RECOGNITION AND PREVENTION OF SECONDARY TRAUMATIC STRESS: A
TRAINING PROGRAM FOR MENTAL HEALTH PROFESSIONALS
Brian C. Sanchez
B.A., California State University, Sacramento, 2006
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF ARTS
in
PSYCHOLOGY
(Counseling Psychology)
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2010
RECOGNITION AND PREVENTION OF SECONDARY TRAUMATIC STRESS: A
TRAINING PROGRAM FOR MENTAL HEALTH PROFESSIONALS
A Project
by
Brian C. Sanchez
Approved by:
, Committee Chair
Dr. Marya Endriga
, Second Reader
Dr. Rebecca Cameron
Date
ii
Name of Student: Brian C. Sanchez
I certify that this student has met the requirements for format contained in the University
format manual, and that this thesis is suitable for shelving in the Library and credit is to
be awarded for the thesis.
, Graduate Coordinator
Dr. Lisa M. Bohon
Department of Psychology
Date
iii
Abstract
of
RECOGNITION AND PREVENTION OF SECONDARY TRAUMATIC STRESS: A
TRAINING PROGRAM FOR MENTAL HEALTH PROFESSIONALS
by
Brian C. Sanchez
An in-service training program was constructed to facilitate recognition and prevention of
secondary traumatic stress for mental health professionals. Secondary traumatic stress is
defined as the natural consequent behaviors and emotions resulting from knowing about a
traumatizing event experienced by a significant other. Graduate training programs are
lacking in preparing mental health professionals for dealing with clients who have
experienced trauma. A training manual was designed and constructed to facilitate
presentation of the two-hour training. The training program was pilot tested at the White
House Counseling Center in Carmichael, California. Participant feedback on an
evaluation questionnaire indicated that most had little knowledge of secondary traumatic
stress and virtually no graduate training in the topic. The in-service training program is
designed to be used with mental health professionals and therapists in training but can be
used with any groups that work with individuals who have experienced trauma.
, Committee Chair
Dr. Marya Endriga
Date
iv
TABLE OF CONTENTS
Page
List of Tables .................................................................................................................... vii
Chapter
1. HISTORY AND OVERVIEW OF AGENCY ..............................................................1
Statement of the Problem .........................................................................................2
Purpose.....................................................................................................................2
2. SECONDARY TRAUMATIC STRESS LITERATURE REVIEW .............................4
Definition .................................................................................................................4
History......................................................................................................................6
Terminology.............................................................................................................8
Models of STS .......................................................................................................13
Measures of STS ....................................................................................................14
Those at Risk..........................................................................................................17
Moderating Factors for Secondary Traumatic Stress.............................................18
Support System ......................................................................................................24
Ethical Considerations ...........................................................................................26
Prevention and Treatment Strategies for Secondary Traumatic Stress ..................27
3. METHOD ....................................................................................................................34
Pre-Training Planning ............................................................................................34
Piloting the Training Program ...............................................................................36
v
4. RESULTS ....................................................................................................................38
General Reaction Portion of Questionnaire ...........................................................44
Improvements Made to Training Program .............................................................46
Discussion ..............................................................................................................47
Appendix A. Recognition and Prevention of Secondary Traumatic Stress Training
Manual .........................................................................................................53
Appendix B. Training Evaluation Questionnaire.............................................................108
References ........................................................................................................................110
vi
LIST OF TABLES
Page
1. Table 1 Raw Data for Question One ............................................................................41
2. Table 2 Raw Data for Question Two, Pre-training ......................................................42
3. Table 3 Raw Data for Question Two Post-training .....................................................42
4. Table 4 Raw Data for Question Three .........................................................................43
5. Table 5 Raw Data for Question Four ...........................................................................43
6. Table 6 Raw Data for Question Five ...........................................................................44
vii
1
Chapter 1
HISTORY AND OVERVIEW OF AGENCY
The White House Counseling Center has been helping students and their families
with low-cost counseling to learn new skills to cope with the daily concerns of family and
school since 1968. The White House Counseling Center uses an existing district facility
during school and after hours and operates on a year round basis. Interns, Trainees, and
Licensed Marriage and Family Therapists from various training and licensing programs
provide counseling for students and their families. The White House Counseling Center
has a well known graduate training internship that is affiliated with many Sacramento
area university graduate training programs. The staff is supervised by five licensed
marriage and family therapists. In addition, the White House Counseling Center employs
an on site psychiatrist and clinical psychologist. The White House Counseling Center is
supported by client fees and contracts with the Sacramento County Department of Health
and Human Services. The White House Counseling Center primarily supports the mission
of the San Juan Unified School District by helping students to gain the most from their
education. The counseling center’s primary purpose is to help students and their families
deal more effectively with the many problems and stresses that occur at school, home,
and work that may affect school performance. In addition, the graduate training
internship program prepares future and current mental health professionals for careers in
mental health. Outpatient counseling (individual, family, and group) and medication
services are available, which may include services for child neglect and physical or
2
sexual abuse. Mental health services are provided at the counseling center or at individual
school sites. It is estimated that as many as 90% of clients seen at the White House
Counseling Centers have experienced trauma.
Statement of the Problem
Counseling and psychotherapist training programs are often lacking in addressing
the knowledge and skills that future professionals will need to work with victims of
trauma. In a national study of clinical and counseling psychologists, participants gave low
ratings to their graduate training programs and internships with regard to treating clients
who have experienced trauma (Pope & Feldman-Summers, 1992). O'Halloran and
O'Halloran (2001) advocate for graduate training programs to address the impact of
working with victims of trauma. This impact on therapists is called secondary traumatic
stress (STS). It has been well established that those working with traumatized clients can
be greatly affected by their experience (Cerney, 1995; McCammon, 1995; McCann &
Pearlman, 1990; Yassen, 1995).
Purpose
The purpose of this project is to construct and pilot an in-service training program
to recognize and prevent secondary traumatic stress. Since the early 1990s, STS has
become more recognized as a hazard of working with traumatized populations and much
has been written about the concept. Because the concept of STS is relatively new,
graduate training programs for counselors and psychotherapists have been slow to
incorporate awareness and prevention strategies into their training programs. This project
3
attempts to fill that training gap. In addition, this project seeks to help professionals and
pre-professionals learn how to recognize and to prevent STS symptoms. Objectives
include constructing an in-service training program that can be presented to therapists in
the mental health field (trainees, interns, and licensed therapists). In addition, the author
constructed a training manual and PowerPoint presentation about STS. The in-service
training program was reviewed by staff experienced in trauma at The White House
Counseling Center. The in-service training was piloted at the White House Counseling
Center.
4
Chapter 2
SECONDARY TRAUMATIC STRESS LITERATURE REVIEW
Definition
The concept of secondary traumatic stress has been developed through theory and
research over the past two decades showing that counselors and psychotherapists who
work with traumatized individuals often experience stress reactions as a result of their
contact with such clients. Secondary traumatic stress (STS) has been defined by 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). The growing field of
traumatology has begun writing about and investigating this phenomenon. Secondary
traumatic stress is often viewed in the context of individual therapists working with the
traumatized, but it has also been applied to describe the reactions of helpers in disasters
such as 9/11, or in conditions of war (Kluft, 2004). In addition, STS is relevant to any
helping professionals who work with traumatized populations, including nurses, police
officers, and sexual assault workers (Pearlman & Saakvitne, 1995). STS can result from
cumulative or acute exposure to traumatic material, and has been described as an
occupational hazard of those working with victims of trauma (Figley, 1999). STS has
been a growing concern in the helping professions and is considered a major component
of counselor burnout (Munroe, Shay, Fisher, Makary, Rapperport, & Zimering, 1995).
STS reactions can often be an inevitable part of working with traumatic client material.
5
Beaton and Murphy (1995) have found a positive correlation between secondary
traumatic stress reactions and large caseloads, reduced longevity of career, long working
hours and increased contact with traumatized clients.
Therapists may have a wide variety of reactions to their work with traumatized
clients. A meta-analysis conducted by Figley (1995) categorized these reactions into three
areas: indicators of psychological distress or dysfunction, relational disturbances, and
cognitive shifts.
Indicators of psychological distress include distressing emotions like sadness or
grief, horror or dread (Figley, 1995). In addition, nightmares and images of the client’s
traumatic material can occur. Somatic complaints including sleep difficulty, gastric
distress and headaches. Addictive behaviors or compulsive behaviors including substance
abuse or workaholism can also be indicators of psychological distress (Dutton &
Rubinstein, 1995). Dutton and Rubinstein (1995) also note impairment of the therapist’s
day to day functioning in social and personal roles, such as missed or cancelled
appointments, decreased use of supervision, chronic lateness, and feelings of isolation.
Relational disturbances refer to the effects of secondary exposure to trauma on
personal and professional relationships. Dutton and Rubinstein (1995) found that a
therapist’s response to a client’s traumatic material can result in either detachment or
over identification with the client. Detachment results in distancing oneself emotionally
from the client because the therapist may feel overwhelmed or vulnerable to the traumatic
material. This defense mechanism on the part of the therapist could result in clients
6
feeling isolated emotionally from the person who is trying to help them (Dutton &
Rubinstein, 1995). Over identification with the client’s traumatic material can also result
in the therapist feeling responsibility for the client’s well being. The therapist in this
position may be ineffective and may place the client in the position of taking care of the
therapist (Dutton & Rubinstein, 1995).
Cognitive shifts as an STS reaction refer to shifts in the therapist’s beliefs,
expectations and assumptions (McCann & Pearlman, 1990). These cognitive shifts can
affect one’s level of trust that results in chronic suspicion of others. One can go from
feeling safe to having a heightened sense of vulnerability. One can move from a sense of
independence to feeling a loss of personal control and freedom (Dutton & Rubinstein,
1995). Dutton and Rubinstein (1995) found that novice trauma therapists feel guilty for
enjoying life while their clients are struggling. Therapists can also feel guilty when their
clients re-experience the trauma.
History
One of the first descriptions in the literature describing STS came from Haley
(1974), a social worker who worked with veterans of the Vietnam War. At the time, the
experiences described by returning combat veterans were very extreme. Haley described
some therapists as “repulsed and frightened” by the material to the extent that some
therapists could not work with these veterans (Haley, 1974). Figley (1978) also wrote
about stress disorders and psychological adjustment in Vietnam Veterans. Figley noted
that caring for those who have been traumatized left marks on the victim’s family
7
members, and professionals were susceptible to “catching” traumatic stress from those in
whom they invested their empathy and energy (Figley, 1978). Courtois’ (1988) work with
incest victims described STS as “contact victimization” in which the therapist may
develop symptoms of post-traumatic stress disorder. In these first descriptions of what
would become known as STS we see the common thread of therapist stress reactions in
response to client traumatic material. The growing field of traumatology began to
describe the effects of working with traumatized clients on mental health professionals.
Secondary traumatic stress and its effects came out of research into post-traumatic
stress disorder (PTSD). Symptoms of PTSD can occur (American Psychiatric
Association, 2000):
following an extremely traumatic stressor involving direct experience of an event
that involves actual or threatened death or serious injury…or learning about
unexpected or violent death, serious harm… or threat of death or injury
experienced by a family member or other close associate. (p. 463)
Included in the definition of PTSD is not only the person who experienced the
trauma but the witness to the trauma. Thus, STS can be thought of as a subsidiary form of
PTSD that occurs following vicarious exposure to a sudden, life endangering or traumatic
event such as childhood sexual abuse, and severe threats to psychological integrity such
as emotional abuse (Figley, 1995). According to the DSM-IV-TR (American Psychiatric
Association, 2000), symptoms of PTSD include intrusive thoughts about the event,
8
hyperarousal in response to thoughts about the event and avoidance situations that remind
the individual about the event.
Figley (1995) argues that the fundamental difference between PTSD and STS is
the position of the stressor. If the stressor directly harms or threatens the individual, it is a
primary stressor that will likely result in PTSD. On the other hand, if the stressor is the
traumatized individual who has been exposed to harm, the stressor is conceived as a
secondary stressor that may result in STS (Buchanan, Anderson, Uhlemann, & Horwitz,
2006). In terms of the helping professions, counselors who suffer from STS are at risk for
experiencing symptoms of PTSD similar to their clients as a result of their clients’
traumatic stories (Figley, 1995).
Terminology
The term secondary traumatic stress is used throughout the literature in addition to
other terms, such as vicarious traumatization, countertransference, compassion fatigue
and burnout. The terms are sometimes used interchangeably and it seems the debate is
not whether STS exists but what to call it. It is important to consider these other terms
and how they may be similar to, or different from, secondary traumatic stress. The
concept of vicarious trauma was introduced by McCann and Pearlman (1990) as a way to
understand the effects of trauma work on therapists. Vicarious traumatization refers to
harmful changes that occur in professional’s view of themselves, others, and the world as
a result of exposure to the traumatic material of clients (McCann & Pearlman, 1990).
Pearlman and Saakvitne (1995) define vicarious traumatization as “the cumulative effect
9
of working with survivors of traumatic life events…anyone who engages empathetically
with victims or survivors is vulnerable” (p. 31). This definition is very similar to Figley’s
(1995) of STS. Although Pearlman and Saakvitne (1995) address vicarious
traumatization in psychotherapists, they explain the phenomenon can be experienced by
any professional who works empathetically with victims and survivors such as EMTs,
fire fighters, police, criminal defense lawyers, medical personnel, battered women and
homeless shelter staff, sexual assault workers, suicide hotline staff, prison personnel and
trauma researchers.
Included in the definition of vicarious traumatization are disturbances in the
therapist’s cognitive frame of reference. McCann and Pearlman (1990) looked at the
effects of empathetically working with traumatized clients using constructivist self –
development theory. They propose that the changes that occur to the therapist’s cognitive
schema of themselves, others, and the world are pervasive, cumulative, and permanent.
For example, a person’s belief that they can safely use public transportation at night, or
that the world is an orderly place, may be challenged by the traumatic material relayed to
the therapist. While terms secondary traumatic stress and vicarious traumatization are
often used interchangeably, vicarious traumatization emphasizes cognitive schemas (how
one views the world, themselves, and others) as a result of exposure to a client’s
traumatic material. Secondary traumatic stress refers to a set of psychological symptoms
that mimic post-traumatic stress disorder and can be a result of exposure to a client’s
traumatic material. The distinctions are minimal in the literature between STS and
10
vicarious trauma. It is becoming more understood that there is convergence between the
two concepts, and therapists working with trauma experience disruptions in both areas
(Jenkins & Baird, 2002; Pearlman & Saakvitne, 1995).
The term countertransference comes from psychodynamic psychotherapy and was
originally defined by Sigmund Freud. According to Freud (1910/1957) “We have become
aware of the counter-transference, which arises in [the physician], as a result of the
patient’s influence on his unconscious feelings” (p. 144). Counter-transference is further
defined as “any projections by therapists that distort the way they perceive and react to a
client” (Corey, Corey, & Callanan, 2007). Freud viewed countertransference as the
inappropriate reaction of the therapist to the client (Corey et al., 2007). Herman (1992)
coined the phrase “traumatic countertransference” to describe STS but Figley (1995)
distinguished it from STS in the following way: STS includes, but is not limited to
counter-transference, which occurs within the context of psychotherapy and a result of
reactions to the transference on the part of the client. Figley (1995) further states that
counter-transference is a negative consequence of therapy and should be avoided. What
makes STS different from counter-transference is that STS is often a natural result of
caring between two individuals in which one has experienced trauma and the other is
affected by their traumatic experiences (Figley, 1995). Figley (2002a) further notes,
“Countertransference is chronic attachment associated with family of origin issues and
has much less to do with empathy toward the client that causes trauma” (p. 1436). STS
includes more trait-like changes to the values, beliefs, and behaviors of trauma workers.
11
Stamm (1999) states that countertransference can occur outside the context of exposure to
traumatic material while STS always arises as a result of exposure to a client’s traumatic
material.
Compassion fatigue is another term that is used interchangeably with STS.
Compassion fatigue was first used by Joinson (1992) in an investigation of the nature of
burnout in nurses. According to Stamm (1999), Figley’s use of the term compassion
fatigue stems from his belief that some find the term secondary traumatic stress
derogatory. Stamm (1999) states, “in 1993 Charles Figley and I discussed using the term
compassion fatigue in place of secondary traumatic stress precisely because of its more
palatable nature” (p. 10). Compassion fatigue as secondary traumatic stress is explored in
the context of the frontline provider’s deep concern for the welfare of others and
empathy. One of the most important elements of the therapeutic relationship is empathy
(Rogers, 2007). An essential component of therapy in Carl Rogers’ (2007) opinion,
empathy is described as, “…to sense the client’s private world as if it was your own…”
(p. 243). In the context of mental health, compassion fatigue develops as result of the
exposure of helpers to experiences of patients in tandem with the empathy they
experience for their patients (Collins & Long, 2003). Figley views STS as a stress
response that can appear suddenly and without warning that results from the use of
empathy and compassion (Figley, 1995).
Burnout is a theory that has received a great deal of attention and is often used in
the context of STS (Freudenburger, 1975; Maslach, 1976; 1982). Pines (1993) defined
12
burnout as, “a state of physical, emotional and mental exhaustion caused by long term
involvement in emotionally demanding situations” (p. 3). Maslach, Jackson, and Letier
(1996) described burnout as having three dimensions including emotional exhaustion,
depersonalization, and reduced personal accomplishment. Jenkins and Baird’s (2002)
research has shown that there is moderate overlap with burnout and STS resulting in
shared variance “over and above common method variance because of empathic ability as
a theoretical vulnerability factor, interpersonal demands as a stressor, and resulting
psychological distress” (p. 425). According to Jenkins and Baird (2002), this finding of
moderate overlap supports the construct validity of STS. Further differentiation between
burnout and STS is the idea that burnout is related to chronic tedium in the workplace
rather than being exposed to specific kinds of client concerns such as trauma (Jenkins &
Baird, 2002). In addition, burnout can be related to goal achievement. When goals with
clients are being attained, mental health professionals have high morale and feel in
control (Valent, 2002). Inability to achieve goals can result in low morale, frustration,
and loss of sense of control, which, according to Valent (2002), can produce common
burnout symptoms. Stamm (1999) notes that burnout can result from emotional
exhaustion and emerges gradually but STS can become apparent more suddenly. Figley
(1995) has asserted that one severe exposure to another person’s experience of trauma
can result in symptoms of STS (Jenkins & Baird, 2002). STS symptoms have a faster
onset and include a sense of isolation from supporters, and a sense of helplessness and
13
confusion; in addition, its symptoms are often disconnected from real causes (Figley,
1995).
Models of STS
Several etiological models of STS have been developed to help explain the nature
of STS and related factors (Ortlepp & Friedman, 2001). Figley (1995, 2002a) proposed
an etiological model in 1995 and updated it in 2002. At the heart of Figley’s model is that
empathy and emotional energy are the driving force in effective work with the suffering
(Figley, 2002a). Empathy and emotional energy comes with a cost. Figley’s model points
to the influence of nine variables that form a casual model for STS: empathic ability,
exposure to the client, empathic response, compassion stress, sense of achievement,
emotional disengagement, prolonged exposure, traumatic recollections, and life
disruptions (Figley, 2002a). Dutton and Rubinstein (1995) proposed a model for
understanding STS that has four different components. The four parts of their model
consist of the traumatic event to which the trauma counselor has been exposed, the
trauma counselor’s post traumatic stress reactions, the trauma counselor’s coping
strategies, and the personal and environmental mediators of STS reactions (Dutton &
Rubinstein, 1995; Ortlepp & Friedman, 2001). Beaton and Murphy (1995) have also
proposed a similar model that also accounts organizational factors, such as role conflict,
cultural norms, and size of the organization (Beaton & Murphy, 1995). In addition, they
look at mediating factors such as training, the counselor’s social support, and experience
(Beaton & Murphy, 1995). Ortlepp and Friedman (2001) have proposed a model that
14
incorporates elements of the previous three models discussed and describe it as
“eclectic.” Ortlepp and Friedman (2001) describe a model in which the first component is
the trauma counseling incident. They distinguish STS from PTSD in those factors such as
the repetitive nature of exposure to traumatic material as experienced by the counselor,
and that counseling is a self selected activity as opposed to the unexpected nature of
traumatic events experienced by primary victims (Ortlepp & Friedman, 2001). The
second component of this model is the appraisal process concerned with the meaning the
counselor attaches to the traumatic counseling incident. The third group of factors
includes the characteristics of the organization in which the counselor works (Ortlepp &
Friedman, 2001). The final component is the STS reaction of the counselor (Ortlepp &
Friedman, 2001).
These models of secondary traumatic stress reflect the differing views of what
specifically can predispose and affect how counselors respond to traumatic material.
These models have a common element of environmental factors such as social support
and life events that may play a part in STS equal to the exposure of the therapist to the
traumatized client.
Measures of STS
Several measures for assessing STS have been developed as a result of research
and theory. Secondary traumatic stress can be measured using the Professional Quality of
Life: Compassion Satisfaction and Fatigue Subscales (ProQOL) (Stamm, 2002). This is a
30-item measure that assesses the risk of CF (compassion fatigue), potential for CS
15
(compassion satisfaction) and risk of burnout. The CF subscale has ten items and a higher
score indicates risk for STS. The CF dimension relates to work related secondary
exposure to extremely stressful events. The CS subscale has ten items and higher scores
indicate satisfaction with his or her ability to provide care (Stamm, 2002). The burnout
subscale has ten items and higher scores indicate risk of experiencing symptoms of
burnout such as hopelessness and helplessness. Alpha scores range from .72 (burnout) to
.80 (CF) and .87 (CS) indicating adequate internal consistency (Stamm, 2002).
A shorter measure of STS was developed by Bride, Robinson, Yegidis, and Figley
(2003). The Secondary Traumatic Stress Scale (STSS) is a 17-item instrument “designed
to measure intrusion, avoidance, and arousal symptoms associated with indirect exposure
to traumatic events via one’s professional relationships with traumatized clients” (Bride
et al., 2003, p. 1). Respondents rate the frequency of an item on a scale from rarely/never
(1) to very often (5). The participants consisted of a random selection of 600 master’s
level social workers of which 287 responded. The initial groups of items were based on
DSM-IV criteria B (intrusion), C (avoidance), and D (arousal) for PTSD (Bride et al.,
2003). The authors had five experts in the area of STS review and add more items that
resulted in a 65-item version of the STSS. The final 17-item STSS had a coefficient alpha
of .94, and the Intrusion subscale alpha was .83, Avoidance subscale alpha was .89, and
Arousal subscale alpha was .85 (Bride et al., 2003). The scores can be summed to
produce a total score. On a five-point Likert scale, respondents indicate their agreement
16
with items that reflect specific responses to their work with trauma victims. A higher
score indicates higher secondary trauma (Bride et al., 2003).
The Impact of Events Scale-Revised (Weiss & Marmar, 1997) is a 22-item selfreport measure that assesses subjective distress. It consists of three subscales
corresponding to three dimensions of the diagnostic criteria for PTSD in the DSM-IV.
The IES-R contains a total score and the 4-point subscales that measure levels of
intrusive imagery, avoidance behaviors, and hyperarousal during the past seven days. The
degree of distress in the last week in response to a specific stressor is rated from 0 = not
at all, to 4 = extremely, giving a score range of 0 to 88. The IES-R has been used to
assess avoidance and intrusive posttraumatic stress symptoms in a variety of traumaexposed populations. According to Newman, Kaloupek, and Keane (1996), it has good
sensitivity and specificity, and the intrusive and avoidance subscales appear to posses
test-retest of .89 and .79 and internal consistency of .78 and .82 reliabilities. PTSD
criterion is established on the basis of a total IES-R raw score ≥26.
These measures of STS can be used to assess STS symptoms but there is a great
need for further research. It is important to understand the paucity of research support for
use of these measures on an individual level. Far more research needs to be conducted
before it is recommended to advise having individuals use the measures. Until further
research on STS using these measures it is not advised to promote use in a training
setting. In addition, further research needs to be conducted to examine the psychometric
17
properties of these measures with different populations (e.g. marriage and family
therapists, clinical psychologists, social workers).
Those at Risk
Mental health professionals are at risk for STS because a significant portion of
clients who seek psychotherapy are trauma survivors (Davidson & Smith, 1990). Cornille
and Myers (1999) found that up to 37% of their sample of child protective service
workers reported experiencing clinical levels of emotional distress associated with STS.
Chrestman (1999) conducted a study with therapists belonging to the International
Society for Traumatic Studies and members of the Association of Marriage and Family
Therapists. Chrestman (1999) found a significant relationship between secondary
exposure to trauma and psychological distress of therapists. A study conducted by
Creamer and Liddle (2005) on mental health workers responding to the 9/11 terrorist’s
attacks showed elevated levels of STS symptoms. In addition to therapists, trauma
counselors and child protective workers, other professions are at risk for experiencing
STS. Health care workers who work with trauma victims are subject to significant stress
and are vulnerable to STS (Collins & Long, 2003). Musa and Hamid (2008) conducted a
study of aid workers in Darfur and found 25% reported elevated levels of STS symptoms.
O'Halloran and O'Halloran (2001) discuss STS reactions in graduate students exposed to
graduate level courses on trauma and violence.
18
Moderating Factors for Secondary Traumatic Stress
The most common predictor variables associated with STS are exposure, personal
trauma history, and level of professional experience; however the overall findings in
terms of these three variables are inconsistent (Chrestman, 1999; Cornille & Meyers,
1999; Ennis & Home, 2003; Ghahramanlou & Brodbeck, 2000; Kassam-Adams, 1999;
Pearlman & Mac Ian, 1995; Schauben & Frazier, 1995.). Lack of uniformity of
participants and measures across the studies may contribute to the inconsistency in
findings. The participants in the studies mentioned here were made up of social workers,
psychologists, child protective workers and counselors. This may have contributed to the
different results in that a child protective worker may have more exposure to client
traumatic material than a psychologist. This reflects the need for further research on STS.
Exposure to Traumatized Clients
Exposure to client traumatic material is a primary risk factor in the development
of STS (Figley, 1999; Pearlman & Saakvitne, 1995). Secondary traumatic stress cannot
occur without this exposure to traumatic material. Correlational findings support a
relationship between STS and exposure to traumatized clients among mental health
professionals (Arvay & Uhlemann, 1996; Birk, 2002; Boscarino, Figley, & Adams, 2004;
Wee, & Myers, 2002). Several studies have reported ranges of symptoms in the mild or
not clinically significant range (Brady, Guy, Poelstra, & Brokaw, 1999; Chrestman, 1999;
Ortlepp & Friedman, 2001; Schauben & Frazier, 1995). Several studies of STS have
found high levels of symptoms (Arvay & Uhlemann, 1996; Birk, 2002; Kassam-Adams,
19
1999; Wee & Myers, 2002). This difference in findings may be a result of the lack of
sensitivity of the measures used in the studies. This reflects the need for more studies
pertaining to STS as well as studies that incorporate multiple measurement methods. In
addition, the type of traumatic material was different in the various studies. For example
Kassam-Adams (1999) focused on sexual trauma while Chrestman (1999) was less
specific suggesting different types of client material can elicit greater or lesser STS
responses. Wee and Myers (2002) looked at STS in mental health workers after disasters
and found their sample was much larger than many studies in this area, which may have
yielded more robust findings.
Bride (2007) conducted a study of master’s level social workers looking at the
prevalence of STS. Of the 282 respondents, 88.9% reported that their work with clients
included addressing client traumatic experiences. Bride found that 70.2% of respondents
reported having experienced at least one symptom of STS in the previous week and
15.2% of respondents reported STS symptoms at a level that met criteria for PTSD.
According to Bride (2007) the rate of PTSD in the general population is approximately
7.8%. Bride (2007) states, “Independent of any other traumas the social workers may
directly experience, the rate of PTSD due to only direct exposure is twice that of the
general population” (p. 68). In similar findings, Meldrum, King, and Spooner (2002)
found that in a sample of 300 case managers working with psychiatric inpatient and
outpatient clients, 17.7% met symptom criteria for STS.
20
Type of Client Traumatic Material
Knight (1997) explored therapist affective reactions to working with adult
survivors of child abuse and found that over 25% of the respondents agreed they felt
overwhelmed by their work with survivors. In addition, their work led to increased
feelings of vulnerability in personal relationships. The most common affective responses
were anger at their client’s perpetrators along with sadness and horror in response to their
client’s victimization (Knight, 1997).
In a qualitative study conducted by Illife and Steed (2000), 18 counselors who
worked with perpetrators of domestic violence and survivors of domestic violence
experienced horror while listening to women talk about being severely abused. Sadness
was also reported among the participants, which was associated with their client’s
experience of violence. Many of the participants stated they experienced visual images of
the material they heard from clients, including several violent images they believed
would be with them permanently. Illife and Steed (2000) note the participants reported
physiological responses ranging from “a general feeling of heaviness, churning stomach,
nausea, to feeling shaken” after listening to violent narratives (p. 401).
Dane (2000) conducted a qualitative study of 10 child welfare workers and each
of them reported difficulty in coping with feelings of sadness related to their work. The
most disturbing material reported by the participants was the death of a child from
maltreatment or neglect. All of the respondents who experienced this reported symptoms
consistent with STS. The symptoms reported included “inability to concentrate,
21
irritability, increased startle response, feelings of vulnerability, anxiety, sleeplessness,
and intrusive images of the trauma” (Dane, 2000, p. 28). As the findings suggest, the type
of traumatic material may be predictive of STS. Studies of STS have focused on different
types of traumatic material but throughout the literature trauma involving children (i.e.
child abuse, severe domestic violence, and child death) is associated with STS symptoms.
Personal History of Trauma
Some researchers reported that therapists who have a personal trauma history
report higher levels of STS than those without a personal trauma history (Cornille &
Meyers, 1999; Nelson-Gardell & Harris, 2003; Pearlman & Mac Ian, 1995). However,
other studies have shown that having a personal history of trauma was not predictive of
STS symptoms (Kassam-Adams, 1999; Ortlepp & Friedman, 2001; Schauben & Frazier,
1995). This discrepancy in findings may be a result of the subjects involved in the
samples used. Cornille and Meyers (1999) and Nelson-Gardell and Harris (2003) used
front-line social workers in child protective agencies. These social workers were exposed
to child abuse cases, child trauma, and child neglect on a far more regular basis than the
studies that did not show that having a personal history of trauma was predictive if STS.
Kassam-Adams (1999) studied a sample that consisted of 100 graduate level
psychotherapists not necessarily working in the same type of environment (high cases of
child abuse, trauma, and neglect) as the Cornille and Meyers (1999) and Nelson-Gardell
and Harris (2003) samples. Ortlepp and Friedman (2001) used professional and lay
counselors in their sample with differing levels of formal education. The type of trauma
22
included in their sample was primarily counselors to victims of bank robbery. This
suggests that type of trauma may be a greater predictor of STS than personal history of
trauma. In addition, the measures used in the studies were not uniform, which reflects the
range of measures used to measure STS. As a result, the findings cannot be adequately
compared or interpreted due to lack of consistency in the methods used in the studies.
Professional Experience
Another important variable associated with risk of STS is level of professional
experience of the therapist (Neumann & Gamble, 1995). Specifically, newer and less
experienced therapists have reported higher levels of psychological distress and increased
STS symptoms than therapists with more experience (Betts Adams, Matto, & Harrington,
2001; Chrestman, 1999; Follette, Polusny, & Milbeck, 1994; Way, Van Deusen, Marin,
Applegate, & Jandle, 2004). However, other research has shown that less experience was
not related to an increased risk of STS (Ghahramanlou & Brodbeck, 2000; Jenkins &
Baird, 2002; Kassam-Adams, 1999; Ortlepp & Friedman, 2001). For example, Cornille
and Meyers (1999) found that child protective workers who were employed for a long
time reported higher levels of STS than those who had logged fewer years in the field. In
addition, Birk (2002) found that the more years working with trauma increased the level
of compassion fatigue and burnout. Wee and Myers (2002) conducted a study with
mental health workers who provided mental health disaster services after the Oklahoma
City bombing. They found that higher risk of STS and burnout was associated with
increased time working with survivors. The discrepancies in findings may be a result of
23
the different populations used, including counselors, marriage and family therapists,
social workers, psychologists. This reflects the diversity of mental health professionals
who come into contact with client traumatic material. Each of these professional groups
receives different training. In addition, the methods of measurement of STS were not
uniform which may affect the outcome of the studies and help explain the differing
results.
Personality Factors
Personality factors and interpersonal style have been suggested to contribute to
STS. Dutton and Rubinstein (1995) have suggested that personality variables such as a
therapist’s self-awareness, self-esteem, ego strength and resources, and ability to self
regulate can affect vulnerability to STS. Included in these variables is maintaining
balance in one’s personal life that involves rest, play and work (Pearlman & Saakvitne,
1995).
Personal Life Stressors
Therapists with high levels of stressors in their personal lives, or those who have a
negative coping style appear to be at greater risk for STS (Follette, Polusny, & Milbeck,
1994; Schauben & Frazier, 1995). Follette et al. (1994) looked at current level of personal
stress that is experienced by therapists and negative coping style and found these
predicted STS symptoms more than a therapist’s personal experience of trauma or actual
exposure to clients STS experiences. Active coping styles, like construction of an action
24
plan to resolve problems have been found to lessen STS symptoms in those counselors
who employ them (Schauben & Frazier, 1995).
Support System
Several studies have found that having a support system can reduce the impact of
working with clients who have experienced trauma (Ennis & Home, 2003; Kadambi &
Truscott, 2003; Schauben & Frazier, 1995). Lower levels of STS have been found among
those therapists that had an outlet to discuss the personal impact of working with
traumatized clients than those that did not (Kadambi & Truscott, 2003). This outlet was
colleagues and supervisors rather than friends or family members. Schauben and Frazier
(1995) found that therapists in their sample who reported that they actively sought social
support reported lower levels of STS than those who did not. Therapists identified
clinical team meetings, meetings with colleagues, debriefing periods with team members
following treatment, and supervision related activities such as forums in which they felt
they had opportunities to address the negative impact of their work (Schauben & Frazier,
1995). Perceived social support was found to be associated with lower levels of PTSD
related symptoms in a study conducted by Ennis and Home (2003). Perceived social
support is the knowledge you have supportive colleagues in the workplace. Seeking
personal psychotherapy and other forms of social and emotional support may help reduce
STS (Ennis & Home, 2003; Follette et al., 1994; Herman, 1992).
25
Spirituality
Spirituality or the meaning the therapist makes out of traumatic life events may
play a part in STS (Brady et al., 1999; Dane, 2000; Pearlman & Saakvitne, 1995).
According to Pearlman and Saakvitne (1995), those therapists who lack a clear
philosophy of life and causality, or who have struggled with issues regarding meaning,
purpose, and spirituality may be at risk for STS. A study conducted by Dane (2000)
found that spirituality was an important coping tool used by child welfare workers that
helped them find meaning in their work. Therapists who do not have a clear philosophy
of life and causality and struggle with issues of meaning in life, purpose, and spirituality
may be at risk for STS.
Work Environment
The work environment in which one works can influence STS, specifically one’s
professional, social, and organizational climate (Pearlman & Saakvitne, 1995). How
trauma is conceptualized by the organization and even by society at large can play a role
in STS. For example, a client’s experience can sometimes be dismissed or even blamed
on the client. Sometimes these clients can be labeled as borderline with little
understanding of the adaptive function of their behavior (Dutton & Rubinstein, 1995;
Pearlman & Saakvitne, 1995).
Supervision
Lack of competent trauma supervision or consultation, inadequate peer support, a
general lack of respect for clients and therapists, and a lack of physically safe, private,
26
and comfortable therapy space can increase therapists susceptibility to STS (Dutton &
Rubinstein, 1995; Pearlman & Saakvitne, 1995). Brady et al. (1999) has stated that
organizations can help reduce STS by providing an “emotionally supportive, physically
safe, and consistently respectful work environment” (p. 38). Other factors that can reduce
the negative impact of STS include health insurance, vacation and personal leave,
adequate pay, and sick leave (McSwain, Robinson, & Panteluk, 1998; Pearlman &
Saakvitne, 1995). In addition, developing networks with other agencies that increase
community resources for clients can help organizations support therapists (Pearlman &
Saakvitne, 1995). Organizations should make competent trauma-specific supervision,
training, consultation, and ongoing professional development available for staff (Cerney,
1995; McSwain et al., 1998; Yassen, 1995). McCann and Pearlman (1990) have
discussed the importance setting aside specific time during supervision for therapists to
talk about feelings and reactions to difficult cases.
Ethical Considerations
Munroe (1999) has outlined important ethical considerations associated with STS
in therapists. Munroe stressed the need for therapists to acknowledge the impact of STS
on themselves and others and the need to take action to ensure the well being of
professionals who work with traumatized clients. This can help ensure that clients are
receiving competent care (Munroe, 1999). Munroe (1999) stated there is an ethical duty
to recognize the need for regular self-care for therapists. Munroe also argues that to be
consistent with guidelines of the American Psychological Association, there is an ethical
27
duty for therapists to be trained on how to cope with exposure to their client’s traumatic
material. The American Counseling Association and the National Association of Social
Workers codes of ethics stress the need for practitioners to be aware of signs of personal
impairment due to psychological distress. Both of these associations stress a commitment
to continued education to promote awareness of emerging developments in the field.
Brady et al. (1999) writes about the need to educate students about the potential
deleterious effects of working with victims of trauma. Brady et al. (1999) suggests that
normalizing a student’s reactions can help lessen the stigma they may feel so that
effective coping strategies can be taught.
Prevention and Treatment Strategies for Secondary Traumatic Stress
Prevention of STS should be considered with the view that STS is a normal
response to an abnormal level of trauma or violence or unusual events such as natural
disasters. While STS is not an inevitable result for all professionals who work with
traumatized individuals, preparing for the impact of stress and preventing normal stress
responses from developing into STS disorder should be part of prevention. Prevention of
STS is built on the idea of preparation, which begins with recognition of the effects of
working with traumatized populations. Working with traumatized populations can bring
with it potential hazards and preparation for this work begins with acknowledgment of
STS’ existence as a response that may result from this work.
28
Improving Training
Many professions such as law enforcement, disaster relief workers, and
psychotherapists come into contact with trauma victims. In the case of therapists, there is
much training in diagnosis, reporting requirements, establishing therapeutic alliance, and
paper work requirements. Little is taught about the nuances of working with clients
traumatic material. Cornille and Meyers (1999) recommend educating those working
with traumatized populations to recognize STS and teach them to identify, anticipate, and
prepare for coping with STS symptoms. STS symptoms need to be normalized and
workers need to be aware of personal factors affecting STS such as personal history of
trauma, coping strategies, and work environment. Pearlman and Saakvitne (1995)
recommend training in traumatology. Traumatology refers to psychological responses to
trauma including STS. Chrestman (1999) found empirical evidence that supported the use
of additional training to decrease the symptoms of PTSD in counselors working with
trauma clients. Follette et al. (1994) found that 96% of mental health professionals
educated about sexual abuse said it was important in making them effective during
difficult client cases. Alpert and Paulson (1990) and O'Halloran and O'Halloran (2001)
have noted student apprehension and anxiety regarding traumatic material such as child
sexual abuse in graduate training programs. O'Halloran and O'Halloran (2001) have used
an approach to help students in the classroom deal with traumatic material using
Herman’s (1992) three main stages of recovery from trauma. Herman’s (1992) three main
stages consist of building safety, remembrance and mourning, and reconnection.
29
O'Halloran and O'Halloran (2001) structure their graduate training courses to
acknowledge and understand that students often have strong emotional responses to
traumatic material. Setting the stage for STS and its impact at this point in a mental
health professionals training can help in later practice. O'Halloran and O'Halloran (2001)
also provide the students with additional self-care strategies that can help in later
professional life. These self-care strategies include behavioral strategies such as eating
balanced meals, proper sleep and exercise, and the importance of relaxation, recreation
and play. O'Halloran and O'Halloran (2001) prepare the students for the impact trauma
work can have by encouraging students to develop self care plans. They recommend
coping strategies such as journaling, physical release such as crying, or talking with
someone the student feels comfortable with. O'Halloran and O'Halloran (2001) stress
developing and using support systems and exploring spirituality as additional prevention
strategies.
Agency Policies
Trippany, White-Kress, and Wilcoxon (2004) have addressed the responsibility of
agencies that treat trauma to prevent STS in their service providers. They have suggested
formal measures of informed consent regarding risks of trauma counseling to prospective
new counselors. In addition, they recommend professional development resources like
opportunities for supervision, continuing education, and consultation be made available.
Pearlman and Saakvitne (1995) have recommended that providing employee benefits to
cover personal counseling, paid vacations and limiting the number of trauma cases on
30
counselor’s caseload can help prevent STS. Cornille and Meyers (1999) recommend that
agencies with high levels of trauma cases reduce the amount of hours employees are
required to work so no employee exceeds 40 hours a week. Cornille and Meyers (1999)
emphasize the need for agencies to ensure a safe and supportive work environment.
Agencies should develop safety procedures for counselors who go into dangerous areas
and situations. Providing a safe place for counselors to release emotions and discuss their
specific fears around trauma cases can help minimize severe STS symptoms (Cornille &
Meyers, 1999).
Professional Peer Group
Flannery (1990) examined the importance of social support within the
professional peer group as a prevention strategy for secondary traumatic stress.
Components of helpful social support include emotional support, information, social
companionship, and instrumental support. These are most effective in the context of a
professional group with explicit formal organization such as a consultation group,
treatment team, case conference, or clinical seminar (Flannery, 1990). Professional peers
can be supportive by providing resources such as how to handle paperwork, or providing
support during non-work hours (Catherall, 1995). In addition, peer support can help
counselors clarify insights and feelings. Peer support can help correct distortions the
counselor can have regarding traumatic cases. It can also provide perspective, reframing,
and empathy, which can all be essential components of preventing STS (Catherall, 1995).
This type of group support should be considered an adjunct to, and not a substitute for,
31
clinical supervision. Figley (2002b) suggests a 5:1 ratio rule. For every five hours of
discussing a case that is traumatic there should be one hour of personal processing time.
This can take the form of non-work conversation or a formal post incident debriefing.
Effective Coping and Self-Care
Effective coping activities have been found that can prevent STS symptoms.
Among these are clear boundaries between home and work and engaging in regular
physical activity that helps one relax and promotes physical health. In addition
scheduling time off from work, journaling, listening to music, pursuing hobbies, and
meditation are recommended coping activities (McSwain et al., 1998; Pearlman &
Saakvitne, 1995; Schauben & Frazier, 1995). Strategies such as limiting exposure to
traumatic material are also recommended (e.g., books, movies). Norcross (2000) wrote
that important self-care strategies for therapists are diversifying and balancing their client
caseloads. STS may be prevented if the therapist’s caseload has an appropriate balance of
client problems (trauma and non-trauma), types of therapy (group, families, individual,
and couple), and other professional activities (supervision, teaching, research, writing)
(Pearlman & Saakvitne, 1995). It is also important to foster relationships with other
professionals in the field for support. Staying connected with others, recognizing the
impact of working with traumatized clients, using support groups, attending workshops,
and sharing coping strategies with other therapists are also effective means of dealing
with STS (Pearlman & Saakvitne, 1995). Moran (2002) recommends the use of humor as
a means of effective means of coping and enhancing physical well being.
32
Self-care is an essential component of prevention of STS. A study of 117 trauma
therapists conducted by Pearlman and Mac Ian (1995) found at least one-third of the
respondents found that socializing, exercising, spending time with family and friends
were helpful in coping with traumatic material. Additional activities were engaging in
social justice activities and having a massage. Wee and Myers (2002) list personal stress
management activities in their study of mental health workers following a disaster. These
include leisure and diversion activities such as dinner, social activities, reading, and
spending time outdoors. Other self care strategies included family time, exercise,
relaxation, meditation, informal group therapy with coworkers, and personal counseling
and prayer (Wee & Myers, 2002).
Building Resilience
An emerging concept in preventing STS is building resilience (Substance Abuse
and Mental Health Services Administration [SAHMSA], 2008). The main conceptual
components that underlie this intervention combine principles of positive psychology and
trauma prevention (SAHMSA, 2008). Part of the intervention focuses on building upon
an individual’s pre- existing strengths, in addition to cultivating well being. The trauma
prevention component involves psychoeducation about normal trauma responses
(SAHMSA, 2008). Cognitive restructuring and skills training are designed to promote
mastery, collaboration, and optimism. Cognitive restructuring is designed to help manage
work related stress. Psychoeducation helps participants understand isolating behaviors
that can be a result of work related stress (SAHMSA, 2008). The intervention had
33
promising results and is part of a growing understanding the resiliency is a moderating
factor in STS.
Treatment Strategies
The Accelerated Recovery Program for Compassion Fatigue (ARP) is a treatment
strategy developed by Gentry, Baranowsky, and Dunning (2002). This program consists
of a five-session treatment protocol. The ARP is a comprehensive treatment program that
is the first of its kind. The program goals include symptom identification, recognition of
STS triggers, identification and utilization of resources, learning grounding and
containment skills, initiating conflict resolution, and implementing a supportive aftercare
plan. This aftercare plan is called PATHWAYS self-care program (Gentry et al., 2002).
The ARP follows a standardized component treatment model that includes addressing
therapeutic alliance, qualitative assessment of STS, anxiety management, narrative,
exposure/resolution of STS, cognitive restructuring, and PATHWAYS self-care and
aftercare plan (Gentry et al., 2002).
34
Chapter 3
METHOD
Pre-Training Planning
An in-service training on STS cannot be successful without the support of the
administration staff of the agency where it is to be presented. The first step was to gain
support of the administration after explaining the professional and ethical need for the
training. The White House Counseling Center is a training facility, and as a result,
trainings are conducted at various times of the year. The author consulted with
individuals who have conducted trainings in the past and gathered information to use in
construction of the STS training program.
A training program Recognition and Prevention of Secondary Traumatic Stress
was constructed in part following recommendations of Tannenbaum and Yukl (1992) in
their article Training and Development in Work Organizations. According to
Tannenbaum and Yukl (1992), the goal of any training program should “support the
strategic direction of the organization, and training goals should be aligned with
organizational goals” (p. 401) In this spirit, the goals of the STS training program are to
help participants learn to recognize and prevent STS symptoms in order to better serve
their clients. Munroe (1999) has discussed the ethical need for mental health
professionals to acknowledge STS and its effects and take appropriate steps to exert selfcare strategies in order to remain effective counselors.
35
Tannenbaum and Yukl (1992) also recommend defining the target population in
order to design and develop a useful training program. The target population for
Recognition and Prevention of Secondary Traumatic Stress includes any mental health
worker that may come in contact with traumatic client material. Mental health workers at
this level may include trainees, interns, and licensed mental health professionals.
The training information was developed from a thorough literature review of
relevant material as described in the Introduction. Many mental health professionals may
be unaware of STS and lack an appropriate knowledge base. A training setting is an
appropriate setting to teach mental health workers about STS.
The next step in constructing the STS training program was to decide the design
and training method of the program. Tannenbaum and Yukl (1992) state, “design of
training should take into account learning objectives, trainee characteristics, current
knowledge about learning processes, and practical considerations such as constraints and
cost in relation to benefits” (p. 403). Tannenbaum and Yukl (1992) recommend
considering the following guidelines:
All available sources of relevant feedback should be used, and feedback should be
accurate, credible, timely, and constructive…the instructional process should
enhance trainee self efficacy and trainee expectations that training will be
successful and will lead to valued outcomes…training methods should be adapted
to differences in trainee aptitude and prior knowledge. (p. 404)
36
With these considerations in mind the design incorporated clear learning
objectives that can be accomplished during the training. Time constraints for the training
and cost concerns facilitated the decision on the training method.
The next step in training construction was consideration of the training method
(Tannenbaum & Yukl, 1992). The Recognition and Prevention of Secondary Traumatic
Stress training program consists of lecture material and a PowerPoint presentation. A
training manual was constructed consisting of all the items for the program and step-bystep instructions for ease of delivery. The training objectives were broken down into
modules designed for presentation. In addition, the author consulted existing training
manuals for reference in order to construct appropriate training material.
Piloting the Training Program
Recognition and Prevention of Secondary Traumatic Stress was pilot tested at the
White House Counseling center with a training group. The training program had been be
reviewed by the White House director for approval. In addition, the training group
provided feedback via questionnaire derived from Kirkpatrick’s four levels of training
evaluation (Kirkpatrick, 1994). The questionnaire used two levels from Kirkpatrick’s four
levels of training evaluation consisting of learning evaluation and general reaction
(Kirkpatrick, 1994). The reaction level of training evaluation provided feedback on how
participants felt about the training and asked for input on how to improve the training.
The learning evaluation portion of the questionnaire consists of pre and post training
knowledge of STS and self care practices. This helped assess where the participants are
37
starting from in terms of knowledge of STS. Feedback from the training group was
incorporated into the Results section of the project.
38
Chapter 4
RESULTS
The in-service training program called Recognition and Prevention of Secondary
Traumatic Stress was constructed utilizing material from the literature review. A training
manual was constructed by the author (see Appendix A) to be used as a guide for trainers.
The author, who is currently completing an internship as an MFT trainee at the White
House Counseling Center, briefly described the concept behind the training to the WHCC
director and made the case for the ethical need for mental health professionals to
understand how to recognize and prevent STS. In addition, the author explained the need
to pilot test the training program with mental health professionals and gather input from
participants in order to improve it. Upon completion of the initial draft of the training
manual it was submitted to Pat George, MFT and Program Director at the White House
Counseling Center, for approval as a suitable training program for the White House
Counseling Center. The training manual was reviewed and approved without suggestions
or changes to the training program, and permission was granted to conduct the training
during the fall 2009 “Training with the Master’s” series.
The training manual was broken down into six sections encompassing material to
be presented in a two-hour format. The structure of the training was designed in part
based on recommendations from Tannenbaum and Yukl (1992) and previous trainings
attended by the author at the White House Counseling Center. In addition, existing
training manuals Therapeutic Community Curriculum (Center for Substance Abuse
39
Treatment, 2006) and Training Manual for Mental Health and Human Service Workers
in Major Disasters (Center for Mental Health Services, 2000) were consulted for
structure and form. A participant activity on self-care was derived from Training Manual
for Mental Health and Human Service Workers in Major Disasters (Center for Mental
Health Services, 2000), which is in the public domain and may be reproduced without
permission from the authors.
Tannenbaum and Yukl (1992) recommend training should support the strategic
direction of the organization and align with organizational goals. The author consulted
the program director of the White House Counseling Center for further clarification of
organizational goals. The primary goal of the White House Counseling Center is to
provide excellent and competent counseling services to its clients. In addition, the White
House Counseling Center seeks to provide up to date graduate training to prepare pre
licensed mental health professionals to work in the field. In keeping with this philosophy,
the White House conducts training throughout the year to maintain the organizations
principles. The training program was created in the spirit of the White House Counseling
Center’s ongoing promotion of professional development and acquisition of knowledge
in order to better serve the client population.
The target population was defined in keeping with Tannenbaum and Yukl’s
(1992) recommendations. The training program was designed and developed with mental
health professionals in mind. Defining the target population guided the material that was
included in the training program. As a result, concepts and language suitable for mental
40
health workers at all levels of training helped guide what was included. With the guiding
concept that graduate training programs are lacking in preparing mental health
professionals for working with client traumatic material, it was determined that this
training would be an introduction for most participants to the topic of STS. As such, the
training reflects entry-level knowledge of the topic and was designed to fit in a two hour
training format. The training information included in the program was derived from a
thorough literature review of the topic of STS.
The design and training method for the program were derived from
recommendations and guidelines from Tannenbaum and Yukl (1992) with regard to
learning objectives, understanding the characteristics of the participants, and constraints
such as cost. The learning objectives were defined at the beginning of each section of the
training program and designed to be accomplished by the material presented. The
learning objectives helped determine what material was included in the training program.
The characteristics of the participants and prior knowledge of the topic of STS
determined the training program would be an introduction to the topic of STS. The twohour time reflects the standard length of White House Counseling Center trainings in the
series. Relevant feedback was gathered from participants in the form of a questionnaire
designed by the author and presented later.
The training manual was constructed to be used in a group training situation. The
training manual was designed with easy to follow procedures to allow for smooth
delivery of training information. It was the intention of the author that an individual could
41
read the literature review and easily transition into the training manual and present the
material with confidence. A PowerPoint presentation was constructed and included in the
training manual. Participant handouts to facilitate delivery of training concepts are also
included in the training manual. Several drafts of the training manual were constructed
and feedback from the project chairperson and the pilot test were incorporated into the
final draft. Structured questions for the training were added to facilitate audience
participation as well as a group activity designed to promote self-awareness and generate
group discussion about self-care practices.
A total of eight participants attended the pilot testing of the training program at
the White House Counseling Center. Of the eight participants, two were licensed
Marriage and Family Therapists (MFT), two were MFT interns, and four were MFT
trainees. In order to evaluate and improve the pilot test, a brief training evaluation
questionnaire (see Appendix B) was constructed and qualitative data obtained. Raw data
for the reaction portion is presented in Tables 1-6.
Table 1
Raw Data for Question One
Participant Responses
Participant #
Pre-training
Post-training
1
3
4
2
2
4
3
2
4
4
1
4
5
2
3
6
3
4
7
3
4
8
2
4
Note. Rating Scale 5 = Excellent; 1= Poor
42
Table 2
Raw Data for Question Two, Pre-training
Participant #
Pre-training
1
2
2
1
3
4
4
1
5
1
6
1
7
1
8
2
Note. Question 2 is different in the pre and post questionnaire and as such should be
considered independent of each other.
Rating Scale 5 = Excellent; 1= Poor.
Table 3
Raw Data for Question Two, Post-training
Participant #
Post-training
1
5
2
4
3
4
4
3
5
4
6
5
7
4
8
4
Note. Question 2 is different in the pre and post questionnaire
and as such should be considered independent of each other.
Rating Scale 5 = Excellent; 1= Poor.
43
Table 4
Raw Data for Question Three
Participant Responses
Participant #
Pre-training
Post-training
1
2
5
2
1
3
3
3
4
4
1
2
5
2
4
6
4
4
7
3
4
8
2
5
Note. Rating Scale 5 = Excellent; 1= Poor.
Table 5
Raw Data for Question Four
Participant Responses
Participant #
Pre-training
Post-training
1
3
4
2
3
2
3
3
4
4
1
3
5
3
5
6
4
5
7
4
5
8
3
5
Note. Rating Scale 5 = Excellent; 1= Poor.
44
Table 6
Raw Data for Question Five
Participant Responses
Participant #
Pre-training
Post-training
1
1
5
2
1
2.5
3
2
4
4
1
3
5
2
4
6
3
4
7
3
4
8
2
4
Note. Rating Scale 5 = Excellent; 1= Poor.
While statistical analysis of the data was not possible, results suggest an increase
in post training ratings as compared to pre training ratings. Generally favorable post
training ratings may suggest effectiveness of the training program. An additional question
on the pre training questionnaire asked to what extent participants had been exposed to
the topic of STS in their academic training program. Participant responses indicate the
topic of secondary traumatic stress was addressed very little or not at all in their academic
graduate training programs.
General Reaction Portion of Questionnaire
In what ways has learning about secondary traumatic stress been helpful for your
overall professional development?
Responses to the reaction portion of the questionnaire indicated the training was
helpful for the participant’s professional development by reducing the level of fear the
topic may generate. Normalizing the stress reactions was also noted as helpful, as well as
giving a name to what one participant had previously experienced. Several participants
45
found it helpful that the training provided a forum for discussing the issue of STS. As a
group, participants appreciated the discussion of the measures of STS.
What aspects of the training did you find most helpful?
As a group, aspects of the training participants found helpful included the group
exercise discussing self-care strategies and the chance to hear what colleagues do to
handle stress. Also helpful was group feedback during the training about personal coping
strategies. In light of these responses, future trainings will include a larger portion of
group time devoted to self-care and feedback from colleagues.
What would have improved the training program?
Responses for improving the training included adding more discussion about the
personal effects of STS and extending the length of the training session. In addition,
respondents noted allowing more time for questions and group interaction may improve
the training, as well as generating a take home list of self care strategies to refer to when
experiencing STS symptoms.
The last portion of the questionnaire asked for any additional comments,
suggestions, or recommendations. General themes emerged reflecting participants
identifying the need for the training. Requests for more training on the subject of STS,
and acknowledgment of an enjoyable training session rounded out the responses for the
questionnaire.
46
Improvements Made to Training Program
Additional feedback on the training program was obtained from the project
chairperson who attended the pilot testing. General feedback regarding presentation style
included the over explanation of some concepts that were repeated and connecting with
the audience by increased eye contact with different audience members. General
corrections to the PowerPoint presentation slides were made based on project chair
feedback. Specific changes to Power Point slides included adding directional arrows to
denote increase and decrease in STS on slides 48 through 50. On slide 49, philosophy of
life as a protective factor for STS was added. Citations were added to any slide that
referenced a specific study. Ethical need for self-care from the American Counseling
Association and the National Association of Social Workers code of ethics were added to
the training manual and presentation slides to reflect similarities across professional
organizations, and strengthen rationale for the training program. Slide 21 was added to
further explain the potential impact on the client of detachment. In response to participant
feedback mentioned previously, spaces for questions were added to the presentation to
allow for more audience participation. At different sections of the training the presenter is
instructed to ask for audience questions. In response to participant feedback more time
will be given to the self care activity and a list of self-care strategies will be generated for
participants to take from the training. These changes reflect the request from participants
for more experiential components to the training.
47
Discussion
The driving focus behind this project was that graduate training programs are
lacking in preparing mental health professionals for the impact of working with
traumatized populations. Secondary traumatic stress and its impact on mental health
professionals have consequences in many areas of a professionals work. The importance
of addressing this issue in graduate training programs can affect how long professionals
remain in the mental health field, effectiveness in delivering mental health services, staff
morale, and general competence. The larger ramifications suggest that in order to have a
vibrant and effective mental health delivery system, graduate training programs need to
address the effects on mental health professionals of working with traumatized
populations. The training questionnaire results suggest most participants have had little
exposure to the topic of STS in their own graduate training programs. While not research
per se, this small group of responses may reflect a need for secondary traumatic stress to
be addressed in graduate training programs. These results are by no means generalizable
and further pilot trainings are needed with larger samples. Examination of the raw data
from participant ratings shows higher ratings on the post-test responses as compared with
the pre-test. Replication of these rating patterns with a larger sample would suggest that
the training program may result in improved knowledge of secondary traumatic stress.
Participant reaction and feedback allowed for the training to be improved and made more
practical for future delivery.
48
One of the limitations of the project was the lack of ability to generalize the
results of the questionnaire due to the sample size. The questionnaire was specifically
designed to improve and evaluate the pilot test of the training program. Two additional
questions attempted to assess the current knowledge of participants of STS, and to what
extent their graduate training programs addressed the topic. The responses suggest there
is a need for this topic to be addressed in graduate training programs. A general question
at the beginning of the training asked what participants had heard about STS. One
participant stated they had only recently learned of the topic in the last six months. Again
this reflects a limitation of the project as it is merely anecdotal, but does suggest a greater
need for this topic to be addressed.
The length of the training program may be another limitation of the project. There
is a great deal of material to present and two hour training may not be sufficient to cover
all of the important aspects. The current training program is merely an introduction to the
topic designed to familiarize participants with STS. The training program could be
extended beyond the two-hour time frame. Future versions of the training could be
extended to day-long presentations with larger sections devoted to experiential activities
that allow for deeper connection between participants. One of the most common
comments on the reaction portion of the questionnaire was a desire for more group
interaction. A longer version of the training could better facilitate this interaction. A
longer version of the training could allow for an extended group interaction regarding
personal experience with STS facilitated by the trainer.
49
The training itself is based on an extensive literature review about the topic of
secondary traumatic stress. One of the concerns about the existing research is the lack of
randomized controlled studies about STS conducted with mental health professionals.
This lessens to a certain degree the inferences we can draw from the research. There
needs to be further controlled experiments on this topic in order to understand the extent
of the impact of STS in the field and lend more credibility to the concept. The various
terms for the same construct in the literature may add to confusion about the topic. In
addition, the lack of uniform measures of the construct inhibits the ability to conduct
large scale research.
The measures of STS discussed in the project need to be viewed in the appropriate
context. The inclusion of the measures in the literature review is intended to show how
STS has been measured in past research. It is a reflection on the utility of the measures
that there has been relatively little research conducted with them. This reflects the need
for far more research before it is recommended to use these measures in this training
program. In addition, there is a paucity of research studies using these measures with
different types of populations. Because of this it has been determined by the author not to
recommend use of the measures by any attendees of the training program until further
research has been conducted.
An additional concern in the literature review is the lack of real specificity as to
what type of trauma causes STS. There is some evidence that child abuse and survivors
of sexual abuse elicit STS reactions in mental health professionals. It is important for
50
research to address what type of trauma rises to the level of causing STS reactions in
individuals. For instance, a client may have experienced child abuse but not at a level that
would illicit STS reactions in therapists. The question is how to determine degree or
severity in different types of trauma and how to measure this? It may be that a trauma
severity scale for mental health clients could help determine this. For example, a trauma
scoring system exists for patients in hospitals and emergency rooms to assess injury
severity. A comparable measure for mental health clients could be constructed and used
in research on STS. This trauma severity scale could be used to assess trauma type, and
severity of trauma, in addition to its role in STS reactions in mental health professionals.
Further pilot testing is warranted to improve and develop this training program.
Pilot testing with other groups in addition to mental health professionals is a possibility.
The training created here has value not only for mental health professionals but all
helpers who come in to contact with individuals who have experienced trauma. The
training could be easily adapted to present to such groups as trauma nurses and other
medical professionals, law enforcement, fire fighters and emergency responders and
disaster responders. Gathering data from larger samples of training groups would help
determine the awareness of the topic in the professional community. Larger data samples
would allow for formal statistical analyses on the pre and post questionnaires. The
training could be marketed and adapted to different professional groups.
While this project has attempted to fill a gap in graduate training programs with
regard to secondary traumatic stress, and raise awareness of the phenomenon, more work
51
is necessary. Students, professors, training program directors, and mental health
professionals need to advocate for this topic to be included on a greater scale in graduate
training programs. Having the tools to become competent mental health professionals
benefits not only practitioners but consumers of mental health services as well.
52
APPENDICES
53
APPENDIX A
Recognition and Prevention of Secondary Traumatic Stress Training Manual
54
Recognition and Prevention of Secondary Traumatic Stress Training Manual
A Training Program for Mental Health Professionals
(RPSTS)
Preface
Secondary traumatic stress (STS) is now recognized as a hazard of working with
traumatized populations. For as long as mental health professional have worked with
traumatized populations there has been for some, a collateral effect or stress reaction that
results from this work. Leaders in the field of traumatology have long called for and
identified a need for entry level training to help mental health professionals understand
the phenomenon of STS. In response, this training manual (RPSTS) will introduce and
explain the concept of STS, provide a background and overview, and help mental health
professionals recognize and prevent STS.
Audience
The primary audience for RPSTS will be mental health professionals including
marriage and family counselors, psychologists, and other mental health counselors
including trainees, interns, and licensed therapists. Although this training program
primarily focuses on mental health professionals, the basic concepts and self-care
strategies can be applied to other professions who work with traumatized populations
such as disaster response workers, nurses, fire fighters, police officers, etc.
55
RPSTS Goals and Objectives
Goals:

To provide a common knowledge base of Secondary Traumatic Stress for
mental health workers working with client’s traumatic material.

To encourage training participants to work on their professional growth
and development.
Objectives: Participants who receive the RPSTS training will:

Understand the definition, history, and basic concepts, of Secondary
traumatic stress.

Understand effective coping strategies and prevention methods.
Use with Authors Permission
56
Part 1
Introduction
Topics covered
1. Distribution of materials
2. Welcome and brief overview of training
3. Training objectives, materials
Objectives
1. Introduce trainer
2. Review training objectives and values underlying training
Time Required
10 minutes
Procedure
1. Power Point Presentation: Begin power point presentation that will accompany
lecture.
2. Distribute materials: Handout materials.
3. Welcome and Brief Overview: Give a welcoming statement and brief overview of
training. State that group participation is encouraged and any and all questions are
welcome.
4. Training Goals and Objectives: Review the goals and objectives for training (see
Handout #1). Use slides #1-7.
57
After reviewing goals and objectives ask the participants this question: What have
you heard about Secondary traumatic stress? Use this question to facilitate
discussion of what participants have heard about STS to begin training.
58
Part 2
Background and Overview
Topics Covered
1. Definition of secondary traumatic stress
2. Vulnerable professions
3. Risk factors and prevalence
4. Type of client material
5. Reactions to working with traumatized clients
6. Brief historical background
7. Primary and secondary traumatic stress symptoms
Objectives
1. To acquaint participants with the definition of Secondary traumatic stress (STS)
2. Understanding of the professions that can be exposed to STS
3. To discuss various reactions mental health workers can have to client traumatic
material
4. Provide historical context and background for STS
5. Understand primary and secondary traumatic stress symptoms
Time Required
30 Minutes
Procedure
1. Definition of STS: Present a definition of STS (see power point slide #8).
59
2. Discuss who may be vulnerable: Using power point slide #9, discuss professions
vulnerable to STS.
3. Risk factors and prevalence: Using power point slide #10-15 discuss risk factors
and prevalence.
4. Reactions to working with traumatized clients: Present various reactions mental
health workers may have to working with traumatized clients. Discuss indicators
of psychological distress, relational disturbances, and cognitive shifts (Slide #1624).
5. Historical background: Provide historical overview of STS and relation to PTSD
(Show slide #25-29.)
6. Primary and secondary traumatic stress symptoms: (use handout #2 to review
relation of PTSD to STS) Show slide #30-31.
7. Please allow time for questions from the audience and ask: Does anyone have any
questions?
60
STS Defined
Mental health professionals who work with traumatized clients are susceptible to a
phenomenon called Secondary Traumatic Stress (STS). This concept has been developed
through theory and research over the past two decades showing that mental health
professionals, counselors and
psychotherapists who work with traumatized individuals may experience stress reactions
as a result of their contact with such clients.
Secondary traumatic stress (STS) has been defined by 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.” Refers to a set of psychological symptoms that mimic
post-traumatic stress disorder and can be a result of exposure to a client’s traumatic
material.
Vulnerable Professions
STS can also be experienced by professionals such as nurses, firefighters, police officers,
sexual assault workers, child protective workers and disaster responders such as in the
Oklahoma City bombing, or in conditions of war.
STS can result from cumulative or acute exposure to traumatic material, and has been
described as an occupational hazard of those working with victims of trauma.
STS has been a growing concern in the helping professions and is considered a major
component of counselor burnout. STS reactions can often be an inevitable part of
61
working with traumatic client material. Research has found a positive correlation between
secondary traumatic stress reactions and large caseloads, reduced longevity of career,
long working hours and increased contact with clients.
Risk factors
Mental health professionals are at risk for STS because a significant portion of clients
who seek psychotherapy are trauma survivors.
Exposure to client traumatic material is a primary risk factor in the development of STS
(Figley, 1999; Pearlman & Saakvitne, 1995). Secondary traumatic stress cannot occur
without this exposure to traumatic material. It is imperative to be aware of your exposure
to client traumatic material.
Type of Client Traumatic Material
A study of therapists working with adult survivors of child abuse and found that over 25
% of the respondents agreed that they felt overwhelmed by their work with survivors
(Knight, 1997).
Counselors who worked with perpetrators of domestic violence and survivors of domestic
violence experienced horror while listening to women talk about being severely abused
(Illife & Steed, 2000).
A study with child welfare workers noted the most disturbing material reported by the
participants was the death of a child from maltreatment or neglect (Dane, 2000).
Prevalence of STS
62
A study of 282 graduate level social workers found 88.9% reported that their work with
clients included addressing client traumatic experiences (Bride, 2007). Of those 70.2%
reported symptoms of STS in the previous week and 15.2% reported symptoms at a level
that met criteria for PTSD.
In similar findings, Meldrum, King, and Spooner (2002) found that in a sample of 300
case managers working with psychiatric inpatient and outpatient clients, 17.7% met
symptom criteria for STS (using STS scale).
WHCC and Trauma
It is estimated that as many as 90% of clients who that are seen at the WHCC have
experienced trauma.
Here you will ask participants this question: What aspect of your clinical work do you
find produce emotional reactions (STS type) when dealing with client traumatic
material? Here you facilitate discussion of clinical situations such as reading a client file,
first contact with client, first CPS report that may produce strong emotional reactions.
Ask participants for input.
Reactions to Working with Traumatized Clients
Therapists may have a wide variety of reactions to their work with traumatized clients. A
meta-analysis conducted by Figley (1995) categorized these reactions into three areas:
indicators of psychological distress or dysfunction, relational disturbances, and cognitive
shifts.
63
Indicators of psychological distress or dysfunction
Indicators of psychological distress include distressing emotions like sadness or grief,
horror or dread (Figley, 1995). Indicators of psychological stress include:
 distressing emotions like sadness or grief
 dread
 nightmares and images of the client’s traumatic material
 Somatic complaints including sleep difficulty, gastric distress and headaches
 Addictive behaviors or compulsive behaviors including substance abuse or
workaholism
 impairment of the therapists day to day functioning in social and personal roles
 missed or cancelled appointments
 decreased use of supervision
 chronic lateness
 Feelings of isolation.
Relational disturbances
Dutton and Rubinstein (1995) found that a therapist’s response to a client’s traumatic
material can result in either detachment or over identification with the client. Detachment
results in distancing oneself emotionally from the client because the therapist may feel
overwhelmed or vulnerable to the traumatic material. Over identification with the client’s
traumatic material can result in the therapist taking on responsibility for the client’s life.
64
The therapist in this position is ineffective and may place the client in the position of
taking care of the therapist.
Cognitive shifts
Cognitive shifts as a STS reaction refer to shifts in the therapist’s beliefs, expectations
and assumptions. These cognitive shifts can affect one’s level of trust that results in
chronic suspicion of others. One can go from feeling safe to having a heightened sense of
vulnerability. One can move from a sense of independence to feeling a loss of personal
control and freedom. Novice therapist may feel guilty for enjoying life while their clients
are struggling. Therapists can also feel guilty when clients re experience the trauma
(Dutton & Rubinstein, 1995).
History
One of the first descriptions in the literature describing STS came from Haley (1974), a
social worker who worked with veterans of the Vietnam War. At the time the experiences
being described by the returning combat veterans were very extreme. Haley described
some therapists as “repulsed and frightened” by the material to the extent that some
therapists could not work with the veterans (Haley, 1974).
Figley (1978) also wrote about stress disorders and psychological adjustment in Vietnam
Veterans. Figley noted that caring for those who have been traumatized left marks on the
victim’s family members and professionals were susceptible to “catching” traumatic
stress from those in whom they invested their empathy and energy (Figley, 1978).
65
Courtois (1988) described STS as “contact victimization” in which “working with incest
survivors, the therapist can expect to experience contact or secondary victimization and
not infrequently to develop symptoms of post traumatic stress disorder” (p. 236).
In these first descriptions of what would become known as STS we see the common
thread of therapist stress reactions in response to client traumatic material. A growing
field of traumatology was beginning to notice and describe the effects on mental health
professionals of working with traumatized clients.
Secondary traumatic stress and its effects came out of research into Post Traumatic Stress
Disorder (PTSD). Symptoms of Post Traumatic Stress Disorder can occur (American
Psychiatric Association, 2000):
following an extremely traumatic stressor involving direct
experience of an event that involves actual or threatened death or
serious injury…or learning about unexpected or violent death,
serious harm or threat of death or injury experienced by a family
member or other close associate (p.463).
Symptoms of PTSD include intrusive thoughts about the event, hyper arousal
in response to thoughts about the event, and avoidance of situations that
remind the individual about the event. STS can be thought of as a subsidiary
form of PTSD.
Figley (1995) argues that the fundamental difference between Post Traumatic
Stress and STS is the position of the stressor. If the stressor directly harms or
66
threatens the individual, it is a primary stressor that will likely result in
PTSD. On the other hand, if the stressor is the traumatized individual who
has been exposed to harm, the stressor is conceived as a secondary stressor
that may result in STS.
Review Handout #3
Primary and Secondary Traumatic Stress Symptoms
67
Part 3
Terminology and Ingredients of STS
Topics Covered
1. Terminology
2. Ingredients of STS
Objectives
1. To acquaint participants with STS terminology
2. To acquaint participants with different causal models of STS
Time Required
30 minutes
Procedure
1. Terminology: Present terminology used in literature regarding STS (use slide #3233, refer to handout #3). Discuss STS as a component of burnout.
2. Ingredients of STS: Discuss causal models (Ingredients) of STS (use slide #34-39).
Discuss interaction of ingredients. Discuss the importance of empathy and
emotional energy expended in the therapeutic process.
3. Please allow time for questions from the audience and ask: Does anyone have any
questions?
68
Terminology
The term secondary traumatic stress is used throughout the literature in addition to other
terms such as, vicarious traumatization, compassion fatigue, in addition to related terms
countertransference, and burnout.
STS: refers to a set of psychological symptoms that mimic post-traumatic stress disorder
and can be a result of exposure to a client’s traumatic material. 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 (Figley, 1995).
Vicarious traumatization: refers to harmful changes that occur in professional’s view of
themselves, others, and the world as a result of exposure to the traumatic material of
clients. Included in the definition of vicarious traumatization are disturbances in the
therapist’s cognitive frame of reference. They propose that the changes that occur to the
therapist’s cognitive schema of themselves, others, and the world are pervasive,
cumulative, and permanent (Pearlman and Saakvitne, 1995)
Compassion fatigue: is a term that is used interchangeably with STS. Figley’s use of the
term compassion fatigue stems from his belief that some find the term secondary
traumatic stress derogatory.
69
Countertransference: any projections by therapists that distort the way they perceive and
react to a client. STS includes, but is not limited to countertransference, which occurs
within the context of psychotherapy and a result of reactions to the transference on the
part of the client. Countertransference can occur outside the context of exposure to
traumatic material while STS always arises as a result of exposure to a client’s traumatic
material.
Burnout: a state of physical, emotional and mental exhaustion caused by long term
involvement in emotionally demanding situations (Pines, 1993). Burnout can result from
emotional exhaustion and emerges gradually but STS can become apparent quicker than
the course burnout takes. Figley has asserted that one severe exposure to another person’s
experience of trauma can result in symptoms of STS. Burnout is related to chronic
tedium. Inability to achieve goals can result in burnout.
Ingredients of Secondary Traumatic Stress
Several etiological models of STS have been developed to help explain the nature of STS
and related factors.
Figley Model: At the heart of Figley’s model (2002a) is that empathy and emotional
energy are the driving force in effective work with the suffering. Empathy and emotional
energy comes with a cost. Figley’s model has nine variables that form a casual model for
STS and includes: empathic ability, exposure to the client, empathic response,
compassion stress, sense of achievement, disengagement, prolonged exposure, traumatic
recollections, and life disruptions.
70
Empathic Ability –is the aptitude of the therapist for noticing the pain of others. Without
empathy there is no STS. But no empathy means not effective response to client.
Empathy is the keystone to helping and being vulnerable (Figley, 2002a).
Exposure to Client – experiencing the emotional energy of the suffering clients through
direct exposure. The cost of direct exposure to the suffering of others can be high (Figley,
2002a).
Empathic Response-the extent to which the therapist makes an effort to reduce the
suffering of the sufferer through empathic understanding. The therapist may experience
the hurt, anger, fear or other emotions experienced by the client (Figley, 2002a).
Compassion Stress –the residue of emotional energy from the empathic response to the
client.
Sense of Achievement – the extent to which the therapist is satisfied with their efforts to
help a client (Figley, 2002a).
Disengagement-the extent to which the therapist can distance themselves from the
ongoing misery of the client in between sessions (Figley, 2002a).
Prolonged Exposure- is the ongoing sense of responsibility for the care of the suffering
over a period of time. Make sure you have adequate breaks from being compassionate
and empathetic (Figley, 2002a).
Traumatic Recollections- Memories that trigger symptoms of STS. These can be
triggered by other clients and cause emotional reactions (Figley, 2002a).
71
Life Disruptions – unexpected changes in schedule, routine and managing life
responsibilities that demand attention. Disruptions combined with the other factors can
increase STS (Figley, 2002a).
Common Ingredients
Common ingredients include exposure to client traumatic material, coping strategies, and
agency culture.
72
Part 4
Measuring Secondary Traumatic Stress
Topics Covered
1. Measures of STS
Objectives
1. To acquaint participants with measures of STS
Time Required
15 minutes
Procedure: Measures of STS
1. Discuss instruments used to measure STS. Use slide #40-46. Explain these
measures are not intended for clients.
2. Explain to participants that the measures are not recommended to be used because
of the lack of research to support their use with individuals.
3. Please allow time for questions from the audience and ask: Does anyone have any
questions?
ProQOL
The Professional Quality of Life Scale: Compassion Satisfaction, Burnout, & Secondary
Traumatic Stress Scales (Stamm, 2002). ProQOL is a 30 item self-report measure to
assess the dimensions compassion satisfaction, burnout and compassion fatigue. The
compassion satisfaction dimension (CS) measures pleasure derived from being able to do
you work well where high scores represent a greater satisfaction related to your ability to
73
be an effective caregiver. The burnout dimension (BO) in this scale is associated with
feelings of hopelessness and difficulties in dealing with your work. Higher scores are
related to higher risk for burnout. The compassion fatigue dimension (CF) relates to
work-related secondary exposure to extremely stressful events. High scores indicate that
you are exposed to frightening experiences at work.
Secondary Traumatic Stress Scale
A shorter measure of STS was developed by Bride, Robinson, Yegidis, and Figley
(2003). The Secondary Traumatic Stress Scale (STSS) is a 17 item instrument designed
to measure intrusion, avoidance, and arousal symptoms associated with indirect exposure
to traumatic events via one’s professional relationships with traumatized clients. These
scores can also be summed to produce a total score. On a five-point Likert scale,
respondents indicate their agreement with items that reflect specific responses to their
work with trauma victims. A higher total score indicates higher secondary trauma.
Impact of Events Scale Revised
The Impact of Events Scale-Revised (Weiss & Marmar, 1997) is a 22-item self-report
measure that assesses subjective distress. It consists of three subscales corresponding to
three dimensions of the diagnostic criteria for PTSD in the DSM-IV. The IES-R contains
a total score and the three subscales measure levels of intrusive imagery, avoidance
behaviors, and hyperarsousal during the past seven days on a 4-point scale. PTSD
criterion is established on the basis of a total IES-R raw score ≥26.
74
Part 5
Moderating Factors for Secondary Traumatic Stress
Topics Covered
1. Personal history of trauma
2. Professional experience
3. Personal life stressors
4. Support system
5. Work environment
6. Supervision
7. Ethical considerations
Objectives
To increase participant knowledge of moderating factors for STS
Time Required
20 Minutes
Procedure
Moderating Factors: Discuss moderating factors for STS (Use slides #47-50).
When discussing this section of slides emphasize that different moderating factors
can either increase or decrease STS symptoms. This is reflected by the
corresponding arrows on the slides indicating direction.
75
Personal History of Trauma
Some researchers reported that therapists who have a personal trauma history report
higher levels of STS than those without a personal trauma history (Cornille & Meyers,
1999).
Professional Experience
Specifically, newer and less experienced therapists have reported higher levels of
psychological distress and increased STS symptoms than therapists with more
experience.
Interestingly Cornille and Meyers (1999) found that child protective workers who were
employed for a long time reported higher levels of STS than those who had logged fewer
years in the field. In addition, Birk (2002) found that the more years working with trauma
increased the level of compassion fatigue and burnout. Wee and Myers (2002) conducted
a study with mental health workers who provided mental health disaster services after the
Oklahoma City bombing. They found that higher risk of STS and burnout was associated
with increased time working with survivors. This suggests prolonged exposure may play
a part in moderating STS.
Personal Life Stressors
Therapists with stressors in their personal lives, or those who have a negative coping
style can influence the level of STS they experience (Follette, Polusny, & Milbeck,
1994). Active coping styles, like construction of an action plan to resolve problems have
76
been found to lessen STS symptoms in those counselors employ them (Schauben &
Frazier, 1995).
Support System
Several studies have found that having a support system can reduce the impact of
working with clients who have experienced trauma. Lower levels of STS have been
found among those therapists that had an outlet to discuss the personal impact of working
with traumatized clients than those that did not (Kadambi & Truscott, 2003). Therapists
identified clinical team meetings, meetings with colleagues, and debriefing periods with
team members following treatment, and supervision related activities such as forums in
which they felt they had opportunities to address the negative impact of their work
(Schauben & Frazier, 1995). Perceived social support is the knowledge you have
supportive colleagues in the workplace. Seeking personal psychotherapy and other forms
of social and emotional support may help reduce STS.
Spirituality
According to Pearlman and Saakvitne (1995), those therapists who lack a clear
philosophy of life and causality, or who have struggled with issues regarding meaning,
purpose, and spirituality may be at risk for STS. A study conducted by Dane (2000)
found that spirituality was an important coping tool used by child welfare workers that
helped them find meaning in their work.
Work Environment
77
The work environment in which one works can influence STS, specifically one’s
professional, social, and organizational climate. How trauma is conceptualized by the
organization and even by society at large can play a role in STS. For example, a client’s
experience can sometimes be dismissed or even blamed on the client (Pearlman &
Saakvitne, 1995).
Supervision
Lack of competent trauma supervision and or consultation, inadequate peer support, a
general lack of respect for clients and therapists, a lack of physically safe , private, and
comfortable therapy space can increase therapists susceptibility to STS. Organizations
should make competent trauma-specific supervision, training, consultation, and ongoing
professional development available for staff (McSwain et al., 1998; Cerney, 1995;
Yassen, 1995).
78
Part 6
Prevention and Treatment Strategies for STS
Topics Covered
1. Prevention of STS in context
2. Ethical considerations
3. Improving training
4. Agency policies
5. Professional peer group
6. Effective coping and self-care
7. Treatment strategies
Objectives
1. Increase participant knowledge of prevention strategies
2. Encourage professional growth
3. Understand effective coping and self care strategies
4. Increase participants knowledge of treatment strategies
Time Required
30 minutes
Procedure
1. Prevention in Context: Stress that while STS is not an inevitable consequence of
working with traumatized clients it is important to prepare for possible STS
reactions. Normalize STS responses. Discuss ethical considerations. Use slide
#51-53.
79
2. Self-Care: Use self-care handout #5 to facilitate activity and discussion of self-care
practices and beliefs. Use slide #54.
3. Improving Training: Discuss need for improving training in the context of
normalizing STS responses. Use slide #55-56.
4. Agency Policies and Peer Group: Discuss agency and organizational role in
preventing STS. Discuss importance of professional peer groups. Use slide #5759.
5. Effective Coping and Treatment Strategies: Provide effective coping strategies and
discuss treatment strategies. Use slide #60-67. Have participants create a list of
coping strategies to take home with them.
Prevention of secondary traumatic stress should be considered with the view that STS is a
normal response to an abnormal level of trauma or violence or unusual events such as
natural disasters. While STS is not an inevitable result for all professionals who work
with traumatized individuals, preparing for the impact of stress and preventing normal
stress responses from developing into STS disorder should be part of prevention.
Ethical Considerations
Munroe (1999) states that there is an ethical duty to recognize the need for regular selfcare for therapists. Munroe also argues that to be consistent with guidelines of the
American Psychological Association, there is an ethical duty for therapists to be trained
on how to cope with exposure to others traumatic material. The American Counseling
Association and the National Association of Social Workers code of ethics stress the need
80
for practitioners to be aware of signs of personal impairment due to psychological
distress. Both of these associations code of ethics stress a commitment to continued
education to promote awareness of emerging developments in the field.
Self Care Activity
Using Handout #5 have participants fill out answers. When participants have completed
this facilitate discussion of handout.
Improving Training
Many professions such as law enforcement, disaster relief workers, and psychotherapists
come into contact with trauma victims. In the case of therapists, there is much training in
diagnosis, reporting requirements, establishing therapeutic alliance, and paper work
requirements. Little is taught about the nuances of working with client’s traumatic
material.
Cornille and Meyers (1999) recommend educating those working with traumatized
populations to recognize STS and teach them to identify, anticipate, and prepare for
coping with STS symptoms. STS symptoms need to be normalized and workers need to
be aware of personal factors affecting STS such as personal history of trauma, coping
strategies, and work environment.
Setting the stage for STS and its impact at this point in a mental health professionals
training can help in later practice.
O'Halloran and O'Halloran (2001) prepare the students for the impact trauma work can
have by encouraging students to develop self care plans. These self care strategies include
81
behavioral strategies such as eating balanced meals, proper sleep and exercise, and the
importance of relaxation, recreation and play. O'Halloran and O'Halloran (2001) structure
their graduate training courses to acknowledge and understand that students often have
strong emotional responses to traumatic material.
They recommend coping strategies such as journaling, physical release such as crying, or
talking with someone the student feels comfortable with. O'Halloran and O'Halloran
(2001) stress developing and using support systems and exploring spirituality as
additional prevention strategies.
Agency Policies
White-Kress, and Wilcoxon (2004) have suggested formal measures of informed consent
regarding risks of trauma counseling to prospective new counselors. In addition, they
recommend professional development resources like opportunities for supervision,
continuing education, and consultation are made available.
Pearlman & Saakvitne, (1995) have recommended that providing employee’s benefits to
cover personal counseling, paid vacations and limiting the number of trauma cases on
counselors caseload can help prevent STS.
Agencies should develop safety procedures for counselors who go into dangerous areas
and situations. Providing a safe place for counselors to release emotions and discuss their
specific fears around trauma cases can help minimize severe STS symptoms (Cornille &
Meyers, 1999).
82
Professional Peer Group
Flannery (1990) examined the importance of social support as a prevention of traumatic
stress. The important components of helpful social support include emotional support,
information, social companionship, and instrumental support. This support is most
effectively provided in the context of a professional group with explicit formal
organization such as a consultation group, treatment team, case conference, or clinical
seminar.
Professional peers can be supportive by providing resources such as how to handle
paperwork, or providing support during non-work hours (Catherall, 1995). In addition,
the peer support can help counselors clarify insights and feelings. Peer support can help
correct distortions the counselor can have regarding traumatic cases. Peer support can
also provide perspective, reframing, and empathy, which can all be essential components
of preventing STS.
Figley (2002b) suggests a 5:1 ratio rule. For every three hours of discussing a case that is
traumatic there should be one hour of personal processing time. This can take the form of
non-work conversation, or a formal debriefing post incident.
Effective Coping and Self-Care
Effective coping activities have been found that can prevent STS symptoms. Among
these are clear boundaries between home and work and engaging in regular physical
activity that helps one relax and promotes physical health. In addition, scheduling time
83
off from work, journaling, listening to music, pursuing hobbies, and meditation are
recommended coping activities.
Strategies such as limiting exposure to traumatic material are also recommended (e.g.,
books, movies). Norcross (2000) wrote that important self-care strategies for therapists is
diversifying and balancing their client caseloads. STS may be prevented if the therapist’s
caseload has an appropriate balance of client problems (trauma and non-trauma); types of
therapy (group, families, individual, and couple); and other professional activities
(supervision, teaching, research, writing).
It is also important to foster relationships with other professionals in the field for support.
Staying connected with others, recognizing the impact of working with traumatized
clients, using support groups, attending workshops, and sharing coping strategies with
other therapists are also effective means of dealing with STS.
Self-care is an essential component of prevention of STS. A study of 117 trauma
therapists conducted by Pearlman and Mac Ian (1995) found at least one-third of the
respondents found the following activities helpful in coping with traumatic material:
socializing, exercising, spending time with family and friends. Additional activities many
found helpful were engaging is social justice activities and having a massage.
Wee and Myers (2002) list personal stress management activities in their study of mental
health workers following a disaster. These include leisure and diversion activities such as
dinner, social activities, reading, spending time outdoors. Other self care strategies
84
include family time, exercise, relaxation and mediation, informal group therapy with
coworkers, personal counseling and prayer (Wee & Myers, 2002).
Building Resiliency
An emerging concept in preventing STS is building resilience (SAHMSA, 2008). The
main conceptual components that underlie this intervention combines principles of
positive psychology and trauma prevention (SAHMSA, 2008). Part of the intervention
focuses on building upon an individual’s pre existing strengths, in addition to cultivating
well being. The trauma prevention component involves psycho education about normal
trauma responses (SAHMSA, 2008). Cognitive restructuring and skills training are
designed to promote mastery, collaboration, and optimism. Cognitive restructuring is
designed to help manage work related stress. Psycho education helps participants
understand isolating behaviors that can be a result of work related stress (SAHMSA,
2008). The intervention had promising results and is part of a growing understanding the
part resiliency plays in reducing STS.
Treatment Strategies
The Accelerated Recovery Program for Compassion Fatigue is a treatment strategy
developed by Gentry, Baranowsky, & Dunning (2002). This program consists of a five
session treatment protocol. The ARP is the first of its kind comprehensive treatment
program. The program goals include symptom identification, recognition of STS triggers,
identification and utilization of resources, learning grounding and containment skills,
initiating conflict resolution, and implementing a supportive aftercare plan. This aftercare
85
plan is called PATHWAYS self-care program (Gentry, Baranowsky, & Dunning, 2002).
The ARP follows a standardized component treatment model that includes addressing
therapeutic alliance, qualitative assessment of STS, anxiety management, narrative,
exposure/resolution of STS, cognitive restructuring, and PATHWAYS self –care and
aftercare plan (Gentry, Baranowsky, & Dunning, 2002).
86
References and Recommended Readings
Birk, A. (2002). Secondary traumatization and burnout in professionals working with
torture survivors. Traumatology, 7(2), 85-90.
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2003). Development and
validation of the secondary traumatic stress scale. Research on Social Work
Practice, 13(10), 1-16.
Catherall, D. (Ed.). (1995). Coping with secondary traumatic stress: the importance of
the professional peer group. In B. H. Stamm (Ed). Secondary traumatic stress:
self care issues for clinicians, researchers, and educators (2nd ed., pp. 80-92).
Baltimore, MD: Sidran Press.
Cornille, T. A., & Meyers, T. W. (1999). Secondary traumatic stress among child
protective service workers: Prevalence, severity, and predictive factors.
Traumatology, 5(1), 15-31.
Courtois, C. A. (1988). Healing the incest would. New York: W.W. Norton and
Company.
Dane, B. (2000). Child welfare workers: An innovative approach for interacting with
secondary trauma. Journal of Social Work Education, 36, 27-39.
Dutton, M. A., & Rubinstein, F. L (1995). Working with people with PTSD: Research
implications. In C. R. Figley (Ed.), Compassion fatigue: Secondary traumatic
stress disorders in those who treat the traumatized (pp. 82-100). New York:
Brunner-Mazel.
87
Figley, C. R. (1978). Psychological adjustment among Vietnam veterans: An overview of
the research. In C. R. Figley (Ed.), Stress disorders among Vietnam veterans:
Theory, research, and treatment. New York: Brunner/Mazel.
Figley, C. R. (1995). Compassion fatigue: Secondary traumatic stress disorders in those
who treat the traumatized. New York: Brunner-Mazel.
Figley, C. R. (2002a). Compassion fatigue: Psychotherapists chronic lack of self-care.
Journal of Clinical Psychology, 58, 1433-1441.
Figley, C. R. (Ed.). (2002b). Treating compassion fatigue. New York: BrunnerRoutledge.
Flannery, R. B. (1990). Social support and psychological trauma: A methodological
review. Journal of Traumatic Stress, 3(4), 593-611.
Gentry, J. E., Baranowsky, A. B., & Dunning, K. (2002). ARP: The accelerated recovery
program (ARP) for compassion fatigue. In C. R. Figley (Ed.), Treating
compassion fatigue (pp. 123-137). New York: Brunner-Routledge.
Haley, S. A. (1974). When the patient reports atrocities: specific treatment considerations
of the Vietnam veteran. Archives of General Psychiatry, 30, 191-196.
Munroe, J. F. (1999). Ethical issues associated with secondary trauma in therapists. In B.
H. Stamm, Secondary traumatic stress: Self care issues for clinicians,
researchers, and educators (2nd ed., pp. 211-229). Baltimore, MD: Sidran Press.
Norcross, J. C. (2000). Psychotherapist self care: Practitioner tested, research informed
strategies. Professional Psychology: Research and Practice, 31, 710-713.
88
O'Halloran, M. S., & O'Halloran, T. (2001). Secondary traumatic stress in the classroom:
Ameliorating stress in graduate students. Teaching of Psychology, 28(2), 92-97.
Pearlman, L. A., & Saakvitne, K. W. (Eds.). (1995). Trauma and the therapist:
Countertransference and vicarious traumatization in psychotherapy with incest
survivors. New York: W.W. Norton.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles,
protocols, and procedures. New York: Guilford.
Wee, D. F., & Myers, D. (2002). Stress response of mental health workers following
disaster: The Oklahoma City Bombing. In C. R. Figley (Ed.), Treating
compassion fatigue (pp. 57-48). New York: Brunner-Routledge.
Weiss, D. S., & Marmar, C. R. (Eds.). (1997). The impact of events scale-revised. In J. P.
Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD: A
practitioner’s handbook. New York: Guilford.
White, G. D. (2002). Trauma treatment training for Bosnian and Croatian mental health
workers. In C. R. Figley (Ed.), Treating compassion fatigue (pp. 171-179). New
York: Brunner-Routledge.
89
Handouts imperative to be aware
Listing of Handouts
Handout #1: Secondary Traumatic Stress Training Goals and Objectives
Handout #2: Traumatic Symptoms of Primary and Secondary Traumatic Stress Disorder
Symptoms
Handout #3: Terminology
Handout #4 Self-Care Activity
90
Secondary Traumatic Stress Training Goals and Objectives
Goals:
 To provide a common knowledge base of Secondary
Traumatic Stress for mental health workers working
with client traumatic material.
 To encourage training participants to work on their
professional growth and development.
Objectives: Participants who receive the RPSTS training will
 Understand the definition, history, and basic concepts,
of Secondary traumatic stress.
 Understand effective coping strategies and prevention
methods.
91
Traumatic Symptoms of Primary and Secondary Traumatic Stress Disorder Symptoms
(Primary) PTSD Stressors
(Secondary) Secondary Traumatic Stressors
A. Experienced an event outside the range Experienced indirectly the traumatic
of usual human experiences that would be stressors through helping those who had
markedly distressing to almost anyone, an experienced these traumas: helping in
event such as rape, the September 11
such roles as a nurse, social worker, rape
terrorist attack, family violence, combat,
counselor, or other roles and activities.
and other terrifying experiences.
B. Traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) Recurrent and intrusive distressing
recollections of the event, including
images, thoughts, or perceptions
(2) Recurrent distressing dreams of the
event
Recurrent and intrusive distressing
recollections of the client/event,
including images, thoughts, or
perceptions
Recurrent distressing dreams of the
client/event
(3) Acting or feeling as if the traumatic
event were recurring (includes a sense of
reliving the experience, illusions,
hallucinations, and dissociative flashback
episodes, including those that occur on
awakening or when intoxicated)
Acting or feeling as if the traumatic event
were recurring (includes a sense of
reliving contact with the client and the
client’s story in order to solve the puzzle
and help the client)
(4) Intense psychological distress at
exposure to internal or external cues that
symbolize or resemble an aspect of the
traumatic event
Intense psychological distress at
exposure to internal or external cues that
symbolize or resemble an aspect of the
work of helping others
(5) Physiological reactivity on exposure to
trauma cues
Physiological reactivity on exposure to
trauma cues that are associated with the
role of helper
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three or more of the
following:
92
(1) Efforts to avoid thoughts, feelings, or
conversations associated with trauma
(2) Efforts to avoid activities, places, or
people that arouse recollections of the
trauma
Efforts to avoid thoughts, feelings, or
conversations associated with the client’s
trauma
Efforts to avoid activities, places, or
people that arouse recollections of the
client’s trauma
(3) Inability to recall an important aspect of Errors in judgment about
the trauma
conceptualizing and treating the trauma
case
(4) Markedly diminished interest or
Markedly diminished interest or
participation in significant activities
participation in significant activities
(5) Feelings of detachment or estrangement
from others
Feelings of detachment or estrangement
from others
(6) Restricted range of affect (e.g., unable
to have loving feelings
Restricted range of affect (e.g., unable to
know the client personally or saviororiented
Sense of foreshortened future (e.g., does
not expect or want to have a long career)
(7) Sense of foreshortened future (e.g.,
does not expect to have a career, marriage,
children, or normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated
by two or more of the following:
(1) Difficulty falling or staying asleep
Difficulty falling or staying asleep
(2) Irritability or outbursts of anger
Irritability or outbursts of anger
(3) Difficulty concentrating
Difficulty concentrating
(4) Hypervigilance
Hypervigilance
(5) Exaggerated startle response
Exaggerated startle response
93
E. 30 days duration
30 days duration
F. Disturbances cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning: Evidenced by increase family
conflict, sexual dysfunction, poor
interpersonal communication, less loving,
more dependent, reduced social support,
poor stress-coping methods.
Disturbances cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning: Evidenced by increased
work conflict, missed work, insensitivity
to clients, lingering distress caused by
trauma material, reduced social support,
poor stress-coping methods.
(Used with author’s permission, Figley, 2002a)
94
Secondary Traumatic Stress Terminology
The term secondary traumatic stress is used throughout the literature in addition to other
terms such as, vicarious traumatization, compassion fatigue, in addition to related terms
countertransference, and burnout.
STS: refers to a set of psychological symptoms that mimic post-traumatic stress disorder
and can be a result of exposure to a client’s traumatic material. 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 (Figley 1995).
Vicarious traumatization: refers to harmful changes that occur in professional’s view of
themselves, others, and the world as a result of exposure to the traumatic material of
clients. Included in the definition of vicarious traumatization are disturbances in the
therapist’s cognitive frame of reference. They propose that the changes that occur to the
therapist’s cognitive schema of themselves, others, and the world are pervasive,
cumulative, and permanent.
Compassion fatigue: is a term that is used interchangeably with STS. Charles Figley’s
use of the term compassion fatigue stems from his belief that some find the term
secondary traumatic stress derogatory.
Countertransference: any projections by therapists that distort the way they perceive and
react to a client. STS includes, but is not limited to countertransference, which occurs
within the context of psychotherapy and a result of reactions to the transference on the
95
part of the client. Countertransference can occur outside the context of exposure to
traumatic material while STS always arises as a result of exposure to a client’s traumatic
material.
Burnout: a state of physical, emotional and mental exhaustion caused by long term
involvement in emotionally demanding situations. Burnout can result from emotional
exhaustion and emerges gradually but STS can become apparent quicker than the course
burnout takes. Figley has asserted that one severe exposure to another person’s
experience of trauma can result in symptoms of STS.
96
Self-Care
1. What do you value most about doing mental health work?
2. What are (or do you expect to be) the most stressful and rewarding aspects of mental
health work?
3. How do you know when you are stressed?
4. How might your co-workers know when you are stressed?
5. What can others do for you when you are stressed?
6. What can you do for yourself?
(Adapted from source in public domain Center for Mental Health Services)
97
PowerPoint Slides for Training
98
99
100
101
102
103
104
105
106
107
108
APPENDIX B
Training Evaluation Questionnaire
Please fill out before the training begins.
What is your current level please circle:
Licensed Mental Health Professional
Intern
Trainee
Instructions: The purpose of this questionnaire is to determine the extent to which you
are familiar with the topic of Secondary Traumatic Stress. The results of the survey will
help assess the effectiveness of the training program and identify ways in which it can be
made more practical for those who attend. Please do not write your name as no
identifying information will be used. You are free to skip any questions you wish.
After each item, please enter the appropriate number in the box.
Excellent = 5 Very Good = 4 Good = 3
Fair = 2
Poor = 1
1. How would you rate your current knowledge of Secondary Traumatic Stress?
2. How would you rate your academic graduate training program in preparing you to
handle the effects on you (the therapist) of working with clients who have experienced
trauma?
3. How would you rate your competence in recognizing Secondary Traumatic Stress?
4. How would you rate your current knowledge of self-care practices?
5. How would you rate your current knowledge of strategies for preventing Secondary
Traumatic Stress?
To what extent was the topic of Secondary Traumatic Stress (or similar topics) addressed
in your academic graduate training program?
109
Please fill out after the training
After each item, please enter the appropriate number in the box.
Excellent = 5 Very Good = 4 Good = 3 Fair = 2
Poor = 1
1. How would you rate your current knowledge of Secondary Traumatic Stress?
2. How would you rate your academic graduate training program in preparing you to
handle the effects on you (the therapist) of working with clients who have
experienced trauma?
3. How would you rate your competence in recognizing Secondary Traumatic Stress?
4. How would you rate your current knowledge of self-care practices?
5. How would you rate your current knowledge of strategies for preventing
Secondary Traumatic Stress?
Please answer these questions
1. In what ways has learning about Secondary Traumatic Stress been helpful for
your overall professional development?
2. What aspects of the training did you find most helpful?
3. What would have improved the training program?
4. Any additional comments, suggestions, or recommendations are greatly
appreciated.
110
REFERENCES
Alpert, J. L., & Paulson, A. (1990). Graduate-level education and training in child sexual
abuse. Professional Psychology: Research and Practice, 21, 336-371.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: Author.
Arvay, M. J., & Uhlemann, M. R. (1996). Counselor stress in the field of trauma: A
preliminary study. Canadian Journal of Counseling, 30(3), 193-210.
Betts Adams, K., Matto, H. C., & Harrington, D. (2001). The traumatic stress institute
belief scale as a measure of vicarious trauma in a national sample of clinical
social workers. Families in Society: the Journal of Contemporary Human
Services, 82(4), 85-90.
Beaton, R. D., & Murphy, S. A. (1995). Working with people in crisis: Research
implications. In C. R. Figley (Ed.), Compassion fatigue: secondary traumatic
stress disorders in those who treat the traumatized (pp.51-81). London: BrunnerMazel.
Birk, A. (2002). Secondary traumatization and burnout in professionals working with
torture survivors. Traumatology, 7(2), 85-90.
Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the
September 11 terrorist attacks: A study of secondary trauma among New York
City social workers. International Journal of Emergency Mental Health, 6(2), 110.
111
Brady, J., Guy, J., Poelstra, P., & Brokaw, B. (1999). Vicarious traumatization,
spirituality, and the treatment of sexual abuse survivors: A national survey of
women psychotherapists. Professional Psychology, 30, 386-393.
Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers.
Social Work, 52(1), 63-70.
Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2003). Development and
validation of the secondary traumatic stress scale. Research on Social Work
Practice, 13(10), 1-16.
Buchanan, M., Anderson, J. O., Uhlemann, M. R., & Horwitz, E. (2006). Secondary
traumatic stress: An investigation of Canadian mental health workers.
Traumatology, 12(4), 272-281.
Center for Mental Health Services. (2000). Training manual for mental health and human
service workers in major disasters. DHHS Publication No. (ADM) 90-538.
Rockville, MD: Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Treatment (2006). Therapeutic community curriculum:
Trainer’s manual. DHHS Publication No. (SMA) 06-4121. Rockville, MD:
Substance Abuse and Mental Health Services Administration.
Cerney, M. S. (1995). Treating the "heroic treaters." In C. R. Figley (Ed.), Compassion
fatigue: Secondary traumatic stress disorders in those who treat the traumatized
(pp. 131-149). New York: Brunner-Mazel.
112
Chrestman, K. R. (1999). Secondary exposure to trauma and self reported distress among
therapists. In B. H. Stamm (Ed.), Secondary traumatic stress: Self care issues for
clinicians, researchers, and educators (2nd ed., pp. 29-36). Baltimore, MD: Sidran
Press.
Collins, S., & Long, A. (2003). Working with the psychological effects of trauma:
Consequences for mental health-care workers-a literature review. Journal of
Psychiatric and Mental Health Nursing, 10, 417-424.
Catherall, D. (1995). Coping with secondary traumatic stress: The importance of the
professional peer group. In B. H. Stamm (Ed). Secondary traumatic stress: self
care issues for clinicians, researchers, and educators (2nd ed., pp. 80-92).
Baltimore, MD: Sidran Press.
Corey, G., Corey, M. S., & Callanan, P. (2007). Issues and ethics in the helping
professions (7th ed.). Belmont, CA: Thomson Higher Education.
Cornille, T. A., & Meyers, T. W. (1999). Secondary traumatic stress among child
protective service workers: Prevalence, severity, and predictive factors.
Traumatology, 5(1), 15-31.
Courtois, C. A. (1988). Healing the incest would. New York: W.W. Norton and
Company.
Creamer, T. L., & Liddle, B. J. (2005). Secondary traumatic stress among disaster mental
health workers responding to the September 11 attacks. Journal of Traumatic
Stress, 18(1), 89-96.
113
Dane, B. (2000). Child welfare workers: An innovative approach for interacting with
secondary trauma. Journal of Social Work Education, 36, 27-39.
Davidson, J., & Smith, R. (1990). Traumatic experiences in psychiatric outpatients.
Journal of Traumatic Stress, 3(3), 459-475.
Dutton, M. A., & Rubinstein, F. L. (1995). Working with people with PTSD: Research
implications. In C. R. Figley (Ed.), Compassion fatigue: Secondary traumatic
stress disorders in those who treat the traumatized (pp. 82-100). New York:
Brunner-Mazel.
Ennis, L., & Home, S. (2003). Predicting psychological stress in sex offender therapists.
Sexual Abuse: A Journal of Research and Treatment, 15(1), 149-157.
Figley, C. R. (1978). Psychological adjustment among Vietnam veterans: An overview of
the research. In C. R. Figley (Ed.), Stress disorders among Vietnam veterans:
Theory, research, and treatment. New York: Brunner/Mazel.
Figley, C. R. (1995). Compassion fatigue: Secondary traumatic stress disorders in those
who treat the traumatized. New York: Brunner-Mazel.
Figley, C. R. (1999). Compassion fatigue: Toward a new understanding of the costs of
caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for
clinicians, researchers, and educators (2nd ed., pp. 3-28). Baltimore, MD: Sidran
Press.
Figley, C. R. (2002a). Compassion fatigue: Psychotherapists chronic lack of self-care.
Journal of Clinical Psychology, 58, 1433-1441.
114
Figley, C. R. (Ed.). (2002b). Treating compassion fatigue. New York: BrunnerRoutledge.
Flannery, R. B. (1990). Social support and psychological trauma: A methodological
review. Journal of Traumatic Stress, 3(4), 593-611.
Follette, V. M., Polusny, M. M., & Milbeck, K. (1994). Mental health and law
enforcement professional’s trauma history, psychological symptoms, and impact
of providing services to child sexual abuse survivors. Professional Psychology:
Research and Practice, 25, 275-282.
Freud, S. (1957). The future prospects of psycho-analytic therapy. In J. Strachey (Ed. and
Trans.), The standard edition of the complete psychological works of Sigmund
Freud (Vol. 11, pp. 139-151). London: Hogarth Press. (Original work published
1910).
Freudenburger, H. J. (1975). Staff burnout symptoms in alternative institutions.
Psychotherapy: Theory, Research & Practice, 12(1), 73-82.
Gentry, J. E., Baranowsky, A. B., & Dunning, K. (2002). ARP: The accelerated recovery
program (ARP) for compassion fatigue. In C. R. Figley (Ed.), Treating
compassion fatigue (pp. 123-137). New York: Brunner-Routledge
Ghahramanlou, M., & Brodbeck, C. (2000). Predictors of secondary trauma in sexual
assault trauma counselors. International Journal of Emergency Metal Health,
2(4), 229-240.
115
Haley, S. A. (1974). When the patient reports atrocities: Specific treatment considerations
of the Vietnam veteran. Archives of General Psychiatry, 30, 191-196.
Herman, J. (1992). Trauma and recovery. New York: Basic Books.
Illife, G., & Steed, L. G. (2000). Exploring counselor’s experience of working with
perpetrators and survivors of domestic violence. Journal of Interpersonal
Violence, 15(4), 393-412.
Jenkins, S. R., & Baird, S. (2002). Secondary traumatic stress and vicarious trauma: A
validation study. Journal of Traumatic Stress, 15(5), 423-432.
Joinson, C. (1992). Coping with compassion fatigue. Nursing, 22, 116-121.
Kadambi, M. A., & Truscott, D. (2003). Vicarious traumatization and burnout among
therapists working with sex offenders. Traumatology, 9(4), 216-230.
Kassam-Adams, N. (1999). The risk of treating sexual trauma: Stress and secondary
trauma in psychotherapists. In B. H. Stamm (Ed), Secondary Traumatic stress:
Self care issues for clinicians, researchers, and educators (2nd ed., pp. 37-48).
Baltimore, MD: Sidran Press.
Kirkpatrick, D. L. (1994). Evaluating training programs: The four levels. San Francisco:
Berrett-Koehler Publishers, Inc.
Kluft, R. P. (2004). Treating compassion fatigue. American Journal of Clinical Hypnosis,
Retrieved February 17, 2009, from
http://findarticles.com/p/articles/mi_qa4087/is_200410/ai_n9460072
116
Knight, C. (1997). Therapists' affective reactions to working with adult survivors of child
sexual abuse: An exploratory study. Journal of Child Sexual Abuse, 6(2), 17-41.
Maslach, C. (1976). Burned-out. Human Behavior, 5, 16-22.
Maslach, C. (1982). Burnout: The cost of caring. Englewood Cliffs, NJ: Prentice-Hall.
Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach Burnout Inventory Manual
(3rd ed.). Palo Alto, CA: Consulting Psychology Press.
McCammon, S. L. (1995). Painful pedagogy: Teaching about trauma in academic and
training settings. In B. H. Stamm (1999). Secondary traumatic stress: Self care
issues for clinicians, researchers, and educators (2nd ed., pp. 105-120). Baltimore,
MD: Sidran Press.
McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor.
New York: Brunner/Mazel.
McSwain, K., Robinson, R., & Panteluk, L. (1998). Implications for practice:
Therapeutic, personal, and organizational coping strategies. Research and
Advocacy Digest, 6(2).
Meldrum, L., King, R., & Spooner, D. (2002). Secondary traumatic stress in case
managers working in community mental health service. In C. R. Figley (Ed.),
Treating compassion fatigue (pp. 85-106). New York: Brunner-Routledge.
Moran, C. C. (2002). Humor as a moderator of compassion fatigue. In C. R. Figley (Ed.),
Treating compassion fatigue (pp. 139-154). New York: Brunner-Routledge.
117
Munroe, J. F. (1999). Ethical issues associated with secondary trauma in therapists. In B.
H. Stamm (1999). Secondary traumatic stress: self care issues for clinicians,
researchers, and educators. (2nd ed., pp. 211-229). Baltimore, MD: Sidran Press.
Munroe, J. F., Shay, J., Fisher, L., Makary, C., Rapperport, K., & Zimering, R. (1995).
Preventing compassion fatigue: coping with secondary traumatic stress disorder in
those who treat the traumatized. In C. R. Figley (Ed.), Compassion fatigue:
Secondary traumatic stress disorders in those who treat the traumatized (pp. 209231). New York: Brunner-Mazel.
Musa, S. A., & Hamid, A. A. (2008). Psychological problems among aid workers
operating in Darfur. Social Behavior and Personality, 36(3), 407-416.
Nelson-Gardell, D., & Harris, D. (2003). Child abuse history, secondary traumatic stress,
and child welfare workers. Child Welfare, 82, 5-25.
Neumann, D. A., & Gamble, S. J. (1995). Issues in the professional development of
psychotherapists: Countertransference and vicarious traumatization in the new
therapists. Psychotherapy, 32(2), 341-347.
Newman, E., Kaloupek, D., & Keane, T. (1996). Assessment of posttraumatic stress
disorder in clinical and research settings. In B. van der Kolk, A. McFarlane, & L.
Weisaeth (Eds.), Traumatic stress (pp. 242-275). New York: Guilford.
Norcross, J. C. (2000). Psychotherapist self care: Practitioner tested, research informed
strategies. Professional Psychology: Research and Practice, 31, 710-713.
118
O'Halloran, M. S., & O'Halloran, T. (2001). Secondary traumatic stress in the classroom:
Ameliorating stress in graduate students. Teaching of Psychology, 28(2), 92-97.
Ortlepp, K., & Friedman, M. (2001). The relationship between sense of coherence and
indicators of secondary traumatic stress in non-professional trauma counselors.
South African Journal of Psychology, 31(2), 38-45.
Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study
on the effects of trauma work on trauma therapists. Professional Psychology:
Research and Practice, 26, 558-565.
Pearlman, L. A., & Saakvitne, K. W. (Eds.). (1995). Trauma and the therapist:
Countertransference and vicarious traumatization in psychotherapy with incest
survivors. New York: W.W. Norton.
Pines, A. M. (1993). Burnout. In L. Goldberger, & S. Breznitz (Eds.), Handbook of
stress-theoretical and clinical aspects (2nd ed., pp. 386-402). New York: Free
Press.
Pope, K. S., & Feldman-Summers, S. (1992). National survey of psychologists' sexual
and physical abuse history and their evaluation of training and competence in
these areas. Professional Psychology: Research and Practice, 19, 43-49.
Rogers, C. R. (2007). The necessary and sufficient conditions of therapeutic personality
change. Psychotherapy: Theory, Research, Practice, Training, 44(3), 240-248.
119
Substance Abuse and Mental Health Services Administration (SAMHSA). (2008). A
quarterly technical assistance bulletin on disaster behavioral health. Retrieved
November 15, 2009, from
http://mentalhealth.samhsa.gov/dtac/dialogue/Issue2_08.asp#three
Schauben, L. J., & Frazier, P. A. (1995). Vicarious trauma: The effects on female
counselors of working with sexual violence survivors. Psychology of Women
Quarterly, 19, 49-64.
Stamm, B. H. (1999). Secondary traumatic stress: Self care issues for clinicians,
researchers, and educators (2nd ed.). Baltimore, MD: Sidran Press.
Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue:
Developmental history of the compassion fatigue and satisfaction test. In C. R.
Figley (Ed.), Treating compassion fatigue (pp. 107-119). New York: BrunnerRoutledge.
Tannenbaum, S. I., & Yukl, G. (1992). Training and development in work organizations.
Annual Review of Psychology, 43, 399-441.
Trippany, R. L., White-Kress, V. E., & Wilcoxon, S. A. (2004). Preventing vicarious
trauma: What counselors should know when working with trauma survivors.
Journal of Counseling & Development, 82, 31-37.
Valent, P. (2002). Diagnosis and treatment of helper stress, traumas, and illnesses. In C.
R. Figley (Ed.), Treating compassion fatigue (pp. 17-37). New York: BrunnerRoutledge.
120
Way, I., Van Deusen, K., Marin, G., Applegate, B., & Jandle, D. (2004). A comparison of
clinicians who treat survivors of sexual abuse and sexual offenders. Journal of
Interpersonal Violence, 19, 49-71.
Wee, D. F., & Myers, D. (2002). Stress response of mental health workers following
disaster: The Oklahoma City Bombing. In C. R. Figley (Ed.), Treating
compassion fatigue (pp. 57-48). New York: Brunner-Routledge.
Weiss, D. S., & Marmar, C. R. (1997). The impact of events scale-revised. In J. P.
Wilson, & T. M. Keane (Eds.), Assessing psychological trauma and PTSD: A
practitioner’s handbook. New York: Guilford.
Yassen, J. (1995). Preventing secondary traumatic stress disorder. In B. H. Stamm,
Secondary traumatic stress: Self care issues for clinicians, researchers, and
educators (2nd ed., pp. 178-208) Baltimore, MD: Sidran Press.