1 Chapter 1 INTRODUCTION Statement of Collaboration Isabel Ulloa Ott and Julaine Rose contributed equally to the overall planning, literature review, and problem formulation, operationalization of the concepts, developing the instrument for data collection, securing the necessary approval from the Human Subjects Committee, data collection, and data analysis and writing the project. Purpose of the Study In 1995, Figley wrote that Traumatology, or the field of traumatic stress studies, has become a dominant focus of interest within the field of human services in the last decade. Figley described that the origin of the study of human reactions to traumatic events could be traced to the earliest medical writings in Kunus Pyprus, published in 1900 B.C. in Egypt. Authors use the terms compassion fatigue, vicarious trauma, secondary trauma, and secondary traumatic stress interchangeably and view these concepts as synonymous (Bride, 2007; Figley, 1999; Jenkins & Baird, 2002 & Stoesen, 2007). Figley defined vicarious trauma or secondary traumatic stress (STS) as the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by another and the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1995). Figley suggested that symptoms of vicarious trauma lead to a pattern of symptoms that are comparable to post traumatic stress disorder (PTSD), however, vicarious trauma is a result of indirect exposure to trauma due to close personal contact with a trauma survivor whereas PTSD involves 2 direct exposure to a traumatic event or experience (Figley, 1995). McCann and Pearlman (1990) describe vicarious trauma as the changes in an individual’s “inner experience as a result of empathic engagement with survivor clients and their trauma material” (p. 25). Growing awareness of vicarious trauma, also known as secondary trauma, of the long-term consequences of shocking events may result in a plethora of psychological and emotional maladies. Figley (1995) discussed how the first time common symptoms experienced by a wide variety of traumatized persons were viewed as a psychiatric disorder, post-traumatic stress disorder (PTSD), one that could be accurately diagnosed and treated. The symptom criteria were later modified as the work with traumatized clients grew, as did the accumulation of research that validated the disorder. The primary difference between PTSD and vicarious trauma is the experience of the traumatic event and in that vicarious trauma can occur from work with a single client (Helm, 2010). One thing is certain, vicarious trauma places professionals at risk and others will have shortlived reactions to these threats. “I knew something was wrong… I was changed somehow, different… I just didn’t have a name for what was wrong” (Pryce, Shackelford, Pryce, 2007, p. 4). When Figley (1996) addressed the concept of Vicarious Trauma, he observed that child welfare emerged as the predominant field impacted by higher incidences of vicarious trauma. This raised the questioned of whether or not child welfare professionals are being affected by vicarious trauma and mistaking it for burnout or compassion fatigue. Recently, nationwide attention has been drawn to child welfare agencies as they are experiencing a severe workforce crisis involving high staff turnover rates estimated to 3 be between 23 to 60% (Drake & Yadama, 1996). Child welfare work requires regular use of empathic engagement to help the child share with the worker, what their traumatic experiences have been and in sharing stories which may be horrific. Unresolved trauma experienced or heard may be drawn to the surface and can take a toll on the worker. Within the first interaction with a traumatized client, impairment, resulting in psychological and physical symptoms can be experienced (Pryce et al., 2007). Background Figley (1996) began using the term compassion fatigue, which he believed to be less stigmatizing after citing concerns that the secondary trauma label might be considered derogatory by some professionals. For the purpose of this project, the terms vicarious trauma which is sometimes also called, “secondary traumatic stress,” “compassion fatigue,” “secondary victimization” or “indirect trauma,” as well as the somewhat older “burnout” will be represented in this project. Stamm (2009) argued that even though nuanced differences might separate vicarious trauma, secondary traumatic stress and compassion fatigue, studies attempting to differentiate the constructs had found no evidence of substantial differences, hence, the terms mentioned may be found in this project interchangeably. Figley (1996) describes that secondary trauma refers to the cumulative effects on the professionals working with survivors of traumatic life events. Professionals are those who provide a service to others such as mental health workers, medical personnel, and first responders, including police. The effects can be positive or negative as it is believed that the rewards of trauma work balance the painful effects of vicarious traumatization, 4 however, workers must be aware of vicarious trauma and its effects. Historically, professionals are often subscribed to the tenet that they should not get involved. Feelings or distress are reinforced by notions that counter transference are bad, signs of weakness, inadequacy, or poor boundaries and unresolved issues. The constructivist self development theory (CSDT), which will be discussed later in this chapter, describes how and why traumatic work changes the professional profoundly. Siegfried (2008) identified that few studies have been done on vicarious trauma in child welfare workers generally. These suggest the incidence of vicarious trauma in this group of professionals is relatively high. Some research shows that workers in the child welfare system have a higher number of symptoms than social workers in other human service fields (Stoesen, 2007). Also, the more trauma survivors a worker have on his or her caseload, the more symptoms of vicarious trauma he or she will likely experience (Schauben and Frazier, 1995). Siegfried (2008) discussed a study done by Bride in 2007 of master’s level workers licensed in a southern state. The study found that 70.2% of workers experienced at least one symptom of secondary traumatic stress in the previous week, 55% met the criteria for at least one of the core symptom clusters, and 15.2% met the core criteria for a diagnosis of PTSD. Bride (2007) study demonstrated that the intrusion criteria was endorsed by nearly half of the respondents and most reported symptoms of intrusive thoughts, avoidance of reminders of clients, and numbing responses. Vicarious trauma and child welfare are likely paired terms and it would appear that the relationship between the two would have been explored since the beginning of 5 professional involvement with abused and neglected children. In 1989, Figley voiced concerns that colleagues were leaving the field because of the pain of working with traumatized clients. Figley theorized that just as a traumatized person can traumatize others with his or her family by sharing the traumatic experience; it is equally possible for the traumatized client to traumatize the worker. Child welfare workers experience material related to physical abuse, sexual abuse, acts of cruelty, severe neglect, including medical neglect and neglect from substance use, exploitation and emotional abuse. As a result, child welfare workers are negatively impacted by the exposure of horrors inherent in their responsibilities (Harowitz, 1998). Saakvitne & Pearlman (1996) identified two specific impacts of vicarious traumatization. The first is determined by the interaction between the situation, such as work setting, number of cases and their trauma, nature of exposure to the trauma, the social, politic al and cultural context of both the original traumas and the current work. The second is the self of the helper, such as the workers professional identity, resources, support, personal history, current life circumstances and coping mechanisms. Bride (2007) says that the experience of secondary trauma is believed to be one reason why many child welfare professionals leave the field prematurely. After trauma, nothing is ever the same and survivors of trauma and the workers who help them confront this reality every day. Workers are asked to face their own vulnerability, their protective beliefs about safety, control, predictability, and protection. Child welfare workers strive to make a difference in the face of devastation and take on a directive to be effective to their client. Saakvitne & Pearlman (1996) describe how many 6 workers may face initial failure and frustration when they hope for rapid success and transformation. In hearing the clients past or present experiences, the worker’s empathic engagement can result in vulnerable to intense or overwhelming feelings. These authors go on to say that disappointment as a result of slow progress can translate into vicarious traumatization. Vicarious trauma in child welfare can be viewed as an occupational hazard. It is the cumulative response to working with many trauma survivors over an extended period of time or can result from reactions to a particular client’s traumatic experience (Siegfried, 2008). He described the common sources of vicarious trauma in child welfare work: 1. Facing the death of a child or adult family member on the worker’s caseload; 2. Investigating a vicious abuse or neglect report; 3. Frequent or chronic exposure to emotional and detailed accounts by children of traumatic events; 4. Photographic images of horrific injuries or scenes of a recent serious injury or death; 5. Continuing to work with families in which serious maltreatment, domestic violence, or sexual abuse occurring; 6. Helping support grieving family members following a child abuse death, including siblings of a deceased child. 7 Child welfare workers may experience a change, in how the worker interacts with the world, their families, friends and themselves. Workers may struggle to make sense of powerful, often painful, feelings and changed beliefs (Figley, 1996). A cost to caring according to Figley (1996) is the cost of listening to the stories of client’s pain, fear, and suffering. These workers may begin to feel similar to fear, pain and suffering including intrusive thoughts and other symptoms that require assistance in managing. Figley (1996) notes that trauma is not something clients do to us; it is a human consequence of knowing, caring, and facing the reality of trauma. It is impossible to hear and bear witness to trauma survivors’ experiences and remain unchanged (Figley, 1996). In addition to vicarious trauma arising from helping children, child welfare workers are exposed to traumatic or life threatening events of their own. In Siegfried (2008) article, Child Welfare Work and Secondary Traumatic Stress, she identifies that vicarious trauma may arise from removing a child from his or her home and sometimes confronting intense verbal or physical assault by clients or community members, including but not limited to violent family members, car accidents and neighborhood violence. Some researchers believe that dealing with the pain of children is especially provocative and makes the worker more vulnerable to secondary trauma than working with adult trauma survivors (Figley, 1995). Statement of the Problem The effects of exposure to traumatic material are evident in child welfare. Child welfare workers’ responsibility of interviewing children, adults and families regarding abuse, reading case files, police reports, medical reports and notes that include 8 descriptions of physical and sexual abuse, as well as removing children from their home or placement changes renders a child welfare worker at risk of trauma. Vicarious traumatization goes beyond the simple recognition that working with trauma survivors is hard and distressing to helpers (Pearlman & Saakvitne, 1996). According to research, vicarious and secondary trauma often leads to problematic job performance and ineffectiveness. In particular, secondary trauma interferes with an individual’s capacity for empathy and thus impacts a clinician’s ability to clearly identify and address a client’s issues. Secondary trauma can impact a professional’s capacity to maintain appropriate boundaries, make thorough assessments, set parameters, and make decisions regarding treatment or course of care. Secondary trauma can also limit a professional’s ability to engage in self analysis and reflection and thus interferes with an individual’s capacity to distinguish between the needs and feelings of the client versus him or herself. In addition to an individual’s job performance, secondary trauma has also been linked to increased rates of absenteeism, employee turnover, and burnout. According to research, symptoms of vicarious trauma can lead to higher rates of physical and mental health conditions which are often associated with increased absenteeism among employees (Siegfried, 2008; Saakvitne & Pearlman, 1996). Furthermore, vicarious trauma has been associated with higher rates of job burnout which is defined as a state of emotional, mental, and physical exhaustion caused by chronic and unrelenting stress in the workplace (Smith, Jaffe-Gill, Segal & Segal, 2010). Studies suggest that burnout is characterized by both physical and psychological 9 symptoms, including: intense fatigue, insomnia, depression, anxiety, despair, disenchantment, physical ailments, poor job performance, and a cynical view of life and others (Salston & Figley, 2003). Thus, the parallel effects of vicarious trauma and burnout often work in conjunction to increase rates of absenteeism, job dissatisfaction, and job turnover. In fact, vicarious trauma is highly correlated with high job turnover. According to research, symptoms of vicarious trauma are frequently identified as one of the major causes for social workers leaving the field precipitately (Figley, 1999). Statement of the Purpose Child welfare workers make an invaluable contribution to our society. These workers are dedicated to serve survivors of trauma and the impact of the trauma on their lives. The purpose of this project is to gather information about vicarious trauma from the perspectives of the professionals in the child welfare field. Vicarious trauma is a significant concern for workers providing services to traumatized clients. An awareness of personal reactions to vicarious trauma may allow workers to implement strategies to ameliorate effects of the trauma by protecting themselves and thus minimizing potential ethical and interpersonal difficulties. The information gathered in this project will increase the level of understanding of vicarious trauma on professionals in the child welfare field. Quantitative and qualitative data gathered will provide a starting point for constructing an approach in helping child welfare workers manage trauma experienced. Theoretical Framework There are several theories to explain the trauma that child welfare workers experience. The constructivist self-development theory is the most common and other 10 theories that can be applied are the psychoanalysis theory, empowerment theory, social network and social constructiveness theories. Constructivist Self-Development Theory (CSDT) Constructivist Self-Development Theory emphasizes he interaction between the work experience and the self of the worker. CSDT as described by Saakvitne & Pearlman (1996) describe the concept of vicarious and secondary trauma as a theoretical model of psychological adaptation to severe trauma. Child welfare professionals who incorporate or develop an understanding of what CSDT is, allow the professionals to cope with traumatic matter based on their current circumstances and early experiences, specifically, interpersonal, familial, cultural and social experiences (Saakvitne & Pearlman, 1996). When professionals are exposed to events that do not fit within their current perceptions of reality, unreasonable or unclear beliefs protect the professional and its meaning from the harm caused by the trauma in an attempt to protect oneself from harm. This can be observed in a child welfare professional who begins to see all parents or caregivers as guilty of allegations of abuse or neglect or the opposite. Professionals affected by vicarious trauma may become less emotionally accessible due to a decrease in access to emotions (Saakvitne & Pearlman, 1996). Trippany, Kress and Wilcoxon (2004) discuss the hazards in the potential for clinical error and therapeutic impasse increase as the vulnerability that the worker experiences increases. This results in the worker compromising therapeutic boundaries such as inappropriate contact, forgotten appointments and unreturned phone calls. The worker may also feel anger toward the client if the client has not complied with some idealized 11 response to therapy and may result in the worker doubting their skill and knowledge and potentially lose focus on clients’ strengths and resources (Trippany, et al., 2004). Other hazards the client may be subjected to when the worker is experiencing vicarious trauma include a decreased ability to attend to external stimuli, misdiagnosis and “rescuing” by the worker and in addition, the client may attempt to protect the worker, which may create an ethical bind based on exploitation of the client. According to this theory, there are five components of self; frame of reference, self capacities, ego resources, psychological needs and cognitive schemas, and memory and perception (Saakvitne & Pearlman, 1996). A professional’s frame of reference includes the professional’s sense of identity and their views of self, relationships, spirituality and the world. Self-capacities refer to the professional’s ability to manage strong emotions, feel entitled to be alive and deserving of love and to hold on to an inner awareness of caring for others. These are reflected in the professional’s abilities to selfsoothe and maintain a sense of inner equilibrium (Saakvitne & Perlman, 1996). Ego resources relate to the capacity for self-awareness, insight and empathy striving to accomplish personal growth. Ego resources include the ability to foresee consequences, make self-protective judgments, and establish healthy boundaries (Saakvitne & Perlman, 1996). Psychological needs and cognitive schemas are the professional’s needs for safety, control, esteem, trust and intimacy. These are reflected in schemas about others such as trust in others and esteem for others and about oneself such as self-trust and self-esteem (Saakvitne & Perlman, 1996). Lastly, memory and perception are affected by traumatic events, which result in fragmented memories. Saakvitne and Pearlman (1996) recognize 12 that memory and perception are complex and multimodal. They describe how any experience is processed and recalled through several modalities, including the cognitive, visual, emotional, somatic and sensory, and behavioral and this result in the worker’s memory being fragmented because of the dissociation or disconnection to aspects of the experience. Saakvitne and Pearlman (1996) give example as the narrative (cognitive) being recalled without the feelings or images, or the feeling, rather it panic or terror, or an image (flashback), without a narrative context. Within these components of CDST that vicarious and secondary trauma emerges where a worker may find disconnected from his or her sense of identity. Psychoanalytic Theory Psychoanalysis is the foundation for effective psychotherapy with survivors of psychological trauma (Pearlman & Saakvitne, 1995). The founder of psychoanalytic theory was Sigmund Freud in the 1890’s. The term psychoanalysis is used to refer to many aspects of Freud’s work and research which he relied heavily upon his observations and case studies. According to Freud, the mind can be divided into two main parts (Cherry, 2005): 1. The conscious mind includes everything that we are aware of. This is the aspect of our mental processing that we can think and talk about rationally. A part of this includes our memory, which is not always part of consciousness but can be retrieved easily at any time and brought into our awareness. Freud called this ordinary memory the pre-conscious. 13 2. The unconscious mind is a reservoir of feelings, thoughts, urges, and memories that exist inaccessible to our conscious awareness. Most of the contents of the unconscious are unacceptable or unpleasant, such as feelings of pain, anxiety, or conflict. According to Freud, the unconscious continues to influence our behavior and experience, even though we are unaware of these underlying influences. Psychoanalytic view holds that there are inner forces outside of a professionals awareness that is directing his or her behavior. In the 1940’s a psychoanalytic notion that was helpful in treatment was the notion of “transference” (Strean, 1979). Psychoanalysis enabled social work professionals to understand why some clients improved quickly while others did not change. The concept of “resistance” helped these professionals appreciate how difficult it was to make alterations in one’s personal and interpersonal life. Before discussing transference and resistance, it is important to discuss attachment as it pertains to trauma because the quality of attachment during the formative years when the brain is developing at exponential rates informs the quality of the person’s relationships throughout the rest of their life. The term "attachment" is used to describe the feeling-based bond that develops between an infant and a primary caregiver. The quality of attachment evolves over time as the infant interacts with his caregiver and is determined partly by the caregiver’s stateof-mind toward the infant and his needs. The father of attachment theory, John Bowlby, M.D., believed that attachment bonds between infants and caregivers have four defining features American Psychoanalytic Association (ASPAA), 2009: 14 Proximity Maintenance: wanting to be physically close to the caregiver Separation Distress: more widely known as "separation anxiety" Safe Haven: retreating to the caregiver when the infant senses danger or feels anxious Secure Base: exploration of the world knowing that the caregiver will protect the infant from danger. In a psychoanalytic treatment setting, the client’s journey towards self-discovery can mimic the attachment theory features presented by infants, with the professional representing the caregiver (ASPAA, 2009). Attachment is critically important in understanding what happens to clients, what their issues are, and why some professionals seem unreachable psychologically while others are accessible. Transference is a concept that refers to a person’s natural tendency to respond to certain situations in unique, predetermined ways predetermined by much earlier, formative experiences usually within the context of the primary attachment relationship (ASPAA, 2009). In psychoanalysis, patterns arise sometimes unexpectedly and unhelpfully. Freud coined the word "transference" to refer to this ever-present psychological phenomenon, and it remains one of the most powerful explanatory tools in explaining human behavior (ASPAA, 2009). Transference points to an important fact about the nature of trauma and the compulsion of the human psyche to repeat traumatic events and discuss these events over and over again. Resistance is one of the two cornerstones of psychoanalysis. The professional is experiencing or burdened by transferences or painful emotions derived from the client, 15 and must use various defenses to avoid the full emotional intensity (ASPAA, 2009). These resistances can take the form of the professional suddenly changing, falling into silence, or trying to discontinue the relationship altogether. Today, the American Psychoanalytic Association (ASPAA), account that the ego psychology that was dominant in American psychoanalytic thought for so many years has been significantly modified and is also currently strongly influenced by the developing relational point of view and an understanding of transference, an interest in the unconscious, and the centrality of the professional-client relationship (ASPAA, 2009). Empowerment Theory Working from a theoretical framework that acknowledges and enhances client strengths and focuses on solutions in the present can feel empowering for client and professional and reduce the risk of vicarious trauma (Arte Sana, 2003). The emphasis in social work of empowerment and linkages plays a major role in assisting people with coping strategies. Empowerment is when an individual gains the ability to achieve their goals and maximize their capacities. There are different forms of empowerment focused ideas where a professional can maximize their capacities and in avoiding vicarious trauma. These ideas include the workload, work environment, group support, supervision and self-care, including coping mechanisms and resiliency factors that minimize the effects of vicarious trauma in the professional. Social workers who provide direct services to clients affected by trauma may benefit from opportunities to participate in social change activities. Agencies might consider providing community education and outreach or working to influence policy. 16 Such activities can provide a sense of hope and empowerment that can be energizing and can neutralize some of the negative effects of trauma work (Arte Sana, 2003). In addition, organizations can also maintain an attitude of respect (Pearlman & Saakvitne, 1995) for both clients and workers by acknowledging that work with trauma survivors often involves multiple, long-term services. Developing collaborations between agencies that work with traumatized clients can provide material support and prevent a sense of isolation and frustration at having to go it alone (Arte Sana, 2003). A safe, comfortable, and private work environment is crucial for those social workers in settings that may expose them to violence (Pearlman & Saakvitne, 1995). Workers need to have personally meaningful items in their workplace that include pictures of their children or of places they have visited, scenes of nature or quotes that help them remember who they are and why they do this work and by placing inspiring posters or pictures of scenic environments, the organization can model the importance of the personal in the professional (Arte Sana, 2003). Trauma-specific education diminishes the potential of vicarious trauma. Empowerment can present itself in the form where individuals name their experience and provide a framework for understanding and responding to it (Arte Sana, 2003). Efforts to educate staff about vicarious trauma can begin in the job interview (Urquiza, Wyatt, & Goodlin-Jones, 1997). Agencies have a duty to warn applicants of the potential risks of trauma work and to assess new workers' resilience (Pearlman & Saakvitne, 1995). Ongoing education about trauma theory and the effects of vicarious trauma, including the symptoms, can be incorporated in staff training and meetings, formal trainings as well as 17 individual supervision. This information provides a useful context and helps social workers to feel more competent and have more realistic expectations about what they can accomplish in their professional role (Arte Sana, 2003). If the professional feels prepared in encountering a traumatic event, by educating and preparing the professional, the effects of the event may be reduced. In emergency, first responders and trauma work, staff opportunities to debrief informally and process traumatic material with supervisors and peers are mandatory. In child welfare, debriefing in this context is not made. Critical incident stress debriefing is a formalized method for processing specific traumatic events. In child welfare, professionals find support in the form of talking to coworkers and not so often, supervisors or administrative staff. Peer support groups may help because peers can often clarify colleagues' insights, listen for and correct cognitive distortions, offer perspective, reframing, and relate to the emotional state of the social worker (Catherall, 1995). Group support can take a variety of forms, such as consultation, treatment teams, case conferences, or clinical seminars, and can be either peer led or professionally led, however, most importantly, peer led groups should not substitute for, self-care or clinical supervision (Arte Sana, 2003). Should potential problems in support groups arise, consideration should be made to discuss this possibility before it happens and normalize the experience of vicarious trauma and its impact on the individual and the group (Arte Sana, 2003). An essential component in the prevention and healing of vicarious trauma is effective supervision. Responsible supervision creates a relationship in which the social 18 worker feels safe in expressing fears, concerns, and inadequacies (Welfel, 1998). Organizations with a weekly group supervision format establish a venue in which traumatic material and the subsequent personal effect may be processed and normalized as part of the work of the organization (Arte Sana, 2003). In addition to providing emotional support, supervisors can also teach staff about vicarious trauma in a way that is supportive, respectful, and sensitive to its effects (Pearlman & Saakvitne, 1995). If at all possible, supervision and evaluation should be separate functions in an organization because a concern about evaluation might make a worker reluctant to bring up issues in his or her work with clients that might be signals of vicarious trauma (Arte Sana, 2003). In child welfare, many professionals encounter the same type of trauma. The Employee Assistance Program is available to workers in the county or state employment setting however, workers with health insurance should get coverage that provides mental health services. The term "resilience" is reserved for unpredicted or markedly successful adaptations to negative life events, trauma, stress, and other forms of risk. If we can understand what helps some people to function well in the context of high adversity, we may be able to incorporate this knowledge into new practice strategies (Fraser, Richman & Galinsky, 1999, p.136). Resilience is a complex and multi-dimensional term with various definitions. In the past, discussions regarding resilience concentrated on individual traits and attributes. In particular, resilience was described in terms of specific characteristics and coping mechanisms that allowed an individual to prevail in the face of hardship and trauma. Today, however, the concept of resilience has grown to include a broader social, developmental, and environmental framework (Goldstein & Brooks, 2005). 19 Specifically, resilience is now conceptualized as a process in which various resources or strengths engage and interact to shield an individual, family, or community from negative outcomes despite significant risks or trauma (Kragh & Huber, 2002). According to the literature, “family cohesion” (Goldstein & Brooks, 2005, p.13) and close engagement promotes healthy adaptation. In addition, supportive ties and peer relations also mitigate the effects of stress and trauma. Extensive social support, individual growth and autonomy and “an internal locus of control” (Ward, Martin & Distiller, 2007, p. 167) also provide protective benefits to the professional. Working with clients who have experienced traumatic events challenges many of the beliefs held in the dominant culture about justice and human cruelty and knowledge of oppression, abuse, violence, and injustice can be a difficult and isolating aspect of work for many social workers (Arte Sana, 2003). Identification of vicarious trauma as a distinct construct encourages those in the profession to reexamine the relationship between trauma and this type of social worker distress (Arte Sana, 2003). Vicarious trauma can be manageable if the resources and education are in place to assist the professional in understanding their feelings. Limitations This study has a relatively small sample of less than 30 participants. The study is focused on individuals with an occupational setting in the child welfare field and thus this study cannot be generalized to other populations and may not be representative of all child welfare workers. The data has little internal validity; the quantitative and qualitative 20 data collected is self-reported by child welfare workers from local child welfare agencies and therefore is subjective. Assumptions The concept of vicarious trauma provides insight into the stressors of the work of child welfare, however, there are assumptions made in regards to vicarious trauma that this project will explore. Assumptions include professionals in child welfare do not receive adequate training regarding vicarious or secondary trauma. Professionals universally experience some degree of vicarious or secondary trauma and professionals would benefit from training regarding vicarious or secondary trauma. The discussions around vicarious trauma in child welfare workers is fairly new and the reality is centered around the premise that child welfare workers are exposed to daily accounts of trauma which makes them vulnerable to potential candidates for vicarious trauma. 21 Chapter 2 REVIEW OF THE LITERATURE Introduction Children who are referred to Child Protective Services (CPS) are often the nations most vulnerable subjected to incomprehensible acts of cruelty and violence that child welfare workers see and hear on a daily basis. In order to understand how child welfare social workers are affected by the trauma they witness, it is essential to access and review literature on vicarious trauma as it relates to the factors that contribute to developing the condition, symptoms of vicarious trauma, effects on job performance and functioning, as well as potential interventions to address the phenomena. The following sections of this chapter focus on each of these themes as discussed in the current literature on vicarious trauma among professionals who work in human service agencies such as child welfare agencies. Vicarious Trauma and Secondary Traumatic Stress The subject of trauma has received increasing attention and focus in the literature over the last three decades. Several factors led to the growth of research in this field, including a greater appreciation for the enduring effects associated with traumatic events and experiences (Figley, 1995). In particular, trauma has been linked to violence, depression, behavior problems, and a wide variety of medical issues. However, research in the field has been predominantly focused on individuals who directly experienced a traumatic event. In contrast, limited research has been conducted to explore the effects on those who experience trauma indirectly (Bride, 2007; Figley, 1999). 22 According to Figley (1995), the American Psychiatric Association’s third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) represented a significant landmark in the recognition of trauma and its effects on individuals. In 1980, the DSM III delineated the diagnostic criteria for post-traumatic stress disorder for the first time. Subsequently, the effects and symptoms of trauma became more widely known and accepted. Over the following three decades, research into the long-standing effects of military combat, sexual abuse, violent crime, family violence, and natural disasters has proliferated. However, research into the secondary effects of trauma on professionals has received significantly less attention (Figley, 1995). In general, prior to the 1980’s, it was largely believed that professionals working with trauma survivors were generally immune to the effects of their client’s experiences. As a result, literature in the field primarily focused on job hazards such as burnout and counter-transference. However, in the mid-1980’s, Charles Figley, an expert in the field of trauma, introduced the concept of “compassion fatigue” and proposed that professionals who treated and cared for trauma victims experienced secondary trauma as a result of their work (Figley, 1995). Figley defined Secondary Traumatic Stress (STS) as the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other “it is the stress resulting from helping or wanting to help a traumatized or suffering person” (Figley, 1995, p. 7). In general, Figley suggested that secondary traumatic stress led to a pattern of symptoms that are comparable to post traumatic stress disorder (PTSD). However, STS is a result of 23 indirect exposure to trauma due to close personal contact with a trauma survivor whereas PTSD involves direct exposure to a traumatic event or experience (Figley, 1995). Although most authors use the terms compassion fatigue, vicarious trauma, secondary trauma, and secondary traumatic stress interchangeably and view these concepts as synonymous (Bride, 2007; Figley, 1999; Jenkins & Baird, 2002; Stoesen, 2007), a few authors delineate between these concepts (McCann & Pearlman, 1990; Saakvitne & Pearlman, 1996). In particular, McCann and Pearlman (1990) describe vicarious trauma as the changes in an individual’s “inner experience as a result of empathic engagement with survivor clients and their trauma material” (p. 25). In this manner, the authors distinguish between secondary traumatic stress which focuses on the symptoms of trauma exposure, and vicarious trauma which looks at the specific effects on an individual’s identity, perception of self, and view of the world (Siegfried, 2008). According to McCann and Pearlman (1990), the concept of vicarious trauma is based on Constructivist Self Development Theory (CSDT) which conceptualizes an individual’s symptoms as a means to cope with or adjust to traumatic circumstances and defend one’s self and one’s belief system from the damage trauma produces (Siegfried, 2008; Saakvitne & Pearlman, 1996; McCann & Pearlman, 1990). According to this theory, exposure to trauma affects all aspects of an individual’s evolving self and directly impacts an individual’s frame of reference, self capacities, ego resources, psychological needs, cognitive schemas, memory and perception (Saakvitne & Pearlman, 1996). Despite these distinctions, vicarious trauma and Secondary Traumatic Stress (STS) describe the same pattern of symptoms and result from the same cause. 24 As previously stated, vicarious and secondary trauma are caused by the indirect exposure to or knowledge of another’s traumatic experiences (Siegfried, 2008; Bride, 2007; Figley, 1995). In light of these circumstances, it is clear that individuals in the helping professions are exceptionally vulnerable to experiencing STS and vicarious trauma. In general, the nature of the work and the use of empathy as a tool in working with clients is a significant risk factor for developing secondary traumatic stress. According to researchers, empathy appears to be a major conduit for the transmission of trauma from a primary to a secondary source. As a result, professionals who convey and experience empathy open themselves up to a client’s distress and trauma and thus are at greater risk of experiencing trauma on a secondary basis (Figley, 1995). In addition, several other factors have been identified which appear to contribute to higher rates of secondary traumatic stress. Specifically, an individual’s prior history of trauma or abuse can lead to increased vulnerability to secondary traumatic stress. According to researchers, an individual can potentially over identify with a client and incorporate a client’s emotions such as pain, sadness, fear, and distress into their own experience (Skovholt, 2001). Similarly, an individual’s unresolved trauma or emotional issues can be triggered by a client’s disclosure of trauma leading to an increased risk for secondary stress symptoms. Finally, exposure to a child’s pain or trauma is frequently described as more difficult for professionals to process than exposure to adult trauma. According to research, police officers, firefighters, medical staff, and other crisis workers indicate that they are most susceptible to secondary stress when working with children (Figley, 1995). 25 Furthermore, other factors may also contribute to the risk of secondary traumatic stress including the number of trauma related cases on an individual’s caseload, the number of years experience in the field, quality of supervision and work environment, training opportunities, and an individual’s tendency to engage in self-care techniques (Siegfried, 2008; Bride, 2007; Saakvitne & Pearlman, 1996; Figley, 1995; Schauben & Franzier, 1995). According to Schauben and Frazier’s research (1995), psychologists and counselors with a higher number of trauma victims on their caseload experienced significantly higher rates of PTSD symptoms, emotional distress, and secondary trauma. Similarly, Bride’s (2007) research showed that 15% of social workers exhibited full diagnositic criteria for PTSD in comparison with only 7.8% of the U.S. population at large. With regards to experience in the field, Pearlman & Mac Ian (1995) found that therapists who were new to the field and had less than two years experience displayed more symptoms of secondary stress than clinicians who were more experienced. Other factors that contribute to a heightened risk of secondary traumatic stress include inadequate supervision, negative working environments, professional and social isolation, lack of knowledge or training regarding the effects of vicarious trauma, and failure to take adequate time off and engage in self-care activities (Bride, 2007; Figley, 1995; Chrestman, 1995). According to research, secondary traumatic stress can be caused by exposure to a single client’s traumatic experience or a cumulative process of working with multiple trauma survivors over an extended period of time (Siegfried, 2008; Saakvitne & Pearlman, 1996; Figley, 1995). In this manner, both those who are new to the field and 26 those who are more experienced are vulnerable to potentially developing secondary traumatic stress. According to Bride (2007) social workers frequently work with clientele who have experienced a high degree of trauma. As a result, social workers are indirectly exposed to trauma on a regular basis, and thus, are at an increased risk for developing secondary traumatic stress. In his research, Bride investigated the prevalence of secondary traumatic stress among a group of 282 social workers in the Southern United States. In particular, he studied the rate and degree of secondary traumatic stress symptoms as well as the rates of Post-Traumatic Stress Disorder. According to his findings, 70% of social workers experienced at least one symptom of secondary traumatic stress during the week prior to the study, while 55% of social workers met the criteria for a complete group of symptoms. In addition, Bride found that that 15% of social workers met the full criteria for a diagnosis Post Traumatic Stress Disorder, twice the national average of PTSD in the general population. Due to these findings, Bride describes secondary traumatic stress as a significant occupational hazard for social workers who work directly with clients exposed to trauma. In light of this data, it appears that social workers in the field of child welfare are potentially at an elevated risk for developing secondary traumatic stress and vicarious trauma when compared to the general population. Due to the nature of the work, social workers often experience chronic exposure to trauma and a high number of trauma related clients on their caseloads. In addition, social workers in child welfare engage primarily with children and thus are exposed to children’s pain and trauma on a regular 27 basis. According to researchers, specific events may potentially lead to secondary trauma for social workers in child welfare. These events include: the death of a child on one’s caseload; investigation of horrific child abuse allegations; ongoing exposure to a child’s description of trauma and abuse; visual exposure to a child’s physical injuries or emotional pain; and ongoing interactions with families who have experienced severe abuse, neglect, and domestic violence (Siegfied, 2008). Additional stressors such as excessively large caseloads, contentious client interactions, limited resources, and difficult working environments only further complicate the experience of social workers in the child welfare system and increase their vulnerability for distress and emotional difficulties (Siegfried, 2008). Symptoms of Vicarious Trauma and Secondary Traumatic Stress Researchers in the field of trauma generally agree that symptoms of secondary traumatic stress (STS) parallel symptoms of post-traumatic stress disorder (PTSD) and mimic the experiences of individuals who are directly exposed to trauma (Siegfried, 2008; Figley, 1999; McCann & Pearlman, 1989). In essence, the symptoms that comprise STS are the same symptoms that characterize PTSD (Bride, 2007). The sole differentiating feature between STS and PTSD is whether an individual experiences trauma directly or indirectly. In general, symptoms of secondary traumatic stress fall within three main categories: intrusion, avoidance, and arousal. Symptoms of intrusion include reexperiencing trauma via nightmares, flashbacks, or distressing imagery. In contrast, symptoms of avoidance refer to persistent efforts to avoid people, places, or activities that 28 remind an individual of a traumatic event. At the same time, avoidance can also involve avoiding thoughts, feelings, or relationships associated with trauma. Finally, arousal includes symptoms such as increased anxiety, hyper vigilance, issues with concentration and focus, physical aggression, irritability, and emotional instability (APA, 2000). In addition to these three major categories, research indicates that symptoms of secondary traumatic stress can also include exhaustion, physical illness, social isolation, alienation, diminished efficiency, a sense of hopelessness, sadness, and despair (Siegfried, 2008; Figley, 1995). Furthermore, individuals may experience feelings of incompetence, emotional numbness, and a loss of faith in prior beliefs and expectations. Secondary trauma may also increase a sense of personal risk, lack of safety, cynicism, and mistrust of others (Schauben & Frazier, 1995; Herman, 1992). Effects of Vicarious and Secondary Trauma Currently, literature in the field clearly recognizes vicarious and secondary trauma as a significant challenge for those who work in the helping professions. In light of this literature, it is apparent that trauma affects not only those who directly witness a traumatic event, but also those who have contact with trauma survivors, including social workers, therapists, attorneys, nurses, doctors, and rescue workers (Bride, 2007; Bride, Robinson, Yedidis, Figley, 2004). Due to the nature of the work, secondary trauma is an inherent yet troublesome aspect of these professions. Furthermore, if not properly addressed, secondary trauma can have negative implications on an individual’s personal as well as professional lives. 29 Effects of Vicarious Trauma on Job Performance According to research, vicarious and secondary trauma often leads to problematic job performance and ineffectiveness. In particular, secondary trauma interferes with an individual’s capacity for empathy and thus impacts a clinician’s ability to clearly identify and address a client’s issues. In addition, symptoms of secondary trauma such as intrusive imagery, avoidance, and arousal lead to inappropriate interactions or ineffective relationships with clients. For example, a clinician who is engaging in avoidance may react to trauma by disassociating from the client. Such a response can harm the therapeutic relationship as well as the client’s confidence in the clinician who appears disinterested or unaffected. Secondary trauma can also impact a professional’s capacity to maintain appropriate boundaries, make thorough assessments, set parameters, and make decisions regarding treatment or course of care. Finally, secondary trauma limits a professional’s ability to engage in self analysis and reflection and thus interferes with an individual’s capacity to distinguish between the needs and feelings of the client versus him or herself. As a result, clinicians may over identify or begin to resent clients based on their particular needs and experiences (Saakvitne & Pearlman, 1996; Figley, 1995). Effects of Vicarious Trauma on Job Turnover In addition to an individual’s job performance, secondary trauma has also been linked to increased rates of absenteeism, employee turnover, and burnout. According to research, symptoms of vicarious trauma can lead to higher rates of physical and mental health conditions which are often associated with increased absenteeism among employees (Siegfried, 2008; Saakvitne & Pearlman, 1996). 30 Furthermore, vicarious trauma has been associated with higher rates of job burnout which is defined as a “state of emotional, mental, and physical exhaustion” caused by chronic and unrelenting stress in the workplace (Smith, Jaffe-Gill, Segal & Segal, 2010). Studies suggest that burnout is characterized by both physical and psychological symptoms, including: intense fatigue, insomnia, depression, anxiety, despair, disenchantment, physical ailments, poor job performance, and a cynical view of life and others (Salston & Figley, 2003). Thus, the parallel effects of vicarious trauma and burnout often work in conjunction to increase rates of absenteeism, job dissatisfaction, and job turnover. In fact, vicarious trauma is highly correlated with high job turnover. According to research, symptoms of vicarious trauma are frequently identified as one of the major causes for social workers leaving the field precipitately. (Figley, 1999). Effects of Vicarious Trauma on Mental Health Although vicarious trauma is primarily associated with challenges in the workplace, symptoms of secondary trauma also have implications on an individual’s personal life and functioning. According to research, knowledge of horrific trauma can lead to significant mental health issues. In particular, vicarious trauma can lead individuals to question prior belief systems, personal values, and attitudes about spirituality as well as the meaning of life. In addition, vicarious trauma can cause individuals to question their sense of identity and self-worth. Finally, according to recent research, it appears that vicarious trauma and Post Traumatic Stress Disorder are strongly correlated with increased rates of depression and anxiety disorders (Jankowsi, 2007). 31 Due to these circumstances, vicarious trauma can disrupt and interfere with interpersonal relationships causing marital conflict and problematic relationships between parents and children. According to research, secondary trauma has also been linked to increased rates of alcohol and substance abuse as well as other addictive behaviors such as gambling further complicating mental health and interpersonal relationships. (Saakvitne & Pearlman, 1996; Figley, 1995). Effects of Vicarious Trauma on Social Connectedness and Isolation In many cases, individuals who experience vicarious trauma withdraw from family, friends, and daily activities. In response to symptoms of the condition (avoidance, intrusion, and/or hyperarousal) individuals may experience emotional numbing, irritability, volatility, anger, and a desire to retreat from others. As a result, the ability to form and maintain close personal relationships is negatively affected. Furthermore, prior social networks and connections are typically lost, and the individual is frequently left isolated and separated from others (Saakvitne & Pearlman, 1996; Figley, 1995). Effects of Vicarious Trauma on Physical Health In addition to mental health implications, research has shown that vicarious trauma can have serious effects on an individual’s physical wellbeing. According to a growing body of research, a correlation exists between exposure to traumatic events and poor health. In particular, research indicates a link between symptoms of Post Traumatic Stress Disorder (PTSD) and various circulatory, gastrointestinal, and musculoskeletal disorders. Furthermore, studies have linked PTSD to higher rates of cardiovascular deaths including increased rates of irregular electrocardiogram results, hypertension, and heart 32 attacks. Research also indicates that symptoms of PTSD may be associated with irregular thyroid and hormone regulation as well as higher rates of infection and immune system disorders (Jankowsi, 2007). At present, the specific relationship between PTSD symptoms and poor health is unknown. However, researchers in the field believe that it involves a complicated interplay between an individual’s psychological, behavioral, and biological functioning. In particular, researchers believe that trauma may cause neurochemical transformations in the brain which may lead to psychological, behavioral, and biological changes which subsequently impact physical health and wellbeing. Currently, research into the specific factors and interplay between these components and systems is ongoing (Jankowsi, 2007). Perception and Recognition of Vicarious Trauma in the Field of Child Welfare Although the literature now recognizes vicarious and secondary trauma as important topics of research, most studies focus on the experiences of medical staff, rescue workers, crisis counselors, and mental health care providers (Bride, 2007; Perron & Hiltz, 2006). As a result, the experience of social workers has been largely ignored. At the same time, social workers appear largely unaware of the concept of secondary trauma. According to Bride (2007) although rates of vicarious trauma among social workers are noteworthy, knowledge of the condition is negligible. Furthermore, due to the lack of awareness, social workers often do not employ effective interventions or techniques to address symptoms of secondary trauma which leads to high numbers of social workers leaving the field each year (Bride, 2007). 33 Vicarious Trauma Interventions Exposure to traumatic matter can affect social work professionals across best practice modalities. When social work professionals witness or hear about traumatic events increases the susceptibility of experiencing vicarious and secondary trauma. Innovative prevention techniques of vicarious and secondary trauma are just as essential as intervention techniques because they both require thorough and considered efforts. Not all child welfare professionals who work with traumatized clients will develop vicarious and secondary traumatization. However, these professionals are at risk. Debriefing Model A debriefing or psychological debriefing is a one-time, structured exchange with an individual or group of individuals who have experienced a stressful or traumatic event. The purpose of debriefing is to reduce the possibility of psychological harm. Debriefing is thought to help participants maintain or regain control over themselves. The Debriefing Model as described by Volanti, Paton & Dunning (2000) is now applied worldwide and according to the general model, debriefing is preferably performed within 24 to 72 hours of the traumatic event. By reconstructing the traumatic event, professionals can create a more realistic perception of it. Debriefing sessions last an average of two hours and may be shorter for individual debriefings and longer for group sessions. A debriefing session normally comprises seven phases (Volanti, et al., 2000), which may also be applied in combination with each other: 34 1. Introduction- explanation of the main “rules of play;” 2. Facts- reconstruction of the factual elements of the event; 3. Thoughts- thoughts that occurred during the event; 4. Experiencing- emotions that occurred; 5. Symptoms- physical and psychological stress reactions; 6. Education- explanation of the stress reactions (normalization) and the useful coping strategies; 7. Closing- answers to any remaining questions and information on opportunities for further care. In practice, debriefing models differ slightly in their format such as timing, intensity and duration, practitioners or number of participants. Debriefing is not the same as treatment. In the event that a debriefing intervention does not occur until a later point in time, professionals may need to be referred to some kind of further counseling (Volanti, et al., 2000). When traumatic events are reconstructed, these create a realistic perception and the information provided to the professional about useful coping strategies, and about opportunities for follow-up care if vicarious and secondary traumatic symptoms occur. Debriefing is thought to help professionals maintain or regain control over themselves (Volanti, et al., 2000). Critical Incident Stress Debriefing (CISD) The creators of CISD, including Jeffrey Mitchell and George Everly (Volanti, et al, 2000), have done an invaluable job in designing a program that helps both victims and professionals in dealing with massive traumas. Mitchell and Everly developed a program 35 based on their own experiences in understanding emergency situations where the writing approach is used as a base where there are two groups, an experimental and a control group. Writing groups are asked to write about assigned topics, thoughts and feelings about a topic that has affected the professional’s life, for 3-5 consecutive days, 15-30 minutes each day. The paradigm demonstrates that when professionals are given the opportunity to disclose aspects of their lives, they readily do so, even though a large number of them report being upset by the experience, the overwhelming majority reports that the writing experience was valuable and meaningful in their lives (Volanti, et al., 2000). Writing about emotional experiences clearly influences measures of physical and mental health where talking and writing about emotional experiences are both superior to writing about superficial topics (Volanti, et al., 2000). The topic of disclosure and value of writing do not distinguish shorter writing from longer writing sessions, however, studies have found that males may benefit more from writing than females because females tend to naturally disclose problems more than the more inhibited males (Volanti, et al., 2000). Another study showed that preselected participants on hostility found that those high in hostility benefitted more from writing than those low in hostility. Overall, there are consistent and significant health improvements found in those professionals who use writing as a form to discuss vicarious or secondary trauma. The implications for CISD propose a number of strategies to consider since individual results differ. The importance of exploring why talking works as discussed by Volanti, et al. (2000) promoted professionals to talk about and acknowledge emotional 36 causes and responses to significant experiences. CISD suggests that the best time to intervene with within the first 48 hours of the incident and that some form of debriefing may be maximally beneficial at a minimum of three weeks post-trauma since the first two weeks, many of the natural debriefing processes occur within social networks. Realms of Intervention There are three realms of intervention in which to address vicarious traumatization as described by Saakvitne and Pearlman (1996) which are professional, personal, organizational, and general coping strategies. Within each realm there are a number of different strategies and interventions that include peer supervising, education, spirituality, agency responsibility, caseload management and personal coping mechanisms (Trippany, Kress & Wilcoxon, 2004). Awareness, balance and connection serve child welfare professionals in the professional realm. If responses to vicarious and secondary trauma are accepted as normal responses, the professional makes it easier on themselves to address the traumatization constructively. Balancing priorities within the professional’s caseload with varying time to have contact with colleagues and time for oneself reinforces the notion of self-care. Self-care at work is overlooked therefore, child welfare professionals need a place to talk about their thoughts and a feeling, including their vicarious traumatization response, hence, the need for supervision is monumental. Some professionals experience a significant change in life priorities, an increased appreciation for life and an increased importance and positive growth in their spiritual or religious lives (Volanti, et al, 2000). 37 Organized support or supervision groups can be created with as few as two or three members or individual or group vicarious traumatization consultations (Saakvitne & Pearlman, 1996). These groups can be a place for these professionals to identify the specific effects of their work on themselves, in the context of each one’s particular frame of reference, emotional style and relevant need areas. Overall, these groups provide an invaluable forum for validation, reality testing, problem-solving, and clinical supervision (Saatvinkne & Pearlman, 1996). A child welfare professional must consider oneself as the priority or both one’s life and work will suffer. The demands of the job are to give, give, and give, creating work the center of one’s life. Not taking time for oneself provides a poor model to clients and deprives the professional of their complexity and humanity (Saatvinkne & Pearlman, 1996). It is important to make time for leisure activities, take care of one’s health- both physical and mental, and nurture all aspects of oneself, including the spiritual, physical, emotional, relational, psychological, and creative activities. The uses of these realms as intervention have strengths and resources that when applied to child welfare professionals, as a means of preventing vicarious trauma, will facilitate wellness. Sommer (2008) stated that as professionals in the field of child welfare, management should be concerned about warning professionals of the potential harm of being exposed to trauma, but that professionals should also be trained on how to cope with that exposure to avoid leave and turnover. 38 Pathogenic Intervention and Salutogenic Approach Pathogenic intervention methods are thought to “script” a professional into traumatic or secondary stress symptoms by implementing rigid techniques and strong group participation (Violanti, 2000). It is implied to the professional that by being affected by the trauma, they need an intervention. An agency may look at the pathogenic model as a “quick fix”, an assumption where an immediate remedy is given, where the professional is not looked at as an active agent in the process of healing and while the incident may develop symptomology in the professional, intervention techniques are required to ameliorate the symptoms. A professional’s perception about the traumatic or secondary stress symptoms, as discussed in group, may be created by the reliance on assumptions, coupled with strong group cohesion (Volanti, 2000). Dunning (1999) refers to this as “affective overload,” where cognitions involving imagery, sensory-motor memory, and interpretive sense of meaning held by the professional who experienced the event may confabulate and bring such material into their trauma set, which is thought of as pathogenesis. Pathogenesis assumes that the professional is ill based on the trauma that they experienced and should follow a “script” in order to feel better. Some agencies have experienced workers leaving or retiring due to their “illness” while other agencies have initiated an employee assistance program. While some of these programs are worthwhile, they sometimes serve as facades for agencies to demonstrate that they are “doing something” about the trauma (Volanti, 2000). For example, the Solano County and 39 Sacramento County Employee Assistance Programs (EAP) allows child welfare professional six therapeutic sessions. Pathogenic outcomes are not necessarily a result of exposure to traumatic events because these may be a positive growth experience. If a professional is seen as an agent of change, their “script” can be a positive, rather than a negative, leading to salutogenic amelioration or salutogenesis (Volanti, 2000). Salutogenesis refers to the professional’s ability to not only survive traumatic events but also to achieve greater personal strength, understanding the purpose from that event by the trauma as promoting growth in the direction of positive change (Antonovsky, 1987). Tedeschi and Calhoun (1996) organized growth from trauma into three broad categories of self-perception, improved personal relationships, and a positive philosophical life. These approaches oppose pathogenesis, which assumes individual helplessness and ignores the capacity for self-exploration and personal growth (Yalom & Lieberman, 1991). Volanti (2000) recommends that the salutogenic approach be perceived by the facilitator role that occurs informally as the professional participates in trauma or secondary stress recovery. Ultimately, recovery is impacted by an individual’s coping abilities. If the professional has a positive coping abilities, this success rate increases, while negative coping abilities may impede or delay recovery. Innovative Ways and Ideas in Helping Professionals Approaches to helping professionals recover from their experiences of traumatic events are an evolving theme. Peer debriefing, increasing vacation time and reducing caseloads are interim techniques. To sustain commitment to addressing vicarious or 40 secondary trauma on an ongoing basis, support is needed (Saakvitne & Pearlman, 1996). There is not significant information found relating to specific new approaches of innovative ways of helping professionals. Volanti (2000) discussed the notion of peer counselors, stating these individuals may not have yet achieved sufficient respect by their peers and can result in group sabotage and recommends that debriefing be a mental health professional. In the contrary, an outside professional who serves as a facilitator may be challenged in ensuring support and safety, hence, the therapeutic alliance between the facilitator and group members does not occur. Agencies can help child welfare professionals by incorporating three central aspects of addressing vicarious and secondary trauma, awareness, balance and connection which has been coined by a colleague, the ABC’s of vicarious trauma. Awareness requires a time for quiet and reflection, where the individual is in tune with their own inner state and disequilibrium sets the stage for responsiveness and self-care. The child welfare professional should have a balance among life activities and within themselves in order to be able to access inner resources and capacities for reflection (Saakvitne & Pearlman, 1996). Summary Over the last three decades, awareness of vicarious trauma and secondary traumatic stress has increased as research has begun to explore the effects of direct as well as indirect trauma exposure. In particular, vicarious or secondary trauma involves changes in an individual’s inner experience, emotions, and behaviors due to knowledge 41 of a traumatic event experienced by another. According to research, vicarious trauma leads to a specific pattern of symptoms that are comparable to post traumatic stress disorder. Furthermore, studies indicate that certain characteristics contribute to the increased likelihood of vicarious and secondary trauma. In particular, social workers in the field of child welfare are exceptionally vulnerable to experiencing secondary stress due to frequent and ongoing exposure to the trauma of children. However, social work professionals in the field are largely unaware of the condition. As a result, secondary trauma often has negative implications on job performance and personal functioning. Finally, specific interventions are effective in dealing with vicarious trauma; however, few social workers in the field of child welfare are aware of these techniques which leads to significant job turnover and social workers leaving the field altogether. Conclusion At present, there is clearly a lack of information and gap in the research regarding the experiences of social workers in child welfare with regards to vicarious and secondary trauma. In particular, the prevalence and nature of vicarious trauma is largely unknown in this field. Although social workers in child welfare are repeatedly exposed to trauma on an ongoing basis, research has failed to explore the nature and effects of such trauma in the child welfare environment. In response, this study is designed to facilitate increased knowledge about the prevalence of secondary traumatic stress among social workers in the child welfare field. 42 Chapter 3 METHODS Introduction This study examined the perceptions of social work professionals regarding the prevalence of vicarious trauma among social workers in Child Welfare Services agencies. This chapter presents the research design, subjects, instrumentation, data gathering procedures, and protection of human subjects. Research Design This research design combined a qualitative and quantitative exploratory format designed to elicit information about a relatively sparsely studied topic. In this case, an exploratory design was chosen as there is currently little research regarding the prevalence of vicarious trauma among social workers in the child welfare field. In fact, few studies have looked at the experiences of social workers in any specialty. Rather, most research has focused on the experiences of firefighters, law enforcement, and medical personnel. As a result, this study employs an exploratory research design intended to gather further information about this topic. Subsequently, the qualitative and quantitative data gathered can provide a basis for further research regarding the need for potential intervention techniques to address vicarious trauma among social workers in child welfare. Subjects The subjects involved in the study included 30 social work professionals who completed an online questionnaire regarding their perceptions of the prevalence of 43 vicarious trauma among social workers in Child Welfare Service agencies. In this case, researchers recruited subjects by contacting social work colleagues in the child welfare field in Sacramento and Solano Counties. Specifically, e-mails were sent to the personal e-mail accounts of social work colleagues requesting their voluntary participation and referring them to an online website and questionnaire. Instrumentation The instrument used in this study is an online questionnaire (see Appendix B). The questionnaire was developed by the researchers after reviewing the current literature on vicarious trauma, and it addresses social worker perceptions regarding the prevalence of vicarious trauma, specific symptoms, and potential recommendations to address vicarious trauma among colleagues. The questionnaire includes basic demographic information regarding the participant’s age, gender, marital status, level of education, and years of experience in the social work field. In addition, it contains quantitative questions with numeric data as well open ended questions of a qualitative nature which allow for additional information and feedback regarding various topics. The questionnaire takes approximately 15 to 20 minutes to complete. It has not been tested for validity or reliability. Data Gathering Procedures In this case, subjects were recruited to participate in an online questionnaire via email requests by the researchers to their personal e-mail accounts. These e-mail requests referred potential participants to a website which linked them to the online questionnaire. Prior to beginning the questionnaire, the website displayed an informed consent 44 document which included all of the elements of a regular signed consent, including the confidentiality disclaimer: “By completing this survey, you are agreeing to participate in the research.” In addition, subjects were informed that participating in the study is strictly voluntary and that they have the right to withdraw their participation at any time prior to submitting the survey, after which point researchers would be unable to identify or remove their responses due to the anonymous nature of the questionnaire. Participants were also provided with information regarding the intent of the study, confidentiality, and the measures taken to protect their identities. In particular, subjects were informed of the value of their participation as data from the study will be made available to their peers and other professionals to access and utilize. Finally, the website included “I agree” and “I do not agree” buttons for subjects to click their choice of whether or not they wished to continue and participate in the research (see Appendix A). Protection of Human Subjects Prior to initiating the study, researchers obtained approval from the Human Subject Review Committee at California State University Sacramento which deemed the research “minimal risk.” Subsequently, prior to completing the online questionnaire, participants were asked to read and consider an Informed Consent form (see Appendix A) which authorizes participation in the research. In addition, the informed consent provided specific details regarding confidentiality. In particular, participants were informed that responses provided on the questionnaire would be kept confidential and all data obtained during the course of the study would be kept in a locked location, except when being used by researchers for the purpose of this study. Furthermore, participants were 45 informed that data collected from the survey would be transmitted in an encrypted format in order to ensure that any data intercepted during electronic transmission would not be decoded and that individual responses would not be traced back to an individual respondent. In this study, the highest level of encryption was used within limits of availability and feasibility. Moreover, participants were informed that at the end of the study all data and records would be immediately and appropriately disposed of by June 2011. In the informed consent form researchers also provided participants with their email addresses as a means to contact researchers if they had any questions or concerns regarding the research process. Researchers also provided the participants with the telephone numbers for the Employee Assistance Programs for Sacramento County and Solano County if they required assistance processing issues or concerns related to their participation in the study. Finally, no identifying information pertaining to any of the participants was included in this research. Conclusion The collection of data via an online questionnaire proved to be an effective tool to gather information about the perceived prevalence of vicarious trauma among social workers in the field of child welfare. This data provides a basis for further research as well as the development of potential intervention techniques and strategies designed to improve worker’s performance and longevity in the field. 46 Chapter 4 FINDINGS AND INTERPRETATIONS Introduction This study consisted of Child Welfare Services (CWS) social workers from Sacramento and Solano Counties. The sample for this project consisted of 35 participants who took part in an online survey with 33 females and two males. The majority of the participants have a minimum of six years of experience in the social work field (see table 1), indicating that the sample of this study included mainly social workers who were knowledgeable about services and modes of intervention through practical application of theoretical principles and regulations required in the field. The majority of the participants have a higher education equivalent to either a Bachelor’s or Master’s degree (see table 2). The data analysis presented several themes as to professional social workers and the presence of vicarious trauma among their peers. These themes include the perceived stress of workers as being high, the importance of developing support systems and training and education being vital in addressing vicarious trauma among child welfare workers. 47 Table 1 Distribution of Participants’ Years of Experience Years of experience in Frequency Percent Valid Percent the social work field? Valid Cumulative Percent Less 1 year 1 2.9 2.9 2.9 1-5 11 31.4 31.4 34.3 6-10 14 40.0 40.0 74.3 11-15 9 25.7 25.7 100.0 Total 35 100.0 100.0 Percent Valid Percent Table 2 Participants’ Level of Education Education Frequency Cumulative Percent Valid Some College 2 5.7 5.7 5.7 LCSW/Other 1 2.9 2.9 8.6 Bachelor’s 17 48.6 48.6 57.1 Master’s 15 42.9 42.9 100.0 Total 35 100.0 100.0 Certification 48 Perceived Stress The level of stress among child welfare workers is perceived by peers to be very high, regardless of the workers relationship status or age. The notion that workers who are married are happier and/or less stressed was supported demystify as the data analysis indicated that regardless of a worker’s relationship status, the perceived stress among child welfare workers was evident as perceived by their peers (see table 3) and the measure of association (Gamma) showed no relationship. Perceived stress was also high amongst workers regardless of the worker’s age. Table 3 Level of Stress Cross Tabulated with Marital Status Marital Status In your perception, what is the Single Married Divorced Partner Total Count 1 2 0 0 3 % within Marital Status 9.1% 10.5% .0% .0% 8.6% 1 0 0 0 1 % within Marital Status 9.1% .0% .0% .0% 2.9% Count 3 0 0 3 % within Marital Status .0% 15.8% .0% .0% 8.6% Count 14 3 2 28 73.7% 100.0% 100.0% 80.0% level of stress among Child Welfare Workers Low Medium High Count 0 9 % within Marital Status 81.8% 49 Both young and old workers perceive high stress irrespective of their years (see table 4) and 77.1% of the participants reported that they had been approached by other colleagues seeking help to manage their stress level as a result of the trauma that they encountered in the field. Due to proximity, an understanding of the nature of the job and the organization, colleagues are the easiest source to debrief or brainstorm. Table 4 Level of Stress Cross Tabulated with Age What is your age? In your perception, what is the 18-27 28-37 38-47 48-57 58-67 Total Count 1 0 0 0 0 1 % within Marital Status 11.1 0% 0% 0% 0% 3.1% Count 0 2 0 1 0 3 % within Marital Status .0% 16.7% .0% 25.0% .0% 9.4% Count 8 10 3 28 88.9% 83.3% 100.0% 75.0% 100.0% 87.5% 9 12 5 4 2 32 100% 100% 100% 100% 100% 100% level of stress among Child Welfare Workers Low Medium High % within Marital Status Total Count % within Marital Status 5 2 50 Experiencing vicarious trauma not only results in worker stress (see table 5), but also substantially vast incidents of symptoms reported by colleagues that include digestion issues by 15 of the 35 participants, fatigue by 25, forgetfulness by 13, headaches by 22, twenty-three 23 of the participants reported irritability and/or aggression, 27 of the participants marked lack of motivation and/or a decrease in work performance, nightmares and/or insomnia by thirteen 13, panic attacks and/or anxiety by 18 and two participants noted hopelessness and thoughts of clients after work hours and on weekends. Table 5 Distribution of Perceived Symptoms of Vicarious Trauma Symptom Frequency Percentage Digestion Issues 15 42.9% Fatigue 25 71.4% Forgetfulness 13 37.1% Headaches 22 62.9% Irritability/Aggression 23 65.7% Lack of motivation/work performance 27 77.1% Nightmare/Insomnia 13 37.1% Panic attacks/anxiety 18 51.4% Other: Hopelessness & thoughts of clients after work 2 5.7% hours and on weekends Developing Support Systems Developing support systems as a way to cope with the experiences resulting in vicarious trauma is methodically identified in the literature. Peer support groups can often clarify colleagues' insights, listen for and correct cognitive distortions, offer perspective 51 and/or reframing, and relate to the emotional state of the social worker (Catherall, 1995). Peer support groups can take a variety of forms, such as consultation, treatment teams, case conferences, or clinical seminars, and can be either peer led or professionally led (Arte Sana, 2003). Participants indicated there is a strong perception in the field that there is a lack of support. The table below (see table 6) identifies participants’ choice of responses on a scale of 1-5 with 1 being Strongly Agree, 2 being Agree, 3 being Neutral, 4 being Disagree and 5 being Strongly Disagree. On a scale of 1-5, participants identified that they did not agree with there being sufficient support in the work place for social work professionals who work in the child welfare field at a mean of 3.94. Participants identified that support groups could be beneficial to social work professionals in managing vicarious trauma at a mean of 1.61; peer debriefing could be beneficial to social work professionals in managing vicarious trauma at a mean of 1.39; supervisory debriefing could be beneficial to social work professionals in managing vicarious trauma at a mean of 1.29; developing workshops of professionals to examine vicarious trauma, its impact, and interventions would be beneficial to social work professionals at a mean of 1.32; and due to the nature of child welfare intervention services, it is possible for social work professionals to be personally affected by the incidents that they witness in their practice at a mean of 1.31. 52 Table 6 Mean Scores for the Perception of Stress among Fellow Professionals N Min. Max Mean Std. Deviation Support group(s) could be beneficial to social work professionals in managing vicarious trauma. 31 1 4 1.61 .882 Peer debriefing could be beneficial to social work professionals in managing vicarious trauma. Supervisory debriefing could be beneficial to social work professionals in managing vicarious trauma. Developing workshops of professionals to examine vicarious trauma, its impact, and interventions would be beneficial to social work professionals. 31 1 3 1.39 .558 31 1 2 1.29 .461 31 1 3 1.32 .541 Due to the nature of child welfare intervention services, it is possible for social work professionals to be personally affected by the incidents that they witness in their practice. In my view, there are sufficient counseling services outside of the work place for social work professionals. In my view, there is sufficient support in the work place for social work professionals who work in the child welfare field. In my view, social work professionals may be impacted by their client’s experiences in the field. In my view, social work professionals may be affected by the things they hear or see at work. Valid N (participants) 32 1 3 1.31 .535 32 1 5 3.13 1.408 32 1 5 3.94 .948 32 1 3 1.56 .564 32 1 2 1.28 .457 31 53 An essential component in the prevention and healing of vicarious trauma is effective supervision and participant’s responses correspond to information presented in the literature. Responsible supervision creates a relationship in which the social worker feels safe in expressing fears, concerns, and inadequacies (Welfel, 1998). Organizations with a weekly group supervision format establish a venue in which traumatic material and the subsequent personal effect may be processed and normalized as part of the work of the organization (Arte Sana, 2003). In addition to providing emotional support, supervisors can also teach staff about vicarious trauma in a way that is supportive, respectful, and sensitive to its effects (Pearlman & Saakvitne, 1995). Education and Training Ongoing education about trauma theory and the effects of vicarious trauma, including the symptoms, can be incorporated in staff training and meetings, formal trainings as well as individual supervision. This information provides a useful context and helps social workers to feel more competent and have more realistic expectations about what they can accomplish in their professional role. As identified earlier in this chapter, the majority of participants had a minimum of six years of experience and only four had had 1-3 trainings on vicarious trauma while seven had never experienced training. Eight workers with experience of 1-5 years have had 1-3 trainings respectively and only one worker with these years of experience reported attending 4-6 trainings on vicarious trauma and three workers who have 11-15 years of experience had 1-3 trainings on vicarious trauma (see table 7). It appears that the more years of experience, the less number of trainings a worker has had and it is supported by a medium level of association 54 Phi at .506 between the variables. However, the association was not statistically significant. Table 7 Trainings Cross Tabulated by Years of Experience Years of experience in social work field? How often have you attended Less 1-5 6-10 11-15 Total trainings on Vicarious Trauma or 1 yr 0 .0% 8 72.7% 4 36.4% 3 33.3% 15 46.9% 0 .0% 1 9.1% 0 .0% 0 .0% 1 3.1% 1 100.0% 2 18.2% 7 63.6% 6 66.7% 16 50.0% 1 11 100.0% 11 100.0% 9 100.0% 32 100.0% related topics? 1-3 4-6 Never Total Count % within Years of experience in the social work field? Count % within Years of experience in the social work field? Count % within Years of experience in the social work field? Count % within Years of experience in the social work field? Qualitative Findings In addition to quantitative data, this project also elicited qualitative data via four open ended questions regarding respondent’s views of vicarious trauma in the field of child welfare. When asked about the topic in general, the vast majority of respondents 55 described vicarious trauma as a significant and problematic issue in the field. In particular, thirty-four of thirty-five respondents reported a high incidence of vicarious trauma among social work colleagues and discussed the negative impact of vicarious trauma on job performance, physical health, and mental wellbeing. For example, one respondent stated, “Vicarious trauma affects social workers in child welfare at an astounding rate. Many times, these workers do not speak of the trauma they have experienced or the feelings they may have.” Another respondent stated, “Vicarious trauma is experienced greatly by child welfare workers due to the ongoing exposure to trauma and listening day in and out to the suffering of the children and families.” A third respondent stated, “I believe that vicarious trauma is often unrecognized in the field of child welfare, but has a significant impact on social workers health and well being as well as their effectiveness in working with clients.” Finally, another respondent indicated that vicarious trauma “diminishes the quality and quantity of work that social worker are able to process” and “affects the overall health of social workers and creates a negative work environment.” In light of the negative effects of vicarious trauma on social workers, several respondents discussed the lack of needed supports in the workplace for social workers who are at risk of vicarious trauma. For example, one respondent stated, “There are not enough proactive measures being taken to assist or help social workers effectively cope or deal with vicarious trauma.” A second respondent stated, “I believe that it exists and that it affects CPS social workers more than they admit. I also believe that management 56 does relatively little to address the existence of vicarious trauma.” Similarly, a third respondent stated, Usually, EAP is the only recourse for these workers unless they go through their own insurance carriers. In a field where best practice is constantly a reminder, best practice in the child welfare field does not include debriefing after a traumatic event and the one hour of supervision a person gets is not enough to discuss these things with a supervisor. Yet another theme discussed by respondents involved the unrecognized nature of vicarious trauma in child welfare. For example, one respondent stated, I believe it is a very significant issue that has not been given much attention to. It seems to be only recently that this issue is coming more to the attention of others. I believe that many social workers are unaware of what they are experiencing and if the information is brought to their attention and the affects of vicarious trauma are recognized it will help many social workers in their daily professional experiences. Several other respondents echoed this sentiment stating, “This type of trauma is real and it affects us even if we think it doesn't.” Another respondent described vicarious trauma as “very common but not talked about or addressed.” Finally, a fourth respondent stated, “I believe that social workers definitely are affected by vicarious trauma and that social workers often take this for granted and don't take time to deal with it.” When asked if differences in the nature of case loads affect social workers differently, a significant majority of respondents indicated “yes” and described various ways in which workers can be affected by these differences. For example, several respondents identified high caseloads as a possible risk factor for vicarious trauma. One respondent stated, “High case loads and working with clients with significant trauma can increase a workers likelihood of experiencing vicarious trauma.” In addition, another 57 respondent stated, “Having a lower more manageable caseload allows workers to respond better to situations and allows them to process the cases.” Several respondents also identified social workers’ individual traits, experiences, and capacities. For example, one respondent stated, Yes, each social worker has his/her own set of skills and life experiences which may or may not make them the best equipped social worker to handle particular cases. Some social workers are stronger in certain areas and some still have room to grow. Each social worker has a threshold capacity of what they can handle in terms of the complexity of a caseload. Also, social workers come from varied backgrounds which may or may not make them best equipped to work with certain clients on their caseload. Similarly, another respondent stated, “Absolutely! We have different upbringings, experiences, and ideas about certain situations- all of which affect the way that we are affected by and able to work with our caseload.” Finally, a third respondent stated, Yes, I believe that each social worker is coming with a unique set of experiences, cultures, values and beliefs that can affect how we are experiencing different circumstances. For one individual, a specific type of case load may unknowingly affect the person more based solely on their experiences while another person is not affected at all. Interestingly, three respondents indicated that they did not believe that the nature of the case load affects social workers differently or increases their risk for vicarious trauma. Rather, these respondents stated that vicarious trauma was simply a reality in the field of child welfare. In particular, one respondent stated, “Unfortunately, in this job, trauma is experienced in all caseloads because it is not just directly experienced but indirectly too.” In addition, another respondent stated, “I believe everyone can and will be affected by it regardless of case loads.” 58 Not surprisingly, when asked how the respondents developed their perspectives regarding vicarious trauma, the vast majority of participants indicated that they acquired their views primarily from their own personal experience. Several respondents also identified the experiences of colleagues and co-workers in the field of child welfare. Furthermore, a small number of respondents reported that they had learned about vicarious trauma from trainings, readings, and course work as a graduate or undergraduate student. Finally, when asked for general thoughts and recommendations, respondents overwhelmingly focused on the need for increased awareness of vicarious trauma in the work place. Many of the respondents lamented the lack of information and training in the field of child welfare. In particular, one respondent stated, “I believe more needs to be done to educate social workers of this notion as well as gain support from the department as a whole in its recognition that this is a problem.” Similarly, another respondent stated, “I think this is a topic that should be discussed more at the workplace through trainings, perhaps. I don't think some of the supervisors here really understand vicarious trauma and it's brushed off quickly, as if telling the social workers to suck it up.” Respondents also focused on the need for more effective interventions to address vicarious trauma among social workers in the field. For example, one respondent stated, “More workshops and information needs to be shared with child welfare social workers on vicarious trauma, the effects and coping mechanisms.” Another respondent stated, “Continued awareness is needed in order to develop appropriate therapeutic intervention and work place accountability and support by the employer.” 59 Several respondents also proposed specific interventions to address vicarious trauma in child welfare. For example, one participant indicated, “Routine staffing of cases and a general discussion of casework issues at unit meetings would help social workers a lot in dealing with issues of vicarious trauma.” In addition, another participant stated, “Support groups and debriefing should be available during work time.” A third respondent agreed stating, “There should be a mandatory vicarious trauma training at least twice a year or as resources permit. There should also be debriefing sessions available at least once a month for social workers to offload transference experienced from their cases/referrals.” Finally, a fourth participant encouraged child welfare organizations to adopt the approach that is afforded for law enforcement officers who are able to process situations with a psychologist. Summary The experiences that child welfare workers encounter are taxing and overwhelming and symptoms associated with vicarious trauma are very prevalent. The way a worker responds to vicarious trauma can vary and each worker copes with trauma differently. It is important to consider that workers will continue to use their colleagues as a means of support if other avenues within the organization are not available. Stress may be manageable, however, unavoidable due to the nature of the job. rauma-specific education diminishes the impact of vicarious trauma and can be manageable if the resources and education are in place to assist the professional in understanding their feelings. As reported by professional child welfare workers, vicarious trauma reduces the quality of work and the amount of time invested in quality in job performance. The views 60 and perceptions discussed in this chapter are indicative of the level of the presence of stress associated with vicarious traumatization and needs to be viewed in the context of the high turn over rate in child protective services. 61 Chapter 5 CONCLUSIONS AND RECOMMENDATIONS Conclusions This project examined the perceptions of social work professionals regarding the prevalence of vicarious trauma among social workers in the field of child welfare. Study findings indicate that vicarious trauma and secondary traumatic stress are highly prevalent in the field of child welfare. In fact, the vast majority of social workers in this study perceived a high degree of vicarious trauma among their peers in child welfare. Furthermore, despite preconceptions that age or marital status may reduce these levels, participants reported high rates of stress regardless of age or relationship status. According to a review of the literature, symptoms of vicarious trauma closely parallel symptoms of Post Traumatic Stress Disorder (PTSD) and mimic the condition (Siegfried, 2008; Figley, 1999; McCann & Pearlman, 1989). In particular, the American Psychiatric Association (2000) indicates that symptoms of PTSD fall within three main categories: intrusion, avoidance, and arousal. This study supported prior research which shows high rates of such symptoms among professionals indirectly exposed to trauma. The researchers noted that 43% of participants reported their colleagues experienced digestion issues, 71% reported fatigue, 37% reported forgetfulness, 63% reported headaches, and 66% reported irritability and aggression. Furthermore, 77% of social workers reported lack of motivation and/or decreased work performance among colleagues due to vicarious trauma, 37% reported nightmares and/or insomnia, and 51% reported panic attacks and/or anxiety. 62 In light of social workers’ perceptions of the high incidence of vicarious trauma and related symptoms, it is important to look at effective interventions and prevention techniques to address the issue in child welfare. According to the data, participants strongly agreed that due to the nature of work in the field of child welfare, it is possible for social workers to be personally affected by the incidents they witness. In addition, participants strongly agreed that support groups, peer debriefing, and supervisory debriefing would be beneficial to social workers in managing vicarious trauma. Participants also strongly agreed that developing workshops to educate professionals about vicarious trauma, its impact, and successful interventions would be helpful to address symptoms and effects of the condition. Findings indicate that social work professionals perceive little support by management or supervisors to implement interventions and prevention techniques to address vicarious trauma in the workplace. According to the results of this study, the majority of participants reported few trainings or workshops regarding vicarious trauma despite significant years of experience in the field. In addition, according to the qualitative responses, participants reported receiving little support from supervisors or managers to provide needed debriefings, education, or supports in the workplace. An interesting finding in the research involved the responses of participants to open ended questions of the questionnaire. In particular, the vast majority of respondents acknowledged the existence of vicarious trauma among social work colleagues and identified negative effects of vicarious trauma on social workers’ physical health, mental well being, and job performance. Participants also discussed the unrecognized nature of 63 vicarious trauma in the field of child welfare and the lack of awareness and knowledge by social workers regarding symptoms related to trauma exposure. Furthermore, participants largely concurred that differences in caseloads potentially affect social workers differently and can increase the risk for vicarious trauma. In particular, participants in the study identified large unmanageable caseloads, caseloads involving significant trauma, as well as social workers’ individual traits, experiences, and capacities as factors which affect the experience of vicarious trauma. Interestingly, an unexpected finding in the data involved responses from participants who did not believe that differences in caseloads affected the incidence of vicarious trauma. Rather, these respondents viewed vicarious trauma as simply a real and present danger for all social workers in the field of child welfare. Finally, participants in the study overwhelmingly focused on the need for increased awareness of vicarious trauma in the work place as well as effective interventions and prevention techniques to address the issue. Many of the respondents lamented the lack of information and training in the field of child welfare. Participants also proposed specific interventions to effectively respond to the needs of social workers when exposed to trauma. Recommendations As evidenced by the study findings and literature review, vicarious trauma is prevalent within the field of child welfare and needs to be addressed on various levels to effectively combat the issue. In particular, social workers in the field need to educate themselves regarding vicarious trauma, its symptoms, effects, preventative measures, and 64 effective interventions. In this manner, social workers can monitor themselves as well as their colleagues for signs of vicarious trauma, engage in prevention, and seek treatment when necessary. In addition to awareness, social workers need to engage in daily self care. Specifically, social workers need to address past histories of personal abuse or trauma which make them more vulnerable to developing vicarious trauma. Moreover, social workers need to seek out personal and professional supports in order to develop strong social support systems. Social workers also need to engage in healthy and balanced lifestyles which include adequate time off from work to recover and recuperate from trauma exposure. Finally, social workers need to actively participate in self-care techniques such as exercise, good nutrition, and adequate sleep as well as positive interests and activities which rejuvenate the spirit and guard against developing vicarious trauma. Supervisors in the field of child welfare must also be educated about the high incidence of vicarious trauma among social workers. In particular, child welfare agencies should provide supervisors with mandatory trainings which detail the signs and symptoms of vicarious trauma as well as effective methods to intervene. Supervisors should also conduct regular, informed and more sensitive supervision with social workers in their units in order to maintain open communication, establish trusting relationships by valuing the workers and address critical incidents as they arise. In addition, supervisors should facilitate and encourage social workers to engage in self care techniques via monthly unit meetings, outside of the office environment when possible, which focus on such techniques and provide a forum to discuss trauma exposure. 65 Furthermore, supervisors should advocate for social workers to take time off or seek treatment when needed to address vicarious trauma. Finally, supervisors must hone their own clinical and interpersonal skills in order to provide needed support, understanding, guidance, and direction to social workers they oversee in the field. In this manner, supervisors would ensure adequate supervision within a supportive work environment that recognizes the high risk of vicarious trauma and responds to the condition when needed. Finally, managers and administrators in the field of child welfare must acknowledge the high rates of vicarious trauma among social workers within their organizations in order to develop an effective and comprehensive plan to address the issue. In particular, managers and administrators must facilitate a thorough training program to educate both social workers and supervisors regarding the signs, effects, and interventions to address vicarious trauma. Within this framework, administrators must create a system of regular debriefings and peer support groups for workers during work hours to facilitate discussions and education as well as prevention techniques in order to address the chronic exposure to secondary trauma. Furthermore, following critical incidents, administrators and managers must ensure that debriefings and individual counseling are immediately available to social workers in order to reduce the risk of developing vicarious trauma. Finally, administrators and managers must reduce social workers’ caseloads to manageable levels as recommended by best practice guidelines. Such caseload reductions would allow social workers and supervisors to process the trauma they are exposed to in the field and participate in support groups and self-care 66 techniques which would further reduce the risk of vicarious trauma. Throughout this process, managers and administrators must provide full support to the model in order to facilitate full participation and effectiveness. Implications for Social Work Practice Policy Currently, there are no policies in place to address the issue of vicarious trauma in the field of child welfare. As a result, it is essential that the National Association of Social Workers (NASW) look at this issue and explore the possibility of developing organizational and state policies to reduce the risk of vicarious trauma in the field. As indicated in the literature, vicarious trauma frequently leads to increased rates of absenteeism, poor job performance, health issues, and job turnover. Such circumstances cost state and local governments significant amounts of money. In an effort to reduce these costs, policies should be developed to set aside funding for stress management workshops, debriefings, individual counseling, and support groups for social workers in child welfare in order to reduce the risk of vicarious trauma and thus maintain a more productive and permanent workforce. With resources and supports, job turnover in the field would be significantly reduced which would effectively reduce costs and improve services to clients within the community. Research As previously stated, few studies have looked at the prevalence and effects of vicarious trauma on social workers in child welfare. As a result, it is imperative that researchers focus on this issue in order to better understand the impact and results of vicarious trauma on social workers as well as the clients they serve. 67 Practice High rates of vicarious trauma have implications at various levels of social work practice. At the micro level, it is important for individual social workers to identify effective social networks and actively engage in self-care techniques in order to decrease the risk of vicarious trauma. On the mezzo level, it is important for child welfare agencies to implement a comprehensive program to reduce vicarious trauma among social workers in the workplace and to provide a variety of options for workers. Programs should include educational workshops to learn more about the condition and enhance support opportunities, effective techniques to reduce the risk and better coping strategies (such as stress reduction, biofeedback, and meditation techniques), and therapeutic resources such as individual and group counseling. In addition, it would be beneficial for supervisors and managers to implement new and innovative programs designed to desensitize social workers to traumatic events such as visual based education and trainings. Finally, on a macro level, it is important for social workers and supervisors to attend national conferences regarding vicarious trauma in an effort to facilitate ongoing education and innovative interventions. Child welfare agencies should fund and support such conferences as well as policies which address vicarious trauma in order to effectively address and reduce the high rates of vicarious trauma in the field. Theory Although this project has previously explored several theoretical frameworks which provide insight into vicarious trauma, there are additional theories which might be helpful in understanding the topic as well as potential interventions. In particular, Person 68 Centered Theory may be helpful in providing a foundation for group work or conditions necessary to maximize health and positive growth in the workplace. Furthermore, Social Networking Theory may be meaningful in understanding why social networks decrease the risk of vicarious trauma and how to effectively develop and improve such networks within agencies. Ethics Finally, the National Association of Social Worker’s Code of Ethics is designed to ensure that social workers engage in appropriate and ethical practice in the field of child welfare. In order to do so, social workers must address vicarious trauma and the negative symptoms associated with the condition. If such symptoms are not addressed, social workers are unable to ethically and effectively engage clients or meet their needs. As a result, developing a comprehensive program of resources and services to reduce vicarious trauma among social workers is both a practical and ethical matter. For agencies who fail to do so is an ethical failing and violates the NASW Code of Ethics. As a result, it is imperative that managers, administrators, supervisors and social workers work collaboratively to address the issue of vicarious trauma in order to ensure ethical conduct and improved outcomes for children, families, and communities. 69 APPENDICES 70 APPENDIX A Consent to Participate Perceptions of Social Work Professionals on Vicarious Trauma among Social Workers in the Child Welfare Field Dear Social Work Professional, You are invited to participate in a study conducted by Isabel Ott and Julaine Rose, Master of Social Work Division of Social Work students at California State University, Sacramento. The purpose of the study is to examine the perceptions of social work professionals regarding vicarious trauma among social workers in the child welfare field. Recruitment & EAP Researchers are aware that authentication of respondents is a major challenge in computer- and internet-based research, and one that threatens the integrity of research samples and the validity of research results. Based on your interest, your participation will consist of completing an online questionnaire. The questions will pertain to your knowledge of the level of vicarious trauma among social work professionals. This questionnaire should take no longer than 20 minutes of your time. If at any time you feel that you cannot complete the questionnaire you are entirely within your right to do so. If you need assistance in processing issues or concerns that arise as a result of your participation in this study, you may contact the Solano County Employee Assistance Program (EAP) at (800) 242-6220 or Sacramento County Employee Assistance Program/Managed Health Network (MHN) at (800)227-1060. Confidentiality, Online Data Collection and Storage Data collected from this survey through http://www.surveymonkey.com will be transmitted in an encrypted format. This helps to ensure that any data intercepted during transmission cannot be decoded and that individual responses cannot be traced back to an individual respondent. The highest level of data encryption will be used, within the limits of availability and feasibility. Informed Consent By completing this survey, you are agreeing to participate in the research. The survey will include “I agree” and “I do not agree” buttons, if you select that you agree, you are consenting to participate in the survey. The results from the questionnaires will subsequently be presented by the researchers in a Thesis Project. Your participation in this study is strictly voluntary. Your participation, however, is extremely valuable as it will be made available for your peers and other professionals to access and utilize. You have a right to withdraw from participation of this study. As a participant, your information will be kept anonymous and in submitting it, the researcher 71 will be unable to remove data from the database should you wish to after you click submit. Nonetheless, your responses will be kept confidential to the degree permitted by the technology used. However, no absolute guarantees can be given for the confidentiality of electronic data. The information you provide in the questionnaire will be kept confidential and all data obtained through the course of this study will be kept in a locked location, except when being used for the purpose of this study. At the end of the study, all data, and records will be immediately and appropriately disposed of by June of 2011. If you have questions regarding this study, you can contact the researchers at [email protected] or their thesis advisor, Dr. Jude Antonyappan, at (916)2784091 or e-mail at [email protected] Sincerely, Isabel Ulloa-Ott and Julaine Rose, MSW students at CSU, Sacramento 72 APPENDIX B Questionnaire Perceptions of Social Work Professionals with regards to the Prevalence of Vicarious Trauma among Social Workers in the Child Welfare Field Part I. Demographics 1. Gender: 1 Female_____ 2. What is your age? 1 18-27_____ 2 28-37_____ 3 38-47_____ 4 48-57_____ 5 58-67_____ 2 Male_____ 6 68+_____ 3. Marital status. 1 Single_____ 2 Married_____ 3 Separated_____ 4 Divorced_____ 5 Partner_____ 4. Indicate your highest level of education completed. 1 High School/Equivalent_____ 2 Some College_____ 3 LCSW/Other Certification_____ 4 College Graduate_____ 5 Master’s Degree_____ 6 Vocational/Technical School_____ 5. Years of experience in the social work field? 11-15_____ 4 5 16-20_____ 6 PP_____ 6 Adoptions____ Less than a year_____ 2 1-5_____ 21-25_____ 6. What unit in CWS do you presently work in? 5 1 7 1 7 26-30_____ Intake_____ Licensing_____ 7. How many years have you worked in this unit? 1 2 8 31-35_____ ER_____ 8 DI_____ 3 3 6-10_____ 9 36+_____ 4 FM/FR_____ Support/Office Assistant_____ Less than a year_____ 2 1-5_____ 3 6- 10_____ 11-15_____ 4 5 16-20_____ 6 21-25_____ Part II. Perceptions of Vicarious trauma 8. What are some of your views on vicarious trauma among social workers in the child welfare field? 9. How did you develop these perspectives concerning vicarious trauma among social workers in the child welfare field? 73 10. How often have you attended trainings on Vicarious Trauma or related topics? 1 1-3_____ 4-6_____ 2 3 7+____ 4 Never_____ Part III. Perceptions of Stressors and Impact 11. In your perspective can the differences in the nature of case loads affect diverse social workers differently? 11a. Could you please provide some details? For question12: Please answer the questions with a check as they most closely describe you. 1 Low 2 Med 3 High 12. In your perception, what is the level of stress among Child Welfare workers? 13. Have you been approached by other colleagues seeking help to manage their stress level as a result of the trauma that they encounter in their practice? 1 Yes_____ 2 No____ 14. Have any of your colleagues experienced or shared any of the following symptoms associated with vicarious trauma: 1 Depression_____ 2 Digestion Issues_____ 3 Fatigue_____ 4 Forgetfulness_____ 5 Headaches_____ 6 Irritability/Aggression_____ 7 Lack of motivation/decrease in work performance_____ 8 Nightmares/Insomnia_____ 9 Panic Attacks/Anxiety_____ 10 Other (please list)___________________________ IV. Needs in managing Vicarious Trauma For questions 15 through 19: Please answer the questions with a check as they most closely describe you. SA-Strongly Agree; A-Agree; N-Neutral; D-Disagree; SD-Strongly Disagree 1 15. In my view, social work professionals may be affected by the things they hear or see at work. 16. In my view, social work professionals may be impacted by their client’s experiences in the field. 17. In my view, there is sufficient support in the work place for social work professionals who work in the child welfare field. 18. In my view, there are sufficient counseling services outside of the work place for social work professionals. 19. Due to the nature of child welfare intervention services, it is possible for social work professionals to be personally affected by the incidents that they witness in their practice. SA 2 A 3 N 4 D 5 SD 74 IV. Recommendations For questions 20 through 22: Please answer the questions with a check as they most closely describe you. 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