1 Chapter 1 INTRODUCTION

advertisement
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.
SA-Strongly Agree; A-Agree; N-Neutral; D-Disagree; SD-Strongly Disagree
1
20. Developing workshops of professionals to examine vicarious
trauma, its impact, and interventions would be beneficial to social
work professionals.
21. Supervisory debriefing could be beneficial to social work
professionals in managing vicarious trauma.
22. Peer debriefing could be beneficial to social work professionals in
managing vicarious trauma.
23. Support group(s) could be beneficial to social work professionals
in managing vicarious trauma.
24. Share your thoughts, recommendations or questions on the topic.
Thank you for your participation.
SA
2
A
3
N
4
D
5
SD
75
REFERENCES
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of
mental disorders (DSM) (4th ed.). Washington, DC: American Psychiatric
Association.
American Psychoanalytic Association: ASPAA (2009). Contributions of psychoanalysis.
Retrieved December 12, 2010 from
http://www.apsa.org/ABOUT_PSYCHOANALYSIS/CONTRIBUTIONS_OF_
PSYCHOANALYSIS.aspx
Antonovky, A. (1987). Unraveling the mystery of health: How people manage stress and
stay well. San Francisco: Jossey-Bass Publishers
Arte Sana (2003). Social worker burnout studied: Organizational prevention of vicarious
trauma. Agency Culture. Retrieved December 14, 2010 from http://www.artesana.com/articles/social_worker_burnout.htm.
Baldwin, D. (2010). Trauma Information Pages. Retrieved October 1, 2010 from
http://www.trauma-pages.com/trauma.php
Bride, B.E. (2007). Prevalence of secondary traumatic stress among social workers.
Social Work, 52, 63-70.
Bride, B.E., Robinson, M.M., Yegidis, B., Figley, C. R. (2004). Development and
validation of secondary traumatic stress scale. Research on Social Work Practice,
14, 27-35.
76
Catherall, D. (1995). Coping with secondary traumatic stress: The importance of the
professional peer group. In B. H. Stamm (Ed.), Secondary traumatic stress: Selfcare issues for clinicians, researchers, and educators (pp. 80-92). Lutherville,
MD: The Sidran Press.
Chrestman, K. (1995). Secondary exposure to trauma and self-reported distress among
therapists. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for
clinicians, researchers, and educators (pp. 29-36). Lutherville, MD: The Sidran
Press.
Cherry, K. (2005). The conscious and unconscious mind: The structure of the mind
according to Freud. Retrieved December 4, 2010 from http://www.about.com
Drake, B., & Yadama, G. (1996). A structural equation model of burnout and job exit
among child protective service workers. Social Work Research, 20(3), 179-187.
Dunning, C. (2000). Post intervention strategies to reduce police trauma: A paradigm
shift. In J. M. Violani & D. Paton. Police trauma: Psychological aftermath of
civilian combat. Springfield, IL. Charles C. Thomas.
Figley, C. R. (1989). Helping traumatized families. San Francisco: Jossey-Bass.
Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An
overview. In C. Figley (Ed.), Compassion fatigue: Coping with secondary
traumatic stress disorder in those who treat the traumatized (pp. 1-20). New
York: Brunner/Mazel.
77
Figley, C. (1999). Compassion fatigue: Toward a new understanding of the costs of
caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for
clinicians, researchers, and educators (2nd ed.) (pp. 3-28). Lutherville, MD:
Sidran.
Fraser, Richman, & Galinsky (1999). Resiliency 136. Retrieved February 20, 2010 from
http://www.naswdc.org/research/naswResearch/0804Resilience/default.asp.
Garrick, J. & Williams M. B. (2006). Trauma treatment techniques: Innovative trends.
London: Haworth Press.
Goldstein, S., Brooks, R., (2005). Handbook of resilience in children. New York:
Springer
Haroqietz, M. (1998). Social workers trauma: Building resilience in child protection
social workers. Smith College Studies in Social Worker, 68(3), 363-377.
Helm, H. (2010) Managing vicarious trauma and compassion fatigue. Retrieved October
6, 2010 from www.lianalowenstein.com/article_helm.pdf.
Herman, J. (1992). Trauma and recovery: The aftermath of violence from domestic abuse
to political terror. New York: Basic Books.
Jankowsi, K. (2007). PTSD and physical health: A national center for PTSD fact sheet.
Retrieved December 3, 2010 from
http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp
Kragh, J., Huber, C. (2002). Family resilience and domestic violence: Panacea or
pragmatic therapeutic perspective? The Journal of Individual Psychology, 58(3).
78
McCann, I. & Pearlman, L.A. (1989). Vicarious traumatization: A framework for
understanding the psychological effects of working with victims. Journal of
Traumatic Stress, 3(1), 131-149.
Mitchell, J.T. and Everly, G.S. (1995). Critical incident stress debriefing: An operations
manual for the prevention of traumatic stress among emergency service workers.
Ellicott City, MD: Chevron.
Pearlman, L.A. & MacIan, P. (1995). Vicarious traumatization: An empirical study on the
effects of trauma work on trauma therapists. Professional Psychology, Research
and Practice, 26, 558-565.
Perron, B.E. & Hiltz, B.S. (2006). Burnout and secondary trauma among forensic
interviewers of abused children. Child and Adolescent Social Work Journal, 2(2),
216-229.
Plaut, E. (1998). Freud's theory: Psychoanalysis: From theory to practice, past to
present. Retrieved December 12, 2010 from
http://www.personalityresearch.org/papers/plaut.html
Pryce, J., Shackelford K., & Pryce, D. (2007). Secondary traumatic stress and the child
welfare professional, Lyceum.
Saakvitne, K.W. and Pearlman L.A. (1995). In C. Figley (Ed.), Compassion fatigue:
Coping with secondary traumatic stress disorder in those who treat the
traumatized (pp. 150-177). New York: Brunner/Mazel.
79
Saakvitne, K.W. and Pearlman L. A. (1996). Transforming the pain: A workbook on
vicarious traumatization for helping professionals who work with traumatized
clients. W.W. Norton and Company.
Salston, M., & Figley, C. (2003). Secondary traumatic stress effects of working with
survivors of criminal victimization. Journal of Traumatic Stress, 16, 167-174.
Schauben, L., & Frazier, P. (1995). Vicarious trauma: The effects on female counselors
of working with sexual violence survivors. Psychology of Women Quarterly, 19,
49-54.
Siegfried, C. (2008). Child welfare work and secondary traumatic stress. Retrieved
October 7, 2010 from http://www.nctsnet.org/nccts/asset.do?id=1332
Skovholt, T. (2001). The resilient practitioner: Burnout prevention and self-care
strategies for counselors, therapists, teachers, and health professionals. Needham
Heights, MA: Allyn & Bacon.
Smith, M., Jaffe-Gill, E., Segal, J., Segal, R. (2010). Preventing burnout: Signs,
symptoms, causes, and coping strategies. Retrieved January 14, 2011 from
http://www.helpguide.org/mental/burnout_signs_symtpoms.htm
Stoesen, L. (2007). Recognizing secondary traumatic stress. NASW News, 52, 4.
Stamm, B.H. (2005). The professional quality of life scale: Compassion satisfaction,
burnout and compassion fatigue/secondary trauma scales. Lutherville, MD:
Sidran Press. Retrieved December 3, 2010 from
http://www.tinyurl.com/27sopm5.
80
Strean, H. (1979). Psychoanalytic theory and social work practice: Treatment in the
Human Services. Free Press.
Tedeschi R., and Calhoun, L. (1996). Posttraumatic growth inventory: Measuring the
positive legacy of trauma. Journal of Traumatic Stress. 16, 167-174.
Urquiza, A. J., Wyatt, G. E., & Goodlin-Jones, B. L. (1997). Clinical interviewing with
trauma victims: Managing interviewer risk. Journal of Interpersonal Violence, 12,
759-772.
Ward, C., Martin, E., Distiller, G. (2007). Factors affecting resilience in children exposed
to violence. South African journal of psychology, 37(1)
Welfel, E. R. (1998). Ethics in counseling and psychotherapy. Pacific Grove, CA:
Brooks/Cole.
Yalom, I.D. & Lieberman, M.A. (1991). Bereavement and heightened existential
awareness. Psychiatry, 10, 39-40.
Download