this work environment, it is not always serious and if something does get serious, someone will all of a sudden flip something and make everyone laugh, it’s really fun to kind of break the tension that way.

Although they recognized the value of humor in dealing with stress, the home visitors also noted that the humor needs to be measured and apt especially when used in the presence of the clients.

Discussion
Research on home visitors suggests that turnover tends to be high (Gill et al., 2008; Lee et al., 2013; Wasik, 1993). STS incurred by working with traumatized families (Osofsky, 2009) and burnout from emotional exhaustion (e.g., Gill et al., 2007; Lee et al., 2013) are believed to be related to high turnover rates that have been observed in this field. In this exploratory study, we utilized a mixed methods approach to address four research questions related to home visitors’ levels of STS, burnout and intention to quit, the situational factors related to these outcomes, and the home visitors’ perceptions of risk and protective factors within their workplace.

Results of a survey administered to the state’s population of home visitors suggest that mean levels of STS and burnout were in the medium range. Overall prevalence rates show that more than two-thirds experienced either medium or high levels of STS and burnout. These results parallel those obtained in other studies conducted with professionals working in highly stressful jobs (e.g., Beck, 2011; Cornille & Meyers, 1999; Linzer et al., 2015). With such high levels of STS and burnout, it is surprising that the home visitors’ reports of intentions to quit were relatively low, with half of the home visitors reporting never or rarely thinking of leaving their job. Such a finding may speak to the protective factors, which may have helped to mitigate feelings of STS and burnout, a topic that we further explored in interviews with the participants.

Using data obtained through surveys, we were also able to explore how situational factors may impact home visitors’ well-being (e.g., Lee et al., 2013; Linzer et al., 2015). Results suggest that there are several key factors which may contribute to the home visitors’ feelings of STS and burnout. First, it appears that the longer the home visitors work with MIECHV families the more at risk for developing STS and burnout they are. This finding corresponds to those obtained in other research with home visitors, which suggest that length of time working as a home visitor is associated with higher emotional exhaustion and lower job satisfaction (Sukhdeep, Greenberg, Moon, & Margraf, 2008). Additional notable factors that may lead to the experience of STS, burnout, and ultimately desire to quit one’s job are unhealthy and insufficiently supportive institutional culture, including inadequate pay and benefits, and negative working alliance with one’s administrative supervisor and RS provider. In a recent study with Early Head Start workers, West and colleagues (2018) also observed that greater job withdrawal was associated with low satisfaction with benefits and perceived lack of supervisor’s concern with one’s safety. One unique aspect our study’s findings was the specific tie between the home visitors’ STS, burnout, and intention to quit and their perception of the alliance they have with their supervisor, suggesting that this relationship may be pivotal for understanding home visitors’ well-being.

Through qualitative interviews we explored two research questions, one related to home visitors’ perceptions of risk factors in their jobs that contribute to STS and burnout and the other related to factors they perceived to mitigate these risks. Few studies have specifically queried these areas with home visitors, thus making this a useful contribution to the literature.

Key findings from the interviews regarding risk factors and STS centered around home visitors’ inability to reconcile the “normalization” of trauma in the families they served, the level of trauma suffered by their clients, and an unhealthy work climate. These themes were consistent with the survey findings, but add depth to how they are understood. For example, home visitors who felt they could not openly communicate with their supervisor were more likely to “bottle” their emotions, which over time led to elevated stress levels, withdrawal, and at times even self-isolation. This was particularly problematic in those teams in which the RS provider was also the administrative supervisor. In such situations, the lack of trust on the part of the home visitors was linked to the concern that the supervisor could use what was disclosed during the reflective time for administrative purposes, potentially leading to negative performance Assessments.

Risk factors related to burnout fell within the domains of direct services and those related to the workplace and ancillary activities. Factors relate to direct services included lack of family buy-in and follow-through and family characteristics. Specifically, it was the mix of high/lower needs families on one’s caseload, not the number of families served per se, that was associated with the experience of burnout. When home visitors had relatively few high-need families, they found their caseloads manageable. However, having the combination of a large caseload with a large number of high-need families resulted in greater experience of burnout.

Risk factors characterized as not related to direct services included required paperwork and trainings and issues around work culture and unrealistic program expectations. Poor work culture was identified as a significant stressor that may directly lead to the experience of burnout or exacerbate the experience of burnout stemming from other stressors. Managing direct services and indirect activities was challenging enough; however, trying to achieve these duties in an unsupportive environment was associated with a greater likelihood of the experience of burnout.

The last research question addressed in the present study was how factors associated with workplace supportiveness, reflective supervision, and the use of humor may mitigate the negative effects of working in a high stress profession. As has been suggested in the discussion of risk factors, the situation of having a supportive workplace environment and supervisor was seen as paramount to mitigating the stresses of the job. Most home visitors appeared to feel comfortable conveying to their supervisors that they were starting to feel overwhelmed. To be able to effectively manage the inherent work stress, the home visitors needed to feel appropriately supported by the agency, be able to work fairly independently, have adequate pay and benefits, and be provided with clear policies about interaction with families. Although having a healthy dose of flexibility and independence was experienced as a protective factor, having too little structure (e.g., the absence of clear regulations prohibiting overtime and a lack of guidance on contact with clients outside of work hours) may quickly become a risk factor.

Having a supportive work environment was also closely related to several coping strategies that were instrumental to managing and mitigating the experiences of STS and burnout. These included learning how to effectively compartmentalize and set clear boundaries. Although some home visitors had prior experience with using these coping strategies, most expressed being thankful for having a supportive supervisor, who was able to recognize when they were struggling and either use humor to lighten the heavy emotional burden stemming from their work with families in need or help them realize that taking time off for self-care, setting clear boundaries, and compartmentalizing are strategies they should not feel guilty about using.

Study limitations and future directions
This research is considered to have a number of strengths; however, there are some limitations as well. These include its descriptive and exploratory nature and the relatively short duration of the project. Due to the state’s very small population of home visitors, the researchers were limited in their ability to conduct more sophisticated statistical analyses. However, gathering qualitative data from 27 home visitors is seen as a strength of the study, as qualitative data provide a depth and breadth that is unique for studies on home visitor stressors. In addition, the limited timeframe may have led us to underestimate levels of STS, burnout and intention to quit in this population. It may be that it takes longer than a year for STS and/or burnout to develop. These problems could not be overcome given the funding parameters of this project.

The knowledge obtained through this study can be used in future work to guide a larger investigation of how workplace culture and policies may relate to STS, burnout, and turnover. Specifically, it might be useful to model how STS and burnout may mediate interaction between length of time working with families, institutional culture, and pay and intention to quit one’s job, and identify points where additional supports or interventions could be most beneficial.

Conclusions and recommendations
In conclusion, some recommendations for “best practices” in terms of supporting home visitors and improving retention may be gleaned. First, the “culture” of home visitors’ workplace seemed extremely important to the participants in the study; those who perceived having a supportive and positive work culture reported on how valuable it was, and those who perceived having a non-supportive and negative work culture made clear how difficult it made their work and how unpleasant it made their lives. Therefore, striving for a healthy workplace culture seems highly important if LIAs wish to do their best to prevent turnover and offer the best quality services to the families enrolled in their programs.

In terms of RS, home visitors often noted that in order for RS to “work,” it needed to be done “well.” Specifically, RS sessions should not be “pushed” or repeatedly rescheduled. They should be provided in accordance with model regulations (or more frequently if needed), and should take place in a private location, free of other distractions. Sessions that occur for shorter periods (e.g., a half-hour) but more frequently (e.g., weekly) were often reported as being preferable to a single, longer monthly session, as they provided more opportunities for home visitors to reflect on situations that developed in their work with families in a timelier fashion. Additionally, a theme emerged suggesting that the reflective supervisor be different from the administrative supervisor or a mental health professional unassociated with the organization be made available to the home visitors on an as-needed or regular basis (e.g, every other month).

Finally, there should be a concerted effort to educate the home visitors about the purpose and value of the large amount of data they are required to collect. If the home visitors do not understand the value of the data, they may perceive it as an unnecessary and burdensome part of their job that only interferes with their ability to establish rapport with families they serve.

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Green, A. E., Albanese, B. J., Shapiro, N. M., & Aarons, G. A. ( 2014 ). The roles of individual and organizational factors in burnout among community-based mental health service providers. Psychological Services, 11, 41 – 49. doi: 10.1037/a0035299

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~~~~~~~~

By Sandina Begic; Jennifer M. Weaver and Theodore W. McDonald

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Result List Refine Search PrevResult 47 of 68 Next
Spirituality and religion as mitigating factors in compassion fatigue among trauma therapists in Romania.
Authors:
Newmeyer, Mark. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US, mnewmeyer@regent.edu
Keyes, Benjamin. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Palmer, Kamala. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Kent, Vanessa. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Spong, Sara. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Stephen, Faith. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Troy, Mary. Regent University, School of Psychology & Counseling, Virginia Beach, VA, US
Address:
Newmeyer, Mark, School of Psychology & Counseling, Regent University, Virginia Beach, VA, US, 23464, mnewmeyer@regent.edu
Source:
Journal of Psychology and Theology, Vol 44(2), Sum 2016. pp. 142-151.
NLM Title Abbreviation:
J Psychol Theol
Page Count:
10
Publisher:
US : University of Biola
Other Publishers:
US : Sage Publications
ISSN:
0091-6471 (Print)
2328-1162 (Electronic)
Language:
English
Keywords:
spirituality, religion, mitigating factors, compassion fatigue, trauma therapists
Abstract:
Emerging research suggests that, among trauma therapists, religiousness and spirituality may (a) buffer against compassion fatigue, secondary traumatic stress, and burnout and (b) bolster spiritual growth and compassion satisfaction (Newmeyer et al., 2014). Despite findings that indicate spirituality and religion are sources of hope for people coping with painful circumstances (Pargament, 2013), research investigating the role of religion and spirituality as a protective factor (Weaver, Flannelly, Garbarino, Figley, & Flannelly, 2003) or as potentially promoting wellness for trauma therapists is limited. This study (N = 46) replicated a previous finding in which trauma therapists who endorsed a strong spiritual orientation reported increased compassion satisfaction when engaged in short-term (1-2 weeks), cross-cultural trauma work. Additionally, these short-term trauma therapists were compared to equally trained professionals working in the same context for 2 to 5 months and 6 months to 1 year (intermediate and long-term trauma therapists, respectively). The self-report instruments evidenced statistically significant increases in secondary trauma in both the intermediate and long-term trauma therapists when compared with short-term therapists. An unanticipated effect of the short-term trauma therapists’ presence was revealed: On pre- and post-measures the long-term trauma therapists reported statistically significant increases in resilience. This implies that the presence of the short-term therapists was beneficial to the long-term therapists. Thus, ‘respite care’ for trauma therapists in long-term trauma settings might increase their capacity to thrive professionally. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Religion; *Spirituality; *Therapists; *Trauma; *Compassion Fatigue
PsycInfo Classification:
Impaired Professionals (3470)
Population:
Human
Male
Female
Location:
Romania
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Aged (65 yrs & older)
Tests & Measures:
Religious Commitment Inventory
Stress Vulnerability Scale
Symptoms Checklist- 45
Professional Quality of Life Scale – Compassion Satisfaction
Compassion Fatigue, Version 5
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Ego-Resiliency Scale DOI: 10.1037/t01072-000
Daily Spiritual Experience Scale DOI: 10.1037/t01587-000
Methodology:
Empirical Study; Followup Study; Quantitative Study
Format Covered:
Print
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20160808
Correction Date:
20180129
Copyright:
Rosemead School of Psychology, Biola University. 2016
Accession Number:
2016-28722-005
Number of Citations in Source:
36
Result List Refine Search PrevResult 48 of 68 Next
Countertransference, defense mechanisms, and vicarious trauma in work with sexual offenders.
Authors:
Barros, Alcina J. S.. Department of Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul/Brazil (UFRGS), Porte Alegre, Brazil, alcina.forense@gmail.com
Teche, Stefania P.. Hospital de Clinicas de Porto Alegre/HCPA, UFRGS, Porto Alegre, Brazil
Padoan, Carolina. UFRGS, Porto Alegre, Brazil
Laskoski, Pricilla. UFRGS, Porto Alegre, Brazil
Hauck, Simone. Department of Psychiatry and Legal Medicine, UFRGS, Porto Alegre, Brazil
Eizirik, Claudio L.. Department of Psychiatry and Legal Medicine, UFRGS, Porto Alegre, Brazil
Address:
Barros, Alcina J. S., alcina.forense@gmail.com
Source:
Journal of the American Academy of Psychiatry and the Law, Vol 48(3), Sep 1, 2020. pp. 302-314.
NLM Title Abbreviation:
J Am Acad Psychiatry Law
Page Count:
13
Publisher:
US : American Academy of Psychiatry & the Law
Other Journal Titles:
Bulletin of the American Academy of Psychiatry & the Law
ISSN:
1093-6793 (Print)
1943-3662 (Electronic)
Language:
English
Keywords:
forensic psychiatrists, psychologists, sexual offenders, countertransference, defense mechanisms
Abstract:
This study aimed to examine the associations between countertransference induced by sex offenders, defense mechanisms, and manifestations of vicarious trauma in forensic psychiatrists and psychologists. A cross-sectional study using a mixed-methods design was performed with 56 Brazilian forensic psychiatrists and psychologists from October 2016 to May 2017. Countertransference, defense mechanisms, and vicarious trauma were assessed with the Assessment of Countertransference Scale, the Defense Style Questionnaire-40, and the Trauma and Attachment Belief Scale (TABS), respectively. Qualitative data analysis based on grounded theory was also performed to explore the influence of sex-offender assessments on the experts’ personal and professional lives. Positive and moderate correlations were found between feelings of indifference and the Other-Safety TABS subscale (rho .43, P < .01) and between immature defense mechanisms and TABS total score (rho .45, P < .01). Qualitative data revealed changes in the professionals’ identity, worldview, and beliefs related to safety and trust. Specific maladaptive coping strategies, such as feelings of indifference and immature defenses, during the assessment of sex offenders were associated with manifestations of vicarious trauma in forensic psychiatrists and psychologists. These findings indicate the need for awareness and care about the forensic expert’s mental health. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Countertransference; *Defense Mechanisms; *Psychologists; *Sex Offenses; *Vicarious Experiences; Forensic Psychology; Psychiatrists; Trauma
Medical Subject Headings (MeSH):
Adult; Brazil; Compassion Fatigue; Countertransference; Criminals; Cross-Sectional Studies; Defense Mechanisms; Female; Forensic Psychiatry; Forensic Psychology; Humans; Male; Middle Aged; Psychotherapists; Qualitative Research; Sex Offenses
PsycInfo Classification:
Professional Psychological & Health Personnel Issues (3400)
Population:
Human
Male
Female
Location:
Brazil
Age Group:
Adulthood (18 yrs & older)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Trauma and Attachment Belief Scale
Defense Style Questionnaire–40 DOI: 10.1037/t20765-000
Assessment of Countertransference Scale DOI: 10.1037/t69195-000
Methodology:
Empirical Study; Interview; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: May 13, 2020
Release Date:
20211129
PMID:
32404359
Accession Number:
2020-80487-001
Number of Citations in Source:
67
Result List Refine Search PrevResult 49 of 68 Next
Examining the examiners: How medical death investigators describe suicidal, homicidal, and accidental death.
Authors:
Miner, Adam S., ORCID 0000-0002-5125-4735 . Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, Stanford, CA, US, miner.adam@gmail.com
Markowitz, David M., ORCID 0000-0002-7159-7014 . School of Journalism and Communication, University of Oregon, Eugene, OR, US
Peterson, Brian L.. Milwaukee County Medical Examiner’s Office, Milwaukee, WI, US
Weston, Benjamin W.. Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, US
Address:
Miner, Adam S., Department of Psychiatry and Behavioral Science, Stanford University School of Medicine Palo Alto, Palo Alto, CA, US, 94305, miner.adam@gmail.com
Source:
Health Communication, Vol 37(4), Apr, 2022. pp. 467-475.
NLM Title Abbreviation:
Health Commun
Page Count:
9
Publisher:
United Kingdom : Taylor & Francis
Other Publishers:
US : Lawrence Erlbaum
ISSN:
1041-0236 (Print)
1532-7027 (Electronic)
Language:
English
Keywords:
medical death investigators, suicidal death, homicidal death, accidental death
Abstract:
This study describes differences in medicolegal death investigators’ written descriptions for people who died by homicide, suicide, or accident. We evaluated 17 years of death descriptions from a midsized metropolitan midwestern county in the United States to assess how death investigators psychologically respond to different manners of death (N = 10,408 cases). Automated text analyses suggest investigators describe accidental deaths with more immediacy relative to homicides, while they also described suicidal deaths in less emotional terms than homicides as well. These data suggest medicolegal death investigators have different psychological reactions to circumstances and manners of death as indicated by their professional writing. Future research may surface context-specific psychological reactions to vicarious trauma that could inform the design or personalization of workplace-coping interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Death and Dying; *Homicide; *Suicide; *Written Communication; Accidents; Legal Processes; Medical Personnel; Personalization; Trauma; Vicarious Experiences; Text Analysis
PsycInfo Classification:
Health Psychology & Medicine (3360)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Grant Sponsorship:
Sponsor: National Institutes of Health, National Center for Advancing Translational Sciences, US
Grant Number: KL2TR001083; UL1TR001085
Other Details: Clinical and Translational Science Award
Recipients: No recipient indicated

Sponsor: Stanford HAI Seed Grant Program, US
Recipients: No recipient indicated
Methodology:
Empirical Study; Longitudinal Study; Retrospective Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20201207
Correction Date:
20220317
Copyright:
Taylor & Francis Group, LLC.. 2020
Digital Object Identifier:
http://dx.doi.org/10.1080/10410236.2020.1851862
PMID:
33950764
Accession Number:
2020-92910-001
Number of Citations in Source:
56
Result List Refine Search PrevResult 50 of 68
When the levees break: The cost of vicarious trauma, microaggressions and emotional labor for Black administrators and faculty engaging in race work at traditionally White institutions .
Authors:
Anthym, Myntha. University of Denver, Denver, CO, US
Tuitt, Franklin, ORCID 0000-0002-9650-5577 . University of Denver, Denver, CO, US, frank.tuitt@du.edu
Address:
Tuitt, Franklin, Morgridge College of Education, University of Denver, 2199 S University Blvd., Denver, CO, US, 80208, frank.tuitt@du.edu
Source:
International Journal of Qualitative Studies in Education, Vol 32(9), Oct, 2019. pp. 1072-1093.
NLM Title Abbreviation:
Int J Qual Stud Educ
Page Count:
22
Publisher:
United Kingdom : Taylor & Francis
ISSN:
0951-8398 (Print)
1366-5898 (Electronic)
Language:
English
Keywords:
Higher education administration, critical race methodology, racial trauma, emotional labor
Abstract:
The purpose of this article is to offer insight to administrators and human resource professionals at Traditionally White Institutions (TWIs) about developing action plans that provide meaningful support to Black administrators and faculty who are coping with racial trauma. Operationalizing tenets of Critical Race Methodology (CRM), the counter-narratives presented here are drawn from 15 years of unpublished professional and personal communication created by an individual Black faculty and administrator. The lectures, conference presentations, commencement addresses and other ephemera trace the development of battlements and emotional battle scars over the early years of one scholar-activist’s career at TWIs. The calamitous aftermath of Hurricane Katrina is considered in this context both as metaphor and collective psychic wound. As such, it illuminates other instances of vicarious trauma, foreshadows the Movement for Black Lives, and provides a devastating illustration of administrative unpreparedness. Revealing the ramifications of racial trauma can serve to help others who suffer to feel less alone and can provide stakeholders in higher education with valuable knowledge for the sake not only of recruitment and retention, but institutional transformation. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Educational Administration; *Educational Personnel; *Emotional Trauma; *Higher Education; *Racial and Ethnic Attitudes; Vicarious Experiences
PsycInfo Classification:
Educational Administration & Personnel (3510)
Population:
Human
Location:
US
Age Group:
Adulthood (18 yrs & older)
Methodology:
Empirical Study; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Jun 3, 2019; First Submitted: Jul 13, 2018
Release Date:
20200618
Copyright:
Informa UK Limited, trading as Taylor & Francis Group. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/09518398.2019.1645907
Accession Number:
2019-57406-002
Result List Refine Search PrevResult 51 of 68 Next
Teaching note—trauma-informed teaching in social work education.
Authors:
Sanders, Jane Elizabeth, ORCID 0000-0002-9039-5805 . Faculty of Social Work, University of Toronto, Toronto, ON, Canada, jane.sanders@mail.utoronto.ca
Address:
Sanders, Jane Elizabeth, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada, M5S 1V4, jane.sanders@mail.utoronto.ca
Source:
Journal of Social Work Education, Vol 57(1), Win 2021. pp. 197-204.
NLM Title Abbreviation:
J Soc Work Educ
Page Count:
8
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Journal of Education for Social Work
Other Publishers:
US : Council on Social Work Education
ISSN:
1043-7797 (Print)
2163-5811 (Electronic)
Language:
English
Keywords:
trauma, teaching, social work education, educational practices
Abstract:
The objective of this teaching note is to further discussion, application, and research on trauma-informed educational practices in social work. Trauma has a pervasive effect across social work service sectors. Both generalist and specialized education about trauma could reduce misinterpretation of coping strategies and retraumatization of vulnerable client groups. Educational practices should recognize the effect of trauma on social work students as well as clients to minimize the risk of vicarious trauma and retraumatization in education. This would foster learning for all students, including those from populations at increased risk for exposure to adversity. Further research is warranted to understand whether trauma-informed education can increase diversity in the profession and trauma knowledge in the field. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Social Casework; *Social Work Education; *Trauma; Risk Factors; School Learning; Social Services
PsycInfo Classification:
Professional Education & Training (3410)
Population:
Human
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20211021
Copyright:
Council on Social Work Education. 2019
Digital Object Identifier:
http://dx.doi.org/10.1080/10437797.2019.1661923
Accession Number:
2021-18077-018
Number of Citations in Source:
42
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Teaching Note—Trauma-Informed Teaching in Social Work Education
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✖
Contents
Trauma-informed care
Implications for social work education
Trauma exposure among social work students: Diversity in the profession
Neurology, emotions, the stress response, and learning
Recommendations for trauma-informed educational practices in social work
Conclusion
References
Full Text
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Introduction

The objective of this teaching note is to further discussion, application, and research on trauma-informed educational practices in social work. Trauma has a pervasive effect across social work service sectors. Both generalist and specialized education about trauma could reduce misinterpretation of coping strategies and retraumatization of vulnerable client groups. Educational practices should recognize the effect of trauma on social work students as well as clients to minimize the risk of vicarious trauma and retraumatization in education. This would foster learning for all students, including those from populations at increased risk for exposure to adversity. Further research is warranted to understand whether trauma-informed education can increase diversity in the profession and trauma knowledge in the field.

Exposure to adversity and traumatic experiences can have a profound effect socially, emotionally, and physiologically (Shonkoff & Garner, [38]). However, 25% of students have reported that they have worked with clients who have experienced trauma yet these students have not received formal trauma training (Adams & Riggs, [ 1]). Given the pervasive and damaging effect of psychological trauma, there are increasing calls for trauma-informed knowledge, skill, and care to become embedded in all social work settings, micro to macro, and across the age span (Levenson, [25]). Currently, education about trauma often occurs within specialty courses, whereas to increase capacity to work with clients exposed to trauma across service setting, education about trauma must be embedded across both generalist and advanced programs (Courtois & Gold, [10]; Vasquez & Boel-Studt, [41]; Wilkin & Hillock, [42]). This must be accomplished in ways that appreciate the significant effect of trauma, not only on our clients but on ourselves (Carello & Butler, [ 8]).

The purpose of this teaching note is to further discussion, application, and research on “trauma informed educational practices” (Carello & Butler, [ 9], p. 264). Within this article, trauma-informed care (TIC) is briefly outlined. The neurological basis of anxiety and stress and the effect on student learning is introduced. To facilitate the application of trauma-informed education, current TIC-informed recommendations for social work are reviewed. These include strategies to support education about trauma that recognize the risk of retraumatization, which in turn can foster learning for all students, including those at higher risk for adversity.

Trauma-informed care
TIC explicates the high prevalence of traumatic experiences among service seekers, as well as service providers (Fallot & Harris, [15]). TIC is a practice that can be instituted in any human service setting and strives to ensure that people affected by trauma are not further retraumatized by the psychosocial services they receive (Fallot & Harris, [15]). Across diverse sectors such as substance abuse services, homelessness, medical settings, education, and child welfare, there is a recognition of the significant effect on service provision of traumatic events and maltreatment histories (Greaves & Poole, [19]; McKenzie-Mohr, Coates, & McLeod, [29]). Moreover, TIC incorporates an awareness of the effect of intergenerational, historical, and racialized trauma (Greaves & Poole, [19]).

TIC stresses the importance of acknowledging and understanding the significant neurological, biological, psychological, spiritual, and social effect of trauma and violence (Fallot & Harris, [15]). TIC seeks to reframe maladaptive behaviors, such as anxiety, self-harm, suicide, substance abuse, anger, aggression, and mistrust as coping strategies common among those who have been exposed to traumatic events. TIC strives to ensure that practitioners are aware of the potential effect of such coping strategies in therapeutic settings and on therapeutic connection, as a lack of awareness can lead to compounding difficulties or misdiagnoses (Greaves & Poole, [19]). Service providers must have knowledge of trauma to ensure that settings, procedures, or treatments are not inadvertently retraumatizing. To be trauma informed does not require that professionals are trauma treatment practitioners or that they are explicitly aware of a trauma history for an individual, only that they work from a culture that understands trauma (Greaves & Poole, [19]). The possibility of trauma must be considered when working with individuals, children, or adults who are experiencing disruptions in daily functioning, even if trauma has not been confirmed (Fallot & Harris, [15]).

Implications for social work education
A trauma-informed approach to social work education would include information about the effect and processes involved in trauma and acknowledge that trauma exposure is likely to be high for service seekers and service providers, regardless of the population or presenting issue (Adams & Riggs, [ 1]; Miller, Green, Fettes, & Aarons, [31]). Courtois and Gold ([10]) recommended an integrated, inclusive approach across curriculum, which begins at the undergraduate level. Similarly, McKenzie-Mohr ([28]) reasoned that Bachelor of Social Work graduates are often working at the front line where service users are likely to have high rates of trauma exposure. Exposure to traumatic materials can shift someone’s worldview, disrupting established strategies used to make sense of the world, and challenge beliefs about the world being a fair place (Fallot & Harris, [15]). Students without trauma-specific training are at increased risk of vicarious trauma (Adams & Riggs, [ 1]). Being aware of countertransference and concerns related to vicarious traumatization is important for both therapist and client, informing intervention and enriching the therapeutic work (Pearlman & Mac Ian, [34]). A theoretical framework for trauma can provide important knowledge and context to understand not only the effect of trauma on clients but on one’s self (Cunningham, [11]). Generalist education on the social, emotional, and behavioral implications of significant trauma exposure could prepare practitioners to respond in empathic, nonjudgmental ways to behavior that would otherwise seem counterproductive or intentionally damaging to the therapeutic relationship. This trauma-informed education can then be augmented in graduate education for those who seek to specialize in trauma studies and services (Courtois & Gold, [10]).

It is fundamental that trauma-informed education incorporate an understanding of the effect of trauma on our students as well as our clients. Butler, Maguin, and Carello ([ 7]) defined retraumatization as “re-activations of negative feelings and memories from past negative events” (p. 9). Exposure to trauma-related material in class and practicum settings is a risk for secondary or retraumatization for students (Butler, Carello, & Maguin, [ 6]) and the risk increases for students who have experienced adversity in childhood (Butler et al., [ 7]).

Trauma exposure among social work students: Diversity in the profession
It is important to appreciate that rates of previous trauma exposure are likely to be higher among social work students than the general population. Butler et al. ([ 7]) conducted an online survey with 195 Master of Social Work (MSW) students at a large northeastern university in the United States (47.6% of those enrolled in the program, n=410). The study used a 10-item Adverse Childhood Experiences (ACE) Calculator (with the addition of two items to explore the prevalence of bullying or community violence) to assess the presence of adversity prior to the age of 18. These authors found that 77.8% of MSW students reported one or more ACEs and 31.3% reported four or more (Butler et al., [ 7]). Gilin and Kauffman ([17]) surveyed 162 MSW students at a university in the eastern United States through a self report survey using 10 ACE items and found 78.3% of students had one or more ACEs and 27.3% had four or more.

There are subpopulations at even greater risk of exposure to trauma or secondary trauma. Racialized populations, those with low income, and sexually diverse populations are at greater risk for adverse experiences (Merrick, Ford, Ports, & Guinn, [30]) and social work students of color are more likely to experience training-related retraumatization than non-Hispanic White students (Butler et al., [ 7]). A trauma-informed educational approach would support diversity and inclusion within the profession by minimizing the potential for retraumatization. Social work programs have a responsibility to provide a trauma-informed, inclusive, and supportive environment where all students have equal opportunity to be successful. There is an important connection between trauma and oppression, and social work education should be critically grounded and prepared to challenge oppressive structures (Shannon, Simmelink-McCleary, Im, Becher, & Crook-Lyon, [37]) for our clients and for ourselves. The field of trauma must continually work to ensure that trauma-informed strategies support culturally informed changes at the curricular, training, research, and institutional levels (Mattar, [27]). The number and diversity of social work students with exposure to trauma is likely to be significant, and so is the contribution they will make to their clients, the profession and society.

It is extremely important to note that despite high rates of early adversity among social work students, their arrival at higher-level education is a testament to their capacity and resilience. It is important to foster a positive view of social work and work with trauma. Conceptualizing vicarious resilience, compassion satisfaction, and posttraumatic growth are important in social work education (Hernández, Engstrom, & Gangsei, [20]). A strengths perspective would foster a sense of resiliency and capacity (Agllias, [ 2]). Many are intimidated at the prospect of supporting clients who have experienced significant adversity in their lives and the approaches taken in training should reinforce the resilience of clinicians and clients, to encourage and support social worker’s capacity and confidence in their ability to help those they are working with, and approach clinical work from a position of openness and positivity rather than avoidance and discomfort, which can inadvertently retraumatize clients. Research has found that despite high trauma exposure among social work students, both in terms of previous history and the effect of trauma material in course work, negative reactions can resolve through the duration of training, moving students toward compassion satisfaction (Shannon et al., [37]).

Neurology, emotions, the stress response, and learning
There is a complex relationship between trauma and neurology, with significant implications for emotion and learning. When emotional arousal is low the executive and emotional areas of the brain work together; however, when emotional arousal is high automatic responses override our conscious thinking (Armstrong, [ 3]). Our stress response, otherwise known as the fight, flight, or freeze response, is engaged at times of stress when the brain perceives a threat. This stress response precedes conscious Assessment of the threat and thought processes related to the threat, such as problem solving, are limited (Armstrong, [ 3]). The fight, flight, or freeze response engages to prepare physically to fight, run, or withdraw from danger, creating a strong emotional experience within an individual that is not easily ignored, drawing away our focus and depleting energy. For individuals with prior exposure to trauma, particularly early in life, this stress response can be more easily triggered (Van der Kolk, [40]). Prior exposure to adversity can have an influence on neurological development, effecting an individual in many ways including emotion regulation and memory (Egan, Neely-Barnes, & Combs-Orme, [14]), which can have a direct effect on learning.

Learners connect new information to past knowledge and experience. Neurological processes are informed by and inform the experience of emotions for an individual, the emotional state is directly related to neurological perceptions of threat, and the fight or flight response limits our ability to accesses problem solving, decision making, and conscious thinking. Emotions are triggered by perceptions of current, remembered, or imagined events that produce physiological changes in brain and body (Immordino-Yang & Damasio, [21]). While these processes can facilitate learning, such changes can also negatively effect focus and attention and in significant cases cause distress and difficulties with emotion regulation and behavior.

The role of stress and emotion in learning is not entirely clear. It is believed that improved learning and retention is achieved when stress is induced in close association with learning (de Kloet, Oitzl, & Joëls, [12]). However, when the levels of stress hormones are raised to a certain level, performance is impaired (Kim & Diamond, [23]). Additionally, it has been hypothesized that there should be consistency between the type of stress (e.g., physical or psychological) and the learning task, and the time of exposure to stress and the learning activity (e.g., significant stress before or considerably after the learning event detracts from learning) (Joëls, Pu, Wiegert, Oitzl, & Krugers, [22]). Chronic overactivity of stress responses, such as long exposure or uncontrollable stress, can impair learning (Joëls et al., [22]). Further, the stress response can block learning for a period of time following the stressful experience (Joëls et al., [22]).

Despite the complex relationship between stress and learning, there is a good deal of interest in learning strategies that raise stress levels and or elicit emotional responses. Some teaching strategies encourage the expression of strong emotions and elicit the expression of past traumatic experiences. Written emotional disclosure, or the Pennebaker paradigm (Pennebaker, [35]) has become a popular pedagogy across a number of disciplines. Studies have demonstrated positive benefit in writing about or revisiting painful experiences and emotions when the author is able to develop a new meaning or a new physiological response in relation to these events (Littrell, [26]). This requires active understanding of the need to rework the experience and a long-enough exposure for the stress response to subside (Littrell, [26]). Without this reworking, preexisting perspectives and coping strategies can be reinforced. The risk of reinforcement of avoidant strategies and distress is higher for those with a more significant clinical presentation (see Littrell, [26] for a review of the literature). Even within trauma treatment, full immersion into traumatic material is recognized as destabilizing and counterproductive (Gold, [18]; Knight, [24]). Engaging stress in a classroom has the potential for unanticipated consequences and the threshold for retraumatizing material varies between students, warranting careful consideration of its use.

A meta-analysis by Frattaroli ([16]) of studies on disclosure elicited during an experiment, such as the Pennebaker paradigm, found a general small positive effect. The effect was strongest when, among other things, studies did not involve a college student sample, disclosures happened at home, participants disclosed in a private setting, samples included more male participants, had fewer participants, paid the participants, had follow-up periods of less than one month, had at least three disclosure sessions, and had disclosure sessions that lasted at least 15 minutes. It is noteworthy that each of the criteria noted to improve benefit are not common practice in a classroom setting. Moreover, in the studies reviewed students were not graded on their trauma narratives, participation was voluntary, and they had the ability to withdraw at any point (Frattaroli, [16]).

Recommendations for trauma-informed educational practices in social work
Social work education has an important role in facilitating trauma knowledge across the profession through trauma-informed educational practices instituted throughout curricula and across levels of education. However, additional research is required to establish best practice guidelines for the broad integration of trauma knowledge that fosters an optimum learning environment for all students. An introduction to the current literature on trauma-informed education is presented to support educators and researchers in this task.

It is generally accepted that a certain amount of exposure to traumatic materials is necessary within a trauma course. Problem-based education provides opportunity to model TIC through case studies, role plays, and simulation (Shannon et al., [37]). There are many examples of trauma treatment–specific courses for social work and related disciplines (e.g., Agllias, [ 2]; Breckenridge & James, [ 5]; Newman, [33]; Strand, Abramovitz, Layne, Robinson, & Way, [39]). These courses identify that care and caution should be taken regarding exposure to trauma information.

There is some debate about the level of importance of exposure to traumatic material when teaching about trauma. Agllias ([ 2]) stated that it is important not to overly protect students, identifying that exposure in the classroom is vital preparation and allows reflection on the effect of traumatic material. Carello and Butler ([ 8]) asserted that transformation in an academic setting is not dependent on increasing the risk that students are exposed to potentially retraumatizing or vicariously traumatizing pedagogical practices. They stress careful consideration of the methods used to engage the topic of trauma, encouraging reducing rather than increasing the risk of retraumatization or secondary traumatization (Carello & Butler, [ 8], p. 155). Additional research is needed to inform social work educators when striking this importance balance in their teaching. Regardless of the amount or level of exposure to traumatic materials, students should be explicitly prepared for the effect of increased awareness of trauma on their own lives and the possibility that they may begin to recognize their own experiences as traumatic (Agllias, [ 2]).

Relational teaching is encouraged, where instructors are open and acknowledge their own struggles with stress and counter transference (e.g. Courtois & Gold, [10]; Shannon et al., [37]). Through a relational approach students experience an emotionally engaging, and supportive learning environment (Edwards & Richards, [13]). However, achieving safety in a classroom is not always possible, and instructors are encouraged to integrate a reflective practitioner paradigm to examine educational practices and issues as they come up in the classroom (Mishna & Bogo, [32]).

While there has been some debate about the use of trigger warnings in academic settings, many authors identify the benefit to students with a trauma history of providing information on course material that allows them to prepare for and control exposure to potentially distressing content (Boysen, [ 4]). Instructors should consider showing powerful videos with the lights on to minimize emotional flooding, providing detailed information on the video content to increase student sense of personal choice and control, and give explicit permission to leave the class if needing a break (Gilin & Kauffman, [17]). Additionally, instructors provide information for referrals to additional support services and consider incorporating this information into the syllabus, as well as professor contact information, as not all students are comfortable discussing concerns after class (Agllias, [ 2]).

Social work educators should consider teaching about secondary trauma early and regularly to normalize the effect of trauma on practitioners, and teach strategies to process emotions in the classroom (Agllias, [ 2]; Shannon, Simmelink-McCleary, Im, Becher, & Crook-Lyon, [36]). Trauma-informed practice includes developing the ability to manage emotions, distress, and functioning (Gold, [18]). Instructors can encourage students to maintain boundaries regarding trauma exposure by carefully selecting and pacing the amount of traumatic material in the class, establishing and maintaining group norms or ground rules for sharing, and monitoring how students are doing (Carello & Butler, [ 9]; Shannon et al., [36]). Pacing and diversifying activities and traumatic content can model for students protective practices of pacing their work where possible when in the field (Agllias, [ 2]).

Student disclosure should be discussed, helping students identify the possible effects and alternatives to self-disclosure in the class setting (Agllias, [ 2]). Self-care strategies can encompass physical, relational, and cognitive strategies and students should incorporate them into their learning about themselves and their work while still in training (Shannon et al., [36]). Agllias ([ 2]) incorporated a relaxed and informal approach when teaching about trauma, capitalizing on the body’s inability to be both relaxed and in the stress response mode at the same time, while incorporating self-care strategies. Self-care should be explicit within social work education and modeled by instructors. Students should have genuine options to not participate in specific learning activities, instructors should be aware of tendencies to interpret nonparticipation as difficulties with engagement or class preparation (Carello & Butler, [ 9]), and be prepared to support students when appropriate, ranging from alternate class activities to linkages to professional services. Carello and Butler ([ 9]) encouraged instructors to carefully consider the rationale for assignments or activities that require personal disclosure and whether the assignment can be adapted to foster appropriate personal and professional boundaries.

Carello and Butler ([ 8]) identified seven principals for educators, which include: prioritizing learning and student safety, recognizing the vulnerability of students with trauma histories, being prepared with referrals to additional services, understanding that trauma may effect performance even when trauma is not the focus of the class, becoming trauma informed, being aware of transference and countertransference and your own reactions to traumatic material, critically reviewing research, and checking assumptions that trauma is good or productive (pp. 163–164). Gilin and Kauffman ([17]) encouraged instructors to consider whether the implicit curriculum within the social work program is working from a trauma-informed framework, addressing self-care across the program, supporting stress management, and presenting the perspective that the effects of trauma on professionals are to be expected rather than a sign of impaired professionalism. It is again stressed that TIC is placed within a “culturally informed traumatology” that considers all levels of trauma education and training, curricular, training, research, and institutional levels to foster diversity, inclusivity, and trust (Mattar, [27], p. 263).

The above discussion is presented to support instructors when educating in a trauma-informed way. However, it is important to note that additional research in each of these areas is needed to develop best practice guidelines that foster an education that is inclusive, that recognizes the effect of trauma on student learning, that encourages self-awareness, that prepares students for work with clients who have experienced adversity, and that allows reflection on the effect of traumatic material and promotes self-care. Additionally, research is required that supports the development of trauma-informed options for field education as social work students recognize and learn to manage the effect of traumatic client material on them personally. This discussion is intended to encourage research and the application of trauma-informed education in generalist and specialized curricula that fosters capacity and confidence to work with trauma, teaches students to manage vicarious and secondary trauma reactions, and ultimately moves toward compassion satisfaction.

Conclusion
The pervasive effect of adversity across service sectors signifies the need to increase trauma-informed skill, knowledge, and care within social work. However, additional research is needed to determine whether trauma-informed educational practices within generalist and specialized curricula will increase the base of trauma-informed knowledge across the profession and maintain an optimum learning environment for all social work students while doing so. Trauma-informed education in social work has the potential to increase diversity in the profession and trauma skill and knowledge in the field.

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~~~~~~~~

By Jane Elizabeth Sanders

Reported by Author

Jane Elizabeth Sanders is with the Factor-Inwentash Faculty of Social Work at the University of Toronto.

Source: Journal of Social Work Education, 20211201, Vol. 57 Issue 1, p197, 8p
Item: 2021-18077-018

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Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients.Open Access
Authors:
Sodeke-Gregson, Ekundayo A.. Redbridge IAPT Service, Ilford, United Kingdom, ayo.sodeke-gregson@nhs.net
Holttum, Sue. Salomons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells, United Kingdom
Billings, Jo, ORCID 0000-0003-1238-2440 . Berkshire Traumatic Stress Service, Reading, United Kingdom
Address:
Sodeke-Gregson, Ekundayo A., Redbridge IAPT Service, Goodmayes Hospital, Barley Lane, Goodmayes, Ilford, United Kingdom, IG3 8XJ, ayo.sodeke-gregson@nhs.net
Source:
European Journal of Psychotraumatology, Vol 4(1), Dec, 2013. ArtID: 21869
NLM Title Abbreviation:
Eur J Psychotraumatol
Publisher:
Sweden : Co-Action Publishing
Other Publishers:
United Kingdom : Taylor & Francis
ISSN:
2000-8066 (Electronic)
Language:
English
Keywords:
Compassion satisfaction, burnout, secondary traumatic stress, Professional Quality of Life Scale, online questionnaire
Abstract:
Background: Therapists who work with trauma clients are impacted both positively and negatively. However, most studies have tended to focus on the negative impact of the work, the quantitative evidence has been inconsistent, and the research has primarily been conducted outside the United Kingdom. Objectives: This study aimed to assess the prevalence of, and identify predictor variables for, compassion satisfaction, burnout, and secondary traumatic stress in a group of UK therapists (N = 253) working with adult trauma clients. Method: An online questionnaire was developed which used The Professional Quality of Life Scale (Version 5) to assess compassion satisfaction, burnout, and secondary traumatic stress and collect demographics and other pertinent information. Results: Whilst the majority of therapists scored within the average range for compassion satisfaction and burnout, 70% of scores indicated that therapists were at high risk of secondary traumatic stress. Maturity, time spent engaging in research and development activities, a higher perceived supportiveness of management, and supervision predicted higher potential for compassion satisfaction. Youth and a lower perceived supportiveness of management predicted higher risk of burnout. A higher risk of secondary traumatic stress was predicted in therapists engaging in more individual supervision and self-care activities, as well as those who had a personal trauma history. Conclusions: UK therapists working with trauma clients are at high risk of being negatively impacted by their work, obtaining scores which suggest a risk of developing secondary traumatic stress. Of particular note was that exposure to trauma stories did not significantly predict secondary traumatic stress scores as suggested by theory. However, the negative impact of working with trauma clients was balanced by the potential for a positive outcome from trauma work as a majority indicated an average potential for compassion satisfaction. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Job Satisfaction; *Occupational Stress; *Quality of Care; *Therapists; *Compassion Fatigue; Sympathy; Trauma
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
United Kingdom
Age Group:
Adulthood (18 yrs & older)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Professional Quality of Life Scale-5
Coping Strategies Inventory
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Dec 30, 2013; Accepted: Nov 26, 2013; Revised: Oct 25, 2013; First Submitted: Jun 30, 2013
Release Date:
20210429
Copyright:
This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.. Ekundayo A. Sodeke-Gregson et al.. 2013
Digital Object Identifier:
http://dx.doi.org/10.3402/ejpt.v4i0.21869
Accession Number:
2020-77103-001
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Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients.
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✖
Contents
Compassion satisfaction
Compassion fatigue
Protective and risk factors
Objectives
Method
Participants
Measures
Independent measures
Coping Strategies Inventory
Dependent measure
The Professional Quality of Life Scale, Version 5
Procedure
Statistical analyses
Results
Prevalence of CS, burnout, and STS amongst therapists
Predictors for CS, burnout, and STS
Predictors for CS
Predictors for burnout
Predictors for STS
Discussion
Contextual issues
Methodological issues
Implications for clinical settings
Conclusions
Conflict of interest and funding
Footnotes
References
Full Text
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Therapists who work with trauma clients are impacted both positively and negatively. However, most studies have tended to focus on the negative impact of the work, the quantitative evidence has been inconsistent, and the research has primarily been conducted outside the United Kingdom. This study aimed to assess the prevalence of, and identify predictor variables for, compassion satisfaction, burnout, and secondary traumatic stress in a group of UK therapists (N=253) working with adult trauma clients. An online questionnaire was developed which used The Professional Quality of Life Scale (Version 5) to assess compassion satisfaction, burnout, and secondary traumatic stress and collect demographics and other pertinent information. Whilst the majority of therapists scored within the average range for compassion satisfaction and burnout, 70% of scores indicated that therapists were at high risk of secondary traumatic stress. Maturity, time spent engaging in research and development activities, a higher perceived supportiveness of management, and supervision predicted higher potential for compassion satisfaction. Youth and a lower perceived supportiveness of management predicted higher risk of burnout. A higher risk of secondary traumatic stress was predicted in therapists engaging in more individual supervision and self-care activities, as well as those who had a personal trauma history. UK therapists working with trauma clients are at high risk of being negatively impacted by their work, obtaining scores which suggest a risk of developing secondary traumatic stress. Of particular note was that exposure to trauma stories did not significantly predict secondary traumatic stress scores as suggested by theory. However, the negative impact of working with trauma clients was balanced by the potential for a positive outcome from trauma work as a majority indicated an average potential for compassion satisfaction.

Keywords: burnout; secondary traumatic stress; Professional Quality of Life Scale; online questionnaire; Compassion satisfaction

It is widely recognised that engaging in trauma work may impact therapists (Figley, [20], [21]). Whilst some therapists report feelings of well-being from working with trauma clients, the American Psychiatric Association (APA) acknowledges that it is possible to become traumatised indirectly by “learning about unexpected or violent death, serious harm, or threat of death or injury experienced” by another person ([ 2], p. 463). Two theoretical concepts have been put forward to describe therapists’ experiences: compassion satisfaction (CS) and compassion fatigue (CF).

Compassion satisfaction
A growing body of literature documents the positive effects of working with trauma. Larsen and Stamm ([26]) proposed CS to be “the sense of fulfilment or pleasure that therapists derive from doing their work well” (p. 282). CS is made up of three elements: ( 1) the level of satisfaction that a person derives from their job; ( 2) how well a person feels they are doing in their job, related to the levels of competency and control that therapists feel they have over the traumatic material they are exposed to; and ( 3) the level of positive collegiate support that a person has, with aspects of structural and functional social support being particularly important (Stamm, [39]). Researchers have reported a high potential for CS in mental health professionals in the United States (Conrad & Kellar-Guenther, [13]), in Ireland (Collins & Long, [12]), and amongst interpreters and therapists working at the Treatment Center for Torture Victims in Berlin (Birck, [ 6]). Additionally, these positive experiences have also been supported by qualitative research (Arnold, Calhoun, Tedeschi, & Cann, [ 3]; Steed & Downing, [41]).

Compassion fatigue
The most commonly used terms to describe the negative consequences of working with trauma clients are CF, secondary traumatic stress (STS), vicarious traumatisation (VT), and burnout. A therapist suffering from CF may experience symptoms such as re-experiencing their client’s traumatic event, avoidance, or anxiety. CF is believed to develop through prolonged exposure to clients’ traumatic material.

STS is believed to be an acute reaction that develops suddenly, and symptoms are nearly identical to those of clients suffering from posttraumatic stress disorder. VT, however, focuses on the disrupted frame of reference which may permanently impact therapists’ beliefs about others and their “sense of self, world view, spirituality, affect tolerance, interpersonal relationships, and imagery system of memory” (Pearlman, [30], p. 52). VT is believed to develop through working with several clients over time.

Burnout, unlike the other concepts, is not specifically limited to those working with trauma clients, but is more a reaction to the demands of one’s job and environment. It is “a state of physical, emotional, and mental exhaustion caused by long term involvement in emotionally demanding situations” (Pines & Aronson, [33], p. 9).

Despite some nuances, these concepts are often used interchangeably in the literature. Adams, Boscarino, and Figley ([ 1]) propose that CF is a broad concept which encompasses STS, VT, and burnout as latent clinical features. Alternatively, Stamm ([39], [40]) argues that CF is made up of STS and burnout, so it is evident that some key researchers believe that there are overlaps between these concepts but that CF is believed to be an over-arching concept.

In summary, therapists suffering from CF are hypothesised to experience posttraumatic stress disorder (PTSD) symptoms, disruptions to their cognitive schemas, relational difficulties, as well as physical, emotional, or behavioural distress symptoms. These experiences are believed to affect therapists’ personal and professional relationships and also impact their ability to effectively work with clients (Collins & Long, [12]). To date, research studies provide mixed support for these hypothesised symptoms in therapists working with trauma clients. For example, whilst severe PTSD symptomology has been reported in some therapists (Chrestman, [10]; Kassam-Adams, [25]), milder or subclinical levels have also been observed (Brady, Guy, Poelstra, & Brokaw, [ 8]; Follette, Polusny, & Milbeck, 1994; Kadambi & Truscott, [24]). Although some studies have documented cognitive disruptions in US therapists (Pearlman & Mac Ian, [31]; Schauben & Frazier, [36]), these have not been replicated by studies in Holland (van Minnen & Keijsers, [42]) and Canada (Kadambi & Truscott, [24]).

Protective and risk factors
The impact of trauma work appears to vary between individuals, and possible protective and risk factors have been examined. Investigated therapist variables have included age, gender, and engagement in personal therapy, but studies have produced inconsistent findings. For example, whilst some studies have reported that therapists with a personal trauma history experienced higher levels of distress (Kassam-Adams, [25]; Pearlman & Mac Ian, [31]), this finding has not been universally replicated (Schauben & Frazier, [36]).

A mixed picture has also emerged when investigating work-related variables like clinical experience and size of caseload. As exposure to trauma is a prerequisite for CF, one would expect there to be a relationship between these two variables. This has been confirmed by some research which has reported that the percentage of trauma clients on therapists’ caseloads was related to PTSD symptoms (Chrestman, [10]; Kassam-Adams, [25]), burnout, and CF (Craig & Sprang, [14]). Surprisingly, others have not found this hypothesised relationship (Devilly, Wright, Varker, 2009; Meyers & Cornille, [28]; Schauben & Frazier, [36]), and some have found that those seeing more trauma clients reported less distress (Baird & Jenkins, [ 4]).

Examined organisational factors include the provision of supervision, perceived workplace support, provision of trauma-specific training, urban versus rural workplace setting, remuneration, and working for public versus private organisations. Research findings in these areas are also inconclusive. For example, whilst Pearlman and Mac Ian ([31]) reported that therapists not receiving supervision showed more cognitive disruptions, others have found that the amount of supervision received was not related to the experience of traumatic stress or PTSD symptoms (Kassam-Adams, [25]; Meldrum, King, & Spooner, 2002).

Whilst it is possible that these inconsistent findings may be due to the variety of different scales being used to measure therapists’ experiences and the research being carried out on differing self-selecting groups, there is, as yet, no clear picture of the variables which are associated with, or most likely to predict, CF. In fact, a systematic review of the empirical evidence supporting CF, STS, and VT concluded that the quantitative evidence for these concepts was “meagre and inconsistent, relying on small and variable correlations between symptomatic distress and trauma exposure” (Sabin-Farrell & Turpin, [35], p. 467). Additionally, the majority of research continues to focus on the deleterious effects of trauma work, which has led to a dearth in research on its positive impact and the factors that might promote positive experiences in therapists.

Much of the published research has been carried out in the United States, where, until recently, there was no provision of universal healthcare and where supervision requirements for therapists differ from those in the United Kingdom. With limited research published in the United Kingdom, the question still remains as to whether and to what extent these concepts are contextually valid for UK therapists working with trauma clients.

Objectives
The objectives for this exploratory study were to:

investigate the reported levels of CS and CF in a national sample of UK therapists working with trauma clients in specialist trauma and secondary-care services (or similar).
examine which variables most strongly predict CS and CF.
Method

Participants
Therapists working for the UK National Health Service in 50 participating trusts or registered with one or more national professional psychological bodies responded to an online questionnaire between June 2010 and January 2011. All were engaged in trauma work with working-age adults.

Three hundred and forty therapists were recruited. However, 87 questionnaires were excluded from further analysis as therapists either identified themselves as working with children (n=4) or with older adults (n=1), or dropped out before the end of the questionnaire (n=82). Participants were 253 therapists (182 women and 71 men), with 64.5% aged between 30 and 49 years. They either worked in specialist trauma services (22.5%) or secondary-care services (62.5%), or identified themselves as working in “other services” (15%), which included specialist and tertiary services, primary care, private practice, and public or voluntary services. The majority of therapists were clinical or counselling psychologists (69.6%); many had a doctoral qualification (39.1%), over half had worked for less than 10 years (56.2%), and over half identified themselves as having a personal history of trauma (59.3%). The predominant therapeutic approach reported was cognitive-behavioural therapy (CBT) (39.1%), and a large group had had more than a week’s trauma-specific training since qualification (47.4%). The majority worked part-time (64%) and had between one and nine trauma clients on their current caseload (65.2%).

Measures

Independent measures
Demographic and background information questionnaire

In addition to demographics, information was sought about therapists’ work setting, core profession, qualifications, caseloads, primary therapeutic modality, trauma training, supervision, perceptions of organisational support, and personal history of trauma.

Coping Strategies Inventory
Therapists’ coping strategies were assessed using the two-part Coping Strategies Inventory (CSI; Bober, Regehr, & Zhou, [ 7]), comprising beliefs and time. The CSI-Beliefs scale explores which coping strategies therapists believe will reduce secondary stress and results in three subscales: leisure, self-care, and supervision which have reported internal reliability coefficients of 0.71–0.82. The CSI-Time scale, which examines the time that therapists spend engaging in activities, results in four subscales: leisure, self-care, supervision, and research and development (R&D), with reported internal reliability coefficients of 0.67–0.80.

Dependent measure

The Professional Quality of Life Scale, Version 5
The Professional Quality of Life Scale (ProQOL; Stamm, [40]) is a 30-item scale which measures the positive and negative effects experienced by those who choose to help others experiencing suffering and trauma. It is made up of three subscales: CS, CF, and burnout.

The ProQOL asks respondents to rate how frequently they experienced certain feelings in relation to their work with clients in the last 30 days. An example item of CS is “I believe I can make a difference through my work.” An example burnout item is “I feel overwhelmed because my case/workload seems endless,” and a STS item is “I avoid certain activities or situations because they remind me of frightening experiences of the clients I help.” Items are rated on a 6-point scale (which includes 0=never, 3=somewhat, and 5=very often). The alpha reliabilities for the scales have good to excellent reliability (CS α=0.88 [n=1,130]; Burnout α=0.75 [n=976]; CF α=0.81 [n=1,135]).

Procedure
Ethics approval was gained from the Central London REC 3 Research Ethics Committee. Potential participants were informed about the study by receiving an email from either a Trust representative or their professional body, by e-bulletins from their professional body, on professional body research notice boards, or by being emailed directly.

The email received by all potential participants introduced the study and contained a link to the homepage of the online questionnaire which included additional information about the study and consent information. Once therapists consented to take part in the study by checking the consent box, they were directed to the anonymous online questionnaire which took approximately 10–15 minutes to complete.

Statistical analyses
A power calculation of required participants was made prior to recruitment. Based on achieving a medium effect size (R2=0.13) (as used in Devilly, et al., [16]), with a statistical power of 0.8 (as recommended by Cohen, [11]), and considering the inclusion of up to 12 predictor variables into the planned multiple regressions, we aimed to recruit between 120 and 150 participants. Two-tailed tests were used with a significance value of 0.05. Analyses were conducted using SPSS 17.0 (for Windows 2001).

Results

Prevalence of CS, burnout, and STS amongst therapists
Participants’ scores were calculated and categorised into the cut-offs for low, average, and high levels of CS, burnout, and STS in accordance with Stamm’s ([40]) guidelines (Table 1). Whilst the majority of the therapists scored within the average range for CS and burnout, 70% of the therapists’ scores indicated that they were at high risk of STS, with no therapists scoring low on STS.

Table 1 Number of therapists at low, average, and high risk of CS, burnout, and STS (N=253)

Compassion satisfaction Burnout Secondary traumatic stress
Low 20 (8%) 25 (9.9%) 0 (0%)
Average 135 (53.2%) 163 (64.2%) 76 (30%)
High 98 (38.8%) 65 (25.8%) 177 (70%)
Predictors for CS, burnout, and STS
Due to the large number of variables and the exploratory nature of the study, it was decided that only those variables that significantly correlated with CS, burnout, and STS would be entered into the multiple regressions. Therefore, Pearson correlations and point-biserial correlations were performed to identify these variables (Table 2). None of the correlations between the independent variables were above r=0.649. CS was negatively correlated with both burnout (r=−0.697, p<0.001) and STS (r=−0.189, p<0.003), whilst burnout was positively correlated with STS (r=0.454, p<0.001).

Table 2 Correlations between CS, burnout, and STS and independent predictor variables

Compassion satisfaction Burnout Secondary traumatic stress
Service setting −0.024 0.008 −0.116
Age 0.265** −0.200** −0.043
Gender −0.039 0.060 0.102
Highest qualification 0.181** −0.157* 0.051
Number of years post qualification 0.151* −0.120 −0.135*
Core profession 0.110 −0.095 −0.070
Number of sessions 0.029 −0.035 −0.092
Number of clients on caseload 0.061 0.013 −0.054
Number of trauma-focused clients on caseload 0.119 −0.027 0.120
Predominate therapeutic approach −0.042 0.027 0.145*
Hours of individual supervision per month 0.031 −0.006 0.187**
Hours of group supervision per month −0.029 0.006 0.035
Hours of peer supervision per month 0.027 0.034 −0.003
Hours of consultant supervision per month 0.060 −0.039 0.123
Days of trauma-specific training during main training course 0.011 −0.070 0.118
Days of trauma-specific training since qualification 0.201** −0.155* −0.054
Personal trauma history −0.058 0.017 −0.139*
CSI-Beliefs: leisure 0.171** −0.145* 0.046
CSI-Beliefs: self-care 0.123 −0.099 0.050
CSI-Beliefs: supervision 0.153* −0.189** 0.013
CSI-Time: leisure 0.048 −0.094 −0.047
CSI-Time: self-care 0.216** −0.173** 0.172**
CSI-Time: supervision 0.196** −0.204** 0.115
CSI-Time: R&D 0.282** −0.192** 0.063
Perceived support by management 0.214** −0.328** −0.111
Perceived support by administrative staff 0.102 −0.113 0.063
Perceived support by peers 0.075 −0.155* −0.057
Perceived support of supervision 0.254** −0.249** 0.063
ProQOL—compassion satisfaction 1 −0.697** −0.189**
ProQOL—burnout 1 0.454**
ProQOL—secondary traumatic stress 1
1 Note: *p<0.05; **p<0.01. Significant correlations shown in bold. CSI=Coping Strategies Inventory; ProQOL=The Professional Quality of Life Scale.

Three simultaneous method multiple regressions were run, one for each of the dependent variables. All variance inflation factors were below 10, tolerance statistics were above 0.2, and casewise diagnostics were reviewed and within accepted parameters as recommended by Field ([19]).

Predictors for CS
A significant model emerged: F (11,220)=5.825, p<0.001, explaining 22.6% of the variance (R2=0.226) (Table 3). Age, time spent engaging in R&D activities, perceived management support, and perceived supervision support were significant positive predictors of CS. This indicated that older therapists had higher potential for CS. Additionally, the more time that therapists spent in R&D activities (i.e., away from therapeutic work), the higher the potential for CS. As therapists’ perceived level of support from management and supervision increased, so did their potential for CS.

Table 3 Regression model for variables predicting CS (n=232)

B SE B β t p
Constant 35.19 3.54
Age 0.80 0.34 0.21 2.39 0.02*
Highest qualification 1.67 1.02 0.11 1.64 0.10
Years of clinical experience 0.38 0.44 −0.07 −0.84 0.40
Trauma training post qualification 0.14 0.25 0.04 0.57 0.58
CSI-Beliefs: leisure 1.51 0.83 0.12 1.82 0.07
CSI-Beliefs: supervision −1.15 0.89 −0.10 −1.30 0.19
CSI-Time: self-care 1.06 0.73 0.11 1.46 0.15
CSI-Time: supervision −2.9 1.17 −0.02 −0.25 0.80
CSI-Time: R&D 1.81 8.2 0.17 2.21 0.03*
Perceived management support 0.84 0.38 0.14 2.22 0.03*
Perceived supervision support 1.31 0.56 0.17 2.34 0.02*
2 R2=0.226 (p<0.001). *p<0.05. Adjusted R2=0.187. CSI=Coping Strategies Inventory.

Predictors for burnout
A significant model emerged: F (10,226)=7.243, p<0.001, which explained 24.3% of the variance (R2=0.244) (Table 4). Perceived management support and age were significant negative predictors of burnout. Being older appeared to be a protective factor against burnout. Additionally, as therapists’ perceptions of management support increased, this was related to a decreased risk of burnout.

Table 4 Regression model for variables predicting burnout (n=237)

B SE B β t p
Constant 69.59 3.31
Age −0.53 0.26 −0.15 −2.05 0.04*
Highest qualification −1.21 0.94 −0.08 −1.29 0.20
Trauma training post qualification −0.09 0.23 −0.03 −0.39 0.70
CSI-Beliefs: leisure −0.81 0.77 −0.07 −1.05 0.30
CSI-Beliefs: supervision 0.82 0.83 0.07 0.99 0.32
CSI-Time: self-care −0.91 0.67 −0.10 −1.36 0.18
CSI-Time: supervision −0.53 1.07 −0.04 −0.49 0.62
CSI-Time: R&D −0.53 0.75 −0.05 −0.71 0.48
Perceived management support −1.59 0.36 −0.29 −4.39 0.001**
Perceived peer support −0.26 0.51 −0.04 −0.52 0.61
Perceived supervision support −1.00 0.54 −0.14 −1.86 0.06
3 R2=0.244 (p<0.001). *p<0.05; **p<0.001. Adjusted R2=0.206. CSI=Coping Strategies Inventory.

Predictors for STS
A significant model emerged: F ( 5,239)=5.286, p<0.001 which accounted for 10.0% of the variance (R2=0.100) (Table 5). Time spent in individual supervision and time spent engaged in self-care were significant positive predictors for STS. Therefore, those therapists who spent more time both in supervision and in self-care activities were at higher risk of STS. Additionally, those therapists that had experienced a traumatic event themselves were at higher risk of STS.

Table 5 Regression model for variables predicting STS (n=245)

B SE B β t P
Constant 60.01 2.67
Years of clinical experience −0.63 0.36 −0.12 −1.75 0.08
Therapeutic model 1.55 0.92 0.10 1.68 0.10
Time spent in individual supervision 1.53 0.75 0.14 2.06 0.04*
Personal trauma history −2.04 0.96 −0.14 −2.12 0.04*
CSI-Time: self-care 1.22 0.60 0.13 2.03 0.04*
4 R2=0.100 (p<0.001). *p<0.05. Adjusted R2=0.081. CSI=Coping Strategies Inventory.

Discussion
This exploratory study aimed to investigate indicators of the prevalence of both positive and negative experiences associated with working with trauma clients for therapists in the United Kingdom. Whilst the majority of therapists reported average potential for CS and average risk of burnout, 70% of therapists had scores that suggested they were at high risk of STS. Higher risks of burnout were associated with higher risks of STS, and they were both associated with a lower potential for CS. Maturity, time spent engaging in R&D activities, and a higher perceived supportiveness of management and their supervision predicted higher potential for CS in therapists. Conversely, youth and a low perceived supportiveness of management were risk factors for burnout. Therapists who spent more time engaged in individual supervision and self-care activities, and who had a personal history of trauma, reported higher risks of STS.

Past studies have used a range of different outcome measures to study these concepts, making direct comparison of prevalence rates difficult. However, the ProQOL-III (an earlier version of the outcome measure used in the present study) was used by Craig and Sprang ([14]) with self-identified trauma specialists in the United States. Whereas they found that only 5% of their 508 therapists were at high risk of burnout and STS, the present study’s findings were drastically different, with 25.8% at high risk of burnout and 70% at high risk of STS. For CS, 53.2% of therapists in the present study had an average potential for CS, whilst 38.8% had high potential for CS. Whilst lower than Craig and Sprang’s ([14]) study, which reported that 46% of their therapists scored high in CS, this is encouraging as it indicates that a large number of therapists enjoy their work with trauma clients and adds to the growing research evidence suggesting there may be a positive impact of trauma work for therapists.

The proportion of therapists at high risk of burnout and STS was much higher in this study than in other studies utilising different measures (Birck, [ 6]; Kassam-Adams, [25]; Meldrum et al., [27]; Meyers & Cornille, [28]; Wee & Myers, [43]). The reason for the higher level of burnout and STS in UK therapists is not immediately apparent. Participants in the present study were similar to those in Craig and Sprang’s ([14]) sample, although other authors have surveyed mental health professionals who may not actively engage in therapy with clients. Craig and Sprang ([14]) surveyed those who identified themselves as having some expertise in trauma treatment, 44.3% of their sample being psychologists and 46.3% from a social work background. In the present study, only 2% of the sample came from a social work background, with the majority (69.6%) being either clinical or counselling psychologists. More research is needed to ascertain what impact different professional training may have on levels of CS, burnout, and STS.

As with Craig and Sprang ([14]), the present study found youth to be a risk factor for burnout. In addition, older therapists reported higher potential for CS. Therapists in the present study were younger than those of Craig and Sprang ([14]), so this may account for the lower levels of CS and higher levels of burnout reported in this study. Other researchers have found that years of clinical experience predicted higher potential for CS (Craig & Sprang, [14]), lower levels of cognitive disruptions (Pearlman & Mac Ian, [31]), lower levels of avoidance, dissociation, anxiety (Chrestman, [10]), and higher levels of emotional exhaustion (Baird & Jenkins, [ 4]). As clinical experience did not significantly predict CS, burnout, or STS in the present research, it appears that maturity and life experience, as opposed to clinical experience per se, were more important in predicting CS and burnout in our sample. It may be that these older clinicians have remained in the field as they have found a way of coping with the demands of trauma work.

Interestingly, perceived supportiveness of supervision as opposed to the provision of supervision predicted a higher potential for CS which may suggest that the quality of supervision was more important than the quantity. In stark contrast with previous research, the more individual supervision therapists were receiving, the higher their risk of STS. It may be that those therapists who were in distress actively sought out more supervision than those who were coping better, or indeed their managers may have insisted on more supervision for the therapists they perceived as not coping. Although the use of supervision has been recommended to ameliorate the negative effects (Pearlman & Mac Ian, [31]; Pearlman & Saakvitne, [32]; Sexton, [38]), less work has been done to identify the elements that constitute good supervision for trauma work. Through her supervision of those who work with sexual abuse clients, Etherington ([18]) suggests that supervision should focus on “the interrelationship between the trauma itself, the person of the counsellor, the helping relationship … and the context in which the work is offered” (p. 183). This seems a good start point; however, more research is needed to further clarify what elements are integral to the supervision of trauma therapists.

The literature suggests that engaging in self-care activities lowers the risk of STS (Rothschild, [34]). Therefore, the finding that those who spent more time engaging in self-care activities were at a higher risk of STS appears surprising. Whilst it is possible that therapists who were struggling more actively engaged in self-care activities in an attempt to alleviate their distress, another alternative explanation may be that these activities had indeed reduced therapists’ risk of STS but that the present study was unable to capture this due to the cross-sectional design of the study. Further research is needed to explore these findings.

Higher perceived levels of management support predicted lower risk of burnout and higher potential for CS. These findings support the theoretical underpinnings of CS (which propose positive collegiate support as an integral part of CS) and burnout (where personal accomplishments are linked to lack of resources such as poor social support) (Schaufeli & Enzmann, [37]). Previous research has also found that therapists who rated the emotional and technical support afforded to them at work as high, exhibited lower scores of work stress (Kassam-Adams, [25]). Although management support was clearly an important part of therapists’ functioning, the present research did not tease out the aspects of management support that were deemed most helpful. It is also interesting that perceived management support appeared to predict CS and burnout which are not exclusive to trauma therapists, suggesting that perceived management support may be important to therapists in general as opposed to trauma therapists per se. Future research should explore the different elements that make up perceived management support and investigate the different ways in which this can be cultivated in services.

As a coping strategy, time spent in R&D activities was found to positively predict the potential for CS. Perhaps this time spent away from direct client work helps therapists bring a balance to their work life. Indeed, Chrestman ([10]) found that those therapists who spent more time doing clinical work as opposed to other activities reported increased avoidance, whilst those who spent more time in research activities reported decreased avoidance.

Mental health professionals report a higher prevalence of personal trauma than other professionals (Follette et al., [22]). Almost 60% of participants reported having a personal trauma history and were shown to be at higher risk of STS. These findings were consistent with research by Pearlman and Mac Ian ([31]) and Kassam-Adams ([25]) which suggests that therapists’ previous experience of trauma may contribute to making them more vulnerable to the trauma stories of others. However, it should be highlighted that some research has contradicted these findings (e.g., Schauben & Frazier, [36]). Regardless, future research is needed to ascertain whether therapists with a personal trauma history require any additional support in their work and indeed what support would be most effective.

It is notable that the number of trauma clients on therapists’ caseloads did not predict STS as would be predicted by the theories of CF, STS, and VT and which has been reported by researchers (Chrestman, [10]; Kassam-Adams, [25]). Other researchers have also not found this theorised relationship (Devilly et al., [16]; Meyers & Cornille, [28]). This calls into question whether it is indeed the exposure to clients’ trauma stories that causes therapists’ distress, whether it is therapeutic work in general, or if other factors are the cause. As van Minnen and Keijsers ([42]) have found STS symptoms in therapists not working with trauma clients, they have argued that “the negative effects of trauma work, reported in previous studies, may have been overestimated” (p. 197).

The National Institute for Clinical Excellence (NICE) guidelines for PTSD ([29]) recommend the use of trauma-focused CBT and eye movement desensitisation and reprocessing (EMDR) for adult trauma clients. In this study, 39.1% of participants worked with trauma clients using CBT and 12.6% used EMDR, whilst the rest used other models. Increased CS and reduced burnout and STS have been found to be associated with evidence-based practice (Craig & Sprang, [14]). Therefore, the finding that almost 50% of participants were making use of non-NICE-evidenced models may also be contributing to the higher risk of burnout and STS seen in this study. Additionally, therapists with special trauma training have been found to report significantly more CS and less burnout than those who did not have training (Craig & Sprang, [14]). Although a large group had over a week’s specific trauma training, future research should focus on therapists’ competence to deliver trauma therapy and the impact that this may have on their risk of burnout and STS as well as their potential for CS.

Contextual issues
The majority of therapists (86%) in this study worked within the UK National Health Service (NHS), and the structure of psychological provision in the United Kingdom differs from that around the world. It is likely that this may have impacted therapists’ experiences of their work. The present study was not able to ascertain the contribution that the NHS structure may have had on the reporting of these concepts. Further research should investigate the differences between reported levels of CS, burnout, and STS in therapists working for the NHS and the private or voluntary sector and explore whether different predictors exist in these varied work settings.

It is also important to remember the context of the present study. Data were collected during a challenging period for the NHS when the United Kingdom was in recession and the newly formed coalition government had announced changes to the NHS which included “up to £20 billion of efficiency savings by 2014,” the reduction of “NHS management costs by more than 45% over the next four years,” and the restructuring of commissioning with abolishment of Primary Care Trusts to be replaced by GP (general practitioner) consortia (Department of Health, [15], p. 5). Anecdotally, this meant that many NHS posts were being cut, under threat, or being restructured, and less money was available for training. It is, therefore, possible that these extraneous factors may have affected these results, in particular burnout which is more related to general work stressors.

Methodological issues
The recruitment method chosen made it impossible to ascertain a response rate, and it was not possible to know if those who chose to participate in the study differed from those who chose not to. The findings of this study are therefore made with caution as it is not known how representative this sample is of UK therapists working with trauma clients.

Although the online methodology has been used to assess trauma and PTSD symptoms in the general population (e.g., Butler et al., [ 9]), this is one of the first studies to use this methodology to assess levels of CS, burnout, and STS in therapists. 52.3% found the online methodology not difficult/easy to complete, and 17.3% found it extremely easy. Additionally, the overwhelming majority of therapists (84.9%) reported being either quite comfortable or extremely comfortable in answering these types of questions online. However, almost a quarter (24%) of those who started the questionnaire dropped out before the end, making their data unusable, and a third of those dropped out immediately after consenting to take part in the questionnaire. Future research should include the provision for participants to save their responses and complete the questionnaire at a later date as this may improve dropout rates.

This study attempted to access those most likely to work with trauma clients by targeting adult specialist trauma services, secondary-care services, as well as those who identified themselves as having a special interest in trauma from professional bodies. It is acknowledged that this sampling procedure excluded a large group of therapists working in child and adolescent teams, older adult services, other specialist services, and primary care. Additionally, the lack of a control group means that it is not possible to ascertain whether these findings are indeed limited to those working with trauma clients. Future research should, therefore, not only consider comparative studies between therapists working with these different client groups as research suggests differences may be present (Dyregov & Mitchell, [17]; Figley, [20]; Hopkins, [23]) but also compare trauma therapists with therapists working with different client presentations.

Implications for clinical settings
Therapists working with trauma clients should be made aware of the possibility of being negatively impacted from working with this client group. Specific risk factors identified in the present research that therapists may want to be aware of include having a personal trauma history and being younger in age. However, they should also be informed that there is the potential for CS and personal growth.

As with all therapeutic work, it is important for therapists to monitor their own well-being and be mindful of the well-being of their colleagues, as being negatively impacted can affect their therapeutic work and professional and personal relationships. Therapists should remain aware of their own possible triggers. It may be helpful for therapists to consider triggers in different domains, including the personal, professional, and environmental domains (Yassen, [44]).

Perceived management support was found to be a positive predictor of CS and a negative predictor of burnout. Therefore, management appears to have a role to play in therapists’ well-being. This study was not able to identify the specific elements that constitute good management support, and this is an area for future research. It is therefore advisable for managers to consult with the therapists in their service who work with trauma clients to determine what support the therapists feel they require from management. Areas that management should consider include organisational culture, workload, work environment, trauma-specific education and training, group support, supervision, resources for self-care (Bell, Kulkarni, & Dalton, [ 5]), and workplace context. For example, Chrestman ([10]) found that lower levels of vicarious trauma were associated with a more diverse caseload.

Supervision is an area that the present research suggests may be advisable for management to review. Services should consider auditing their supervision provision as these results suggest that the perceived supportiveness of supervision, which may be related to the quality of supervision, may be more important to therapists’ well-being, specifically therapists’ potential for CS, than the quantity of supervision.

Conclusions
This study made a first attempt at exploring the prevalence of CS, burnout, and STS in a sample of UK-wide therapists who worked with adult trauma clients. The findings paint a different picture from those reported by international colleagues, with a large number of therapists in the United Kingdom seemingly at high risk of STS. However, the majority of therapists’ scores suggested average potential for CS and risk of burnout. The study highlighted factors which predicted levels of CS, burnout, and STS in therapists. Of particular note was that exposure to clients’ trauma stories, measured by the number of trauma-focused clients in therapists’ caseload, was not found to be a predictor of STS, as has been hypothesised, suggesting that the distress experienced by therapists in this sample may have been due to other factors. Whilst there were contextual and methodological limitations to this research, there is a need for further research to explore and replicate these findings in a representative sample of UK therapists. Attention also needs to be given to finding ways to support therapists who may be in distress.

This was the first large-scale study in the United Kingdom, and the first to use an online questionnaire, to explore the positive and negative experiences of therapists working with trauma clients. Further research is needed to continue building our knowledge in this area.

Conflict of interest and funding
There is no conflict of interest in the present study for any of the authors.

Footnotes
1 1This research was submitted in partial fulfilment of the requirements of Canterbury Christ Church University for the degree of Doctor of Clinical Psychology.

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~~~~~~~~

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‘. . . The forgotten heroes’: A qualitative study exploring how friends and family members of DV survivors use domestic violence helplines.
Authors:
Gregory, Alison, ORCID 0000-0002-4768-1574 . University of Bristol, Centre for Academic Primary Care, Bristol, United Kingdom, alison.gregory@bristol.ac.uk
Taylor, Anna Kathryn. University of Manchester, Manchester, United Kingdom
Pitt, Katherine. University of Bristol, Centre for Academic Primary Care, Bristol, United Kingdom
Feder, Gene, ORCID 0000-0002-7890-3926 . University of Bristol, Bristol, United Kingdom
Williamson, Emma, ORCID 0000-0002-0912-0303 . University of Bristol, Bristol, United Kingdom
Address:
Gregory, Alison, Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Rd., Clifton, Bristol, United Kingdom, BS8 2PS, alison.gregory@bristol.ac.uk
Source:
Journal of Interpersonal Violence, Vol 36(21-22), Nov, 2021. pp. NP11479-NP11505.
NLM Title Abbreviation:
J Interpers Violence
Page Count:
27
Publisher:
US : Sage Publications
ISSN:
0886-2605 (Print)
1552-6518 (Electronic)
Language:
English
Keywords:
domestic violence, disclosure of domestic violence, vicarious trauma
Abstract:
Many women who experience domestic violence (DV) seek support from friends, relatives, colleagues, and neighbors. There are substantial knock-on effects for informal supporters, and they may seek help themselves. Tailored services for this group are rare, but DV helplines can provide listening and signposting support. The aim of this exploratory study was to understand which informal supporters contact DV helplines and what form these calls take. Three focus groups, following a topic guide, were conducted with staff and volunteers for DV helplines during autumn 2015. Discussions were digitally recorded, transcribed verbatim, and imported into NVivo10 software. Transcripts were coded line-by-line, and a thematic analysis carried out. All participants were female, aged between 22 and 54 years, with between 2 months’ and 8 years’ experience of taking helpline calls. Findings indicate that people with broad ranging connections to a survivor call a helpline. Calls can be triggered by disclosures, abuse escalation, witnessing incidents, feeling overwhelmed, and media highlighting of DV. Informal supporters respond to survivors, and experience impacts, in differing ways, often associated with their gender and their relationship with the survivor. Frequently, they feel a sense of responsibility and a desire to rescue the survivor, often calling a helpline to reduce feelings of helplessness and to seek a ‘magic’ solution. Many people are concerned about the legitimacy of their involvement and seek reassurance about the validity of their own help-seeking. Helpline workers feel that informal supporters would benefit from opportunities to reduce isolation, have their predicament acknowledged, and learn from peers. DV helplines have an important role in helping informal supporters of survivors. The help requested is predominantly to equip and empower the informal supporter, so that they feel more adept at coping themselves and, are thus, better able to offer support to the survivor. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Domestic Violence; *Family Members; *Friendship; *Hot Line Services; *Volunteers; Help Seeking Behavior; Trauma; Vicarious Experiences
Medical Subject Headings (MeSH):
Child, Preschool; Domestic Violence; Family; Female; Friends; Humans; Infant; Qualitative Research; Survivors
PsycInfo Classification:
Behavior Disorders & Antisocial Behavior (3230)
Community & Social Services (3373)
Population:
Human
Female
Location:
United Kingdom
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Focus Group Guide
Grant Sponsorship:
Sponsor: National Institute for Health Research, School for Primary Care Research
Recipients: No recipient indicated

Sponsor: Wellcome Trust
Grant Number: 105612/Z/14/Z
Other Details: Elizabeth Blackwell Institute for Health Research
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Focus Group; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20220328
Copyright:
The Author(s). 2019
Digital Object Identifier:
http://dx.doi.org/10.1177/0886260519888199
PMID:
31762395
Accession Number:
2022-06930-055
Number of Citations in Source:
58
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Stressors of rape crisis work from the perspectives of advocates with and without sexual assault victimization history.
Authors:
Mihelicova, Martina, ORCID 0000-0003-2126-9909 . DePaul University, Chicago, IL, US, mmiheli1@depaul.edu
Wegrzyn, Annie. DePaul University, Chicago, IL, US
Brown, Molly. DePaul University, Chicago, IL, US
Greeson, Megan R.. DePaul University, Chicago, IL, US
Address:
Mihelicova, Martina, DePaul University, 2219 N. Kenmore, Chicago, IL, US, 60614, mmiheli1@depaul.edu
Source:
Journal of Interpersonal Violence, Vol 36(19-20), Oct, 2021. pp. NP10766-NP10789.
NLM Title Abbreviation:
J Interpers Violence
Page Count:
24
Publisher:
US : Sage Publications
ISSN:
0886-2605 (Print)
1552-6518 (Electronic)
Language:
English
Keywords:
sexual assault, adult victims, intervention, vicarious trauma, violence exposure, rape, rape crisis centers, volunteers, perspectives, advocates, victimization history
Abstract:
Rape crisis centers largely rely on volunteers for delivering emergency room advocacy to survivors of sexual assault. Volunteer advocates bear witness to trauma as part of their role, such as when listening to details of sexual assault. This exposure may negatively affect advocates long term, which may lead to secondary traumatic stress and vicarious traumatization, and possibly reduce their ability to provide quality services and remain in their role. In addition, some advocates may be survivors of sexual assault themselves. Survivors may differentially experience the toll of advocacy work. The present qualitative study sought to identify stressors that advocates face within their role, aspects of stressors unique to survivors who advocate, and the effects of stressors on advocates. Semistructured interviews were conducted with 18 current volunteer advocates, 11 of whom identified as survivors, from three rape crisis centers. Findings demonstrated stressors associated with self-Assessment; rules or expectations of the role (including the crisis nature of the role); witnessing lack of client support; helplessness around sexual assault as a systems issue; identifying with the client; witnessing the physical and emotional impact on clients; and being reminded of their own assault. Results also revealed how these stressors and advocacy overall influenced advocates. Unique aspects of stressors to survivors arose in the way advocates experienced the stressors. In addition, survivors exclusively described being reminded of past trauma within advocacy work. Findings have implications for supporting advocate well-being by better understanding the stressors that may lead to negative outcomes and informing individual coping, training, and overall organizational support of advocates. Such measures may ensure retention of volunteers and maintain quality advocacy services. (PsycInfo Database Record (c) 2022 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Crisis Intervention Services; *Rape; *Vicarious Experiences; *Victimization; *Volunteers; Advocacy; Sex Offenses; Stress; Survivors; Trauma
PsycInfo Classification:
Criminal Behavior & Juvenile Delinquency (3236)
Community & Social Services (3373)
Population:
Human
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Grant Sponsorship:
Sponsor: DePaul University, US
Other Details: Graduate Research Fund
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20220303
Copyright:
The Author(s). 2019
Digital Object Identifier:
http://dx.doi.org/10.1177/0886260519876715
PMID:
31542983
Accession Number:
2021-87067-075
Number of Citations in Source:
25
Result List Refine Search PrevResult 55 of 68 Next
Caring for the caring professionals within a cancer hospital: Research into compassion fatigue, burnout, and distress.
Authors:
Drake, Julia, Julia.drake@calvarymater.org.au
Walker, Melissa
Gallant, Noelle
Sturgess, Emma
McGill, Katie
Address:
Drake, Julia, Julia.drake@calvarymater.org.au
Source:
Australian Social Work, Sep 24, 2021.
Publisher:
United Kingdom : Taylor & Francis
Other Journal Titles:
Australian Journal of Social Work
Other Publishers:
Australia : Australian Association of Social Workers
United Kingdom : Blackwell Publishing
ISSN:
0312-407X (Print)
1447-0748 (Electronic)
Language:
English
Keywords:
Death, Dying, Compassion Fatigue, Burnout, Distress, Hospital Staff, Vicarious Trauma
Abstract:
ABSTRACT Providing quality care to people approaching the end of their life within the hospital system is important. To date, only limited research has investigated the impact that providing care to people who are dying has on the diverse range of hospital staff who provide the care. As part of a needs assessment to identify the resources and service development required to support all hospital staff, Calvary Mater Newcastle Social Work Department invited hospital staff to complete a questionnaire. A total of 162 respondents agreed to participate. Both clinical and nonclinical staff reported feeling impacted by the death of patients. Participants identified that their current coping strategies and support structures addressed some professional and personal needs, but many were unaware of other available supports and felt that the availability and type of support offered could be broadened to better meet staff needs. IMPLICATIONS All hospital staff (individually and as a group) irrespective of background are affected by caring for those that are dying. Current support structures used by health workers are examined for their efficacy in providing self-care to these workers; other available supports that could better meet these workers’ needs are then explored. Social workers have an essential role to play in creating systems that support and enable health workers to engage in restorative and wellbeing practices. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Document Type:
Journal
Subjects:
No terms assigned
PsycInfo Classification:
Health & Mental Health Treatment & Prevention (3300)
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication Status:
Online First Posting
Publication History:
Accepted: Apr 5, 2021; First Submitted: Sep 15, 2020
Release Date:
20210927
Copyright:
Australian Association of Social Workers. 2021
Digital Object Identifier:
http://dx.doi.org/10.1080/0312407X.2021.1944235
Accession Number:
2021-88954-001
Number of Citations in Source:
22
Result List Refine Search PrevResult 56 of 68 Next
The impact of trauma work on trauma workers: A metasynthesis on vicarious trauma and vicarious posttraumatic growth.
Authors:
Cohen, Keren. Department for Professional and Community Education, Goldsmiths College, University of London, United Kingdom, k.cohen@gold.ac.uk
Collens, Paula. Department for Professional and Community Education, Goldsmiths College, University of London, United Kingdom
Address:
Cohen, Keren, Department of Social, Therapeutic and Community Studies, Goldsmiths College, University of London, New Cross, United Kingdom, SE14 6NW, k.cohen@gold.ac.uk
Source:
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 5(6), Nov, 2013. pp. 570-580.
NLM Title Abbreviation:
Psychol Trauma
Page Count:
11
Publisher:
US : Educational Publishing Foundation
ISSN:
1942-9681 (Print)
1942-969X (Electronic)
Language:
English
Keywords:
metasynthesis, posttraumatic growth, qualitative methods, vicarious posttraumatic growth, vicarious trauma, trauma work
Abstract:
The current study examines the impact that trauma work has on those who are working with traumatized clients, within the framework of both vicarious trauma (VT) and vicarious posttraumatic growth (VPTG), by using a metasynthesis of findings from 20 published qualitative articles. The synthesis found that the impact of trauma work can potentially increase short- and long-term levels of distress and that such psychological impact can be managed through personal and organizational coping strategies. Nevertheless, it also highlighted that distress does not necessarily preclude growth. Furthermore, it was found that trauma work leads to changes in schemas and day-to-day routines and that these changes can be both negative and positive, implying a nonbinary view of the impact of trauma work. The schematic changes correspond to both VT and VPTG, but for VPTG to occur, trauma workers will need to be exposed to the client’s own growth. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Emotional Trauma; *Vicarious Experiences; *Health Personnel; *Posttraumatic Growth; Distress; Qualitative Methods
PsycInfo Classification:
Health & Mental Health Treatment & Prevention (3300)
Population:
Human
Male
Female
Location:
Australia; Canada; Israel; United Kingdom; Netherlands; Sri Lanka; US
Age Group:
Adulthood (18 yrs & older)
Methodology:
Meta Analysis
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Nov 12, 2012; Accepted: Jul 25, 2012; Revised: Jun 20, 2012; First Submitted: Nov 4, 2011
Release Date:
20121112
Correction Date:
20201008
Copyright:
American Psychological Association. 2012
Digital Object Identifier:
http://dx.doi.org/10.1037/a0030388
Accession Number:
2012-30277-001
Number of Citations in Source:
59
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The Impact of Trauma Work on Trauma Workers: A Metasynthesis on Vicarious Trauma and Vicarious Posttraumatic Growth
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✖
Contents
Method
Selection of Articles
Analysis
Results
Theme 1: Emotional and Somatic Reactions to Trauma Work
Theme 2: Coping With the Emotional Impact of Trauma Work
Theme 3: The Impact of Trauma Work–Changes to Schemas and Behavior
Theme 4: The Process of Schematic Change and Relating Factors
Discussion
Footnotes
References
Full Text
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By: Keren Cohen
Department for Professional and Community Education, Goldsmiths College, University of London, United Kingdom;
Paula Collens
Department for Professional and Community Education, Goldsmiths College, University of London, United Kingdom
Acknowledgement:

In the last two decades, there has been a growing body of evidence looking at the effects that trauma work has on those who are working with traumatized individuals. Initially, an interest emerged within the framework of secondary traumatic stress (STS, Figley, 1995; Sabin-Farrell & Turpin, 2003) and vicarious trauma (VT; McCann & Pearlman, 1990). The former refers to the experiencing in the trauma worker of symptoms similar to those seen in people with posttraumatic stress disorder (PTSD). The latter refers to personal transformations experienced by trauma workers resulting from a cumulative and empathic engagement with another’s traumatic experiences (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995) that can lead to long-term changes to an individual’s way of experiencing themselves, others, and the world, and symptoms that may parallel those of their client (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). The averse vicarious impact of trauma has been recorded in various groups; for example, therapists (Iliffe & Steed, 2000; Pearlman & Mac Ian, 1995), firefighters (Brown, Mulhern, & Joseph, 2002), and ambulance workers (Clohessy & Ehlers, 1999). However, within the framework of posttraumatic growth (Tedeschi & Calhoun, 1995, 1996; Tedeschi, Park, & Calhoun, 1998), interest and research have been extended to explore the potential positive changes that emerge from trauma work. Accordingly, there has been a growing recognition that some people who are indirectly exposed to trauma cope well (e.g., Brady, Guy, Poelstra, & Brokaw, 1999) and even report positive outcomes (Eidelson, D’Alessio, & Eidelson, 2003). The aim of the current paper is to examine more closely the process of vicarious posttraumatic growth and to contextualize this within the larger framework of the overall impact of trauma work. The methodology used in the current article is a metasynthesis, which is a systematic method used to combine, merge, and interpret information from qualitative studies in an area of interest (Jensen & Allen, 1996). Accordingly, in order to achieve its aim, the current article will involve reinterpreting and synthesizing qualitative articles on the experiences of trauma workers.

When considering earlier research on vicarious trauma, the most prominent theoretical framework is the constructivist self-development theory (CSDT; McCann & Pearlman, 1990), which suggests that individuals construct their realities through the development of cognitive structures or schemas. These schemas include a person’s beliefs, assumptions, and expectations about self, others, and the world, and these are then used to interpret events and make sense of experiences (e.g., Janoff-Bulman, 1992). When possible, new information is assimilated into existing schemas (McCann & Pearlman, 1990); however, if the new information is incompatible with existing schemas and cannot be assimilated, the original schemas are challenged. When experiencing trauma and also in VT, the original schemas can become invalidated or shattered (Janoff-Bulman, 1992; (McCann & Pearlman, 1990). In these cases, the schemas must be modified to incorporate the new information into the belief system through the process of accommodation. According to CSDT, when an individual experiences vicarious traumatization, schemas are modified in a negative way, and this causes distress and heightened awareness to information that supports the new negatively modified schema (McCann & Pearlman, 1990).

Two systematic reviews in the area (Beck, 2011; Sabin-Farrell & Turpin, 2003) highlighted various factors that can contribute to VT. These include negative coping strategies, personal stress, gender (with women reporting higher levels of symptoms than men), and personal trauma history. In relation to the latter, however, Dunkley and Whelan (2006) found that the link between personal trauma and VT is inconsistent across the literature. The two reviews also highlighted the influence of organizational factors, such as percentage of trauma work within the caseload and overall extent of exposure to clients’ trauma. However, these findings were also found to be inconsistent, as some studies failed to find a connection between the extent of exposure to client’s trauma and VT (Sabin-Farrell & Turpin, 2003). Other writers focused on preventative measures and strategies to manage VT. These included organizational factors, such as provision of support and adoption of a tolerant attitude to suffering therapists (Catherall, 1995), and maintenance of an overall encouraging, acknowledging, and respectful working atmosphere (Rourke, 2007). Promoting conversations on the impact of the work among professionals (Rourke, 2007) was also considered as a strategy for prevention and management of VT. In terms of the influence of personal factors in managing the negative impact of trauma work, these can be categorized in terms of personal strategies and individual characteristics. Personal strategies included self-care, the balancing of work and private lives (Baum, 2004; Bober & Regehr, 2006), and the use of social support (Bober & Regehr, 2006); while personal characteristics included spirituality, humor, and the capacity to maintain a realistic optimism (Sexton, 1999).

Alongside investigations on the potential negative impact of trauma work, there has also been a recognition that some people who are indirectly exposed to trauma cope well (e.g., Brady et al., 1999) or even report positive outcomes (Eidelson et al., 2003; Steed & Downing, 1998). The possibility for personal growth as a result of trauma work sits within a larger framework of the concept of posttraumatic growth (PTG). This was defined as a significant positive psychological change following a major life crisis/trauma (Tedeschi & Calhoun, 1995; Tedeschi, Calhoun, & Cann, 2007). The process of PTG is normally perceived within the same constructivist framework as VT. Accordingly, prominent theories in the area (Joseph & Linley, 2008; Tedeschi & Calhoun, 1995, 2004) postulate that trauma challenges an individual’s schemas (or assumptive world) and therefore triggers cognitive processes that can result in either no change to previous schemas (assimilation), positive change to previous schemas (positive accommodation), or negative change to previous schema (negative accommodation). Joseph and Linley (2008) equate positive accommodation with growth and negative accommodation with psychopathology and distress. Nevertheless, they acknowledge that the self is multifaceted and that people may change some schemas in one direction, some in another direction, and some schemas may stay unchanged. They also highlight the difference between subjective well-being, a hedonistic perspective of well-being, and psychological well-being (PWB; Ryff, 1989), which refers to a eudemonic perspective of well-being. Shmotkin (2005) articulates the difference between these two originally philosophical traditions. A hedonistic perspective on happiness defines well-being or happiness in terms of maximizing pleasurable emotions and experiences over negative ones, while a perspective akin to Aristotelian concepts, a eudemonic approach, defines it in terms of self-realization rather than pleasurable emotions (for more details on these distinctive traditions see Shmotkin, 2005). PTG can thus be understood in relation to the latter, as growth defined by positive changes in perceptions of self and the world, rather than an increase in or dominance of positive emotions.

In terms of vicarious posttraumatic growth, there are no specific theoretical models to explain how the phenomenon occurs (Brockhouse, Msetfi, Cohen, & Joseph, 2011); however, a few studies have observed positive changes following vicarious exposure to trauma (e.g., Brady et al., 1999; Pearlman & Saakvitne, 1995; Radeke & Mahoney, 2000; Schauben & Frazier, 1995), and others (Arnold, Calhoun, Tedeschi, & Cann, 2005; Linley & Joseph, 2007; Linley, Joseph, & Loumidis, 2005) have investigated vicarious posttraumatic growth directly. Areas of positive change that were identified among trauma workers included gaining a new appreciation for spiritual paths, a heightened awareness of the individual’s own good fortune, and a strengthened sense of optimism (Arnold et al., 2005). Predictors of VPTG included higher levels of sense of coherence (Linley et al., 2005; Linley & Joseph, 2007), empathy, social support, and organizational support (Linley & Joseph, 2007).

Considering the relatively recent interest and investigations into vicarious posttraumatic growth and the lack of an established model of the process by which it occurs, the current study aims to adopt a metasynthesis approach to examine the process of growth in trauma workers within a wider context of the overall impact of trauma work. More specifically, it aims to provide a theoretical model for understanding the process of VPTG and its relation to VT, and to highlight relevant issues that may require further research. In its essence, a metasynthesis is a qualitative secondary analysis of existing findings and, ultimately, it is an interpretive rather than aggregative work (Noblit & Hare, 1988), seeking to build, develop, and refine theories, increasing our understanding of a topic while retaining the richness and uniqueness of the original studies (Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004).

Method

Selection of Articles
Articles were selected following an extensive search by using electronic databases PsycInfo, PsycArticles, ASSIA, Social Services Abstracts, Sociological Abstracts, and ISI during February, 2011. The terms used for the search were (vicarious trauma or working with trauma* or secondary trauma*) AND qualitative. The search yielded 113 abstract from PsycInfo and PsycArticles; 13 abstracts from ASSIA, 89 abstracts from Social Services Abstracts, 31 from Sociological Abstracts, and 48 abstracts on ISI. The abstracts were screened and relevant articles were extracted.

Articles were included if they: (a) were qualitative articles or mixed methods articles with a qualitative part; (b) investigated predominantly or partially the impact of trauma work on trauma workers and/coping with trauma work; (c) were published in a peer-reviewed journal; and (d) were written in English. Articles were excluded if they dealt with: (a) a traumatic session or difficult clients (e.g., Raingruber & Kent, 2003) rather than a vicarious exposure to traumatic material; (b) immediate reactions to a traumatic event, such as informing families about the death of a family member (Somer, Buchbinder, Peled-Avram, & Ben-Yizhack, 2004) rather than engaging with a client who underwent a traumatic event. An additional article was excluded (Wasco & Campbell, 2002), as its aims were too specific; namely, investigating only responses of fear and anger, and so not allowing a general exploration of the impact of trauma work. Following this screening process, 20 articles were selected for the metasynthesis. Finally, please note that following a review process, an additional search using the term compassion fatigue was preformed but did not yield any new articles that matched our screening criteria. The articles’ descriptions can be found in Table 1.

tra-5-6-570-tbl1a.gifDescriptive Details of the Reviewed Studies
tra-5-6-570-tbl1b.gifDescriptive Details of the Reviewed Studies

The articles were assessed for quality according to the criteria suggested by Atkins et al. (2008); however, in line with Atkins et al. (2008) we decided to take an inclusive approach, including all the articles that were selected in the analysis, in order to achieve a greater representation of the area. Nevertheless, the quality assessment can be seen in Table 2.

tra-5-6-570-tbl2a.gifCriteria For the Assessment of Quality of the Reviewed Studies

Analysis
This metasynthesis followed Noblit and Hare’s (1988) metaethnographic method. Initially, the selected articles were read and reread. Then, the original findings such as key phrases, metaphors, ideas, and concepts were put into a table and provided the “raw data” for the synthesis. A process of “reciprocal translation” took place, whereby the synthesis data were integrated and translated into one another, producing second-order themes (for further details, please see Campbell et al., 2003). These themes then formed the final four major themes of the study. The themes were audited by the second author, who traced them back to the original articles to ensure that the current analysis reflects the original articles’ findings.

Results

From the analysis, four separate but interrelated themes have emerged, and these describe the overall immediate and long-term, emotional, and cognitive impact of a vicarious exposure to trauma. The themes include the emotional and somatic impact of trauma work, coping with the emotional impact of trauma work, changes to inner schemas and behaviors as a result of the trauma work, and the process of schematic change. These themes will now be outlined and discussed.

Theme 1: Emotional and Somatic Reactions to Trauma Work
When hearing the client’s traumatic story, trauma workers reported an array of emotional responses. These included sadness (Satkunanayagam, Tunariu, & Tribe, 2010; Schauben & Frazier, 1995; Shamai & Ron, 2009; Splevins, Cohen, Joseph, Murray, & Bowley, 2010), anger (Iliffe & Steed, 2000; Satkunanayagam et al., 2010; Schauben & Frazier, 1995; Steed & Downing, 1998), fear (Schauben & Frazier, 1995; Splevins et al., 2010), frustration (Satkunanayagam et al., 2010; Steed & Downing, 1998), helplessness (Schauben & Frazier, 1995; Steed & Downing, 1998), powerlessness (Satkunanayagam et al., 2010), despair (Etherington, 2007; Splevins et al., 2010), and shock (Pistorius, Feinauer, Harper, Stahmann, & Miller, 2008; Smith, Kleijn, Trijsburg, & Hutschemaekers, 2007; Splevins et al., 2010; Steed & Downing, 1998), with some participants noting that they have “never heard anything like it before” (Etherington, 2007), and that they never thought that things “like that” can happen (Splevins et al., 2010). In some articles, participants also reported somatic responses such as numbness and nausea (Iliffe & Steed, 2000), tiredness (Pistorius et al., 2008), and even craving sweets (Shamai & Ron, 2009). In reaction to these intense feelings and somatic responses, some trauma workers reported feeling detached (Clemans, 2004) and having difficulties performing their therapeutic work as they normally would; for example, maintaining boundaries and establishing trust (Schauben & Frazier, 1995).

The intense immediate negative emotions and somatic responses seem to linger beyond a given session, and participants have reported that memories from the session, thoughts and the feeling of sadness, remained with them for weeks to come (Shamai & Ron, 2009). In some cases, participants noted that they had difficulty “switching off” after sessions (Splevins et al., 2010), experiencing insomnia (Splevins et al., 2010; Steed & Downing, 1998), irritability (Splevins et al., 2010), and distress from overwhelming feelings (Lonergan, O’Halloran, & Crane, 2004).

Theme 2: Coping With the Emotional Impact of Trauma Work
In order to cope with the overwhelming feelings, somatic responses, and distress, participants have utilized an array of coping strategies and techniques. Many of the articles outlined the role of organizational factors in managing and mitigating the potential harmful effects of the work. This included managing workload (Harrison & Westwood, 2009; Iliffe & Steed, 2000; Lonergan et al., 2004), diversifying the work to include various roles in addition to one-to-one therapy (such as teaching and supervising; Benatar, 2000; Harrison & Westwood, 2009; Iliffe & Steed, 2000), providing training and education on vicarious trauma and secondary traumatic stress (Benatar, 2000; Harrison & Westwood, 2009; Hunter & Schofield, 2006; Lonergan et al., 2004; Naturale, 2007; Pistorius et al., 2008), and promoting a nonauthoritative and inclusive style of working (Harrison & Westwood, 2009). Peer support and supervision have also been reported as a way of coping with the difficulties (Clemans, 2004; Iliffe & Steed, 2000; Lonergan et al., 2004; Pistorius et al., 2008; Smith et al., 2007), combating feelings of isolation, and providing an opportunity for sharing emotions and debriefing (Hunter & Schofield, 2006). The importance of support was also noted in relation to family and friends (Harrison & Westwood, 2009; Hunter & Schofield, 2006; Splevins et al., 2010).

Another aspect of coping referred to the individuals’ day-to-day behaviors. Self-care behaviors seem to have been one of the major ways in which individuals regulated their emotions and experiences. This included exercising to alleviate stress (Hunter & Schofield, 2006; Iliffe & Steed, 2000; Naturale, 2007; Pistorius et al., 2008; Splevins et al., 2010; Steed & Downing, 1998), healthy eating (Naturale, 2007; Pistorius et al., 2008; Steed & Downing, 1998), and resting and meditating (Naturale, 2007; Pistorius et al., 2008; Splevins et al., 2010; Steed & Downing, 1998). Promotion of self-care was also achieved by a conscious and intentional effort to engage in pleasurable activities, such as taking holidays, socializing, watching films, and going out (Harrison & Westwood, 2009; Hunter & Schofield, 2006; Iliffe & Steed, 2000; Splevins et al., 2010). Political activism was mentioned by Iliffe and Steed (2000) and Clemans (2004) as a way to combat the cynicism and channel the anger that the work triggered. Separating between work and personal life was also used to regulate participants’ emotions through attempts to “tune out” from thinking about work (Iliffe & Steed, 2000); for example, by engaging in some sort of activity such as listening to music, to symbolically and practically note the end of the working day (Hunter & Schofield, 2006). Separation between self and client was also mentioned in terms of differentiation between empathy and sympathy (Hunter & Schofield, 2006), and one of the participants in Lonergan et al.’s (2004) study noted that during her career a colleague reminded her that “it’s not happening to you.” Finally, a few studies mentioned participants’ own psychotherapy as a strategy to cope with the stress and emotions experienced in their work (Bell, 2003; Hunter & Schofield, 2006; Lonergan et al., 2004; Pistorius et al., 2008; Splevins et al., 2010). Personal therapy provided participants with a safe place to explore their emotions (Pistorius et al., 2008) and gain insight into their feelings (Lonergan et al., 2004). For those who also suffered trauma themselves in the past, it was also a way to resolve their own traumatic experiences (Bell, 2003). It should be noted that Iliffe and Steed (2000) also recorded potentially harmful behaviors to regulate participants’ experiences, which included drinking too much coffee or alcohol and risk-taking behaviors such as speeding.

The last aspect of coping was related to attitudes and beliefs. Spirituality was mentioned in several studies (Bell, 2003; Clemans, 2004; Harrison & Westwood, 2009; Hunter & Schofield, 2006; Pistorius et al., 2008; Shamai & Ron, 2009) as a buffer to negative impact (Bell, 2003) and as a coping mechanism that counters isolation and despair (Harrison & Westwood, 2009) and provides meaning for the participants’ work (Shamai & Ron, 2009). Seeing their work as meaningful was also mentioned by Bell (2003), who noted that adopting an identity of “a helper” related to lower levels of stress. Another internal source of coping was positivity. In a few studies, participants mentioned that optimism (Bell, 2003; Lonergan et al., 2004; O’Neill, 2010), keeping an overall positive outlook on life (Harrison & Westwood, 2009; Hunter & Schofield, 2006), and humor (Clemans, 2004; Pistorius et al., 2008) all helped them to cope with their work. A participant in Lonergan et al.’s (2004) study noted “People who do trauma work have some sort of eternal hope. There are others who can’t find that and leave.”

Theme 3: The Impact of Trauma Work–Changes to Schemas and Behavior
The impact of trauma work in the reviewed studies stretched beyond an emotional impact on participants and their coping strategies. It was quite clear that the experiences of working with trauma had triggered a cognitive activity that resulted in changes to internal schemas. As noted earlier, the traumatic material was “shocking” for participants (Etherington, 2007; Pistorius et al., 2008; Smith et al., 2007; Splevins et al., 2010; Steed & Downing, 1998); however, overtime, just as shocking was the discovery of the clients’ abilities to cope and grow (Splevins et al., 2010). In order to make sense of their vicarious experiences, participants reported engaging in an existential meaning-making process (Benatar, 2000; Harrison & Westwood, 2009; Satkunanayagam et al., 2010; Steed & Downing, 1998), questioning themselves, their lives, and their identities (Goldblatt, Buchbinder, Eisikovits, & Arizon-Mesinger, 2009). Steed and Downing (1998) quote a participant saying “I spend a lot more time by myself, thinking, like going for walks and trying to make sense of life—spending more time thinking about what the whole point of everything is.” In Goldblatt et al.’s (2009) study, one participant reflected “[you are] asking many questions about your own couplehood, womanhood, and how it relates to you”; in Benatar (2000) a participant asked “How do you live in a world where horrible things happen? How do you make peace with this? How do you forgive? How do you?”; and in Bell (2003) a participant noted “I think that you see the worst of people, working here…it just leaves you feeling a little baffled about…the way things are in the world, your role in it, and all that.” Various participants provided different answers to questions such as these, and perceived changes to their beliefs and attitudes about the world and life, their personal values and their perception of self. These changes occurred in both negative and positive directions.

When looking at the world in general, one theme related to the perception of safety. Views of the world as unsafe (Bell, 2003; Benatar, 2000; Clemans, 2004; Iliffe & Steed, 2000; Pistorius et al., 2008; Schauben & Frazier, 1995) and having a cynical dark view of reality (Benatar, 2000; Schauben & Frazier, 1995) were highlighted by participants. These were in line with descriptions of increased awareness of potential personal vulnerability (Benatar, 2000; Clemans, 2004; Iliffe & Steed, 2000); although awareness of potential dangers for one participant in Clemans’ (2004) study increased her sense of safety. Another participant in that study provided some insight into this issue by noting that “sometimes awareness is good—it’s a part of caution, and it’s part of knowing things to help you protect yourself. But at the other end, it is too much and it makes you so afraid it inhibits you living a natural life.”

An unsafe feeling was also expressed in relational terms toward people in general, manifesting itself in mistrusting others (Clemans, 2004; Iliffe & Steed, 2000; Pistorius et al., 2008; Schauben & Frazier, 1995). This, however, seemed to be present in studies which included trauma workers who were working with survivors of sexual assault/domestic abuse, and the mistrust was directed predominantly toward men. Views on humanity in general, or more specifically on human resilience, were on the whole more positive. Inspired by their clients (Benatar, 2000), participants recorded their amazement at the “human spirit” (Splevins et al., 2010) and its resilience (Clemans, 2004; Schauben & Frazier, 1995). One participant in Steed and Downing’s (1998) study noted “I’ve learnt how strong and resilient people are, and how much inner resources and strengths people have.” These revelations about the strength of the human spirit can be linked to the fact that some participants were not only vicariously exposed to the traumatic material but also, with time, were vicariously exposed to change and growth in their clients. This concept was noted in three of the studies (Bell, 2003; Schauben & Frazier, 1995; Splevins et al., 2010) and highlighted by one of Bell’s (2003) participants: “I have follow up with some of my clients and I’m reminded that…women learn how to laugh and be silly again…I truly feel it’s watching a rebirth of a human being.”

As for life in general, an increase in an overall appreciation of life was noted (Bell, 2003; Ben-Porat & Itzhaky, 2009; Benatar, 2000; Pistorius et al., 2008; Splevins et al., 2010) as participants realized how lucky (Pistorius et al., 2008) and blessed (Bell, 2003) they were. A participant in Benatar’s (2000) study reflected “I think that it pushed me to pay attention to things like this (pause) yeah, want to live…in a very alive, awake, way.” In addition to a new appreciation for life, in some studies participants reported changes to their values. This was expressed in terms of “putting things into perspective” (Bell, 2003) and looking at what is really important in life (Shamai & Ron, 2009). Family and social ties became more valued for some participants (Bell, 2003; Benatar, 2000; Splevins et al., 2010), others experienced an increased sense of social justice (Clemans, 2004; Hunter & Schofield, 2006; Shamai & Ron, 2009; Splevins et al., 2010), and some reported becoming less materialistic (Splevins et al., 2010).

In various studies, participants reported changes in personal qualities and attitudes, including becoming more compassionate (Bell, 2003; Ben-Porat & Itzhaky, 2009; Splevins et al., 2010; Steed & Downing, 1998), more accepting toward others (Bell, 2003; Ben-Porat & Itzhaky, 2009), and more humble (Benatar, 2000). There were also reports of having gained wisdom (Benatar, 2000; Lonergan et al., 2004; Pistorius et al., 2008; Splevins et al., 2010), and self-awareness and insight (Clemans, 2004; Lonergan et al., 2004; Pistorius et al., 2008; Schauben & Frazier, 1995). An increased sense of self-worth, empowerment, and self-validation (Benatar, 2000), was attributed by participants to their trauma work. A participant in Goldblatt et al.’s (2009) study stated about her work “it allowed me to compromise and accept myself as a woman. I think that I am more of a woman today than I once was.” Finally, participants described changes to the meanings that they attached to their professional roles and practice, noting that they valued their profession more than before (Shamai & Ron, 2009), gained more faith and trust in the therapeutic process (Lonergan et al., 2004), and have become better therapists/social workers (Lonergan et al., 2004). It should be noted that alongside the numerous indications of growth from participants, some participants in Pistorius et al.’s (2008) study also felt that they have become less compassionate toward others, and in Steed and Downing’s (1998) study some felt that due to their heightened sense of vulnerability, they had become more suspicious of others. Nevertheless, it seems that perceived changes to self were predominantly in the direction of positive growth.

The final aspect of change was reported in relation to participants’ day-to-day activities and life. Participants in Goldblatt et al.’s (2009) study stated that their work tended to intensify problems and difficulties, as one participant noted “the various issues brought home from work tend to sharpen and dramatize the otherwise trivial everyday struggles facing couples in their lives.” In line with this, participants in Ben-Porat and Itzhaky (2009) and in Clemans (2004) reported difficulties in family life, as they felt that they were less attentive or emotionally available (Ben-Porat & Itzhaky, 2009; Pistorius et al., 2008), and more hyper-vigilant. In terms of parenthood, some participants reported becoming more protective, and sometimes overprotective, parents (Clemans, 2004; Pistorius et al., 2008), though others felt that their work had improved their communication with their children and, therefore, made them better parents (Pistorius et al., 2008). In Benatar’s (2000) study, some participants noted that they felt an increased distance from friends, who they felt did not really understand their work. Splevin et al. (2010) also reported that some participants changed their friends as a result of their work. On the other hand, a few participants reported an increase in their social, political, and community involvement (Iliffe & Steed, 2000; Satkunanayagam et al., 2010).

Theme 4: The Process of Schematic Change and Relating Factors
As far as the process of change is concerned, a few themes and concepts emerged in relation to participants’ process of change and growth. Experience and time were noted as key factors, moderating the negative emotional impact of the work, with more experience and time leading to less overwhelming emotions and distress (Hunter & Schofield, 2006; Lonergan et al., 2004; Shamai, Kimhi, & Enosh, 2007). One of Hunter and Schofield’s (2006) participants attributed that to a reduced sense of shock; “I have heard this before” they noted. Harrison and Westwood’s (2009) study, however, highlights a more complex picture, where positive changes could co-occur alongside some of the negative emotional impact of trauma work. For Iliffe & Steed’s (2000) participants, the belief that they can overcome the difficult emotional aspect of their work facilitated participants’ sense of growth and positive change. One of Harrison and Westwood’s (2009) participants highlighted this duality “I feel very sad, very sorry, but I feel very…empowered. I feel very honored that I am asked to Help people. And that for me is something that I can grab like you know a real light switch.” In line with this, Lonergan et al. (2004) also highlighted that in their study, participants’ growth trajectory was not a simple linear one. Finally, it seems that having been a witness to the growth of their clients, this witnessing process facilitated the participant’s own growth (Bell, 2003; Etherington, 2007; Schauben & Frazier, 1995; Splevins et al., 2010).

Discussion

The current article aimed to synthesize qualitative articless on experiences of trauma workers, looking specifically at the process of growth. A summary of the themes and concepts found in the synthesis are outlined in Figure 1.

tra-5-6-570-fig1a.gifFigure 1. Vicarious posttraumatic growth in trauma workers.

Overall, it was found that alongside the potential negative emotional and schematic impact of trauma work, usually presented within the framework of vicarious trauma, trauma workers also experienced growth as a consequence of their engagement in trauma work. It seems that the two processes of vicarious trauma and vicarious posttraumatic growth stem from an empathic engagement with traumatized clients and occur as a result of challenges to current cognitive schemas that lead to their adaptation. The challenge to the schemas is experienced due to the shocking revelations in relation to either the clients’ traumatic experiences or the clients’ own posttraumatic growth. These two cognitive processes also seem to be separate (though possibly linked). The coexistence of positive and negative changes to schemas correspond to Joseph and Linley’s (2008) notion that the self is a multifaceted structure and that some facets can be accommodated positively, some negatively, and some assimilated. Thus, VT and VPTG can be seen, to some extent, as independent processes leading to different outcomes for different schemas. This raises the question whether mutually exclusive (usually quantitative) investigations of either VT or VPTG are limiting our understanding of both of these phenomena.

The link between emotional distress (that could be reduced by adopting personal coping strategies as well as organizational factors and support) and growth also appears to be more complex, suggesting that the two may not necessarily be mutually exclusive. Although successful coping with the emotional distress was mentioned as a potentially contributing factor to growth, it was also found that growth can occur while still feeling some level of distressing emotions. The possibility of experiencing growth while still feeling some distressing feelings may be seen through the two broader approaches to well-being (Joseph & Linley, 2008) and positions VPTG within the eudemonic tradition of self-actualization rather than positive or pleasurable emotions.

The emotional responses to trauma work seemed to occur both while and after hearing the client’s traumatic story. The negative emotions, distress, and somatic responses have been previously conceptualized within the framework of secondary traumatic stress (Figley, 1995). In the current metasynthesis, these experiences were prominent across the studies and highlighted the concerns around being involved in the delivery of this type of work. They also point to the importance of individual and organizational recognition and acknowledgment of the effects and emotional costs of being a professional practitioner in this field of work. Personal factors such as optimism and spirituality also play a part in coping with the work-related distress and can be considered as resilience factors. It should be noted that optimism appeared to be both a coping strategy and an aspect of growth. This dual role of optimism as a factor contributing to well-being and as an indicator of well-being has been mentioned in previous writings (Ryff, 1989; Shmotkin, 2005). While particular personal qualities may be able to moderate the negative impact of trauma work for those who possess these qualities, organizational factors and personal coping strategies can make a considerable difference for all trauma workers in managing their distress. Although time (or experience) seemed to play a role in reducing overall distress, throughout the articles it seemed there was evidence to indicate that organizations could be instrumental in Helping their employees with this process through the provision of institutional support. It was also found that individuals’ coping strategies can be useful in alleviating distress and, therefore, such strategies should be encouraged and fostered as part of an overall systemic organizational approach to managing the impact of trauma work.

Indications of both VT and VPTG were found in this metasynthesis. In line with theories on VT (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995) and PTG (Joseph & Linley, 2008; Tedeschi & Calhoun, 1995, 1996), these changes were triggered by exposure to traumatic material and by forming a professional relationship with a person who was traumatized. The challenge to existing schemas was expressed by participants in terms of shock. Negative changes to schema were triggered by the shock caused by the exposure to the client’s traumatic experience, while positive changes to schemas seemed to be triggered by the sometimes unexpected vicarious exposure to the client’s own growth. This finding may have implications for clinical work. If the process of practitioner growth is linked to vicariously experiencing of the client’s growth, interventions which do not allow the time and scope for this process to occur may be less facilitative of the practitioner’s growth. This, of course, requires further research in order to test this hypothesis and seems to be an important area for future studies.

Both the positive and negative schematic challenges led to a preoccupation with existential questioning, with the aim of making sense of the world and finding meaning in participants’ experiences. Negative and positive changes to schemas occurred in relation to world views, perception of self, and the day-to-day living, while positive changes were also expressed in relation to personal values. Although the areas of change were similar, the particular beliefs/schemas within each of these broad categories varied. While on the negative end, the world could be viewed as unsafe and people as untrustworthy, on the positive end, humanity can be perceived as resilient and a new appreciation of life is expressed. In terms of the self, it seems that some participants felt less compassionate and more suspicious, while others felt that they had become more compassionate as a result of their work. The findings suggested that the negative changes to self-schema were predominantly expressed by participants who were working with victims of sexual abuse (Clemans, 2004; Iliffe & Steed, 2000; Pistorius et al., 2008; Schauben & Frazier, 1995) or domestic abuse (Iliffe & Steed, 2000), and the mistrust seemed to be directed mainly toward men. This implies that specific types of trauma work may impact different schemas in different ways. The impact of the type of trauma work on VT and VPTG would therefore be an interesting area for future studies. Nevertheless, even among those who perceived themselves as less compassionate and more suspicious, other more positive changes to perception of self were able to occur and included elements such as increased self-awareness and self-worth and becoming a better professional. Finally, the negative and positive changes that participants have expressed throughout the articles extended beyond schemas into actual behaviors and day-to-day routines. Further studies are required in order to examine this point.

Finally, the above positive and negative changes to schemas found in this metasynthesis partially correspond to those mentioned by VT theories, such as changes to schemas in relation to safety, trust/dependency, esteem, control and intimacy (Pearlman & Mac Ian, 1995), and PTG theories which outline positive changes to schemas on relationships, new possibilities, appreciation for life, sense of personal strength and spiritual development (Tedeschi & Calhoun, 2008).

The above discussion should be considered within the synthesis’s limitations. To an extent, the analysis in this metasynthesis, as with any other review, is dependent on the quality of the original articles. In the current synthesis we have made a decision to be inclusive and not exclude articles on the basis of methodological rigor. This decision was taken in line with Atkins et al.’s (2008) position that there are no clear and agreed quality guidelines when it comes to qualitative articles, and that an exclusion of articles may skew relevant information and variations that may be important to the development of an overall theory. Another limitation relates to our search criteria, which included only journal articles. This decision was taken with the aim of maintaining the systematic nature of locating articles and also practical considerations. It may be, however, that there are additional qualitative findings which may be relevant to our questions that we have not considered because they were published in books rather than journals.

With these methodological issues in mind, the current metasynthesis explored the impact of trauma work, examining the concept of VPTG more closely and more specifically outlining the process of VPTG and its relation to the process of VT. It was found that the impact of trauma work can potentially increase short- and long-term levels of distress in professionals engaged in this type of work and that such distress can be managed through personal and organizational efforts. It was also found that trauma work leads to changes in schemas and day-to-day routines and that these changes can be both negative and positive, suggesting a more complex and combined view of the impact of trauma work. Finally, it was found that for VPTG to occur trauma workers need to be exposed to their clients’ own growth and that the type of trauma work may impact specific schemas.

A few implications stem from the current work. First, in terms of practical implications, this metasynthesis provides reinforcement for advocating provision of organizational support systems to manage the impact of trauma work on their employees. This could be, for example, in the form of procedures, support structures, or the fostering of an organizational culture that recognizes and acknowledges the impact of trauma work on individual practitioners. This study also highlights the possibility that in order to experience growth, trauma workers may need a more long-term (even if intermittent) engagement with clients so that there will be an opportunity to experience and witness the client’s recovery process and growth. In terms of implications for future research, this work highlights the need for a more cohesive view of trauma work rather than the traditional binary perception of either PTG or VT. It also highlights the possibility that VPTG is a similar but not identical construct to PTG, as the areas of growth in VPTG include some specific aspects such as becoming a better professional, developing greater awareness of and becoming actively involved in promoting issues relating to social in/justice. Therefore, VPTG may require further specific investigations into its nature and the development of specific measures to assess it.

Footnotes
1 Asterisks were used as part of the search terms to allow for all endings after the initial term to emerge; for example, “trauma*” would allow for all terms starting with “trauma” (e.g., traumatic, traumatised, etc.) to be included in the search results.

References
 Asterisks are used to differentiate between the synthesized studies and other papers/references included in this paper. Studies which were part of the synthesis are marked by an asterisk.

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Submitted: November 4, 2011 Revised: June 20, 2012 Accepted: July 25, 2012

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Source: Psychological Trauma: Theory, Research, Practice, and Policy. Vol. 5. (6), Nov, 2013 pp. 570-580)
Accession Number: 2012-30277-001
Digital Object Identifier: 10.1037/a0030388

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Trauma across generations and paths to adaptation and resilience.
Authors:
Lehrner, Amy. James J. Peters Veterans Affairs Medical Center, Bronx, NY, US, amy.lehrner@va.gov
Yehuda, Rachel. James J. Peters Veterans Affairs Medical Center, Bronx, NY, US
Address:
Lehrner, Amy, James J. Peters Veterans Affairs Medical Center 526 OOMH PTSD, 130 West Kingsbridge Road, Bronx, NY, US, 10468, amy.lehrner@va.gov
Source:
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 10(1), Jan, 2018. Posttraumatic Embitterment Syndrome. pp. 22-29.
NLM Title Abbreviation:
Psychol Trauma
Page Count:
8
Publisher:
US : Educational Publishing Foundation
ISSN:
1942-9681 (Print)
1942-969X (Electronic)
Language:
English
Keywords:
trauma, Holocaust, embitterment, biology, intergenerational transmission
Abstract:
Objective: There is a growing literature on the intergenerational transmission of trauma, representing approaches across psychodynamic, family systems, epidemiological, sociological, and biological levels of analysis. Embitterment has been proposed as a response to severe, but normative, stressful events, different from the life-threatening trauma that precedes posttraumatic stress disorder (PTSD). Method: This article reviews the potential applicability of the construct of embitterment to trauma and intergenerational effects through (a) a historical review of the intergenerational transmission of trauma literature, (b) a discussion of embitterment versus PTSD, (c) a brief review of theories of mechanisms of transmission, and (d) a discussion of biological findings and their interpretation. Results: Mechanisms of intergenerational transmission of trauma, which may include psychodynamic processes, vicarious trauma, learning and modeling, parenting and family environment, and biological influences, are reviewed. Survivor coping and resilience, and specifically the presence of PTSD, has emerged as an important moderator of parental trauma effects on the second generation. A table comparing posttraumatic embitterment disorder and PTSD is provided. Conclusion: The discussion emphasizes the importance of construing biological findings as flexible adaptations to stressors rather than deterministic indicators of damage, the relevance of context in interpreting such findings, and the role of community-level processes for healing. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Holocaust; *Transgenerational Patterns; *Trauma; Adaptation; Biology; Coping Behavior; Epidemiology; Family Systems Theory; Holocaust Survivors; Posttraumatic Stress Disorder; Psychodynamics; Resilience (Psychological); Sociology
PsycInfo Classification:
Psychological Disorders (3210)
Population:
Human
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: May 30, 2017; Revised: May 24, 2017; First Submitted: Mar 29, 2017
Release Date:
20180111
Copyright:
American Psychological Association. 2018
Digital Object Identifier:
http://dx.doi.org/10.1037/tra0000302
Accession Number:
2018-00130-004
Number of Citations in Source:
53
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Trauma Across Generations and Paths to Adaptation and Resilience
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Contents
History of the Study of the Intergenerational Transmission of Trauma
Embitterment as a Response to Trauma
Evidence for the Intergenerational Transmission of the Effects of Trauma
Biological Transmission of the Effects of Trauma
Interpreting Biological Findings
Conclusion
References
Full Text
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By: Amy Lehrner
James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Department of Psychiatry, Icahn School of Medicine at Mount Sinai;
Rachel Yehuda
James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Department of Psychiatry, Icahn School of Medicine at Mount Sinai
Acknowledgement:

There has been a broad, interdisciplinary approach to the question of whether and how the experience and consequences of surviving trauma are passed from one generation to the next. Studies range across levels of analysis, including psychodynamic, family systems, epidemiological, sociological, and biological (Abrams, 1999; Danieli, 1998; Sangalang & Vang, 2017). At present, there are more than 500 published articles and numerous books on the intergenerational transmission of trauma, with a small body of work investigating affects in the third generation (Giladi & Bell, 2013; Letzter-Pouw, Shrira, Ben-Ezra, & Palgi, 2014; Lev-Wiesel, 2007; Sagi-Schwartz, van IJzendoorn, & Bakermans-Kranenburg, 2008). This literature has sought to understand whether there are intergenerational effects of trauma, the nature of such effects, and the mechanisms of their transmission. At the core of this research are questions about the road to optimized biological and psychological adaptation and resilience in the aftermath of trauma and suffering.

In addition to posttraumatic stress disorder (PTSD), the most widely researched mental disorder resulting from trauma, the psychological construct of embitterment has been described following a life event “that is severe but not out of the range of normal” and that is “not fear based” (Linden, 2003; Linden, Rotter, Baumann, & Lieberei, 2006). Such events might include stressors such as divorce, losing one’s job, being turned down for a promotion, or being the victim of discrimination. Embitterment has been conceptualized as existing on a continuum from normal to pathological, where brief or manageable levels of embitterment may reflect a normative response to a stressor, but prolonged and disabling levels indicate psychopathology (Linden, 2003). Pathological embitterment (posttraumatic embitterment disorder [PTED]) includes a mood state of anger and helplessness, a belief that the world has treated one unfairly and that there has been a violation of one’s basic beliefs and value system, a desire for vengeance, and a deep sense of injustice. On the one hand, embitterment as a pathological response to a relatively normative experience would seem to exclude its application to trauma (despite the name “posttraumatic embitterment disorder”). On the other hand, the clinical description of embitterment may very well reflect a common response to individual or communal trauma. Furthermore, the conceptualization of embitterment as a complex emotional response to injustice or trauma (Linden, 2013) invites consideration of its application to circumstances of significant, communal trauma and injustice, such as genocide.

The label “embitterment” may carry a connotation of judgment, a suggestion that the embittered person is pathologically ruminative, stubbornly and unreasonably refusing to let go of a past wrong. The association is of a narrow-minded, obsessive, narcissistic, slightly paranoid personality, exemplified through literary figures such as Charles Dickens’ Ebenezer Scrooge (Diamond, 2012). In the context of the history of the study of intergenerational trauma effects, it initially seems that the construct of embitterment conveys misplaced blame and psychopathology and would not be applicable to the intergenerational response to trauma. This article investigates whether embitterment is a potentially useful construct in describing the intergenerational transmission of trauma effects through a review of (a) the history of research on the intergenerational transmission of trauma, (b) the relevance of embitterment versus posttraumatic stress disorder, (c) theories about mechanisms of transmission, and particularly (d) the role and interpretation of biological findings in the intergenerational transmission of the effects of trauma.

History of the Study of the Intergenerational Transmission of Trauma

Social scientists such as sociologists and anthropologists have long taken the logic and mechanisms of the intergenerational transmission of social and cultural phenomena as their object of study, and this has included the influence of communal trauma (e.g., Argenti & Schramm, 2009; Scheper-Hughes, 1993). These studies emphasize community-level, rather than individual-level, factors such as rituals, beliefs, and embodied practices. They also posit that cultural trauma refers to “a tear in the social fabric, affecting a group of people that has achieved some degree of cohesion” (Eyerman, quoted in Argenti & Schramm, 2009). As such, the impact of community level trauma such as war or genocide on individuals is transmitted through the ruptures in the community, the shifts in identity, and the concrete sociostructural changes wrought by the traumatic historical event.

At an individual, psychological level, early investigations into clinical and functional outcomes in offspring of traumatized parents emerged following World War II, as clinicians and researchers sought to understand the legacy of the Holocaust among survivors and their children. This research led to an expansion of investigations into the intergenerational transmission of trauma across many communities and populations that have experienced war, genocide, and trauma, such as First Nation/Native American communities, survivors of the Rwandan, Croatian, and Cambodian genocides, war refugees who have been tortured, and combat veterans (Daud, Skoglund, & Rydelius, 2005; Davidson & Mellor, 2001; Dekel & Goldblatt, 2008; Evans-Campbell, 2008; Field, Muong, & Sochanvimean, 2013; for critiques, see Kirmayer, Gone, & Moses, 2014; Maxwell, 2014).

As with all research, studies of the intergenerational transmission of the effects of trauma take place in a social and political context, and are open to different interpretations. Particularly regarding survivors of genocide, such research has sparked debate about the implications of emphasizing resilience versus pathology. Early research on Holocaust survivors’ offspring emerged from psychoanalytic clinical reports of psychopathology in this population. There were rapid responses by social scientists attempting to dismiss this literature, arguing that offspring have evidenced resilience and success, that “living well is the best revenge,” and that second-generation survivors are no more damaged or ill than any other group. Epidemiological studies in Israel comparing Holocaust offspring with comparable controls did not identify higher rates of psychopathology or impairment among offspring (Major, 1996; Levav, Levinson, Radomislensky, Shemesh, & Kohn, 2007; van IJzendoorn, Bakermans-Kranenburg, & Sagi-Schwartz, 2003). Indeed, some research found that Holocaust offspring raised in Israel had higher levels of optimism than comparable controls (Shrira, Palgi, Ben-Ezra, & Shmotkin, 2011).

Into this apparent standoff between those who argued the importance of recognizing that many offspring feel traumatized, damaged, and impaired and those who argued that there were no deleterious effects of the Holocaust on the second generation, came researchers and clinicians who posited that an assumption of damage to the second generation (or of benefit, for that matter) is overly simplistic, and that it would be more fruitful to investigate different types of responses to parental trauma. Certainly offspring are deeply touched by their parents’ experiences during the Holocaust, and many have turned to the arts to explore and express these influences (e.g., Spiegelman, 2003). One central issue to emerge is the meaning of resilience in second-generation offspring. Resilience implies adaptability, strength, or flexibility in the face of a stressor. However, resilience in children of trauma survivors is difficult to operationalize and measure. It may reflect the absence of psychopathology, the presence of positive attributes or outcomes, or certain biological adaptations. The presence of multiple, possibly conflicting, indicators further complicate any simple definition. A second key development in the literature was the recognition that the survivor’s own coping and distress, rather than simply the fact of their exposure to trauma, is crucial to outcomes observed in their offspring (described in more detail below).

Embitterment as a Response to Trauma

PTSD is a well-characterized and widely studied response to life-threatening trauma such as torture, genocide, war, and catastrophe. Embitterment has been proposed as a response to a severe, if not life-threatening, stressor. It has been proposed in contrast to a PTSD conceptualized as a fear-based disorder, built on a process of fear conditioning. However, the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013) recently reclassified PTSD from the anxiety disorders into a new class of “Trauma and Stressor-related Disorders.” New diagnostic criteria allow for presentations that are more depressive or dissociative, for example, than fearful. Pervasive negative cognitions and affect such as distorted blame of self or others, and guilt and shame, have broadened the conceptualization of PTSD. This section explores whether embitterment provides additional or different diagnostic purchase on posttrauma presentations.

There are similarities and differences between PTED and PTSD. Table 1 provides a comparison of the diagnostic criteria, which shows that the additional signs and symptoms of PTED, rather than the core diagnostic criteria, appear to have the most overlap with PTSD. Many of the clinical descriptions of PTED could be observed in trauma survivors. Especially in the context of DSM–5, the challenges to worldview and sense of self described by Linden in PTED (Linden, 2013) are now explicitly subsumed as symptoms of PTSD. According to Linden, the embittered person finds the recall of the event both painful and rewarding, and becomes increasingly ruminative about the event. Thus the person continually revisits the old wrong, stoking the anger and helplessness. This is a distinction from PTSD, in which the individual will go to any lengths to avoid thinking about the trauma, as the memory triggers a reexperiencing of fear, horror, shame, and other aversive feelings. Trauma memories are thus avoided, and trauma-related thoughts and images are experienced as unwanted and intrusive rather than intentionally ruminated upon. However, feelings of anger and helplessness, a shattered belief about the fairness of the world, and the meaningfulness of basic beliefs and values, and rage and desire for vengeance could all be conceptualized within the PTSD framework. In PTSD, the individual often has an internalized component, feeling that the trauma has left them damaged and changed, and there is often a residue of shame. Embitterment appears to be a more externalizing phenomenon, characterized by righteous anger at the injustice that was not deserved and must be avenged. Regardless of one’s innocence, the person with PTSD will wonder “why me?” whereas the person with embitterment may wonder “how dare they!?”

tra-10-1-22-tbl1a.gifComparison of Posttraumatic Embitterment Disorder (PTED) and Posttraumatic Stress Disorder (PTSD) Diagnostic Criteria

The emphasis in embitterment on (in)justice and the violation of basic beliefs and values are intriguing in the context of a real and catastrophic injustice, ranging from genocide to rape (as opposed to natural disaster). After man-made and intentional horrors such as genocide, survivors may well be deeply preoccupied by righteous anger and existential questions about the possibility of justice and human value in the world. The psychological construct of PTED proposes a pathological and self-defeating reaction to a negative life event, but does not address the question of what the adaptive response to injustice and the upheaval of a value system should look like. Perhaps there is a healthy or appropriate degree of embitterment; perhaps this is determined by whether it becomes impairing or conversely spurs individuals or communities to action. In Judaism, there is a core value of remembering and even commemorating traumatic events. A common mantra in the Jewish religion with respect to Holocaust Remembrance Day is “never forget.” Memorializing traumatic events and persecutions are at the heart of many Jewish holidays, most notably Passover, Chanuka, and Purim. Surely those remembrances are designed to elicit some degree of negative affect, but they are designed to also acknowledge that there is life after tragedy, triumph following adversity, and value in the communal celebration of endurance and survival. Remembering trauma may also have adaptational value in terms of ensuring that communities and individuals maintain vigilance for their safety and survival and stand in solidarity with other communities facing violence and injustice.

While Holocaust survivors certainly experienced events “outside of the range of normal” and characterized by fear, their offspring were born into difference circumstances. They learned of the Holocaust, saw the direct effects in their parents, and for many, felt its complex legacy within themselves. Embitterment is a reaction to being wronged, which for Holocaust offspring may be especially complicated. Most obviously, offspring may feel angry and helpless in the face of history, wronged by Nazis, by Germans, by a world that did not act fast enough to come to the rescue of the Jews. As this wrong was mediated through their parents, however, some offspring may also feel wronged by their parents, for their abusive or neglectful parenting, for their strange behaviors and their difference, for their fragility or their neediness. Anger and helplessness toward their own survivor parents is of course deeply conflicting, generating feelings of shame, guilt, and anger at the self. Embitterment might turn toward the self, feeding feelings of anger and helplessness at being unable to save or heal one’s parents, at one’s inadequacy, weaknesses, and failures.

Both embitterment and PTSD may be reactions to severe life stressors. Short of PTED, the response of feeling embittered may represent one potential normalized reaction, whereas PTSD has been rendered a psychopathology. Once in the realm of PTED, however, it may be that whether the trauma sequelae are more fear based or more embitterment focused, if the psychopathological response is to a life-threatening trauma, some intergenerational mechanisms of transmission may be the same. In both cases these reactions occur in the minority of trauma survivors, necessitating inquiry into who becomes impaired and why. The events themselves are not sufficient to explain the response. Individual and intergenerational differences in vulnerability and resilience have thus become targets of research.

Evidence for the Intergenerational Transmission of the Effects of Trauma

As noted above, there are many approaches to the study of intergenerational effects of trauma. Regarding Holocaust offspring, clinical samples have found that second-generation survivors have a predisposition to PTSD and differences in individuation/separation (Kellerman, 2001). In community samples, offspring had higher rates of PTSD and mood and anxiety disorders compared to Jewish controls (Yehuda, Schmeidler, Wainberg, Binder-Brynes, & Duvdevani, 1998). Other nonclinical and epidemiological samples have found that offspring do not evidence higher rates of psychopathology than comparable control subjects (Kellerman, 2001; Levav et al., 2007; van IJzendoorn et al., 2003) and even report greater well-being (Shrira et al., 2011). Interestingly, despite the subjective reports of well-being, offspring in the Shrira et al. (2011) study also reported more physical health problems, which may imply negative effects of repression coping or biologically transmitted stress effects. International research has also documented significant impacts of parental trauma on children. For example, immigrant children of tortured parents had more symptoms of anxiety, depression, posttraumatic stress, attention deficits, and behavioral disorders than controls (Daud et al., 2005). A recent literature review of the intergenerational transmission of trauma in refugee families found a higher risk of psychological problems and vulnerability to stress in offspring in over half the studies reviewed (Sangalang & Vang, 2017).

Some of the mixed findings in the literature likely reflect the important difference between assessing parental exposure to trauma versus parental coping and adaptation following trauma, as noted above. In fact, studies have consistently found that it is the failure to recover from trauma, indicated by the presence of PTSD or high rates of posttraumatic stress symptoms, that in fact mediates the impact of parental trauma on their children. For example, parental PTSD has been associated with higher rates of PTSD, depression, and anxiety in Holocaust offspring compared to controls and offspring with no parental PTSD (Yehuda, Halligan, & Bierer, 2001). Across two samples of Cambodian mother–child dyads in which mothers had survived the Khmer Rouge regime, the mother’s PTSD symptoms, rather than trauma exposure, predicted anxiety in their daughters (Field et al., 2013). A literature review of the impact of combat exposure in fathers on offspring likewise found that veterans’ PTSD rather than combat exposure per se was associated with greater offspring distress (Dekel & Goldblatt, 2008). There is no empirical research to date on the potential role of embitterment or PTED on the intergenerational transmission of trauma effects.

Thus, at the individual level the intergenerational transmission of trauma is likely more accurately conceptualized as the intergenerational impact of parental PTSD. At the community level, the transmitted effects may be less about the event itself than about the resources (cultural, political, spiritual, etc.) of the community to absorb, make sense of, respond to, and heal from the trauma. The traumatic event clearly resonates across generations, but not with a singular outcome. Offspring may show vulnerability to social or interpersonal stressors or they may show resilience, and these reactions to historical events are mediated through their parents’ responses.

Researchers have studied how Holocaust effects are transmitted by parents through psychodynamic influences, vicarious trauma, learning and modeling, parenting and family environment, and biological influences (Dekel & Goldblatt, 2008). Vicarious trauma refers to the impact of hearing details of traumatic events, resulting in PTSD-like symptoms of nightmares and intrusive images. In terms of learning and modeling, offspring may directly learn from parents to be fearful and anxious, that threat is everywhere, that the world is unsafe, and that people cannot be trusted. In the case of a primary reaction of embitterment in the survivor, this pervasive emotional state and its associated preoccupations may be absorbed by their children. Trauma can profoundly affect parenting, especially trauma that included the loss of family members. Offspring have described overprotection by parents, but also numbness, distance, and neglect. Among combat veterans, paternal emotional detachment, an aspect of PTSD, has been observed to specifically contribute to offspring distress (Ruscio, Weathers, King, & King, 2002) In our most recent study of offspring (n = 73), 32% described a sense of being abandoned by their parents, and 20% reported having to take care of a mother (unpublished data; see Yehuda et al., 2014, for a description of sample and methods). Children may become parentified in the face of fragile or poorly functioning parents, and this may have negative effects on their functioning and mental health. For example, research with high school students whose parents were survivors of the Cambodian Khmer Rouge genocide found that parenting styles characterized by role reversal and maternal overprotection mediated the relationship of parental trauma symptoms with depression and anxiety in the adolescent offspring (Field, Om, Kim, & Vorn, 2011). Follow-up studies confirmed the role of maternal role reversal, characterized by parental helplessness, incompetence, use of guilt, demands for attention, request for direction, and relating to children as a peer, as mediating the influence of maternal PTSD on their children’s anxiety (Field et al., 2013).

Research with Holocaust survivors and their children in Brazil identified a number of mechanisms within the family that may lead either to the transmission of trauma effects or to resilience (Braga, Mello, & Fiks, 2012). They suggested that the degree to which the survivor has been able to work through their traumatic experiences is central to the functioning of their children. When survivors are unable to process their experiences and evidence psychological and somatic symptoms, this may lead to communication styles characterized by fragmentation, indirectness, silence, and the keeping of secrets. Repercussions for the offspring include feelings of guilt, victimization, and identification with the survivor, and the development of a terrifying worldview. In contrast, survivors who found ways to work through their experiences, who developed personal narratives and stories, cultural rituals, and who maintained a defense of universal values developed communication styles characterized by openness and love, directness, and the use of humor as a symbolic resource of resilience. The resilience of their offspring takes many forms, including artistic creation, visits to places of importance to their parents and a search for knowledge, forms of collective bonding and the ability to develop and use social support networks, a commitment to universal values and social and political activism, and a mirroring of parental patterns of resilience.

It is important that research on the intergenerational effects of trauma assess and report such indicators of resilience, rather than implying that the only possible outcomes are mental health and functional problems or a null effect. For example, research with parents and their children (ages 10–12) exposed to warzone threats in Gaza, Palestine, found that maternal war-related trauma exposure was associated with less, rather than more, psychological maltreatment of their children (Palosaari, Punamäki, Qouta, & Diab, 2013). Maternal trauma exposure in this study was in fact associated with less childhood depression and aggression, mediated by reduced maltreatment.

Biological Transmission of the Effects of Trauma

One of the significant shifts in the debate about whether trauma may have intergenerational effects was the finding that Holocaust offspring had biological signatures similar to those who have been directly traumatized. Importantly, this research showed that these biological echoes are observed in offspring of parents with PTSD, rather than in all Holocaust offspring, findings consistent with research in animals and other human populations (Palma-Gudiel, Córdova-Palomera, Eixarch, Deuschle, & Fananas, 2015; K. Liu et al., 2016; Rodgers, Morgan, Leu, & Bale, 2015). This research has repeatedly documented dysregulation of the hypothalamic–pituitary–adrenal axis, also observed in PTSD, in Holocaust offspring with parental PTSD regardless of their own PTSD status. Circadian rhythm, urinary and plasma cortisol levels, glucocorticoid sensitivity, and epigenetic regulation of the glucocorticoid receptor gene have all been shown to distinguish offspring with parental PTSD from those without and from controls (Lehrner et al., 2014; Yehuda et al., 2000, 2014; Yehuda, Blair, Labinsky, & Bierer, 2007; Yehuda, Teicher, et al., 2007). For example, urinary cortisol in offspring with parental PTSD is lower than that of comparison subjects and offspring whose parents did not evidence PTSD, consistent with a profile of lower cortisol in PTSD (Yehuda et al., 2000). Parental PTSD associates with greater glucocorticoid sensitivity in Holocaust offspring, a pattern observed in those with PTSD (Lehrner et al., 2014; Yehuda, Blair, et al., 2007). Most recently, upstream molecular mechanisms reflecting epigenetic regulation of glucocorticoid sensitivity have been found to differ in offspring with parental PTSD compared with controls (Yehuda et al., 2014). The glucocorticoid receptor 1F exon promoter is less methylated in Holocaust offspring with maternal PTSD, a finding consistent with the higher glucocorticoid responsiveness in offspring previously observed.

Potential mechanisms for this transmission include in utero programming resulting from exposure to maternal stress hormones, postnatal accommodation to parental behavior, or direct transmission of a trauma-related epigenetic change from parent to offspring. Evidence for the potential of in utero glucocorticoid programming comes from research with women who survived the World Trade Center attacks on September 11, 2001, and their children. Women who had been pregnant at the time of the attacks and who developed PTSD had lower cortisol levels than women without PTSD, and so did their 7-month-old infants (Yehuda et al., 2005). There was a significant effect of trimester such that babies exposed during the third trimester had significantly lower salivary cortisol.

Epigenetic accommodations could result from postnatal influences of parenting and family environment, or more directly from parent to child. Findings from animal research demonstrate that postnatal environmental influences, such as maternal licking and grooming, can influence glucocorticoid receptor methylation and stress responses in offspring (D. Liu et al., 1997; Weaver et al., 2004). In the first demonstration of an association of preconception trauma with epigenetic marks in parents and offspring, Yehuda et al. (2016) recently reported an association of FKBP5 methylation levels in Holocaust survivor parents and their offspring. Furthermore, there were site- specific effects of parental trauma versus early child abuse, suggesting that it may be possible to distinguish epigenetically transmitted effects from those acquired through direct experience.

Interpreting Biological Findings

Biological mechanisms of the transmission of the effects of trauma are complex and still largely unknown. Regardless, research to date suggests that the feeling that offspring have been affected by parental Holocaust exposure can be supported by biology. However, the interpretation of these findings is not inherent in the data and can be quite subjective. It is easy for popular media and others to espouse a biological reductionism, in which biological markers are assumed to destine an individual to some negative outcome, rendering him or her the same as the trauma survivor. However, offspring may demonstrate similar biological signatures as their parents, or quite different ones reflecting adaptations or reactions to parental biology and behavior. Furthermore, biology is not valenced positively or negatively; trauma-related biological changes simply reflect our species’ ability to adapt flexibly to environmental stressors and threats, giving us an evolutionary advantage.

Therefore, the fact that children of traumatized parents may show differences in their stress-response systems does not necessitate an interpretation that they are damaged. Certainly, a biological adaptation is not so specific as to transmit or induce embitterment. In research with adult Holocaust offspring, a full 87% endorsed that they are more sensitive to violence and injustice as a result of their parents’ Holocaust experiences, and 74% reported that they believe they have unique strengths as a result of being raised by Holocaust survivors (unpublished data). A large minority, 42%, reported believing that they are more resilient to stress than others their age not raised by Holocaust survivors. Many described political activism and community volunteering that enhances their lives and that they directly link to their offspring status. This is consistent with findings of higher levels of optimism and hope among offspring compared with controls (Shrira et al., 2011), and with research on posttraumatic growth (Lev-Wiesel & Amir, 2003; Prati & Pietrantoni, 2009).

The observation of biological effects in the offspring of parents exposed to significant stressors is not unique to the Holocaust. Epidemiological research on starvation and food availability has shown a differential risk of diabetes, obesity, and heart disease in children and even grandchildren (Kaati, Bygren, & Edvinsson, 2002; Painter, Roseboom, & Bleker, 2005). Such developmentally programmed changes allow for flexible and adaptive responding to the environment. This may lead to a mismatch for offspring facing profoundly different environments than their parents, but heightened sensitivity or reactivity does not necessitate psychopathology. Humans are unique in our capacity for meaning making, and knowledge about ourselves and our past can give us leverage to make choices about how we respond to the world around us.

Conclusion

Feelings of embitterment, including a sense of having been profoundly wronged, righteous anger and a desire for justice, even vengeance, may be normal rather than pathological in individuals and communities traumatized by genocidal violence. Such experiences are profoundly social and relational; they are community-level as well as individual-level traumas. As such, the damage done by such experiences requires not only individual- and family-level interventions, but also community-level responses for healing and recovery. Injustice done requires public acknowledgment, the making of amends, restitution, or reparations, and the willingness of the larger community to bear witness and honor the suffering. Many models have been developed to promote this kind of healing, ranging from the prosecution of war crimes through the United Nations, to truth and reconciliation commissions at the national level, to restorative justice programs in local communities (Bazemore & Walgrave, 1999; Kaminer, Stein, Mbanga, & Zungu-Dirwayi, 2001; Van Ness & Strong, 2014). These models are not without controversy and challenge, and require balancing issues of accountability and forgiveness (Mamdani, 2002). Ideally, however, such opportunities promote agency and dignity for survivors and their children, providing venues to turn anger and helplessness at injustice into self-efficacy.

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Submitted: March 29, 2017 Revised: May 24, 2017 Accepted: May 30, 2017

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Source: Psychological Trauma: Theory, Research, Practice, and Policy. Vol. 10. (1), Jan, 2018 pp. 22-29)
Accession Number: 2018-00130-004
Digital Object Identifier: 10.1037/tra0000302

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Grundlingh, Heidi, ORCID 0000-0002-2761-4913 . Social and Mathematical Epidemiology Group, Gender Violence and Health Center, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, gloriahheidi@gmail.com
Knight, Louise. Social and Mathematical Epidemiology Group, Gender Violence and Health Center, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
Naker, Dipak. Raising Voices, Kampala, Uganda
Devries, Karen, ORCID 0000-0001-8935-2181 . Social and Mathematical Epidemiology Group, Gender Violence and Health Center, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
Address:
Grundlingh, Heidi, Social and Mathematical Epidemiology Group, Gender Violence and Health Center, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom, gloriahheidi@gmail.com
Source:
BMC Psychiatry, Vol 17, Jun 2, 2017. ArtID: 204
NLM Title Abbreviation:
BMC Psychiatry
Publisher:
United Kingdom : BioMed Central Limited
ISSN:
1471-244X (Electronic)
Language:
English
Keywords:
Secondary distress, Emotional distress, Vicarious trauma, Secondary traumatic stress, Violence, Debriefing, Trial, Epidemiology, Researchers
Abstract:
Background: Secondary distress including emotional distress, vicarious trauma (VT) and secondary traumatic stress (STS) due to exposure to primary trauma victims have been described in helping professionals and in violence researchers. To our knowledge, there are few prevalence studies, and no tailored interventions have been tested to reduce secondary distress in violence researchers. The study aims to (1) describe the epidemiology of secondary distress experienced by violence researchers; to (2) assess the effectiveness of group debriefings in mitigating secondary distress; to (3) assess risk and protective factors. Methods: We conducted an un-blinded, individually randomised trial with parallel assignment. Eligible participants were 59 Ugandan researchers employed by the Good Schools Study to interview children who experienced violence in a district of Uganda. Fifty-three researchers agreed to participate and were randomly allocated. The intervention group (n = 26) participated in three group debriefings and the control group (n = 27) in three leisure sessions (film viewings). The primary outcome was change in levels of emotional distress (SRQ-20); secondary outcomes were levels of VT and STS at end-line. A paired t-test assessed the difference in mean baseline and end-line emotional distress. Un-paired t-tests compared the change in mean emotional distress (baseline vs. end-line), and compared levels of VT and STS at end-line. Separate logistic regression models tested the association between end-line emotional distress and a-priori risk or protective factors. Results: Baseline and end-line levels of emotional distress were similar in control (p = 0.47) and intervention (p = 0.59) groups. The superiority of group debriefing over leisure activities in lowering levels of emotional distress in the intervention group (n = 26; difference in SRQ-20 = 0.23 [SD = 2.18]) compared to the control group (n = 26; difference in SRQ-20 = 0.23 [SD = 1.63]) could not be detected (p = 1). In regression analysis (n = 48), baseline distress increased the odds of end-line distress (OR = 16.1, 95%CI 2.82 to 92.7, p = 0.002). Perceived organisational support (OR = 0.09, 95%CI 0.01 to 0.69, p = 0.02) and belief in God (OR = 0.21, 95%CI 0.03 to 1.26, p = 09) was protective against end-line distress. Conclusion: We found no evidence that violence researchers experienced elevated emotional distress after doing violence research. There was no difference between group debriefings and leisure activities in reducing distress in our sample. However, the hypotheses presented should not be ruled out in other violence research settings. Our findings suggest that organisational support is a significant protective factor and belief in God may be an important coping mechanism. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Distress; *Experimenters; *Impaired Professionals; *Trauma; *Violence; Epidemiology
PsycInfo Classification:
Impaired Professionals (3470)
Population:
Human
Male
Female
Location:
Uganda
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Self-Report Questionnaire-20
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Impact of Event Scale–Revised DOI: 10.1037/t12199-000
Vicarious Trauma Scale DOI: 10.1037/t03119-000
Grant Sponsorship:
Sponsor: Medical Research Council, United Kingdom
Recipients: No recipient indicated

Sponsor: DfID
Recipients: No recipient indicated

Sponsor: Wellcome Trust
Other Details: Joint Global Health Trials scheme
Recipients: No recipient indicated

Sponsor: Hewlett Foundation
Recipients: No recipient indicated
Clinical Trial Number:
NCT02390778 ; NCT01678846
Methodology:
Clinical Trial; Empirical Study; Followup Study; Interview; Quantitative Study
Supplemental Data:
Experimental Materials Internet
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jun 2, 2017; Accepted: Apr 24, 2017; First Submitted: Apr 8, 2016
Release Date:
20170619
Correction Date:
20200706
Copyright:
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.. The Author(s). 2017
Digital Object Identifier:
http://dx.doi.org/10.1186/s12888-017-1327-x
PMID:
28578682
Accession Number:
2017-24915-001
Number of Citations in Source:
59
Images:
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Posttraumatic stress symptoms in palliative care professionals seeking mindfulness training: Prevalence and vulnerability.
Authors:
O’Mahony, Sean. Section of Palliative Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, US
Gerhart, James I.. Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, US, james_gerhart@rush.edu
Grosse, Johanna. Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, US
Abrams, Ira. Shambhala Meditation Center of Chicago, Chicago, IL, US
Levy, Mitchell M.. Warren Alpert Medical School, Brown University, Providence, RI, US
Address:
Gerhart, James I., Department of Behavioral Sciences, Rush University Medical Center, 1725 W. Harrison St. 950, Chicago, IL, US, 60612, james_gerhart@rush.edu
Source:
Palliative Medicine, Vol 30(2), Feb, 2016. pp. 189-192.
NLM Title Abbreviation:
Palliat Med
Page Count:
4
Publisher:
US : Sage Publications
Other Publishers:
United Kingdom : Hodder Arnold
ISSN:
0269-2163 (Print)
1477-030X (Electronic)
Language:
English
Keywords:
Posttraumatic stress disorder, compassion fatigue, burnout, traumatic stress, experiential avoidance, cognitive fusion
Abstract:
Background: Vicarious exposure to trauma is ubiquitous in palliative medicine. Repeated exposure to trauma may contribute to compassion fatigue and posttraumatic stress disorder symptoms in medical and supportive care professionals such as physicians, nurses, and social workers. These symptoms may be intensified among medical and supportive care professionals who use avoidant or rigid coping strategies. Aim: This study aimed to provide an estimate of posttraumatic stress disorder symptoms in a sample of professionals who work in palliative care settings, and have already been enrolled in mindfulness-based communication training. Design: Palliative care providers provided self-reported ratings of posttraumatic stress disorder symptoms, depression, and coping strategies using validated measures including the Acceptance and Action Questionnaire, Cognitive Fusion Questionnaire, and the Posttraumatic Stress Disorder Checklist–Civilian Version. Setting/participants: A total of 21 professionals working with palliative care patients completed assessments prior to beginning mindfulness-based communication training. Results: Posttraumatic stress disorder symptoms were prevalent in this sample of professionals; 42% indicated positive screens for significant posttraumatic stress disorder symptoms, and 33% indicated probable posttraumatic stress disorder diagnosis. Conclusion: Posttraumatic stress disorder symptoms may be common among professionals working in palliative medicine. Professionals prone to avoidant coping and those with more rigid negative thought processes may be at higher risk for posttraumatic stress disorder symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Palliative Care; *Posttraumatic Stress Disorder; *Mindfulness; *Experiential Avoidance; Coping Behavior; Stress
PsycInfo Classification:
Health & Mental Health Services (3370)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Posttraumatic Stress Disorder Checklist–Civilian Version
Acceptance and Action Questionnaire–Version II
PTSD Symptom Checklist
Beck Depression Inventory–II DOI: 10.1037/t00742-000
Cognitive Fusion Questionnaire DOI: 10.1037/t29449-000
Grant Sponsorship:
Sponsor: Prince Charitable Trusts
Recipients: No recipient indicated
Methodology:
Empirical Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20161027
Correction Date:
20190211
Copyright:
The Author(s). 2015
Digital Object Identifier:
http://dx.doi.org/10.1177/0269216315596459
Accession Number:
2016-04077-009
Number of Citations in Source:
22
Result List Refine Search PrevResult 60 of 68 Next
The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: A systematic review.Open Access
Authors:
van Mol, Margo M. C.. Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands, m.vanmol@erasmusmc.nl
Kompanje, Erwin J. O.. Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
Benoit, Dominique D.. Department of Intensive Care, Medical Unit, Ghent University Hospital, Ghent, Belgium
Bakker, Jan, ORCID 0000-0003-2236-7391 . Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
Nijkamp, Marjan D., ORCID 0000-0001-7335-9653 . Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Heerlen, Netherlands
Address:
van Mol, Margo M. C., m.vanmol@erasmusmc.nl
Source:
PLoS ONE, Vol 10(8), Aug 31, 2015. ArtID: e0136955
NLM Title Abbreviation:
PLoS One
Publisher:
US : Public Library of Science
ISSN:
1932-6203 (Electronic)
Language:
English
Keywords:
healthcare professionals, compassion fatigue, emotional distress, burnout, mindfulness
Abstract:
Background: Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally charged challenge that might affect the emotional stability of medical staff. The quality of care for ICU patients and their relatives might be threatened through long-term absenteeism or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order to preserve their own health. Purpose: The purpose of this review is to evaluate the literature related to emotional distress among healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and compassion fatigue and the available preventive strategies. Methods: A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl, Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles published between 1992 and June, 2014. Studies reporting the prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals were included, as well as related intervention studies. Results: Forty of the 1623 identified publications, which included 14,770 respondents, met the selection criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%; five studies described the prevalence of secondary traumatic stress ranging from 0% to 38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide range of intervention strategies emerged from the recent literature search, such as different intensivist work schedules, educational programs on coping with emotional distress, improving communication skills, and relaxation methods. Conclusions: The true prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals remains open for discussion. A thorough exploration of emotional distress in relation to communication skills, ethical rounds, and mindfulness might provide an appropriate starting point for the development of further preventive strategies. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Empathy; *Fatigue; *Intensive Care; *Occupational Stress; *Health Personnel; Epidemiology; Psychological Stress; Mindfulness
Medical Subject Headings (MeSH):
Adaptation, Psychological; Anxiety Disorders; Burnout, Professional; Compassion Fatigue; Critical Care; Empathy; Health Personnel; Humans; Intensive Care Units; Mindfulness; Prevalence; Stress, Psychological; Surveys and Questionnaires
PsycInfo Classification:
Impaired Professionals (3470)
Population:
Human
Age Group:
Adulthood (18 yrs & older)
Tests & Measures:
Post Traumatic Stress Syndrome 10 Questions Inventory
Professional Quality of Care Questionnaire
Secondary Traumatic Stress Scale DOI: 10.1037/t06768-000
Maslach Burnout Inventory
Posttraumatic Diagnostic Scale DOI: 10.1037/t02485-000
Methodology:
Literature Review; Systematic Review
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Aug 31, 2015; Accepted: Aug 11, 2015; First Submitted: Sep 27, 2014
Release Date:
20151012
Correction Date:
20200625
Copyright:
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.. van Mol et al.. 2015
Digital Object Identifier:
http://dx.doi.org/10.1371/journal.pone.0136955
PMID:
26322644
Accession Number:
2015-40766-001
Number of Citations in Source:
93
Result List Refine Search PrevResult 61 of 68 Next
Exploring the counselor’s experience of working with perpetrators and survivors of domestic violence.
Authors:
Iliffe, Gillian. Curtin U of Technology, Bentley, WAU, Australia
Steed, Lyndall G.
Source:
Journal of Interpersonal Violence, Vol 15(4), Apr, 2000. pp. 393-412.
NLM Title Abbreviation:
J Interpers Violence
Page Count:
20
Publisher:
US : Sage Publications
ISSN:
0886-2605 (Print)
1552-6518 (Electronic)
Language:
English
Keywords:
professional & personal impact from working with perpetrators & survivors of domestic violence, counselors (mean age 45.8 yrs)
Abstract:
Examined the professional and personal impact on counselors from working with domestic violence (DV) clients. Semi-structured interviews with 18 counselors (mean age 45.8 yrs) having case loads of more than 50% DV clients yielded themes including initial impact of DV counseling, personal impact of hearing traumatic material, changes to cognitive schema, challenging issues for DV counselors, burnout, and coping strategies. Ss described classic symptoms of vicarious trauma, and reported changes in cognitive schema, particularly in regard to safety, world view, and gender power issues. Challenging aspects of DV counseling included changes in counseling practice to meet the unique needs of DV clients, difficulties with confidentiality, and feelings of isolation and powerlessness. 12 Ss reported feelings of burnout. Reported adaptive strategies included monitoring client caseloads, debriefing, peer support, self-care and political involvement for social change. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Counselor Attitudes; *Domestic Violence; *Occupational Stress; *Psychotherapeutic Processes; Perpetrators; Psychotherapeutic Counseling; Victimization
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Middle Age (40-64 yrs)
Methodology:
Empirical Study
Format Covered:
Print
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20000601
Correction Date:
20200827
Digital Object Identifier:
http://dx.doi.org/10.1177/088626000015004004
Accession Number:
2000-08063-004
Result List Refine Search PrevResult 62 of 68
The emotional challenges faced by sexual assault nurse examiners: ‘ER nursing is stressful on a good day without rape victims’.
Authors:
Maier, Shana L.. Department of Criminal Justice, Chester, PA, US, slmaier@mail.widener.edu
Address:
Maier, Shana L., Department of Criminal Justice, Widener University One, University Place, Chester, PA, US, 19013, slmaier@mail.widener.edu
Source:
Journal of Forensic Nursing, Vol 7(4), Dec, 2011. pp. 161-172.
NLM Title Abbreviation:
J Forensic Nurs
Page Count:
12
Publisher:
United Kingdom : Wiley-Blackwell Publishing Ltd.
Other Publishers:
US : International Association of Forensic Nurses (IAFN)
US : Lippincott Williams & Wilkins
ISSN:
1556-3693 (Print)
1939-3938 (Electronic)
Language:
English
Keywords:
emotional challenges, sexual assault, nurse examiners, rape victims
Abstract:
Although research has indicated that counselors, advocates and social workers who Help rape victims experience vicarious trauma or psychological consequences as a result of their exposure to victims’ traumatic experiences, little is known about Sexual Assault Nurse Examiners’ (SANEs’) experiences. This qualitative research explores SANEs’ experiences of vicarious trauma and burnout as a result of treating rape victims, and the coping strategies they implement to reduce both. Data from interviews with 39 SANEs reveal that when asked about their difficulties as a SANE and the hardest part of their job, the majority (67%) discussed vicarious trauma, the emotional demands associated with the job, worrying about victims after they leave the hospital, and burnout. More than half (51%) of SANEs interviewed specifically indicated that they have experienced vicarious trauma as a result of treating rape victims, and 46% indicated they have experienced burnout at least to some degree. All SANEs, regardless of whether they believe they have experienced vicarious trauma or burnout, have ways to cope after hard cases. These coping mechanisms include talking to family members, calling or reaching out to other SANEs, program coordinators or rape victim advocates and detectives, participating in meetings with other SANEs where the focus is on problems after difficult cases, and finding relaxing activities. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Nurses; *Rape; *Sex Offenses; *Trauma; *Victimization; Medical Personnel
Medical Subject Headings (MeSH):
Adult; Burnout, Professional; Crime Victims; Emergency Nursing; Emergency Service, Hospital; Female; Humans; Middle Aged; Nurse-Patient Relations; Nursing Assessment; Nursing Staff, Hospital; Rape; Sex Offenses; Surveys and Questionnaires; United States; Young Adult
PsycInfo Classification:
Inpatient & Hospital Services (3379)
Population:
Human
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Traumatic Stress Institute Belief Scale
Symptom Checklist-90–Revised-Global Severity Index
Symptom Checklist-90–Revised-Compassion Fatigue Test
Maslach Burnout Inventory
Symptom Checklist-90–Revised DOI: 10.1037/t01210-000
Impact of Event Scale DOI: 10.1037/t00303-000
Coping Strategies Inventory
Penn Inventory for Posttraumatic Stress Disorder DOI: 10.1037/t07464-000
Grant Sponsorship:
Sponsor: Provost’s Grant
Recipients: No recipient indicated

Sponsor: Widener University
Other Details: Faculty Development Grant
Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Accepted: Apr 5, 2011; First Submitted: Feb 17, 2011
Release Date:
20120409
Correction Date:
20130318
Copyright:
International Association of Forensic Nurses. 2011
Digital Object Identifier:
http://dx.doi.org/10.1111/j.1939-3938.2011.01118.x
PMID:
22123036
Accession Number:
2011-27862-004
Number of Citations in Source:
51
Result List Refine Search PrevResult 63 of 68 Next
Conducting interviews with survivors of sexual assault.
Parent Book Series:
Psychology of women (APA Division 35)
Authors:
Ullman, Sarah E.. University of Illinois, Chicago, IL, US, seullman@uic.edu
Address:
Ullman, Sarah E., Department of Criminology, Law, and Justice (M/C 141), University of Illinois at Chicago, 1007 West Harrison Street, Chicago, IL, US, 60607-7140, seullman@uic.edu
Source:
Talking about sexual assault: Society’s response to survivors. Ullman, Sarah E.; pp. 121-143; Washington, DC, US: American Psychological Association; 2010. x, 210 pp.
Page Count:
23
ISBN:
1-4338-0741-6 (Hardcover)
978-1-4338-0741-1 (Hardcover)
1-4338-0742-4 (Digital (undefined format))
978-1-43380-742-8 (Digital (undefined format))
Language:
English
Keywords:
sexual assault, survivor interviews, advocates, clinicians, ethical issues, coping
Abstract:
This chapter builds on the previous chapter’s theme of presenting and analyzing experiences of advocates and clinicians working with and listening to sexual assault survivors. In this chapter, I provide a first-person account of my own experience interviewing sexual assault survivors about their experiences of help-seeking following assault. I also discuss the ways I reacted to this experience and coped with it and the positive and negative aspects of interviewing survivors. I highlight ethical issues in interviewing survivors and giving back to survivors in the context of such research. This account is intended to provide an example of how listening to survivors and hearing their stories can affect researchers in this area of work. By describing the process of coping with this experience and seeking support to process the interviews I hope to provide ideas about how to take care of oneself and cope with hearing about sexual assaults. This information may also be informative to clinicians, other professionals, and informal social network members who hear survivors’ stories and wish to provide support to female victims. In this chapter, I begin by discussing an empowerment model that guided my work interviewing the survivors. Next, I describe my experience of conducting the Women’s Life Experiences Interview Project, which involved interviewing female sexual assault survivors about their experiences talking with others about their assaults, including both informal and formal social support providers (see Introduction, this volume, for a detailed description of the study design). I then discuss some ethical considerations involved with the research, primarily the need to protect myself and my graduate student researchers from vicarious trauma and secondary traumatic stress. Finally, I reflect on my experience overall in the hope that this will be helpful for other researchers. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
Document Type:
Chapter
Subjects:
*Diagnostic Interview Schedule; *Interviewers; *Interviews; *Rape; *Survivors; Advocacy; Clinicians; Coping Behavior; Emotional Trauma; Occupational Stress; Professional Ethics
PsycInfo Classification:
Professional Psychological & Health Personnel Issues (3400)
Behavior Disorders & Antisocial Behavior (3230)
Population:
Human
Female
Intended Audience:
Psychology: Professional & Research (PS)
Methodology:
Interview
Format Covered:
Print
Publication Type:
Book; Authored Book
Release Date:
20100308
Correction Date:
20170522
Digital Object Identifier:
http://dx.doi.org/10.1037/12083-006
Accession Number:
2009-18375-006
Result List Refine Search PrevResult 64 of 68 Next
Exploring the experiences of survivor students in a course on trauma treatment.
Authors:
Shannon, Patricia J.. School of Social Work, University of Minnesota, St. Paul, MN, US, pshannon@umn.edu
Simmelink, Jennifer. School of Social Work, University of Minnesota, St. Paul, MN, US
Im, Hyojin, ORCID 0000-0001-9577-6714 . School of Social Work, University of Minnesota, St. Paul, MN, US
Becher, Emily. Department of Family Social Science, University of Minnesota, MN, US
Crook-Lyon, Rachel E.. Counseling Psychology and Special Education, Brigham Young University, US
Address:
Shannon, Patricia J., School of Social Work, University of Minnesota, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN, US, 55108, pshannon@umn.edu
Source:
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 6(Suppl 1), 2014. Special Issue: Recent Developments in Trauma Studies. pp. S107-S115.
NLM Title Abbreviation:
Psychol Trauma
Page Count:
9
Publisher:
US : Educational Publishing Foundation
ISSN:
1942-9681 (Print)
1942-969X (Electronic)
ISBN:
1-4338-1957-0
Language:
English
Keywords:
trauma education, student survivors, vicarious trauma
Abstract:
Research on student experiences has indicated that approximately 30% of graduate students in the helping professions are likely to be survivors of trauma (Adams & Riggs, 2008). Most of the published literature about the experiences of students with trauma histories in a course on trauma treatment is provided anecdotally by clinical instructors who have observed, through their experience, that student survivors face challenges unique to their trauma histories. The lack of research on the classroom experiences, coping strategies, impact on learning, and resiliency of student survivors makes it difficult for instructors to know how to best protect such students from retraumatization while facilitating their learning. This article presents the findings from a subset (n = 8) of study participants (n = 17) who self-identified as trauma survivors. Students completed journals at 4 different times in a 15-week graduate course on trauma treatment. Students’ responses to questions related to thoughts, feelings, behaviors, and self-care strategies were analyzed using consensual qualitative research (CQR) methods (Hill, 2012). Students’ personal connections to trauma emerged as a separate domain in the analysis and included 3 categories of experiences: reactions to personal trauma material, the integration of learning with personal trauma material, and questions about personal trauma material. Student survivors also reported a wide variety of self-care strategies. Recommendations for the pedagogy of student survivors include education about vicarious trauma, exploring the personal and professional impact of trauma while in training, and developing a wide variety of self-care strategies, including supervision, consultation, and peer support. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Graduate Students; *Social Work Education; *Survivors; *Trauma; *Treatment; Trauma Treatment
PsycInfo Classification:
Professional Education & Training (3410)
Population:
Human
Male
Female
Location:
US
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Defense Style Questionnaire DOI: 10.1037/t45555-000
Trauma Symptom Inventory
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
First Posted: Jun 3, 2013; Accepted: Feb 10, 2013; Revised: Jan 30, 2013; First Submitted: May 3, 2012
Release Date:
20130603
Correction Date:
20200713
Copyright:
American Psychological Association. 2013
Digital Object Identifier:
http://dx.doi.org/10.1037/a0032715
Accession Number:
2013-19088-001
Number of Citations in Source:
34
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Exploring the Experiences of Survivor Students in a Course on Trauma Treatment
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Contents
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Participants
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Survivor Student Reactions to Personal Trauma Material
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By: Patricia J. Shannon
School of Social Work, University of Minnesota;
Jennifer Simmelink
School of Social Work, University of Minnesota
Hyojin Im
School of Social Work, University of Minnesota
Emily Becher
Department of Family Social Science, University of Minnesota
Rachel E. Crook-Lyon
Counseling Psychology and Special Education, Brigham Young University
Acknowledgement: Hyojin Im is now at the Mack Center on Mental Health & Social Conflict, University of California–Berkeley.

Research indicates that approximately 80% of women and men report having experienced at least one traumatic event in their lifetime that meets the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000) definition of trauma (Courtois & Gold, 2009). Research on student experiences has indicated that approximately 30% of graduate students in the helping professions are likely to be survivors of trauma (Adams & Riggs, 2008). Having a personal history of trauma has been identified as a risk factor for vicarious trauma among clinicians working with survivors (Chrestman, 1999; Pearlman & Mac Ian, 1995) and among trauma therapist trainees (Adams & Riggs, 2008; Alpert, 2009; Cunningham, 2004; Miller, 2001; Newman, 2011). However, there are few empirical studies of vicarious trauma among students during clinical coursework, and even fewer of these studies explore the specific and unique reactions of students who have personal histories of trauma (Adams & Riggs, 2008; Black, 2008). This study explores the experiences of student survivors in a course on trauma treatment through their own writing.

Trauma scholars have developed a growing literature describing the stress experienced by clinicians resulting from clinical work with survivors of trauma, labeling it compassion fatigue, secondary trauma, or vicarious traumatization (Bride, Radley, & Figley, 2007; Figley, 1995; Killian, 2008; Pearlman & Saakvitne, 1995; Talbot, Dutton, & Dunn, 1995). Pearlman and Saakvitne (1995) describe vicarious trauma as negative changes in the inner psychological and sensory experiences of trauma therapists due to their repeated empathic engagement with survivors. These reactions often mirror symptoms of posttraumatic stress disorder (PTSD), including symptoms of reexperiencing, avoidance, and hyperarousal, as well as depression and anxiety (Pearlman & Saakvitne, 1995). Reexperiencing can involve reliving trauma in the form of flashbacks and nightmares in which the survivor believes that they are living through the exact trauma that they already survived (American Psychiatric Association, 2000). Such reexperiencing can lead to the worsening of symptoms of trauma without the benefit of working through traumatic experiencing in a therapeutic context. Some techniques to address and respond to compassion fatigue, secondary trauma, and vicarious traumatization have been developed and have been proven to be effective with clinicians (Pearlman & Saakvitne, 1995; Talbot et al., 1995). To date, no one has investigated the extent to which reexperiencing occurs in a classroom context and whether or not the triggering of trauma symptoms is damaging to graduate students in enduring ways.

The empirical research that exists on graduate trainees indicates that students with a history of trauma are more likely to struggle with symptoms of vicarious trauma in the classroom (Adams & Riggs, 2008). This research used the Trauma Symptom Inventory (Briere, Elliott, Harris, & Cotman, 1995) and the Defense Style Questionnaire (Bond, Gardner, Christian, & Sigal, 1983) to investigate the relationship between defensive styles and experiences of vicarious trauma among psychology trainees. The findings indicated that survivor students who use a self-sacrificing defensive style are at increased risk of experiencing vicarious trauma reactions, including intrusive symptoms, defensive avoidance, and anxious arousal symptoms. They recommended that supervisors provide close monitoring of countertransference reactions among survivor students who are at increased risk of developing symptoms of vicarious trauma.

Instructors writing about their experiences teaching trauma treatment report that student survivors struggle with unique experiences related to their trauma histories in the classroom. Survivors may revisit their own painful trauma histories as they see themselves reflected in the literature (Cunningham, 2004; Newman, 2011). They may develop their own first awareness of trauma or they may know about their trauma histories but be unprepared for the impact that studying trauma may have on them (Black, 2008; Miller, 2001). Students may also endure traumas during the course that affect their ability to function such as losses, domestic violence, or the serious illness of loved ones (Alpert, 2009). Cunningham (2004) noted that students who are unprepared to encounter their own trauma may also run the risk of burdening their classmates through inappropriate self-disclosures.

Such pervasive concerns have prompted these instructors to write recommendations and guidelines for the pedagogy of trauma that include outlining best practices for creating safe classroom environments for all students but especially for students with trauma histories (Black, 2008; Bussey, 2011; Cunningham, 2004; Miller, 2001; Newman, 2011). These recommendations include a combination of education about trauma and vicarious traumatization (Bussey, 2011; Cunningham, 2004; Newman, 2011; Miller, 2001), normalizing reactions to traumatic material (Miller, 2001), limiting or titrating trauma exposure in the classroom (Black, 2008; Cunningham, 2004; Newman, 2011), and nurturing a variety of self-care practices (Adams & Riggs, 2008). Recommended self-care practices included teaching grounding and relaxation techniques (Black, 2008), the use of personal therapy (Newman, 2011), and the use of student journals (Miller, 2001). Pearlman and Saakvitne (1995) further recommend that survivor therapists in training have at least one place where they can talk about their survivor history and its interaction with their work. However, the lack of research on the classroom experiences, coping strategies, impact on learning, and resiliency of student survivors makes it difficult for instructors to know how to best protect such students from reexperiencing while facilitating their learning. Research is needed on the experiences and risks involved in teaching trauma to student survivors of trauma. This study aims to establish a baseline for understanding the range of experiences reported by survivors in a course on trauma through a qualitative exploration of their own writing. The study explores their reactions to traumatic material, self-care practices, and the impact of learning over time in the course.

Method

We chose a qualitative research method to study the depth and evolution of student experiences across the course. We incorporated structured journaling into the course and our research because writing is an evidence-based practice for addressing stress (Pennebaker, 1993; Pennebaker & Chung, 2007), and journaling has been highly recommended for monitoring stress during courses on trauma (Miller, 2001). Journaling has also been effectively used as a method for studying the experience of graduate trainees who are becoming psychotherapists (Hill, Sullivan, Knox, & Schlosser, 2007). One of the strengths of using course journals is that it allows the researcher to track student experience over time through ordinary course assignments, even when analysis of the data cannot ethically begin until the course is finished.

This study used consensual qualitative research (CQR; Hill, 2012) methods to analyze journals completed as course assignments during a graduate-level social work course on trauma treatment. CQR is a methodology that allows for a comparative cross-analysis of responses to open-ended questions. CQR uses a team approach to coding and analyzing the data, and decisions about coding and analysis are made through consensus. The method also employs an outside auditor to confirm analysis. CQR was an appropriate method for this study of student journals because data analysis began after all the data was collected and participants responded to the same set of journal questions. CQR provides a clear method for examining responses from multiple respondents to similar questions. The method allowed for comparison between respondents as well as comparing responses for each respondent individually across time. The method, sample, and study procedures are described next.

Participants
Student participants

The participants highlighted in this study were selected from a larger sample of 17 students in a study investigating, in general, the experiences of students in a course on the treatment of trauma (Shannon, Simmelink, Becher, Im, & Crook-Lyon, in press). The participants in this sample represented 47% (n = 8) of the larger sample that reported having experienced a traumatic event in their lifetime. All eight participants were female and 75% (n = 6) were White, 12.5% were Asian (n = 1), and 12.5% were another race, not African American (n = 1). The participants ranged in age from 22 to 50 years, and half had completed a Bachelor in Social Work degree. These participants were asked if they had ever experienced a traumatic event in their lifetime and approximately how many traumatic events. The participants were not given a definition of “traumatic event” but instead were able to define the term for themselves. The mean number of traumatic events experienced by participants was 2.14.

The nature of trauma histories was reported in journals. Although we never specifically asked students to write about their own histories of trauma, students reported diverse personal connections to traumatic experiences. Participants’ diverse connections to trauma included being a survivor of familial emotional, physical, or sexual abuse; being a survivor of domestic violence between parents; surviving stranger rape; being related to deployed veterans or being a returned veteran survivor; having witnessing the 35W bridge when it collapsed in Minneapolis; being related to a Japanese tsunami survivor; being a refugee survivor; and being related to a trauma survivor.

Research team and auditor

As previously reported (Shannon et al., in press), the principle investigator (PI) is an experienced White female trauma therapist who was the instructor for the course. As the instructor, she asserted the biggest influence on the course, student experiences, and the analysis of the data. One bias that she brought to understanding the data was informed by preexisting knowledge of organized categories of traumatic experience, based on the symptoms of posttraumatic stress disorder delineated in DSM–IV–TR. Two female doctoral-level student coders in social work, one White and one Korean, and a White female doctoral-level student in family social science served as graduate research Helpants. They recruited participants and coded data. These students noted that they coded very close to the student experience but they did not identify any other biases. The outside auditor is a professor at another university with considerable experience in teaching, psychotherapy, and CQR methodology (Hill, 2012). She exerted her largest influence on catching biases in core ideas and leading the research team through the steps of CQR.

Procedures
The procedures for this study of survivor students are the same as the procedures described in a previous study of students’ experiences of stress in a trauma treatment course (Shannon et al., in press). They are summarized here.

Recruitment of participants

Students received an e-mail from the professor prior to the first day of class, informing them that they might have the opportunity to participate in research attached to the class. Students were recruited during the first day of the course through graduate research Helpants (GRAs) who were also co-investigators. Participants were informed of the purpose of the study and that participation was voluntary and would not affect their grade in the course. Interested students met with the GRAs outside of class, reviewed informed consent, and received a deidentified study number to enter on journals. This study was approved by the institutional research review board.

Description of the class

The course meets weekly for 2 hours and begins by introducing students to the experience and diagnostic assessment of complex and single-incident traumas through first-hand accounts such as listening to interviews with bridge-collapse survivors and reading novels such as Push by Sapphire (1996). Because reading and listening to trauma can be difficult, students are expected to take self-care seriously and to work on the development of their self-care practices. The second session of this course focuses on understanding and addressing vicarious trauma reactions and evidence-based recommendations for self-care, such as journaling (Pennebaker, 1993), and mindfulness-based stress reduction (Kabat-Zinn, 2005). This is the only session explicitly focused on self-care. Students complete journals at 3-week intervals to encourage the development of reflexive processes related to understanding their own reactions to trauma and tracing the development of their self-care practices. They also practice relaxation and mindfulness strategies when they are included as components of evidence-based approaches to treatment that are covered in the course. Many of the exposure therapies taught in this course incorporate relaxation exercises that provide students the opportunity to practice self-care.

Students proceed to integrate research on diagnostics, neurobiology, and the developmental antecedents of complex trauma with survivors’ stories in psychosocial assessments. The course introduces students to evidence-based approaches to the treatment of complex and single traumas across diverse populations, combining Herman’s (1992) “trauma and recovery” framework with psychodynamic and cognitive–behavioral approaches. Students practice several exposure techniques and learn integrated models of treatment such as dialectical behavioral therapy (Dimeff & Koerner, 2007). The course ends with a focus on special populations (i.e., domestic violence and refugees) and includes co-occurring disorders such as substance use. The class is taught with a mixture of lecture, group discussion, and expert guest speakers. Students complete several written assignments during the course, including the journals used in this study.

Journals

Participants completed four 2- to 3-page journal assignments as part of regular course assignments. The journal assignments were spaced evenly, every 3 to 4 weeks throughout the semester. Journal assignments were semistructured, meaning the students were asked to respond to the same set of questions for each journal: (a) What are your feelings in response to the readings? (b) What are your thoughts about the readings? (c) What are your behavioral responses (positive and negative) to the material? (d) What are your self-care strategies?

Data collection

All data for the study was collected anonymously through a secure online survey form administered by the university. After giving consent, participants were sent an e-mail link to complete a demographic questionnaire, including questions about race/ethnicity, gender, undergraduate concentration, and previous training in trauma treatment. Prior to the due date for each of the four journal assignments, participants were sent an e-mail link to upload their journal. Participants were sent up to two reminder e-mails to ensure full participation. After completion of the study, the data was downloaded from the online survey form and stored in a secure location.

Data Analysis
Data analysis began after the semester ended and followed CQR guidelines (Hill, 2012). The steps in data analysis included coding data into broad domains, creating summaries of core ideas conveyed by each participant in each domain, and conducting cross analysis, which involves identifying themes or categories across participants within each domain. Differences and disagreements are respected and negotiated to arrive at a consensual analysis (Hill, Thompson, & Williams, 1997). An example of this process related to the usefulness of journaling is provided here:

“Doing these journal entries has been a big help to me in processing course material and my reactions to it, and I plan to start a trauma journal for my field placement this summer and again when I find a job in the field of child welfare. There is so little time for reflection in any of our fields, but reflection is a great tool for getting the most out of supervision and avoiding burnout.”
Domain: 3. Self-care
Category: g. journals
Core Ideas: Participant recognizes the usefulness of journaling for processing course material and reactions. She plans to continue journaling as a self-care practice in the field. The self-reflection involved is a great tool for getting the most out of supervision and avoiding burnout.
Data analysis proceeded by analyzing each set of journals for domains and core ideas. Consensus was reached among the research team through discussion and the auditor’s comments were incorporated in the final domain list. This procedure was followed for all four sets of journals. Once journal domains were agreed on, the research team developed the cross-analysis by coding the categories within each domain across all 17 participant journals. Again, the comments of the outside auditor were incorporated into final categories. To analyze changes in the amount of evidence for each domain and category across the 15 weeks, frequencies of domains and categories were calculated (see Table 1).

tra-6-s1-s107-tbl1a.gifFrequencies of Categories Over Time

Trustworthiness

The integrity of the data was established in this study through using a relatively large (n = 17), homogenous sample of students. The coding system was developed through the consensus of multiple independent readers, all of whom had professional expertise in trauma. Reflexivity of the researchers was reflected in the coding process and final analysis. Use of an outside auditor provided “investigator” triangulation to help address bias. Finally, negative case analysis was used after the cross-analysis stage to inform decisions about final categories. For example, some categories that appeared distinct initially became subsumed under others through discussion. Member checks were conducted with several students who volunteered to respond to the major findings via e-mail. Students were sent a draft of domains and categories along with a summary of preliminary findings. Two students responded and these responses were incorporated into the final analysis.

Results

Students’ personal connections to trauma emerged as a separate domain in the analysis and included four categories of experiences: reactions to personal trauma material, the integration of learning with personal trauma material, questions about personal trauma material, and self-care strategies. In response to the journal questions, students discussed how their personal connection to trauma impacted their reactions in the course as well as their self-care strategies. The results discussed here reflect the specific domains and categories that were discussed by this subset of participants.

Survivor Student Reactions to Personal Trauma Material
Reexperiencing

Many student survivors reacted to traumatic course material through the lens of their own experiences of trauma. They commented that it was hard not to think about their own experiences when reading about trauma. When reading course material, they reported reexperiencing symptoms of posttraumatic stress, including heightened fear, terror, nightmares, and flashbacks to their own trauma experiences. One student participant described this experience:

When we were listening to the interview of the 35W Bridge collapse survivors, my heart was pounding. Particularly salient for me was when she said that she couldn’t think clearly at the time the trauma was happening to her. I’ve had major traumas in my life, one of which was coming home from work one day to a [sudden death in the family]. At that moment, I couldn’t think clearly either, and listening to her talk about that aspect of her trauma brought it back for me. Another major trauma was being sexually molested as a child. Reading the explicit description of sexual assaults was more than I was willing to bear. I felt violated just reading it, and I refuse to read any more sexually explicit passages from the book. (Participant 35, Journal 1)
Intrusive thoughts

Intrusive thoughts from the clinical material were also common among survivors:

I had a negative behavioral response to [the reading], namely thoughts about the sexual abuse scenes were popping into my head when I didn’t want them to and disturbing me. Also, when I was in bed and had finished reading for the night, I found myself having to do deep breathing to calm myself a couple of times because I felt hyper-aroused. I think that I didn’t want to think about the book anymore when I put it down and it bothered me that I did continue to think about it. (Participant 49, Journal 1)
Intense feelings

In addition to describing typical feelings of sadness, horror, and guilt, some survivors responded with anger when reminded of their own trauma:

I have been thinking about my own experiences and experiences in overcoming them. I don’t think the results of traumatic experiences go away—even after therapy. This in turn makes me angry (the feeling I’m the most comfortable feeling and expressing, like most people). It makes me angry that there are people who exist and do bad things to other people. (Participant 25, Journal 2)
Avoidance behaviors

Survivors expressed increased avoidance behaviors, such as refusing to read course material and a sense of resignation, overwhelm, and dissociation. One survivor reported, “Resignation. I find myself immediately plopping on the couch as soon as I get home and have a ‘give me a break’ attitude” (Participant 31, Journal 2). Another described panic followed by dissociation:

I have admittedly been avoiding writing this journal, but my efforts to figure out the root of my avoidance were futile until I found myself, during a panic attack two nights ago, lying on the floor in my bedroom doing a body scan . . . During my body scan I recognized a strong undercurrent of feeling extremely disconnected from my body, a souvenir from a sexual assault that now only creeps into my daily life when I’m not practicing self-care. (Participant 36, Journal 1)
Hyperarousal

Student survivors also reported symptoms of hyperarousal coupled with vulnerability. One student wrote, “I find I am feeling quite vulnerable in most settings. Vigilance is up, and patience is down . . . I noticed that I am keeping my guard up” (Participant 55, Journal 1). One student articulated her fear that she may have been victimized in the past by saying, “When I’m emotionally distressed, I have intense fear that I will remember a terrifying experience I’ve had that I don’t remember now” (Participant 27, Journal 1). This student’s experience worsened in Journal 2, as she described an experience that she had during meditation that led her to begin personal therapy:

I had a brief but terrifying change in my perception, in which my partner seemed to be a different person to me and I was in danger . . . I had moments of remembering the experience and feeling terror several times a day for about a week. I also had some very scary nightmares in the days following but now feel numb to them. It is difficult for me to understand what the source of these feelings of fear, sense of having experienced trauma, and changed moments of perception is. It does not feel normal and I want it to be normalized. (Participant 27, Journal 2)
Growing awareness of personal trauma

Another student questioned whether or not she had experienced early trauma based on what she learned in the course:

I wonder if I have some unresolved trauma from my own childhood. I had to flee with my family late at night in buses, as the country we were living in was experiencing civil war when I was a child . . . to this day I am traumatized by the sound of sirens, which was the warning for us to run indoors and shut off all the lights. (Participant 31, Journal 2)
One student did not identify as a trauma survivor on the initial demographic form but came to the label of “trauma survivor” through knowledge gained in the course. This participant stated:

I have felt personally connected to the trauma stories because my childhood was defined by domestic violence, physical and emotional abuse. I was raised to believe that family matters are to be kept private, and thus have never spoken to anyone to this day about what I went through. I have always felt uncomfortable about the idea of seeking therapy because I did not feel like I could open up to a stranger about my personal problems. (Participant 51, Journal 3)
The integration of learning with personal trauma experiences

Student survivors struggled to integrate new learning in the course with their trauma experiences. Students commented that they saw themselves reflected in the readings and they worked to integrate this new insight with their personal trauma stories:

I saw my own story unfold in Dr. Herman’s description of trauma and recovery. First was the fact that the traumatized child must find some way to make sense of her experience without acknowledging the fact that her parents are untrustworthy. The unavoidable conclusion is that there is something inherently wrong with herself, that she is fundamentally flawed in some inescapable way (not to mention identifying with the voice of the perpetrator who constantly berates her). Herman writes that ‘this malignant sense of inner badness is often camouflaged by the abused child’s persistent attempts to be good’ (p. 106). Thus, I was simultaneously a model student and perfectly behaved child who was constantly given the message that I was somehow the worst nightmare with which any parent could have ever been cursed. (Participant 35, Journal 4)
Some students revisited their past armed with new knowledge that cast a different light on their past recovery attempts, and others felt the readings affirmed their healing process:

I first read Judith Herman’s book (Trauma and Recovery) after my own sexual assault. Reading it again now, after I have healed from my own trauma and after I have worked with hundreds of survivors of other traumas, has been a fantastic way for me to gauge my own healing journey and application of trauma-informed practice skills. A lot of my classmates have mentioned that Herman’s book was especially difficult to read, but I haven’t had that problem; in fact, I’ve had a hard time putting it down. That makes me think that I have integrated my own traumatic experience in a healthy way. I find that kind of amazing. (Participant 36, Journal 2)
Several participants commented on their struggle to establish healthy boundaries with loved ones who are also survivors. For example, one student wondered how much trauma knowledge is appropriate to share with a sibling who had recently survived a rape. By the end of the course, this student commented, “I plan to talk to her about the characteristics of PTSD and basically just give her a little heads up of future obstacles that she may face” (Participant 50, Journal 4). Another survivor struggled with how to set appropriate boundaries with a sibling who had a spouse deployed in Afghanistan. She stated, “I have to maintain a tenuous boundary between friend, family member, and helping professional” (Participant 36, Journal 3). One student used the journal entry to evaluate what type of treatment would be most helpful in the future:

With each approach or therapy that we learn about, I try to think if it could work for me. For example, I don’t think that exposure therapy is right for me because there is no one defining experience that I struggle with. It is more the cumulative experiences that I worry about, and how they will impact my relationship with my fiancé and my own children one day. I also worry a lot about how my personal experiences will impact my practice with clients. (Participant 50, Journal 3)
By the end of the course, students were reacting less to traumatic material and reflecting more on integrating learning with their experiences. For example, one survivor reflected productively on her experience listening to the lecture on domestic violence and animal abuse:

I have a much better understanding of trauma in humans and I know how resilient child victims of abuse can be. I’ve seen great healing happen, and that includes my own healing from sexual trauma as an adult. I think my current resistance to hearing these stories of animal abuse without shutting down has to do with the fact that I know the feeling of helplessness and terror that comes with being attacked, and I also know that humans are able to dissociate and, later, process that terror. Animals can’t, and they have no context for the abuse; you can’t really social work an animal. I also think I overidentify with their terror because I’ve experienced it. I have learned through practice, supervision, and this class not to overidentify with the trauma responses of children and adults. (Participant 36, Journal 4)
Questions raised by student survivors

Student survivors generated questions that demonstrated their integration of new learning with case material and their personal experiences with trauma. They questioned their own need for therapy and they raised questions about their understanding of themselves in light of new learning. Student survivors also raised questions inspired by the readings. They wondered how to help military spouses and children, how to help survivors of rape and domestic violence, and what the best treatment approach is for particular traumas. Student survivors also seemed to answer their own questions as they struggled to integrate learning with experience. One participant stated, “Seeing my life story in Herman’s description of trauma and full recovery, I realize that I have recovered well enough. Finally, ‘good enough’ really is good enough” (Participant 35, Journal 4).

Use of self-care strategies by survivors

Early journals revealed that survivor students had difficulty doing self-care and most commented that they intended to do more. One survivor explained, “I have not been doing this enough yet. As I said, learning about mindfulness-based stress reduction has been a goal of mine for some time now. The problem is actually finding the time to do it” (Participant 49, Journal 1). When survivors were able to engage in self-care, they identified a wide array of self-care strategies throughout the course. These included many of the strategies identified by students who were not trauma survivors, including physical strategies such as exercise or yoga, relational strategies such as spending time with family and friends, and cognitive strategies such as learning to limit exposure to traumatic material as a strategy for preventing vicarious trauma reactions. Survivor participants were particularly creative with their self-care strategies that included things like Bollywood dancing, art, attending musicals and theater, and spending time with pets. Many survivors also embraced mindfulness strategies as well as journaling as an outlet for processing feelings. In fact, all of the students who commented on the usefulness of journaling in the course were survivors of trauma. One student wrote:

Doing these journal entries has been a big help to me in processing course material and my reactions to it, and I plan to start a trauma journal for my field placement this summer and again when I find a job in the field of child welfare. There is so little time for reflection in any of our fields, but reflection is a great tool for getting the most out of supervision and avoiding burnout. I also think that doing this kind of writing will allow me, at least somewhat, to leave my work at the office. In sitting down a few times a week to write, I’ve developed a tangible connection with the act of self-care that I didn’t previously think I had time for. (Participant 36, Journal 4)
Another survivor wrote about the usefulness of processing for professional growth:

I have really enjoyed this class and the journaling process. It has been an assignment I look forward to doing rather than procrastinating, and I think it is the only one like that! It has been really helpful to just be able to spit out what I am feeling on paper and to have the time to collect my thoughts. It has created an awareness of my feelings, my stress levels, and the ways I’m managing that (or sometimes lacking in the managing part). I don’t think it was just helpful in the context of this class, although this class was one in which we could explore the things we were learning that may have needed additional processing. I, however, found myself thinking about everything when I was journaling—this class and what we were learning/reading, other classes, field placement, my job stress, and stress of everyday life. I have really appreciated the opportunity to reflect on all these things we juggle as grad students and to know someone is on the other end reading it. (Participant 46, Journal 4)
It is noteworthy that survivor students found several additional strategies helpful for remaining and thriving in the course, including the use of supervision, therapy, and support groups. One survivor wrote, “About a month ago, I started seeing a therapist to try to sort through some of my reactions that felt too personal to bring to supervision” (Participant 27, Journal 2). Another student was proactive about seeking therapeutic support from the start:

I knew, coming into this class, that vicarious traumatization would be an issue, so I had already planned to join a student support group on campus . . . however, I’ve come to the conclusion that individual therapy is likely to be more efficacious for me, and am currently seeking it. (Participant 35, Journal 1)
Changes over time

Table 1 summarizes changes in domains and categories over time in the 15-week course. Examining changes in categories over time reveals that survivor students tend to report fewer reactions over time and a wider variety of self-care strategies. In particular, by Journal 4, survivor students are incorporating professional strategies for self-care, such as being proactive about vicarious trauma, using journals as self-care, and thinking about practice as part of self-care.

Discussion

The findings of this exploratory study are consistent with the research that indicates that survivors are more vulnerable to vicarious trauma reactions in courses on trauma (Adams & Riggs, 2008). In particular, the PTSD symptoms of reexperiencing, avoidance, and hyperarousal were all reported by survivors as being triggered by course material. Although Adams and Riggs (2008) postulated that defensive style mediates the experience of vicarious trauma, student journals reveal that these intense vicarious trauma reactions result from symptoms connected to the direct intrusion of survivors’ memories of personal trauma that are triggered by course material. At these moments of reexperiencing, students often described their efforts at coping as avoidance or “trying not to think about it.” They seemed to have very little control over the experience of PTSD symptoms and few, if any, adaptive coping strategies that were defined by Adams and Riggs (2008) as including suppression, sublimation, and humor.

These findings also confirm the range of experiences reported by instructors of trauma courses (Black, 2008; Bussey, 2011; Cunningham, 2004; Miller, 2001; Newman, 2011). The survivors in this study did report revisiting painful trauma memories as they saw themselves reflected in the literature. Some survivors did uncover their own trauma for the first time during the course and others experienced personal trauma during the course. For example, some survivors were related to soldiers who were living in constant danger during the course. Although the students in this course did not burden their classmates through inappropriate self-disclosures, many of them were unprepared for the impact the class would have on them.

Tracking students’ reactions and self-care strategies throughout the course did provide insight into how enduring these reactions are. By the end of this course, only two students reported struggling with reactions to trauma, and most students reported developing effective self-care strategies. These findings indicate that although many student survivors may revisit their own trauma symptoms during trauma courses, these initial difficulties may not be enduring when students take seriously their need for support and when they are successful at practicing self-care.

Implications for Teaching
The findings of this study have important implications for the training and supervision of student survivors. Instructors of novice therapists need to be prepared to encounter a range of experiences among their survivor students. Students in this course were at very different stages of acceptance, understanding, and recovery in relation to their own trauma histories. Some survivors had completed therapy and used their new learning in the course to confirm and deepen their processing of personal trauma. Other survivor students were just beginning to recognize the impact of trauma in their lives, and at least one student developed the courage to reveal a history of trauma kept “secret” until this course. When students acknowledge their personal connections to trauma in their journals, their reactions and thoughts triggered by course material were unique to their particular traumas and recovery processes. However, like their nontrauma survivor classmates, they were able to struggle with these reactions to productive outcomes and despite their difficulties in the course; all of these participants expressed their enthusiasm for learning.

Instructors also need to be flexible to support the individual needs of each survivor student. Students in this course were extremely creative in their efforts toward developing self-care strategies that would be effective for them. The instructor also provided accommodations that included providing alternative assignments for students who felt that the case material was “too close to home.” Students were given a list of trauma therapy resources and support groups on campus and in the local area. Students were taught evidence-based practices for self-care early in the course, including journaling and mindfulness-based stress reduction, which proved helpful. The usefulness of these methods for managing stress in this course supports the limited research findings on the helpfulness of education about self-care among students (Antal & Range, 2005; Napoli & Bonifas, 2011; Pennebaker & Chung, 2007; Shapiro, Brown, & Biegel, 2007; Schure, Christopher, & Christopher, 2008). It also supports the findings of Schure and colleagues (2008), who suggest that giving students choices among self-care strategies maximizes their likelihood of choosing an approach that they will practice effectively.

Recommendations for the pedagogy of trauma include educating students about vicarious trauma reactions as normal responses to empathic engagement with trauma early in the course. Such education should acknowledge that a significant percentage of clinical graduate trainees are trauma survivors and provide recommendations specific to survivors in training. These include educating survivor students about the usefulness of exploring the impact of their particular trauma histories on them and their professional relationships, developing self-care strategies that may include ongoing supervision and consultation on vicarious trauma, continuing education, and personal therapy and peer support as needed.

We concur with the recommendations of Courtois and Gold (2009), who advocate for providing trauma training in a relational context in which instructors can model humanness and their own struggles with countertransference and vicarious trauma reactions. A relational context for learning allows clinical instructors to model a compassionate attitude toward vicarious trauma reactions, to normalize these reactions, and to demonstrate how self-exploration benefits both the therapist and the client toward the goal of greater understanding of the therapeutic relationship with survivors. Central to this training is a focus on cultural variation in response to traumatic stress and cultural influences on the healing process (Brown, 2008; Courtois & Gold, 2009). Providing a safe and open context for learning maximizes students’ ability to explore cultural variation in response to trauma material through dialogical processes in the classroom. The use of role plays in the classroom can also enhance the exploration of culture and provide a relational model for how to address the oppressive social conditions that give rise to interpersonal trauma in marginalized and vulnerable groups.

It is imperative that courses on trauma treatment include evidence-based practices for self-care as part of early education about vicarious trauma. Students in this course did gravitate toward the practice of mindfulness-based stress reduction (Kabat-Zinn, 1990) and writing about stress (Pennebaker, 1993) as self-care strategies. Journaling offered trauma survivor students in this study the opportunity to integrate learning with their own trauma history, develop self-care plans, and to reflect on the impact of personal trauma on their future work. As Miller (2001) suggests, journaling provides an opportunity for instructors to monitor student reactions and encourage reflective practice. Student survivors also gravitated toward the use of social support, such as supervision, personal therapy, and support groups. It may be important for the supervisors and therapists of student survivors in trauma training programs to normalize the likelihood that they may experience vicarious trauma reactions and to provide a safe framework for the exploration and resolution of those reactions. In this regard, supervisors and therapists can provide important modeling for survivor students who may one day be providing supervision or treatment for student survivors of trauma.

Previous instructors have also recommended the importance of titrating trauma exposure in the classroom (Black, 2008; Cunningham, 2004; Newman, 2011). The findings of this study suggest that students can learn to titrate their exposure to traumatic course material on their own and that developing this self-care strategy may be important to the success of survivor students in training. Many students acknowledge that they learned not to read before bed or they planned to meet a friend and see a movie after class. Titrating trauma material is one of the strategies students learned for being proactive about self-care. It may be helpful for instructors to discuss this strategy with students, especially when courses are focusing on techniques related to learning exposure therapies that require repeated exposure to traumatic material. Ultimately, clinical students need to learn how to tolerate traumatic material and work effectively with trauma survivors in treatment. This exploratory study demonstrates that student survivors of trauma can learn to become proactive about managing their reactions to traumatic material and develop professional strategies for self-care in courses on trauma treatment. Instructors can also be proactive about encouraging the development of professional practice behaviors through acknowledging the special challenges that survivor students face in trauma training and providing education about vicarious trauma and evidence based practices for self-care.

Limitations and Implications for Research
This study is based on a convenience sample drawn from course volunteers, and conclusions may not be generalizable to larger or more diverse student samples. This study also failed to measure clinical levels of distress, so no conclusions can be drawn about the overall intensity of distress experienced by students. The findings from this study are also impacted by the particular course, which involved exposure to personal accounts of trauma; however, this course contains material that is likely to be similar to many other courses on trauma. The findings of this study are also limited by the questions that we asked and the semistructured nature of the journals. It is possible that more in-depth interviews would reveal a richer constellation of findings related to survivor experiences.

Research that further assesses risk factors, protective factors, and the effects and duration of vicarious trauma among clinical graduate students who are survivors of trauma is needed. Very little is known about the experiences of trauma survivors in graduate school and, more specifically, in courses on trauma. Understanding more about their inner experiences, coping strategies, growth, and resilience would guide instructors and the field toward articulating best practices for educating and promoting the growth of trauma survivors in training.

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Submitted: May 3, 2012 Revised: January 30, 2013 Accepted: February 10, 2013

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Source: Psychological Trauma: Theory, Research, Practice, and Policy. Vol. 6. (Suppl 1), 2014 pp. S107-S115)
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Traumatized by association: The risk of working sex crimes.
Authors:
Catanese, Shiloh A.. Sharper Future, CA, US
Source:
Federal Probation, Vol 74(2), Sep, 2010. pp. 36-38.
NLM Title Abbreviation:
Fed Probat
Page Count:
3
Publisher:
US : Administrative Office of the United States Courts
ISSN:
0014-9128 (Print)
1555-0303 (Electronic)
Language:
English
Keywords:
traumatization, risk assessment, working sex crimes, vicarious trauma, rehabilitation, risky behavior, professionals
Abstract:
Professionals working with the victims or offenders of crimes that result in trauma have the potential to be deeply affected by the stories and the images they are exposed to during their work. Vicarious, or ‘secondary,’ trauma occurs in someone who is not the primary person experiencing the trauma. Resilience is an important factor in how a person will handle the exposure to a traumatic event. It is an innate buffer that allows people to compartmentalize work from the rest of life and, more specifically, the unpleasant situations of work from the rewarding experiences. People who are particularly resilient have the ability to emotionally detach for a short amount of time while they perform their job duties. Professionals should avoid negative coping skills such as alcohol consumption, risky behaviors, or isolation, and they should know the signs and symptoms and, if necessary, seek Helpance from appropriate mental health professionals. Training and education on vicarious trauma should be provided to individuals working in the specialized area of sexual offenses. Professionals in the area of sex offender investigation, prosecution, and management have a unique but important role in the realm of public safety. Self-care is important for continued service to others. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Occupational Stress; *Sex Offenses; *Trauma; *Vicarious Experiences; *Health Personnel; Crime; Criminal Rehabilitation; Risk Assessment
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Age Group:
Adulthood (18 yrs & older)
Format Covered:
Print
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20110502
Accession Number:
2010-22723-008
Number of Citations in Source:
10
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Working with sex offenders: The impact on Australian treatment providers.
Authors:
Hatcher, Ruth. School of Psychology, Forensic Section, University of Leicester, Leicester, United Kingdom, rmh12@le.ac.uk
Noakes, Sarah. Grampians Community Health Centre, VIC, Australia
Address:
Hatcher, Ruth, School of Psychology, Forensic Section, University of Leicester, 106 New Walk, Leicester, United Kingdom, LE1 7EA, rmh12@le.ac.uk
Source:
Psychology, Crime & Law, Vol 16(1-2), Jan, 2010. Special Issue: Contemporary perspectives on sex offending, its assessment, and treatment. pp. 145-167.
NLM Title Abbreviation:
Psychol Crime Law
Page Count:
23
Publisher:
United Kingdom : Taylor & Francis
ISSN:
1068-316X (Print)
1477-2744 (Electronic)
Language:
English
Keywords:
sex offenders, treatment providers, traumatization, compassion fatigue, burnout, compassion satisfaction, job satisfaction
Abstract:
This paper reports on an exploratory study of compassion fatigue, burnout, compassion satisfaction, and vicarious traumatization amongst sex offender treatment providers in Australia. The research uses a nationwide sample of treatment providers from correctional settings and quantitative and qualitative methods to assess the impact of working compassionately with sex offenders. In addition to assessing levels of negative psychological affect, the study also considers the influence of demographic and work-related variables and explores the coping strategies used and the role of collegial support in mediating any negative effects. Contrary to previous research within this field, the quantitative analysis determined low levels of vicarious trauma, and low to moderate levels of compassion fatigue and burnout amongst the sample. In addition, over 85% of the sample reported moderate to high levels of compassion satisfaction, indicating that they derived pleasure from their work. The work-related factors of environmental safety and role problems were found to significantly predict the compassion satisfaction and compassion fatigue variables respectively, indicating the influence of organizational factors on psychological wellbeing. The qualitative analysis, however, revealed shifts in the cognitive schemas of the sample to accommodate the traumatic material to which they are exposed. Given that such shifts were observed but negative psychological impact was not, future research could usefully draw on the psychological resilience literature in an investigation of the qualities which protect treatment providers from negative psychological consequences. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Fatigue; *Job Satisfaction; *Occupational Stress; *Sex Offenses; *Treatment; Emotional Trauma; Sympathy; Compassion Fatigue
PsycInfo Classification:
Professional Personnel Attitudes & Characteristics (3430)
Population:
Human
Male
Female
Location:
Australia
Age Group:
Adulthood (18 yrs & older)
Young Adulthood (18-29 yrs)
Thirties (30-39 yrs)
Middle Age (40-64 yrs)
Tests & Measures:
Quality of Work Life Survey
Professional Quality of Life Scale DOI: 10.1037/t05192-000
Impact of Event Scale–Revised DOI: 10.1037/t12199-000
Methodology:
Empirical Study; Qualitative Study; Quantitative Study
Format Covered:
Electronic
Publication Type:
Journal; Peer Reviewed Journal
Publication History:
Revised: Nov 10, 2009; First Submitted: Jul 24, 2009
Release Date:
20100809
Correction Date:
20160114
Copyright:
Taylor & Francis. 2010
Digital Object Identifier:
http://dx.doi.org/10.1080/10683160802622030
Accession Number:
2010-08389-009
Number of Citations in Source:
58
Vicarious traumatisation: Current status and future directions.
Authors:
Dunkley, Jane. Department of Psychology, Monash University, Australia
Whelan, Thomas A.. School of Psychology, Psychiatry and Psychological Medicine, Department of Psychology, Melbourne, VIC, Australia
Address:
Whelan, Thomas A., School of Psychology, Psychiatry and Psychological Medicine, Department of Psychology, PO Box 197, Caulfield East, Melbourne, VIC, Australia, 3134
Source:
British Journal of Guidance & Counselling, Vol 34(1), Feb, 2006. pp. 107-116.
NLM Title Abbreviation:
Br J Guid Counc
Page Count:
10
Publisher:
United Kingdom : Taylor & Francis
ISSN:
0306-9885 (Print)
1469-3534 (Electronic)
Language:
English
Keywords:
vicarious traumatisation, therapists, trauma clients
Abstract:
Theorists and practitioners have long recognised that working with trauma clients can trigger reactions in the therapist similar to those experienced by the client. Nevertheless, research in this area has been lacking. One obstacle has been confusion regarding key terms. Vicarious traumatisation is the most appropriate concept given that it relates specifically to trauma work, incorporates intrinsic and extrinsic factors, and can be located within the framework of the constructivist self-development theory. Although limited, research has identified a range of factors that influence vicarious traumatisation, such as experience, personal trauma history and coping style. Future investigation is required to examine aspects that could enhance counsellor resilience. In addition, vicarious traumatisation needs to be studied in terms of a broad range of clientele and occupations. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
*Emotional Trauma; *Therapists; *Vicarious Experiences; Psychotherapeutic Processes
PsycInfo Classification:
Professional Psychological & Health Personnel Issues (3400)
Population:
Human
Format Covered:
Print
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20060530
Digital Object Identifier:
http://dx.doi.org/10.1080/03069880500483166
Accession Number:
2006-03577-007
Number of Citations in Source:
36
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Vicarious traumatisation: current status and future directions.
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Contents
Vicarious traumatisation and related concepts
Constructivist self-development theory
Factors that influence vicarious traumatisation
Counselling groups and vicarious traumatisation
Conclusions & recommendations
References
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Theorists and practitioners have long recognised that working with trauma clients can trigger reactions in the therapist similar to those experienced by the client. Nevertheless, research in this area has been lacking. One obstacle has been confusion regarding key terms. Vicarious traumatisation is the most appropriate concept given that it relates specifically to trauma work, incorporates intrinsic and extrinsic factors, and can be located within the framework of the constructivist self-development theory. Although limited, research has identified a range of factors that influence vicarious traumatisation, such as experience, personal trauma history and coping style. Future investigation is required to examine aspects that could enhance counsellor resilience. In addition, vicarious traumatisation needs to be studied in terms of a broad range of clientele and occupations.

‘It is inevitable that the doctor should be influenced to a certain extent and even his nervous health should suffer. He quite literally “takes over” the sufferings of his patient and shares them with him. For this reason he runs a risk and must run it in the nature of things’ (Jung, [19], pp. 171–172).

It appears that working with trauma clients can involve considerable risk. According to McCann and Pearlman ([22]), some counsellors experience nightmares, intrusive thoughts, and disturbing imagery along with affective states such as anger, sadness, and anxiety that relate to their clients’ traumatic material. Such experiences are said to lead to short or long term defensive reactions including psychological numbing, denial, and distancing. Not surprisingly, when a counsellor is suffering the quality of work and the effectiveness of the organisation may be compromised. That is, the counsellor’s empathic abilities, efforts to maintain a therapeutic stance, and establishment of boundaries with the client can be disrupted (Sexton, [31]).

McCann and Pearlman ([22]) conceptualised the risks of working with trauma clients as vicarious traumatisation. This refers to the transformation that is thought to take place within the counsellor as a result of empathic engagement with the trauma client (Thomson, [36]). For McCann and Pearlman, vicarious traumatisation is a normal reaction to trauma work and so it does not pertain to any particular therapeutic approach.

Despite early recognition by practitioners and the potential emotional costs, the term vicarious traumatisation was only introduced into the literature within the last two decades (Hartman, [16]). Unfortunately, since its introduction development in the area has been limited by uncertainty regarding key concepts, a lack of empirical research, and a focus on selective groups of trauma therapists.

Vicarious traumatisation and related concepts
The literature on countertransference provides an important background for understanding vicarious traumatisation (Blair & Ramones, [ 5]; Neumann & Gamble, [25]; Pearlman & Saakvitne, [28]). For example, the writings on both concepts have incorporated the painful images, feelings, and thoughts that can accompany work with trauma survivors (McCann & Pearlman, [22]). As clients describe the details of their trauma, the therapist can experience parallel states of fear, grief, and helplessness. These reactions can become intrusive, repetitive, and disruptive (McCann et al., [24]). However, the concept of vicarious traumatisation is broader than countertransference as it not only considers characteristics of the counsellor, but also of the situation (McCann & Pearlman).

Like countertransference, the concept of burnout can apply to those who Help trauma clients (McCann & Pearlman, [22]). Burnout refers to the psychological strain of working with difficult populations and is a progressive state of fatigue and/or apathy (Astin, [ 4]; Figley, [11]; McCann & Pearlman, [22]). Symptoms can include depression, cynicism, boredom, discouragement, emotional exhaustion, depersonalisation, loss of compassion, and reduced feelings of accomplishment (McCann & Pearlman, [22][23]; Neumann & Gamble, [25]). Similar symptoms can apply to vicarious traumatisation; even so, the potential effects of working with trauma clients appears to be distinct from dealing with other difficult populations (Blair & Ramones, [ 5]; McCann & Pearlman, [22][23]; O’Halloran & Linton, [26]; Schauben & Frazier, [30]).

Therefore, the literature on countertransference and burnout reflects two lines of thinking. In terms of countertransference, the counsellor’s personal characteristics determine his or her response to the client’s trauma, while burnout places emphasis on the characteristics of the stressor (McCann & Pearlman, [22]). By comparison, vicarious traumatisation views the counsellor’s response to the client’s trauma material as formed by aspects intrinsic to the individual therapist as well as characteristic of the situation (McCann & Pearlman).

Secondary traumatic stress disorder and compassion fatigue are often used interchangeably with vicarious traumatisation throughout the literature, creating considerable confusion. Figley ([11]) introduced the term ‘secondary traumatic stress’ to describe the behaviours and emotions resulting from helping or wanting to help a traumatised person. Based on the diagnostic conceptualisation of posttraumatic stress disorder (PTSD), the symptoms include reexperiencing, avoidance or numbing reminders, and persistent arousal (O’Halloran & Linton, [26]). Unlike, vicarious traumatisation, secondary traumatic stress disorder gives limited attention to context and aetiology, restricting its focus to observable symptoms (Gamble, [14]). Vicarious traumatisation involves a consideration of the individual as a whole and places the observable symptoms in context (Pearlman & Saakvitne, [29]). In addition, as noted by Hartman ([16]), vicarious traumatisation avoids the confusion of meaning associated with the notion of retraumatisation. For example, the legal process can secondarily traumatise a rape survivor.

Figley ([11]) suggested that secondary traumatic stress can be operationalised as compassion fatigue. He defined compassion fatigue as the natural consequence of working with people who have experienced stressful events. This reaction develops as a result of the helper’s exposure to his/her clients’ experiences and his/her empathy for them. Like vicarious traumatisation, compassion fatigue is most prevalent in those who help trauma survivors (Gentry et al., [15]). Nevertheless, compassion fatigue is a more general term and can be used to describe such broad concerns as the ‘cost of caring’ (Figley, [11], p. 1).

Vicarious traumatisation is specific in its recognition that counsellors who are exposed to their clients’ trauma material can also be traumatised. It incorporates both internal and external influences (McCann & Pearlman, [22]) and consequently considers the individual as a whole (Pearlman & Saakvitne, [29]). In addition, vicarious traumatisation avoids the confusion of other more general terms such as compassion fatigue and secondary traumatic stress. As such, the term is unique to trauma work (Hartman, [16]). Clearly, the impact of working with trauma clients on therapists can best be understood through an investigation of vicarious traumatisation.

Constructivist self-development theory
McCann and Pearlman’s ([22]) constructivist self-development theory (CSDT) provides a comprehensive conceptual framework for understanding vicarious traumatisation. Applied to the trauma therapist, the theory identifies specific ways in which working with trauma clients can disrupt the counsellor’s imagery system of memory, as well as schema about the self and others (McCann & Pearlman, [23]). The CSDT is interactive in that it takes into account variability in responses among people who have experienced the same trauma. This suggests that each person’s reaction is based on a complex interplay between the person, the traumatic event and the context of the work (McCann & Pearlman, [22]; Pearlman & Saakvitne, [29]). Thus, the effects of vicarious traumatisation are unique to each therapist.

According to the theory, people construct their reality through the development of cognitive structures. These cognitions are then used to interpret events (McCann & Pearlman, [22]). McCann and Pearlman indicated that trauma can disrupt the counsellor’s cognitive schemata in one or more of five fundamental need areas: safety (feeling safe from harm by oneself or others), trust/dependency (being able to depend on or trust others and oneself), esteem (to feel valued by others and oneself and to value others), control (the need to be able to manage one’s own feelings and behaviours, as well as to manage others), and intimacy (feeling connected to others or to oneself).

In addition to its focus on schemas, the CSDT emphasises the importance of ego resources (resources that allow one to connect with others), self-capacities (being able to establish a sense of self that is consistent over time), and frame of reference (framework through which the individual interprets experiences) in understanding vicarious traumatisation (McCann & Pearlman, [22]).

Over the past decade, researchers (e.g. Iliffe, [17]; Johnson & Hunter, [18]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [30]) have supported the theory in terms of trauma counsellors experiencing disruptions in cognitive beliefs. For example, Iliffe found that therapists working with domestic violence survivors felt less secure in the world, identified with feelings of powerlessness, and had an increased awareness of gender power and control issues. In addition, she discovered that single female domestic violence therapists were less trusting of men when forming new relationships. Consequently, Iliffe concluded that many of these domestic violence workers experienced changes in cognitive schemata, particularly those that pertain to the needs of trust, safety, and power. Similarly, Johnson and Hunter investigated counsellors who worked with sexual assault survivors. The investigators administered their Beliefs and Values Questionnaire which measures participants’ beliefs of safety, trust, power, intimacy, and esteem. Compared to the control group, respondents indicated that they had more problems with intimacy with people outside work, were more likely to experience a negative shift in their power beliefs, and had more negative changes in their general attitudes and beliefs.

The CSDT also stresses the importance of the imagery system of memory. According to McCann and Pearlman ([22]), counsellors can incorporate their clients’ painful stories into their own memory which may lead to flashbacks, dreams or intrusive thoughts, symptoms considered central to PTSD. Indeed, the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, [ 2]) indicates that PTSD can be developed through ‘learning about unexpected or violent death, serious harm, or threat of death, or injury experienced by a family member or close associate’ (p. 463).

Several investigators (e.g. Gabriel, [13]; Iliffe, [17]; Schauben & Frazier, [30]) have identified PTSD symptoms such as distressing images and thoughts in trauma counsellors. For example, Schauben and Frazier investigated the negative effects of being a female psychologist and rape crisis therapist, and found that the percentage of survivors in the counsellors’ caseloads correlated significantly with PTSD symptomatology. Similarly, Gabriel reported that group therapists who experienced the death of group members from AIDS were experiencing symptoms such as ‘death imprints’, ‘indelible images’ and ‘psychic numbing’ (pp. 170, 172). Likewise, Iliffe found that most of the domestic violence counsellors in her study experienced visual imagery of what they had heard, and almost all had one or two visual images of severe violent incidents that they felt would stay with them forever. Consequently, counsellors who listen to accounts of trauma can internalise the memories of their clients and have their own memory systems altered temporarily or permanently (McCann & Pearlman, [22]).

McCann and Pearlman ([22]) explained that specific areas of disruption will differ for different individuals depending on which area is more or less salient for them as a reflection of their unique life experiences. For example, Astin ([ 4]) noted that despite her extensive work with several types of trauma clients, vicarious traumatisation was not a problem until she began counselling survivors of rape. Similarly, in the study by Steed and Downing ([33]), therapists explained that their responses to clients’ trauma material varied depending on a number of factors relating to both themselves and their clients such as the nature of the abuse, the age of the client, and the abuse’s impact on the client’s life. Therefore, it is likely that not everyone will react the same way to what objectively may be labelled as a traumatic event (Cerney, [ 6]).

Although of explanatory value, the CSDT fails to recognise the full range of effects of trauma counselling. For example, working with trauma clients can result in positive changes for the therapist. Steed and Downing ([33]) investigated the effects of providing therapy to sexual assault/abuse survivors. They found that many of the counsellors reported positive changes in their sense of identity, and beliefs about self and others. Recent trauma research (e.g. Frazier et al., [12]; Tedeschi & Calhoun, [35]) indicates that people who undergo a traumatic event can experience posttraumatic growth, that is, increased functioning and positive change. According to Tedeschi and Calhoun, posttraumtic growth can coexist with distress. Thus, it appears that the CSDT needs to be expanded to incorporate the wide variety of potential effects.

A further limitation of CSDT is that it does not distinguish between increased awareness and disturbances in cognitive schemas. For example, a counsellor who works with women who have survived domestic violence and sees a couple arguing in public may conclude that the man is going to physically assault his partner. Rather than demonstrating a disruption in cognitive schemas, it could be that this counsellor is more mindful of domestic violence issues, as a consequence of working in the field (Steed & Downing, [33]). Steed and Downing suggested that disruptions in cognitive beliefs can be conceptualised on a continuum ranging from awareness, to exaggeration and paranoia.

Despite these limitations, the CSDT offers a useful theoretical basis for understanding vicarious traumatisation. Studies (e.g. Iliffe, [17]; Johnson & Hunter, [18]; Mauldin, [21]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [30]) have demonstrated that trauma counsellors can experience PTSD symptoms and disruptions in cognitive beliefs. According to the theory, a counsellor’s response to hearing their clients’ trauma story will depend on the multiple influences of the work and aspects intrinsic to the counsellor (Pearlman & Saakvitne, 1990).

Factors that influence vicarious traumatisation
Although attention to the psychological impact of working with trauma clients is increasing, most of the focus has been directed toward theory building and clinical practice (Steed & Downing, [33]). The literature speculates about the detrimental effects of vicarious traumatisation and discusses ways to overcome it (e.g. Blair & Ramones, [ 5]; Figley, [11]; Steed & Downing, [33]). As indicated by Steed and Downing, empirical research investigating the impact of vicarious traumatisation on professionals is lacking.

Of the limited research, an area that has received some attention is the variety of factors that are thought to affect vicarious traumatisation. One of the more common investigated is the counsellor’s personal trauma history. To date, there have been conflicting findings as to whether personal trauma history negatively influences vicarious traumatisation. For example, Pearlman and Mac Ian ([27]) investigated vicarious traumatisation in 188 self-identified trauma therapists. Counsellors with a personal trauma history showed greater disruptions than those without such a history. In contrast, Schauben and Frazier ([30]) studied therapists who worked with sexual violence survivors and found that symptomatology was not related to personal trauma history (i.e. having experienced either rape or incest). The investigators concluded that these negative personal experiences could enable the therapist to identify with clients’ problems and relate to them in an empathic manner.

The influence of counsellors’ caseloads has also been examined. For example, Schauben and Frazier ([30]) found that therapists with a higher percentage of trauma clients in their caseload reported more disturbed beliefs about themselves and others, more PTSD symptoms, and more self-reported vicarious trauma. Arvay and Uhlemann ([ 3]) developed a profile of impaired counsellors from their research. This included counsellors who had a client caseload between 10 and 26 trauma clients per week. These counsellors said that they had ‘too many traumatised clients’ and they felt that their caseload was ‘very intense’ (p. 203). As English ([10]) noted, ‘if one wayward child can impair the morale of a whole family, it therefore stands to reason that ten disturbed patients are going to take their toll on the therapist’ (p. 197).

Another factor that can influence vicarious traumatisation is the counsellor’s level of experience. Investigations (e.g. Adams et al., [ 1]; Crothers, [ 8]; Pearlman & Mac Ian, [27]) have indicated that ‘newer’ therapists experience the most difficulties. This suggests that a therapist’s schemas might become less disruptive over time. In line with this, Steed and Downing ([33]) found that a majority of counsellors did not perceive the negative effects of working with sexual abuse/assault survivors as increasing with time. Similarly, Pearlman and Mac Ian found that experienced counsellors who did not have a trauma history reported that they had less disrupted cognitive schemas and showed significantly less general distress. These findings appear to contradict McCann and Pearlman’s ([22]) definition of vicarious traumatisation as a condition that develops as a result of gradual exposure to clients’ traumatic experiences. Consequently, the influence of experience on vicarious traumatisation is yet to be determined.

Another area of research has focused on ways to ameliorate the effects of vicarious traumatisation. In particular, studies have examined the coping strategies of those who work with trauma clients. Dyregrov and Mitchell ([ 9]) investigated the coping mechanisms used by emergency personnel who work with traumatised children. They found that suppression of emotions, distancing from certain aspects of the event, and dehumanising were frequently used as coping strategies. Talking about their feelings after the event was also helpful for emergency personnel. Similarly, Hodgkinson and Steww (1998) reported that the most commonly used coping strategy amongst social workers involved in counselling survivors of a train crash was that of sharing their experience with colleagues.

Schauben and Frazier ([30]) assessed the effects of working with sexual violence survivors. The most often used coping methods included active coping, seeking emotional support, planning, seeking instrumental support, and humour. The least common strategies were using alcohol or drugs, denial, and behavioural disengagement. All five of the most common coping strategies were associated with lower symptom levels of vicarious trauma, whereas the least common methods were related to higher symptom levels or were not associated with vicarious trauma. Participants listed additional coping strategies such as physical health and well-being, spiritually-orientated activities and various leisure activities. Together, these studies demonstrate the importance of identifying active coping strategies to deal with vicarious traumatisation.

A number of investigators have recommended that counsellors be provided with supervision in order to cope with hearing others’ trauma experiences (e.g. Arvay & Uhlemann, [ 3]; Mauldin, [21]; Sexton, [31]; Sommer, [32]). Neumann and Gamble ([25]) suggested that inexperienced counsellors were particularly vulnerable to vicarious traumatisation when supervision was not provided. Also, Pearlman and Mac Ian ([27]) claimed that experienced counsellors were significantly less distressed because they were more likely to have engaged in continuing education and consultation. According to McCann and Pearlman ([22]), a counsellor’s level of vulnerability to vicarious traumatisation could depend on the extent to which he or she is able to engage in a process, like the client, of integrating and transforming the traumatic experiences. Presumably, such a process would diminish the disruption of vicarious traumatisation.

Despite the apparent importance of supervision, it appears that many counsellors are not receiving adequate Helpance. Pearlman and Mac Ian ([27]) found that only 64% of trauma therapists reported receiving supervision. Arvay and Uhlemann ([ 3]) identified even lower levels of professional support with just 1% of counsellors seeking supervision. Consequently, it is essential that future studies further examine the extent of supervision available to counsellors and determine the impact of a variety of forms of supervision on vicarious traumatisation.

Counselling groups and vicarious traumatisation
Typically, the limited research on vicarious traumatisation has been conducted on counsellors who work with sexual violence survivors (Astin, [ 4]; Johnson & Hunter, [18]; Schauben & Frazier, [30]; Steed & Downing, [33]). Yet as Tedeschi and Calhoun ([34]) pointed out, traumatic events are sudden, unexpected and out of the ordinary, and they create powerlessness and long-lasting problems. Similary, Cerney ([ 6]) highlighted that traumatic occurrences are any situations ‘in which the person is flooded with intense stimulation that he or she cannot control’ (p.131). Therefore, many experiences other than sexual abuse/assault can be considered traumatic. Consequently, it is important that further investigations involve a wider range of traumatic experiences.

Further, most of the research to date has been restricted to face-to-face counsellors (e.g. Astin, [ 4]; Iliffe, [17]; Johnson & Hunter, [18]; Sommer, [32]; Steed & Downing, [33]). It is likely that other professionals are affected by vicarious traumatisation. Gentry et al. ([15]) noted that professionals such as social workers, lawyers, disaster relief workers, nurses, doctors, emergency service professionals, and police who work with a range of trauma clients are all susceptible to vicarious traumatisation.

In particular, research on telephone counsellors has been neglected. There is a large number of international telephone counselling services. For instance, Lifeline International, a crisis telephone service is represented in 19 countries (Lifeline International, [20]). Telephone counselling provides the client with immediacy, anonymity, interim counselling, the perception of control and easy access (Coman et al., [ 7]). Despite their prevalence and importance, a search of the literature found only one study that has focused on telephone counsellors. Mauldin ([21]) investigated telephone counsellors who work with sexual violence survivors and discovered that they were experiencing significant PTSD symptoms.

Conclusions & recommendations
In conclusion, conceptualisations that relate to vicarious traumatisation are countertransference, burnout, secondary traumatic stress, and compassion fatigue. Despite similarities, vicarious traumatisation is the most appropriate term for identifying the unique effect that working with trauma clients has on the professional (Hartman, [16]). Notwithstanding the limitations with the CSDT, it provides a useful explanatory framework for vicarious traumatisation. Research (e.g. Gabriel, [13]; Iliffe, [17]; Johnson & Hunter, [18]; Mauldin, [21]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [30]) has supported the theory’s claim that vicarious traumatisation can lead to changes in cognitive beliefs/schemas, as well as the development of PTSD symptoms. Although not conclusive, studies (e.g. Steed & Downing, [33]; Pearlman & Mac Ian, [27]; Schauben & Frazier, [30]) have found that a counsellor’s caseload, amount of experience, personal trauma history, and coping strategies can influence levels of vicarious traumatisation. Even though investigators (e.g. Mauldin, [21]; Neuman & Gamble, [25]; Sommer, [32]) have suggested that supervision has a positive effect on vicarious traumatisation, this proposal requires further examination.

Vicarious traumatisation appears to be a natural by-product of relieving trauma clients’ emotional suffering and so is a crucial issue for helping professionals. Researchers need to investigate vicarious traumatisation amongst a variety of professionals who work with a range of clients who have experienced trauma. One group that requires particular research attention is telephone counsellors.

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By Jane Dunkley and ThomasA. Whelan

Reported by Author; Author

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