Download Secondary traumatic stress among psychotherapists: determinants

Andrzej Gołąb*, University of Finance and Management in Warsaw
Małgorzata Partyka, Gestalt Therapy Institute in Cracow
Marcin Rzeszutek, University of Finance and Management
in Warsaw
Secondary traumatic stress among
psychotherapists: determinants and
consequences1
Abstract
The1aim of the paper is to present the phenomenon of secondary traumatic stress (STS),
i.e. stress resulting from contact with trauma victims. The authors discuss conceptual
issues related to STS (as well as terminological questions), characterize several methods
of assessment of STS and data on its prevalence in samples from various populations.
The main part of the article is devoted to considering STS among psychotherapists treating survivors of trauma. The problem is examined from the point of view of occurrence of
STS among therapists, its predictive factors and consequences.
Keywords
secondary traumatic stress (STS), psychotherapists
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Introduction
For the last 20 years there has been increased attention to people who
experience trauma indirectly by working with trauma victims or by being in
contact with them.
* Corresponding author: Andrzej Gołąb, Faculty of Psychology, University of Finance
and Management in Warsaw, 55 Pawia St., 01-030 Warsaw, Poland; e-mail: andgolab@
gmail.com.
1
A first draft of the paper was prepared by M. Rzeszutek. M. Partyka has contributed to
a paragraph on consequences of STS for psychotherapists. A. Gołąb collected data on history of
the STS concept and on methods of diagnosing STS. He is also responsible for the final version
of the paper. Authors (in alphabetical order) specify their contribution as 40%; 20% and 40%
respectively.
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Andrzej Gołąb, Małgorzata Partyka, Marcin Rzeszutek
Various terms are used to describe this phenomenon, such as „secondary trauma”, „vicarious trauma”, „compassion fatigue” and others2. Although
many authors treat these concepts as roughly synonyms (Bride, 2012), in this
paper we prefer the terms „secondary traumatic stress” (STS) and „secondary traumatic stress disorder” (STSD). They were first introduced by Charles
R. Figley3 who used them in his seminal book (Figley, 1995a): Compassion
fatigue: coping with secondary traumatic stress disorder in those who treat
the traumatized. Figley defined STS as „the stress resulting from helping
or wanting to help a traumatized or suffering person” (Figley, 1995b, p. 7).
Such a stress may lead to symptoms identical to posttraumatic stress disorder (PTSD) i.e.: intrusive images, hyperarousal, numbing and avoidance
reactions. That is why Figley proposed for the these PTSD-like symptoms
the analogical name „secondary traumatic stress disorder (STSD).
PTSD was first introduced as a diagnosis in 1980 (Friedman, 2014) in
the third edition of the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-III). The diagnostic criteria for
PTSD were modified in next revisions of the DSM (DSM-III-R, DSM-IV, DSMIV-TR, and the 2013 update DSM-V).
Although STSD was never included in any former or contemporary official
classification of diseases, one can find opinion that „recently [terms] secondary traumatic stress and secondary traumatic stress disorder (STS / STSD)
have become increasingly commonly used” (Renshaw et al., 2011, p. 461).
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Assessment of secondary traumatic stress
One of the first tools used in diagnosis of secondary stress was Compassion Satisfaction / Fatigue Self-Test for Helpers developed by Charles Figley and
Beth Hudnall Stamm4 (Figley & Stamm, 1996). The instrument underwent
later further improvements and now is known as Compassion Satisfaction
2
In the last paragraph of our paper we devote some space to the consideration of these
terminological variants.
3
A pioneer in the field of traumatic stress, a renowned professor, the founder and
director of the Traumatology Institute at Florida State University (1998–2008), the founder
and the first editor of Traumatology: An International Journal (1995–2012).
4
B.H. Stamm was a professor and director of Institute of Rural Health at Idaho State
University (according to personal communication by her to A. Gołąb in email received on 1
October 2014, she is now retired). She was an initiator and director of the research program
Professional Quality of Life (ProQOL – see: http://www.proqol.org/ )
Secondary traumatic stress among psychotherapists: determinants and consequences
65
and Compassion Fatigue (PROQOL) version 5 (Stamm, 2010)5. Apart from
a subscale for measuring Secondary Traumatic Stress (10 items, alpha scale
reliability.81) it has a subscale for Burnout (10 items, alpha scale reliability.75) and for Compassion Satisfaction (10 items, alpha scale reliability.88).
There are also other diagnostic instruments to detect symptoms of secondary stress. In 1999 Robert W. Motta and coauthors elaborated a 20-item
secondary trauma questionnaire (Motta et al. 1999, 2001). Original scale was
later (Motta et al. 2004) reduced to 18 items measuring two factors: Intrusion and Avoidance (with alpha coefficient.89).
In 2004 Brian E. Bride with co-workers published a 17-item Secondary
Traumatic Stress Scale (STSS, cf. Bride et al., 2004). It consisted from 3 subscales: Intrusion (5 items), Avoidance (7 items) and Arousal (5 items).
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Prevalence of secondary traumatic stress
Roman Cieślak and collaborators (Cieslak et al., 2013) report prevalence
rates for PTSD-like diagnosis of STS in various groups. The data are based
on studies using STSS as a diagnostic tool and DSM-IV-TR6 criteria B, C, and
D (symptoms of re-experiencing, avoiding, and hyperarousal). These criteria were met by 15.2% of social workers, 16.3% of oncology staff, 19% of
substance abuse counselors, 20.8% of providers treating family or sexual violence, 32.8% of emergency nurses, 34% of child protective services workers,
and 39% of juvenile justice education workers. The quoted authors found
that among mental health providers working with the military the prevalence of STS was 19.2%.
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Secondary trauma among psychotherapists
The occurrence of secondary stress symptoms has also been identified in
psychotherapists, especially those, who deal with traumatic stress.
Laurie Pearlman and Paula Mac Ian asked 188 self-identified trauma
therapists about their own psychological well-being. The authors noticed
5
PROQOL version 5 has now 19 different language versions ( see: http://www.proqol.
org/ProQol_Test.html ).
6
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision, (American Psychiatric Association, 2000).
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Andrzej Gołąb, Małgorzata Partyka, Marcin Rzeszutek
significant level of PTSD-like symptoms in 62 percent of examined trauma
therapists (Pearlman & Mac Ian, 1995).
Shelah Adams and Shelley Riggs (2008) investigated 129 trauma therapy
trainees and established that 31% of them exceeded the clinical cut-off score
in the Trauma Symptom Inventory.
Toni Farrenkopf (1992) observed that 33% of therapists who treated
sexual offenders reported high levels of secondary traumatic stress, especially hypervigilance, suspiciousness and fear for the safety of loved ones.
As an example may serve what said in an interview Helen Fitzgerald
(2009), who worked for ten years in criminal justice social work: „I worked
with sex offenders because I wanted to help them, but I began suspecting
every man”. She continued: „I hated that it had seeped into my personal life.
I couldn’t get to sleep at night. Images flashed – no, crashed – before me, of
the things I had read or heard that day: X touching the nine-year-old girl; Y
masturbating in front of his two boys”.
According to Laurie Pearlman and Karen Saakvitne who studied psychotherapists of adult incest survivors (Pearlman & Saakvitne, 1995), secondary
trauma stems from psychotherapists’ empathic engagement with clients’
traumatic history. The result of this process, which may be viewed as kind
of a countertransference, is a transformation in the inner experience of
the therapist. The authors call this transformation vicarious traumatization.
It undermines a therapist’s adaptive assumptions of personal security and
a meaningful world, increasing the likelihood of feelings of pain and loss
(Chrestman, 1999). In contrast to countertransference, which is specific to
a given therapy, vicarious traumatization is “accumulative across many therapies” (Rasmussen, 2011, p.230).
QQ Determinants of secondary trauma among psychotherepists
Research suggests that some of the psychotherapist characteristics are
important for developing symptoms of secondary traumatic stress.
One of such characteristics, which are mentioned in literature, is a therapist’s prior history of trauma7.
Victoria Follette with her collaborators (Follette et al., 1994) assessed
past trauma experiences in several hundred mental health professionals who
Marydale Salston and Charles Figley maintain that „(…) literature supports the belief
that most trauma therapists have experienced some traumatic event” (Salston & Figley, 2003,
p. 170).
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Secondary traumatic stress among psychotherapists: determinants and consequences
67
worked with child sexual abuse survivors. They found that 29.8% of therapists reported experiencing some form of childhood trauma. Professionals
with a history of child abuse exhibited significantly higher levels of PTSD-like
symptoms.
Many authors are convinced that if a therapist has an increased capacity for empathy, it may contribute to an intense empathic engagement with
the client’s traumatic issues. An old saying goes: „It is both a blessing and
a curse to feel everything so deeply”.
An example of a study showing the statistically significant relationship
between dispositional empathy (measured by the Interpersonal Reactivity Index) and STS is the dissertation of Victoria MacRitchie (2006) from
Johannesburg.
Higher rates of secondary traumatic stress are noted among those mental health specialists, who have high number of traumatized patients in their
caseload.
Laura Schauben and Patricia Frazier studied counselors working with
sexual violence survivors (Schauben & Frazier, 1995). Counselors with
a higher percentage of survivors in their caseload reported more symptoms
of post-traumatic stress disorder independently from their own history of
victimization.
Development of secondary stress symptoms is believed to be associated
with deterioration of social support (Emery, Tracey and McLean, 2009).
Age, gender, and education level ot the therapist have not shown clear
relations with their susceptibility to STS.
Young age of the therapist was associated with greater level of STS in
one study (Ghahramanlou and Brodbeck, 2000), but not in two others (Kassam-Adams, 1999; Meldrum et al., 2002). Lower level of therapist education
was linked to higher STS in one study (Baird and Jenkins, 2003), but was not
related in another (Ghahramanlou and Brodbeck, 2000). There is no consensus on the impact of therapist gender on the occurrence of STS (Meldrum et
al., 2002).
QQ Consequences of secondary trauma among psychotherapists
There are several long-term effects of secondary traumatic stress, which
include constant feeling of being overwhelmed, drained, and exhausted in
working with clients (Catherall, 1995; Figley, 2002). STS symptoms can also
lead to therapist’s preoccupation with thoughts of clients outside of work and
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Andrzej Gołąb, Małgorzata Partyka, Marcin Rzeszutek
overidentification with the clients’ material (Beaton and Murphy, 1995; Miller, 1998). In addition, STS symptoms may be visible in therapist’s behaviors,
which the most frequent are distancing, numbing, detachment and cutting
clients off (Figley, 1995a, 2002; Pearlman and MacIan, 1995).
Secondary trauma can also impact the therapist on a personal level. More
specifically, the therapist might encounter relational problems (with spouse/
partner, family, and friends). Some therapists may start abusing substances
(Beaton and Murphy, 1995).
While the term „ burnout” is often thrown around in discussions of stress
it is risky to identify conceptually secondary stress with the syndrome of professional burnout (Newell & MacNeil, 2010). Burnout syndrome is described
as an experience of a long-term emotional exhaustion and reduced sense of
personal accomplishment. Of course it can be observed also among people
who work with other people (Maslach, 1993, 2001; Rzeszutek and Schier,
2014). It can result from work stress and work constraints, as well as work
pressure. Burnout differs from STS in that it does not impact the therapist’s
inner experience of safety or intimacy (Benson and Magraith, 2005). Moreover, unlike burnout, STS is associated with a sudden onset of symptoms that
are pervasive. Nevertheless, both STS and burnout can lead to decrease in
concern and esteem for clients, as well as to a decline in the quality of work
with clients (Raquepaw and Miller, 1989).
Working with traumatized clients, psychotherapists should take into
consideration the risks which are associated with trauma work. Especially
new trauma therapists should be aware that they are at great risk of being
traumatized as a result of their work (Neumann and Gamble, 1995). Therefore, trauma therapists should consider participating in clinical supervision,
consultation, or engaging in other forms of self-care. In particular, professionals in private practice settings may be more prone to the effects of STS due
to the lessened daily interaction with other mental health professionals and
greater isolation. Mental health professionals should also continue to engage
in additional training and coursework to broaden their abilities in working
with trauma clients. More specifically, professionals who work with trauma clients regularly may want to take into an account receiving supervision
for techniques that can assist a client in determining and expressing their
feelings. Clinical supervision and supervisory feedback have been said to
increase levels of self-efficacy in working with patients (Harrison and Westwood, 2009; Meldrum et al., 2002).
Trauma therapist should keep in touch with new approaches and ideas in
the realm of her or his work. A relatively new invention in the field of treating
Secondary traumatic stress among psychotherapists: determinants and consequences
69
trauma survivors are elaborated by David Berceli Trauma Releasing Exercises
(TRE, cf. Berceli, 2005). Berceli’s approach is continuation of Alexander Lowen’s bioenergetics (Lowen, 1975). TRE consists in evoking muscle tremors in
order to release muscular tension stemming from experienced traumas.
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Remarks on terminology
The extensive bibliography on secondary traumatic stress published
by Beth Stamm (2010a) includes over 1000 references. It is a result of internet
search8. Among terms used in titles of searched documents the most frequent
were: „secondary trauma / traumatization / traumatic stress (appeared 203
times), „vicarious trauma / traumatization (186 times) and „compassion fatigue” (123 times).
In the remarks which follow we are going to concentrate on two aspects of terminology: one is semantic point of view, another is historical one:
the authorship of the terms and time of their first appearance.
A rationale for using composition of two words: „secondary” and „trauma”
seems obvious: on the one hand a trauma defines the essence of the situation,
on the other the trauma is not experienced first-hand. Instead one it is experienced indirectly and as if „secondarily” through reports of trauma victims.
The same could be said about „vicariousness” of trauma. The adjective
„vicarious” comes from Latin word „vicarius” meaning „substituting”. So „to
experience anything vicariously” means „undergo at second hand through
sympathetic participation in another’s experiences”9. A psychotherapist,
a social worker or another person who works with the victim of trauma and
learns in details her traumatic experience as if participates in her experience
and this way may become a „vicarious” victim of it10.
8
It is interesting to note that vast majority of references were published after 2000.
The number of publications in the consecutive periods of five years was as follows: 1980–84:
3 items; 1985–1989: 9 items; 1990–1994: 60 items, 1995–1999: 253 items; 2000–2004: 373
items; 2005–2009: 345 items.
9
British Dictionary definitions for „vicarious” – retrieved 12.09.2014 from: http://dictionary.reference.com/browse/vicariousness
10
The term „vicarious trauma” was coined in 1990 by Lisa McCann and Laurie Anne
Pearlman. They give the following rationale: „Therapists who work with victims may find their
cognitive schemas and imagery system (…) altered or disrupted by long-term exposure to
the traumatic experiences of their victim clients” (McCann & Pearlman, 1990, p. 132).
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Andrzej Gołąb, Małgorzata Partyka, Marcin Rzeszutek
The third term is „compassion fatigue”11. The specifity of the phrase
„compassion fatigue” consists in joining two aspects of helping professionals’ activity. One side of helper’s activity is compassion (uniting two positive
motives: empathy and sympathy). Another side of helping may be negative
feeling of exhaustion or tiredness. In this context one should mention another term which may be found in the literature on secondary traumatic stress,
namely „burnout”12 (for instance: Craig & Sprang, 2010). In order to prevent
the suggestion that helping has mainly negative consequences some authors
insist that one should study not only „compassion fatigue” but also „compassion satisfaction” (Stamm, 2010b).
In the literature one may find attempts to make semantic clarifications
and propose more precise definitions of the mentioned above four basic
terms in order to elucidate the differences between their meanings (for example: Bush, 2009; Newell & MacNeil, 2010).
However our strong impression is that probably the most adequate description of the present status of discussed terminology give Katie Baird and
Amanda Kracen (2006, p. 181) who so formulate their view: „there still exists
a lack of conceptual clarity in the literature about VT [vicarious trauma], STS
[secondary traumatic stress], and the related constructs of burnout and compassion fatigue”.
QQ
Prospects for the future
Perhaps the future will bring some unification of meaning of concepts
related to secondary stress.
First author who wrote about „compassion fatigue” was Carla Joinson (1992). Charles
Figley (1995) has used the term in the title of his famous book (Figley, 1995a). In another book
devoted to the problem Figley (2002, p. 2) expresses the following view: „Compassion fatigue is
the latest in an evolving concept that is known in the field of traumatology as secondary traumatic
stress. Most often this phenomenon is associated with the ‘cost of caring’ for others in emotional
pain”. History of the concept „compassion fatigue” assessed Christopher Marchand (2007).
12
Stamm (2010a, Introduction) informs that she did not use „burnout” in her search
terms „as it (…) can apply to any type of job” and „not unique to working with people who have
experienced extreme suffering”. Nevertheless about 70 titles of texts in her bibliography contains
word „burnout”. Some authors propose the psychoanalitical term „countertransference” to
describe facts denoted by others as secondary stress. Similarily as in case of „burnout” it is
evident that „countertransference” should be related to much broader range of situations then
secondary stress. „Countertransference” is not restricted to psychotherapies helping victims
of trauma.
11
Secondary traumatic stress among psychotherapists: determinants and consequences
71
For sure a further research is needed to increase the accuracy and scope
of known facts and to systematize them.
In Poland the described topic seems relatively new: both in terms of lacking research studies and a paucity of literature dealing with applied questions.
One may ask, whether there are chances to introduce the term „secondary traumatic stress disorder” (or any of its equivalents) as a nosological
term into official classifications of diseases. The late appearance of the term
„postraumatic stress” in taxonomies of diseases (DSM, ICD) makes us quite
pessimistic in prognosing official recognition of secondary stress symptoms
as a disease13.
However in principle it should not hinder continuing accumulation of
theoretical and practical knowledge about secondary traumatic stress.
QQ
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13
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