As B. Hudnall Stamm (1995) states in the preface of Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators, trauma professionals are always at risk for being "wounded by the work" (p. ix). Professionals who work with the traumatized and PTSD sufferers are potentially at risk for developing a condition known as compassion fatigue or secondary traumatic stress disorder (STSD; Figley, 1995; Miller, 1998). Secondary traumatic stress disorder is defined by Figley as:
the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experience by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person. (p. 7)
Secondary traumatic stress disorder and PTSD are virtually the same, with the difference being between direct exposure versus vicarious exposure. Figley (1995) considers compassion fatigue, compassion stress, and secondary traumatic stress disorder as synonymous. It is also sometimes referred to as burnout, emotional contagion, secondary victimization, covictimization, or secondary survivor syndrome. Figley (1995) has even developed an instrument to measure compassion fatigue in professionals called the Compassion Fatigue Self-Test for Psychotherapists.
Although it may seem obvious to some, why should STSD even be of concern? As Shay (1995) states, "what is the ethical standing of the needs of the trauma therapist?" (p. 253). When does the care of the caregiver become an important issue or an even more important issue than the care of the patient? Shay shies away from taking a firm stance on this question, but I would propose that the answer to this question is that both parties involved have equal right to self-care, and, in fact, a professional who neglects his or her self-care regarding work with trauma sufferers is serving the best interest of no one. The simplest approach to take here is that an impaired professional is less likely to provide effective treatment and help.
Symptoms of STSD include intrusive imagery related to a client's trauma, avoidance, arousal, somatic complaints, distressing emotions, addictive behaviors, compulsive behaviors, and problems in functioning. Chrestman (1995) conducted a survey of therapists and found an association between STSD and secondary trauma exposure. Intrusion and avoidance symptoms were found. However, the mean levels of these symptoms were not in the clinical or diagnos-able range despite the levels being higher than in professionals not secondarily exposed to trauma. This finding can be misleading, however. Although the mean levels for these subjects were not clinical, there was a percentage of the sample that did, in fact, experience clinical levels. In this study, there was a relationship between the amount of time therapists spent with trauma sufferers and certain changes in behavior, including decreasing the therapist's children's activities away from home, decreased so-called risky behavior, feeling less comfortable seeing clients when alone in the office, increased checking of doors, and increased listening for noises. Also, therapists with a higher percentage of trauma clients on their caseloads talk less to family and friends and attend more professional conferences. This study also cited that as professional experience, income, and postgraduate training increased, reported symptom levels went down.
Secondary traumatic stress disorder can develop from either a one-time exposure, as might be the case with a crisis worker with ongoing exposure with treatment cases, or in some other setting. For example, a pediatric neuropsychologist who works for an attorney assessing obstetrician malpractice claimants might develop STSD or compassion fatigue from assessing hundreds of young children and toddlers with neuropsychological deficits secondary to medical trauma at birth. Such an individual is exposed to the trauma of the child and the parents alike, not to mention the powerful effects of repeated exposure to heart-wrenching stories, dashed hopes, struggles to make sense in the family and by the parents, and actual disabling deficits. Danieli (1985) makes the important observation that a professional's exposure to traumatic stories serves as a powerful reminder of the reality of such events and of one's potential vulnerability. Certainly, being reminded on a regular basis of one's vulnerability can take its toll. Dutton and Rubinstein (1995) remind us that repeated exposure in long-term treatment is the rule. That is, with long-term treatment, a therapist will have to hear about a traumatic event again and again. These authors also remind us that therapists are also privy to graphic details and information that typically only a sufferer, a victim, or a perpetrator (in the case of violent trauma) would know. Other factors play a role in determining STSD reactions, including level of predictability of the event; source of information about the trauma (e.g., verbal recall versus photographs, etc.); relationship with a perpetrator; the extent to which the event violates vital assumptions about the world and people; level or degree of threat to life; level of professional development; whether there is a current threat; presence of mind control or mind-games, such as manipulation, on the part of the client; solo practice versus group versus institution; whether the therapist has knowledge of other traumas in other cases or was a survivor him- or herself; and level of intimacy in the traumatic event, such as an incest case (Dutton & Rubinstein, 1995).
Protective factors for not developing STSD include more experience; training; increased social and professional support; engaging in more than just clinical work with trauma victims, such as teaching; and reduced stressors in other areas of the clinician's life (Chrestman, 1995). Other protective factors include recreation in addition to work, having a network of emotionally supportive relationships, self-exploration, taking care of personal needs, personal therapy, supervision, and diversifying clients (Dutton & Rubinstein, 1995). Still other important issues include obtaining training and information about STSD in the spirit of stress inoculation. Such training should include learning how to identify signs, make adjustments when necessary, and seek help when necessary. Trauma clinicians with a personal history of trauma should be well aware of the potential for their own issues to become salient in their professional work. This need not be a negative indicator, however, in that it can sometimes be positive by leading to potentially more empathy for clients. Finally, Janet Yassen (1995) provides a good list of individual-oriented prevention tools:
1. Maintaining physical health, including getting adequate sleep and nutrition.
2. Having a balanced life between work, play, and other activities.
4. Contact with nature.
5. Creative expression.
6. Skill development.
7. Meditation or spiritual practice.
10. Social support.
11. Professional help.
12. Social activism.
13. Professional balance.
14. Good professional boundaries and limits.
15. Not overworking.
16. Professional support by peers and in supervision and consultation.
17. Having a mentor or role model.
18. Commitment to the job.
19. Continuing to grow as a professional.
One more important issue needs to be addressed before moving on to treatment. That is the issue of vulnerability. Are some of us more vulnerable to developing STSD than others? Certainly, professionals exposed to trauma versus those who are not are more at risk. But are there other factors? Williams and Sommer (1995) provide the following list of potential vulnerabilities in professionals:
1. Not having strongly formed ethical beliefs and values consistent with the profession and type of work.
2. Lacking a strong foundation in trauma theory.
3. Nonresolution and examination of your one's trauma history.
4. Lack of treatment skill, competence, available strategies, and techniques.
5. Lack of awareness for the potential of STSD and how one would cope with its onset.
Pearlman and Saakvitne (1995) group treatments for STSD into three categories: personal, professional, and organizational. Personal treatment should involve identifying and analyzing disrupted schemas that arise from working with a particular trauma victim or victims. Schemas that are particularly related to safety, trust, self-esteem, intimacy, and control should be focused on. Also, trauma clinicians should have personal lives outside of work. They should also engage in healing activities such as art, music, spending time with loved ones, or even community services. This will vary for every individual, of course. Finally, one should attend to his or her spiritual needs.
Professional strategies discussed by Pearlman and Saakvitne (1995) should include arranging for and utilizing supervision. It is also important to develop professional connections. Similar to having a personal life outside of work, one should have a balanced work life with varied activities, not all trauma work, for instance. Clinicians should remain aware of their goals of being mental health practitioners, reminding themselves from time to time why they got into to the business to begin with. Also, continue to develop professionally in the form of continuing education and training.
Finally, certain organizational strategies are helpful in ameliorating the effects of STSD. The physical setting is important in trauma work. A safe, private, and comfortable space is vital. Organizations should also provide adequate training and warnings of the potential for STSD in working with particular populations. Adequate professional resources should be available, such as supervision and consultation. An atmosphere that encourages professional development and activities is also very important. The atmosphere should also be one of respect. Adjunctive services such as professional self-help groups, newsletters, books, and other supportive material are helpful.
Of course, if none of these work or if more help is needed, a professional should never hesitate to get professional help for him- or herself in the form of therapy, medication, or both.
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