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Reducing the Impact of Secondary Trauma in
International Development Organizations that Serve Trauma Survivors
Deb Ekeren
Saint Mary’s University Of Minnesota
Schools of Graduate & Professional Programs
In partial fulfillment of the requirements for GM689
Instructor: Janet Dunn
August 21, 2009
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Table of Contents
Chapter One: Introduction ......................................................................................................... 3
Purpose........................................................................................................................... 3
Significance.................................................................................................................... 3
Scope .............................................................................................................................. 4
Terms ............................................................................................................................. 5
Chapter Two: Literature Review ............................................................................................... 7
NOTE:Definition
On this pageClarification
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Factors Affecting
Secondary Trauma ............................................................................ 9
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Organizational Strategies
for Addressing Secondary Trauma ....................................... 12
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International Development
Context ............................................................................... 18
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Organizational Models of Staff Support ........................................................................ 22
Summary ........................................................................................................................ 26
Chapter Three: Recommendations ............................................................................................. 28
Lessons Learned............................................................................................................. 28
Recommendations .......................................................................................................... 29
Further Research ............................................................................................................ 32
Summary ........................................................................................................................ 33
References .................................................................................................................................. 35
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Reducing the Impact of Secondary Trauma in
International Development Organizations that Serve Trauma Survivors
Chapter One: Introduction
Purpose
In this paper, I explore organizational approaches to lessen the risks and impact of
secondary trauma on trauma professionals in the field of international development in order to
provide recommendations for organizations providing psychosocial support.
Significance
Trauma professionals working in the international development sector are involved in
responding to natural and human-made disasters, and they work closely with the human impact
of the disasters. By providing basic needs and ongoing development support, staff members are
exposed to tragic stories of trauma and vulnerability. Over time, the exposure to traumatic
experiences can cause emotional, mental, spiritual and sometimes physical harm to trauma
professionals. Secondary trauma, as defined by Figley (1995), “is the natural consequent
behaviors and emotions resulting from knowing about a traumatizing event experienced by a
significant other - the stress resulting from helping or wanting to help a traumatized or suffering
person” (p.7). Trauma professionals in international development face high risk of exposure to
direct and indirect threats and trauma. Nearly a third of international development professionals
displayed clinically significant symptoms of emotional distress (Erikkson, Kemp, Gorusch,
Hoke, & Foy, 2001). The compound effect of stress and burnout result in problematic factors for
organizations through high rates of turnover, high risk of accidents and illnesses, diminished
decision-making skills, reduced efficiency, high risk of self-destructive behavior, and heightened
tendency to become either over-involved with beneficiaries or apathetic (Ehrenreich, 2006). In
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order for organizations that work with trauma to achieve their missions of helping communities
recover from tragic events, the effects of secondary trauma must be examined and addressed.
As a human resources professional in an international development organization that
serves trauma survivors, I am aware of the complexities of hiring and maintaining a healthy,
stable, and productive workforce. The organization for which I work delivers psychosocial
support in post-conflict and refugee-receiving countries for survivors of torture and war trauma.
The organization employs expatriate trauma psychologists from around the world who provide
training and supervision to staff members hired locally as counselors. Most direct counseling is
provided by national staff members, but both staff groups are exposed on a daily basis to
traumatic stories and material.
Understanding effective organizational approaches to secondary trauma will help my
organization and others in the field of international development develop effective practices that
support trauma professionals who are asked to work in a difficult field. Specifically,
identification of practices will illuminate ways in which international development organizations
can increase retention of trauma professionals, strengthen dynamics within workforces, position
organizations as leaders in staff care practices, and ultimately, provide high level of care to
survivors of trauma.
Scope
This paper explores research on secondary trauma, generally, with a focus on
organizational practices that support trauma professionals in their work. The paper will offer
recommendations on practices targeted specifically to international development settings. While
significant research has been published on practices that individual professionals can utilize in
order to manage their risks of secondary trauma, content on individual approaches will remain
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outside of the scope of this paper. Also, the paper will focus on recommendations for the
psychosocial sector in the field of international development. International development staff
members in other sectors such as microfinance, rule of law, and water and sanitation are exposed
to risks associated with secondary trauma, but the needs may be less specialized than for
professionals who are responsible for addressing emotional needs of trauma survivors.
Terms
Compassion fatigue. Compassion fatigue is a term that blends the concept of secondary
trauma with burnout (Adams, Boscarino & Figley, 2006).
Compassion satisfaction. Compassion satisfaction is the amount of fulfillment that
trauma professionals derive from their work
Debriefing. As used in this paper, “debriefing” refers to a structured meeting following a
difficult incident in which reactions to the event are discussed.
Expatriate staff members. In the international development field, the term refers to
staff members hired to work in a country other than their home country.
International development. The term refers to the international sector involved in
humanitarian work, disaster assistance, and ongoing development.
National staff members. The term refers to employees hired to work in their home
country.
Posttraumatic stress disorder. The term refers to a set of symptoms following the
exposure to traumatic situations, including personal experiences, witnessing events, or learning
about traumatic events. The disorder is characterized by intrusion, avoidance, and arousal
(American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., text revision).
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Psychosocial support. The term refers to an approach in the international development
sector that encourages healing and resiliency development in communities by addressing
psychological and social support needs.
Secondary trauma (secondary traumatic stress or compassion fatigue). The term
refers to a set of psychological symptoms that mirror posttraumatic stress disorder as a result of
exposure to people who have suffered from trauma. The stress is the result of empathizing with
survivors (Figley, 1995).
Self-care. The term refers to mechanisms that increase trauma professionals’ physical,
intellectual and social functioning, so they can approach their work in a healthy, optimistic
manner.
Trauma. The term refers to an emotional and or physical wound that causes lasting and
substantial damage to the psychological development of a person (Alexander, Eyerman, Giesen,
Smelser & Sztompka, 2004).
Trauma professionals. The term refers to psychologists, social workers, counselors, and
other professionals who address emotional healing of survivors of trauma.
Vicarious traumatization. The term refers to cumulative and permanent changes that
take place in trauma professionals’ views of themselves, others, and their world, as a result of
exposure to traumatic stories or materials (McCann & Pearlman, 1990).
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Chapter Two: Literature Review
The review of literature on organizational practices to address secondary trauma in
international development organizations that serve survivors of trauma begins with a review of
the concept of secondary trauma. Due to limited research on factors affecting secondary trauma
within international development organizations, research from domestic organizations that serve
survivors of trauma is used to build an understanding about factors associated with secondary
trauma and organizational interventions that can lessen its impact. Research on the international
development field is reviewed next, including prevalence of secondary trauma, risks associated
with international development, and successful interventions for secondary trauma. Finally,
several models of good practice in the field of international development are reviewed for
recommendations that mitigate the impact of secondary trauma.
Secondary Trauma: Definition Clarification
Psychologists, social workers, and other mental health professionals whose work involves
listening to the stories of trauma survivors face a risk of secondary trauma. The concept of
secondary trauma was defined by Figley (1995) as the emotions and behaviors that are the result
of exposure to traumatic stories experienced by another person. He further elaborated that
secondary trauma is the result of empathizing with the person who has suffered trauma. The
impact can mirror the symptoms of posttraumatic stress disorder experienced by primary
survivors of a trauma, including re-experiencing, hypervigilance, avoidance, and numbing
(American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., text revision).
Secondary trauma can hinder the ability of trauma professionals to carry out their work to
their full potential. Pearlman and Saakvitne (1995) identified that secondary trauma can cause
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cynicism and despair, undermining the ability of trauma professionals to share hope with their
clients. In addition to impacting professional work, secondary trauma can bleed into the personal
lives of trauma professionals. Killian (2008) argued that in order for professionals to address the
needs of trauma survivors, they must be healthy, committed, and psychologically present.
Researchers demonstrated the prevalence of secondary trauma among trauma
professionals (Birck; 2001; Conrad & Kellar-Guenther, 2006; Way, VanDeusen, Martin,
Applegate, & Jandle, 2004). Among child protection workers in Colorado, almost 50% had a
high or extremely high risk of secondary trauma (Conrad & Kellar-Guenther, 2006). Fifty seven
percent of therapists who treated torture survivors in Germany reported a high level of secondary
trauma (Birck, 2001). Trauma professionals who treated survivors of sexual abuse and sexual
offenders reported high levels of secondary trauma with 52% of providers reporting clinically
significant risk for secondary trauma (Way et al.).
Researchers built on the concept of secondary trauma and introduced several other related
concepts: vicarious traumatization, burnout, and compassion fatigue. McCann and Pearlman
(1990) introduced vicarious traumatization, a concept that advanced the definition of secondary
trauma and included profound and harmful psychological effects that alter the way in which
professionals see themselves, others and the world. The changes are the result of trauma
professionals integrating the traumatic experiences of clients into their personal memory. The
impact is cumulative, pervasive and permanent for trauma professionals (Baird & Kracen,
2006).
Burnout was differentiated from secondary trauma as the response to long-term exposure
to challenging interpersonal situations. Characteristics of burnout include emotional exhaustion,
depersonalization, and reduced feelings of personal accomplishment (Maslach, Schaufeli &
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Leiter, 2001). Burnout can develop in a variety of stressful environments, including situations
that are not related to trauma.
Compassion fatigue is a term that blends the concept of secondary trauma with burnout
(Adams, Boscarino & Figley, 2006). Trauma professionals who have secondary trauma and face
intense workplace stress over a long period of time may develop compassion fatigue. In some of
the research, compassion fatigue was used interchangeably with secondary trauma, and in other
research the term included symptoms of burnout (Figley, 2002; Killian, 2008).
For the purpose of this paper, secondary trauma refers to the set of symptoms associated
with repeated exposure to traumatic stories of clients. The differences between the concepts
secondary trauma, vicarious traumatization, and compassion fatigue are not significant for the
focus for this paper. Other researchers have applied a similar approach and used the terms
interchangeably (Baird & Kracen, 2006; Figley, 1999; Killian; 2008; Pross, 2006).
Factors Affecting Secondary Trauma
A growing body of research has emerged exploring factors that contribute to secondary
trauma. Contradictory conclusions have been reached about some demographic, workplace, and
environmental factors and their relationship to secondary trauma. The diversity of results
reinforces the need for further research to understand factors that impact secondary trauma.
Trauma history. Concerns have emerged about the predisposition to secondary trauma
based on personal experiences of trauma. Several research studies demonstrated that trauma
professionals who have their own personal trauma histories face an increased risk of secondary
trauma (Baird & Kracen, 2006; Buchanan, Anderson, Uhlemann, & Horwitz et al., 2006; Killian,
2008). Contradictory results were found among trauma professionals who worked with violence
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and sexual violence that indicated personal history with trauma was not associated with
secondary trauma (Bober & Regehr, 2006; Schauben & Frazier, 1995; Way et al., 2004).
Tenure in the field and age. The relationship between length of time working in the
field of trauma and secondary trauma is another factor that has been explored by researchers.
For trauma professionals focusing on sexual violence, shorter time in the field was associated
with increased risk of secondary trauma (Way et al., 2004). Trauma professionals who were
newer to the field showed more distress than experienced professionals. Older counselors
reported lower levels of distress than younger counselors (Bober & Regehr, 2006). International
development workers in Darfur who were older reported lower impact of secondary compared to
younger workers (Musa & Hamid, 2008). The correlation between age and length of time in the
field is important to recognize. Older staff members and those who have been in the field for a
longer period of time may be more effective at managing the emotional challenges of working
with trauma. Trauma professionals who are not able to develop effective coping mechanisms
may choose to leave the field.
Exposure to trauma. Inconsistent results were shown for the relationship between the
amount of exposure to trauma survivors and secondary trauma. (Baird & Kracen, 2006; Birck,
2001; Bober & Regehr, 2006; Buchanan et al., 2006; Eidelson, D’Alessio, & Eidelson, 2003).
Exposure can encompass hours with traumatized clients and percentage of trauma survivors on a
caseload. In an exploration of 16 research articles and dissertations on secondary trauma
published between 1994 and 2003, Baird and Kracen (2006) found evidence on both sides of the
hypothesis. They found persuasive evidence linking the amount of exposure to traumatic
material of clients and an increased risk of secondary trauma. They also found reasonable
evidence to the contrary that increased exposure was not associated with increased risk of
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secondary trauma. Research not included in the meta-analysis showed similar contradictory
findings. Among trauma professionals working with torture survivors, long hours spent with
traumatized clients did not increase the risk of secondary trauma (Birck). In contrast, increased
levels of secondary trauma were associated with caseloads comprised predominantly of trauma
survivors among 280 Canadian mental health workers (Buchanan et al.). Diversified caseloads
with a combination of trauma survivors and mainstream clients was viewed as an important
factor in low levels of emotional stress among psychologists working in New York following the
September 11 terrorist attack (Eidelson, D’Alessio, & Eidelson, 2003). Bober and Regehr
(2006) found similar results among 259 therapists; the amount of time spent counseling survivors
of trauma was directly associated with secondary trauma. Researchers have not found a clear
relationship between secondary trauma and exposure to traumatic material.
Compassion satisfaction. The amount of fulfillment that trauma professionals derive
from their work is another factor that has been researched in relation to secondary trauma. The
term compassion satisfaction refers to the amount of satisfaction gained from helping clients heal
who have endured suffering (Radey & Figley, 2007). A high level of compassion satisfaction
among children protection workers was associated with a low level of secondary trauma (Conrad
& Kellar-Guenther, 2006). The results supported a theory by Stamm (2002) that compassion
satisfaction may be a protective factor against secondary trauma. Finding strategies that raise the
level of fulfillment that trauma professionals gain from their work may minimize the risks of
secondary trauma.
Work culture. Aspects of work culture were related to secondary trauma. Killian
(2008) observed that two factors were closely associated with secondary trauma: a therapist’s
sense of powerlessness and work drain. The sense of powerlessness encompassed feelings that
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social support systems were impeding the healing of clients, leaving the therapist feeling
frustrated and hopeless. Work drain encompassed a high level of stress that carried over into
time therapists spend away from work. Work environments that address powerlessness and work
drain will be better positioned to mitigate the effects of secondary trauma.
Social support. The final factor considered was the association between social support
and secondary trauma. Social support can include relationships with colleagues, family, and
friends, encompassing relationships at work and in the personal lives of therapists. Trauma
professionals working with trauma survivors identified social connections with peers as an
important component in managing their work stress (Killian, 2008). A strong association was
demonstrated between social support systems and satisfaction with trauma-oriented work, in a
quantitative analysis conducted as part of the same study. Reduced stress and increased
satisfaction mitigated risks of secondary trauma. Among psychologists working in New York
City following the September 11 terrorist attack, a high social support environment contributed
to low levels of stress and an increase in positive feelings about their work (Eidelson et al.,
2003). Social support appears to serve as a protective factor against the effects of secondary
trauma.
Organizational Strategies for Addressing Secondary Trauma
Secondary trauma is a risk that is inherent in working with trauma survivors. Much of
the research in the field has focused on specific practices that individuals should employ in order
to manage personal risks related to secondary trauma (Bell, Kulkarni, & Dalton, 2003). An
alternative perspective holds that within organizations that serve survivors of trauma, secondary
trauma is an occupational hazard that requires organization-wide strategies. Organizations have
an obligation to create a safe work environment and a culture that promotes healthy behaviors.
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A review of research will identify key practices that organizations can utilize in order to mitigate
the effects of secondary trauma.
Culture. A culture reflects the values and priorities of an organization. For
organizations that serve survivors of trauma, the culture must embrace trauma-related stresses as
legitimate and expected, and the stresses are the shared responsibility of the organization and the
individual (Sexton, 1999). Creating a culture of openness and acceptance is a useful method to
mitigate other potentially difficult characteristics of organizations that serve survivors of trauma.
Addressing conflicts, providing clear roles and job descriptions for trauma professionals, and
promoting cooperation are additional components of culture that should be enhanced in
organizations (Hormann & Vivian, 2005). Deliberate efforts aimed at strengthening the culture
will result in organizations that are better able to address secondary trauma.
Administrative stresses and their relationship to secondary trauma warrant examination.
Cultures of bureaucracy amplify feelings of disempowerment and helplessness and increase risks
for secondary trauma (Sexton, 1999). Minimizing administrative stresses can have positive
outcomes related to secondary trauma. Killian (2008) recommended that administrative stresses
can be reduced by providing trauma professionals with opportunities for decision-making on
workplace issues. The recommendation was based on research that an increased sense of control
and input increased compassion satisfaction (Killian).
Lastly, building a culture that reflects on the meaning and values of the work can be
protective against secondary trauma. Providing opportunities and a culture that welcomes
reflection about the impact of working with trauma can help sustain trauma professionals in their
careers (Fischman, 2008; Hormann & Vivian, 2005; Trippany, Kress, & Wilcoxon, 2004). Also,
building a culture of positivity is protective against secondary trauma. By encouraging trauma
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professionals to focus on strengths and successes of their clients, instead of disappointments,
compassion satisfaction increases (Radey & Figley, 2007). Creating a supportive culture can
foster a positive environment and reduce the risk of secondary trauma.
Trauma caseload. Limiting the number of trauma survivors within a caseload is a
strongly recommended practice (Bell et al., 2003; Pross, 2006; Trippany et al., 2004).
Researchers found a direct relationship between longer hours spent counseling trauma survivors,
a decrease in compassion satisfaction, and an increase of secondary trauma (Bober & Regehr,
2006; Killian, 2008). Diversifying caseloads with clients with varying levels of symptoms was a
useful strategy at strengthening the ability of trauma professionals to remain optimistic (Radey &
Figley, 2007). Allowing staff members to work part-time in trauma and part-time seeing
mainstream populations, possibly in a different environment, was another strategy offered (Pross,
2006). Composition of caseloads and hours spent counseling trauma survivors are two critical
factors that organizations must address.
Education and training. Enhancing the knowledge of trauma professionals is a widely
endorsed practice for organizations. Providing education to trauma professionals about
secondary trauma can reduce the risks of developing symptoms (Bell et al., 2003; Campbell,
2007; Fischman 2008; Radey & Figley, 2007; Trippany et al., 2004). Training on secondary
trauma should be viewed holistically and integrated throughout the employment experience,
beginning with interviewing and continuing with the hiring process and regular professional
development (Bell et al.). Researchers have recommended different types of interventions:
comprehensive psycho-educational training (Fischman, 2008), training on techniques to address
secondary trauma individually (Bell et al.), training on therapeutic self-awareness (Pross, 2006),
and targeted education following a high-intensity situation (Paton,, 1997). Researchers also
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emphasized the value in providing training on topics outside of secondary trauma that increase
the competency of trauma professionals and counteract feelings of hopelessness that can be a
characteristic of secondary trauma (Campbell, 2007; Schauben & Frazier, 1995). Investing in
education and training may help organizations reduce the risk of secondary trauma.
Formal social support. Designing an environment and structure in which colleagues are
supportive of one another is closely tied to increasing the satisfaction that trauma professionals
gain from working with trauma survivors (Killian, 2008). Beginning with the configuration of
workforces, organizations can shape environments that encourage group support by
implementing team treatment models that share the weight of survivors’ stresses across a group
of professionals and create a sense of shared responsibility (Sexton, 1999). Team members can
support each other in secondary trauma reactions and reduce the risk of isolation. Specifically,
group case consultation was recommended as a strategy for processing experiences formally on a
regular basis among peers (Bell et al., 2003; Sexton, 1999; Trippany et al., 2004; Way et al.,
2004). The process can be useful for sharing new perspectives, clarifying distortions, and
empathizing with the emotional responses of colleagues (Bell et al.). Despite the benefits of
group case consultations, some possible risks should be anticipated, including a tendency toward
conformity in thinking, potential for traumatizing other team members, and hesitancy of some
group members to share their vulnerabilities (Bell et al.; Sexton, 1999). With carefully
supported facilitation, group case consultations can support trauma professionals in reducing
their risks of secondary trauma.
Informal social support. Creating a culture of informal peer support can reduce the
risks of secondary trauma. Killian (2008) advocated for creating physical space and allocating
time for regular interactions that promote relationships among colleagues. Bell et al. (2003)
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acknowledged the importance of trauma professionals having time with each other to celebrate
personal milestones, participate in team-building activities, and connect on staff retreats.
Building into an organization a diverse range of formal and informal social support mechanisms
will strengthen factors that protect against secondary trauma (Holmqvist & Andersen, 2003).
Supervision. Providing clinical supervision to professionals who work with trauma
survivors is a strongly recommended practice for reducing the impact of secondary trauma (Bell
et al., 2003; Holmqvist & Anderson, 2003; Killian, 2008; Sexton, 1999; Trippany et al., 2004).
Clinical supervision provides trauma professionals with an opportunity to reflect on their work,
remain grounded in trauma theory, gain objective feedback, and explore their risks associated
with secondary trauma (Sexton, 1999). Baird and Kracen (2006) found some evidence that
clinical supervision served as a protective factor against secondary trauma. Organizational
culture and values surrounding clinical supervision will impact the level of effectiveness. Bell et
al. advocated for the separation between evaluative supervision and clinical supervision, in order
to build trusting relationships in which trauma professionals feel comfortable expressing their
vulnerabilities and fears without concerns about how their feelings will impact their
employment. Clinical supervision can serve as a supportive mechanism to help trauma
professionals remain in the field of trauma and provide high quality care to survivors, while
minimizing risks associated with secondary trauma.
Self-care and coping strategies. Self-care and coping mechanisms are important
considerations related to secondary trauma. Emotionally negative coping and self-care practices,
such as denial, avoidance and venting, were associated with a high level of work stress, while
positive coping strategies, such as reduced workload, supervision, and social support, were
associated with a low level of stress (Killian, 2008). Cultivating self-care practices has been
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viewed as an individually-oriented pursuit for trauma professionals that includes a broad range of
activities supporting their rejuvenation from stresses of trauma work. A potential risk with
organizations supporting self-care is transferring the responsibility for trauma reactions to trauma
professionals, rather than the organization sharing the responsibility (Bober & Regehr, 2006;
Killian, 2008). Implementation of practices related to self-care should reflect the shared
accountability.
Specific activities remain the responsibility of individuals, but organizations can play a
role in creating a culture that encourages trauma professionals to pursue positive self-care.
Providing benefits and employee programs can support positive self-care activities.
Recommended practices for organizations include providing health insurance with coverage for
mental health care (Bell et al., 2003), mindfulness practices (Bell et al.; Berceli & Napoli, 2006),
stress management training (Bell et al.), paid time away from work (Trippany et al., 2004; Way
et al., 2004), and physical wellness programs (Radey & Figley, 2004).
Very little research has been conducted to determine the relationship between specific
self-care practices and secondary trauma (Radey & Figley, 2007). Bober and Regehr (2006)
studied 259 therapists and analyzed the relationship between time devoted to perceived useful
practices and secondary trauma scores. Specifically, they examined leisure activities, self-care,
supervision, and other professional activities outside of direct trauma counseling, including
research and educating others. They found no association between time devoted to the practices
and a reduction in symptoms of secondary trauma. The research calls into question long held
beliefs about the correlation between self-care and secondary trauma. Further research that
validates the findings could create significant shifts in thinking about caring for trauma
professionals.
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International Development Context for Secondary Trauma
While the international development field shares the same challenges inherent in trauma
work within domestic environments, the international development field introduces further
complexities. Staff members are working and living in communities that have suffered human or
natural disasters, and they are exposed to a broad range of risks and threats. Emanuel and
Ursano (1999) identified four categories of risks that people working in disaster areas face.
Physiological risks include physical exertion, accidents, diseases, intentional violence, and loss
of life. Psychological risks are actual or perceived threats of harm, exposure to trauma survivors,
and isolation from social support, which can result in secondary trauma and burnout.
Occupational risks include overwhelming responsibilities attached to a position and inability to
put limits around work. Organizational risks emerge with role conflicts, tension between
personal and organizational needs, and conflicts within work teams.
While studies on exposure to risks among international development professionals are
limited, researchers revealed that international development workers are regularly exposed to
serious risks that impact individuals and organizations. (Augsburger et al., 2007; Cardozo et al.,
2005; Jones, Müller & Maercker, 2006). Among international development professionals
working in Kosovo after the end of the conflict, expatriate staff members experiences on average
2.8 traumatic events, and national staff members experienced 3.2 (Cardozo et al.). Traumatic
events included sniper fire, threats to life, murder of a family member or friend, separation from
family, and handling dead bodies. Among international development workers from Germany
who were placed around the world, 47% experienced and 7% witnessed a traumatic event during
their service (Jones et al.). International development workers in Darfur and Chad experienced a
high level of stress (Augsburger, 2007). More than half of staff members reported they felt
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physically stressed within the previous two weeks. Just less than half reported they were
emotionally stressed, and a third felt they were mentally stressed. The highest level of stress was
associated with exposure to trauma (41.1%), separation from family (40.3%), workload (29.2%),
fear of traumatic events (27.8%), and moral dilemmas (25%). Risks and stresses are present at
high levels among international development workers.
Limited research has been conducted on secondary trauma among international
development workers, but the significance of secondary trauma was demonstrated.
Approximately 30% of expatriate international development workers identified significant
symptoms of posttraumatic stress disorder and 51.3% reported partial symptoms (Eriksson et al.,
2001). Among 53 international development workers in Darfur, 25% reported high levels of
secondary trauma and 50% showed psychological distress (Musa & Hamid, 2008). All
international development workers in Gujarat, India, reported at least one symptom of secondary
trauma, while 8% met the full criteria for posttraumatic stress disorder (Shah, Garland, & Katz,
2007). Among Israeli social workers who responded to terrorist attacks, nearly half reported
high or extremely high levels of secondary trauma, and less than a quarter reported low to
moderate levels of symptoms (Cohen, Gagin, & Peled-Avram, 2006). High level of secondary
trauma among international development workers reinforced the importance of organizations'
taking comprehensive measures to mitigate the impact.
Researchers who compared secondary trauma prevalence between expatriate and national
staff members reported that national staff members showed higher levels of trauma than
expatriate staff members (Cardozo et al., 2005; Musa & Hamid, 2008). National staff members
are generally part of the communities in which they are working, and they may have experienced
events similar to the trauma survivors they are serving. Among national staff members,
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separating primary trauma from secondary trauma was a challenge cited by several researchers
(Musa & Hamid, 2008; Shah et al., 2007). Secondary trauma involves not only exposure to
traumatic material but also empathy with a survivor of trauma. National staff members may
identify more closely and empathize with survivors because they share the same community and
cultural identity compared to expatriate employees (Cardozo et al.). In a meta-analysis of 177
studies of disaster victims, highest risks for emotional trauma were reported by women, ethnic
minorities, people of low socioeconomic status, and people from traumatized communities
(Norris, Byrne, & Diaz, 2001). All international development workers face risks for secondary
trauma, but national staff members may face more pronounced risks. International development
organizations need to examine the potential risk of trauma within their workforce and take
protective measures to limit further exposure.
Addressing secondary trauma within international development organizations
necessitates understanding the relationship between secondary trauma and various interventions.
Social support was a prominent factor in literature on secondary trauma. Within the international
development context, the importance of social support was validated. Among returning
humanitarian workers, social support was a protective factor against posttraumatic stress disorder
symptoms and exposure to traumatic events (Eriksson et al., 2001). International development
workers with high exposure to traumatic events reported lower levels of posttraumatic stress
disorder if they had a high level of social support. The lowest levels of posttraumatic stress
disorder were reported among international development workers who had the lowest exposure
to traumatic events and the highest levels of social support. Cardozo et al. (2005) examined the
relationship between communication with family and mental health outcomes for international
development workers in Kosovo and found that inadequate communication with family
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members, for both expatriate and national staff members, resulted in poorer mental health
outcomes. Among German international development workers, social support was found to
mitigate the effects of posttraumatic stress disorder. In particular, international development
workers who experienced a traumatic event had fewer symptoms of posttraumatic stress disorder
when they received social support in the form of social acknowledgement as a victim (Jones et
al., 2006). The research about social support and secondary trauma implies the need for
organizations to integrate social support mechanisms into their culture and operations. Actions
that create team cohesion, provide opportunities for employees to communicate with family
members, and offer education among team members about how to support their colleagues may
prove valuable to reducing the prevalence and impact of secondary trauma within international
development organizations.
Debriefing is another intervention addressed within the literature on secondary trauma.
Specifically, debriefing following traumatic events has been a practice widely endorsed by
mental health practitioners, yet research conducted on the practice revealed that was ineffective
and, in some cases, harmful (Devilly, Gist, & Cotton, 2006). Within international development
organizations that serve survivors of trauma, witnessing and experiencing trauma is an
anticipated and regular occurrence, so organizations must operate with practices that are safe and
effective. Following exposure to highly traumatic events, specialized interventions may be
necessary. Devilly et al. (2006) conducted an extensive review of research on debriefing and
offered a model for addressing traumatic experiences that was grounded in research-validated
practices. First, organizations should develop plans and train all staff members on procedures for
handling traumatic events, such as safety measures and communication plans. Second,
organizations should provide immediate support that emphasizes natural social supports and
SECONDARY TRAUMA
22
resilience, including connecting individuals impacted by trauma with family and other social
support networks and providing clear information. Third, psychological interventions should
take place, as needed, and at graduated levels of assistance. Depending on the response of the
individual affected by trauma, specialized psychological services may be necessary. The model
emphasizes building on the healing approaches that are most helpful for the individual impacted
by trauma. Gelder and Berhoff (2002) advocated for special efforts to minimize the
traumatization of other staff members, with specific emphasis placed on the protection of
national staff members. Utilizing support resources rather than relying on staff members
working at the same program site will reduce the spread of trauma responses. As demonstrated
in the prevalence data, traumatic events are a part of international development work, and
organizations must have clear plans in place to address trauma for individuals and organizations.
Organizational Models of Staff Support
Three widely adopted standards were developed for international development
organizations that offer some recommendations for the care of staff members: Interaction’s PVO
Standards (Interaction, 2007), Code of Good Practice in the Management and Support of Aid
Personnel (People in Aid, 2003), and IASC Guidelines on Mental Health and Psychosocial
Support in Emergency Settings (Inter-Agency Standing Committee, 2007). Most of the practices
were developed with the goal of improving the productivity and effectiveness of international
development organizations or addressing the well-being of staff members. While not addressing
secondary trauma in a comprehensive manner, the practices include recommendations that are
relevant to the care of staff members working in trauma. The review of organizational models
also includes recommendations offered by two researchers: Ehrenreich (2006) and Fawcett
(2000).
SECONDARY TRAUMA
23
In order to mitigate the effects of secondary trauma, organizations should consider a
systemic approach to managing staff members that encompasses all aspects of the organization
and should last throughout the employment life cycle (Wilson & Gielissen, 2004). As a starting
point, organizations need to develop a culture of well-being in which the health of staff members
is a strategic priority (Ehrenreich, 2006; People in Aid, 2003). Within a supportive culture, the
relationship between the well-being of staff members, quality of care to trauma survivors, and
fulfillment of the mission will be widely understood. Organizations must allocate sufficient
financial resources for staff well-being by establishing a budget specifically for the care of staff
members (Fawcett, 2002; People in Aid, 2003), and develop comprehensive policies and plans in
order to address emergencies, security issues, and crises that are inevitable in international
development work (Ehrenreich, 2006; Fawcett, 2002; IASC, 2007; Interaction, 2007; People in
Aid, 2003). Comprehensive plans deliver a message to staff members than their safety and care
are serious concerns.
Deliberate care in hiring and training staff members will help to mitigate the impact of
secondary trauma. Fawcett (2002) argued the importance of a comprehensive hiring process that
explores psychiatric history, resiliency, strength of social and team skills, previous field
experiences, and leadership style of potential staff members, in addition to technical
competencies. Focusing on protective factors for secondary trauma will help to mitigate some
risks from the onset. Once hiring decisions are made, international development staff members
should have a thorough orientation covering all policies, plans, risks, and supportive measures
offered by the organizations (Ehrenreich, 2006; IASC, 2007; People in Aid, 2003). Clarity about
expectations and systems will reduce ambiguity and limit the likelihood of poor decision-making
by staff members. Orientation is the first opportunity for training, but it should not be the only
SECONDARY TRAUMA
24
experience. Ongoing training and development on security, stress management, team cohesion,
technical expertise, and leadership training focusing on organizational stress management should
be part of a comprehensive plan (Fawcett, 2002; People in Aid, 2003). Ongoing training will
help build skills that are essential for effective operations.
International development staff professionals need to work in a context in which they can
be successful and supported while completing difficult work. The quality of leadership and
management was emphasized in the literature as an important protective factor in managing the
stress of international development staff members (Ehrenreich, 2006; Wilson & Gielissen, 2004).
Leaders can promote clarity and purpose in day to day work, and they are critical in supporting a
culture of well-being. Fostering leadership that is attuned to the complex dynamics in an
international work environment and possess the skills necessary to implement changes when
needed can make a significant impact in shaping a culture. Clearly defining job descriptions and
reporting relationships will help to clarify expectations (Ehrenreich, 2006; Fawcett, 2002; People
in Aid, 2003). Organizations working in communities with high emotional needs should
introduce clearly defined job descriptions, and organizational structures can mitigate feelings of
being overwhelmed because of lack of clarity.
In order to manage exposure to traumatic material and limit the stress of staff members,
organizations need to attend to the hours staff members work. Organizations should provide
limits around the number of work hours on a regular basis (IASC, 2007; People in Aid, 2003).
Living in an isolated environment, surrounded by unmet needs in the community, can create
significant pressure on international development professionals to work more than is healthy.
Organizations must provide time away from the work site and require staff members to use this
SECONDARY TRAUMA
25
time at regular intervals (Fawcett, 2002; IASC, 2007; People in Aid, 2003). Time away provides
staff members with an opportunity for relaxation, rejuvenation, and reduction in stress.
Providing a culture in which international development staff members feel supported
involves a comprehensive approach. Team cohesion is an important part of supporting staff
members in international development (Ehrenreich, 2006; IASC, 2007, Wilson & Gielissen,
2004). Team members can provide regular feedback and support, and they can serve as a safety
net that allows trauma professionals to work intensively with survivors of trauma in difficult
environments.
Organizations must support international development professionals with benefits
designed to addressed the unique needs of trauma-oriented field work. Access to mental health
resources is a critical measure of support when working with trauma survivors (Ehrenreich,
2006; Fawcett, 2002; IASC, 2007). Some organizations are large enough and can provide the
resources internally. Other organizations may need to utilize international employee assistance
programs. Organizations should address unhealthy living or coping strategies, such as alcohol
use (IASC, 2007). Resources for mental health care should support staff members in
implementing healthy strategies for responding to traumatic work. Following highly traumatic
incidents, organizations should have clear plans that provide comprehensive support (IASC,
2007).
Providing ongoing support is an important role that organizations should play.
Organizations should allow employees to communicate with family members, friends and other
social support networks on a regular basis (Fawcett, 2002; IASC, 2007). Encouraging
employees to utilize their social supports systems will help build resiliency.
SECONDARY TRAUMA
26
Finally, organizations should provide comprehensive debriefing at the end of
employment and provide resources to help staff members through their transition (Ehrenreich,
2006; IASC, 2007; People in Aid, 2003). Debriefing will provide employees with an
opportunity to reflect on their feelings and experiences and allow the organization to offer
education about the challenges of re-entry. Organizations will benefit from hearing the
experiences of staff members, and their feedback may provide useful recommendations to
improve organizational functioning.
The standards developed for international development organizations offer a starting
point for addressing the effects of the secondary trauma. Further recommendations that are
grounded in research will assist in the development of a comprehensive plan. Supporting
international development professionals working with trauma survivors requires a multi-faceted
approach in order to mitigate the effects of secondary trauma.
Summary
Secondary trauma is the result of repeated exposure to traumatic stories of survivors of
trauma that can cause emotional harm to trauma professionals and undermine the quality of their
work, and it represents a serious risk for professionals who work in the field of international
development. In addition to facing risks associated with trauma work, international development
professionals are exposed to risks inherent in post-disaster environments, and they are usually
working in areas removed from family and friends. Organizations have an obligation to treat
secondary trauma as an occupational risk and address it through organizational measures, rather
than relying on trauma professionals to be solely responsibility for their reactions to the work. A
number of interventions were recommended in the literature, including creating a culture that
recognizes secondary trauma risks, managing caseloads and work expectations, providing
SECONDARY TRAUMA
education, building systems of social support, providing clinical supervision, planning and
managing high trauma events, and supporting self-care practices. Several models of
organizational standards were reviewed that provide a framework for a model focused
specifically on secondary trauma in international development organizations.
27
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28
Chapter Three: Recommendations
Tragic events such as wars, earthquakes, genocide, terrorism, and famines, initiate
international responses with teams of international development professionals responding to the
needs of affected communities. International development professionals who address the
psychological needs of communities following human-made and natural disasters face risks due
to repeated exposure to tragic stories of loss, violence, and threats. Secondary trauma is the
reaction that trauma professionals may experience by empathizing with survivors of traumatic
events, and it can result in symptoms that mirror posttraumatic stress disorder. International
development organizations have an obligation to address the risks of secondary trauma among
their staff members, in order to protect their emotional health, ensure that quality of care to
beneficiaries remains high, and fulfill their mission of healing communities impacted by tragic
events.
Current research on secondary trauma and international development provided clarity on
some factors that impact secondary trauma and interventions that are useful at mitigating its
effects within organizations that address trauma. Some of the interventions included creating a
culture that recognizes secondary trauma risks, managing caseloads and work expectations,
providing education, building systems of social support, providing clinical supervision, planning
and managing high trauma events, and supporting self-care practices. The research encompassed
interventions that can lead to a comprehensive model to reduce the effects of secondary trauma
within international development organizations that serve trauma survivors.
Lessons Learned
I was surprised to discover the limited amount of research that has been conducted within
the field. Several prominent international agencies, institutions, and international development
SECONDARY TRAUMA
29
networks have promoted awareness about the emotional risks faced by international development
professionals, so I anticipated that I would find more studies that explored interventions.
Perhaps the newness of secondary trauma with only 15 years of research and the recentness of its
recognition to the field of international development can explain the limited amount of research.
Another possibility is that funding is limited for research on internal practices within
organizations. The result is that effective practices may not be studied or findings disseminated
broadly. Finally, for a field in which there is limited research, the true need is for conducting
primary research. With additional time and resources, I would have valued the opportunity to
contribute to the field with new findings that move the field closer to effective solutions that
mitigate the effects of secondary trauma.
Recommendations
Standards of practice such as the People in Aid’s Code of Good Practice and
InterAction’s PVO Standards provide a model of comprehensive guidelines that international
development organizations can implement. I recommend the development and implementation
of a parallel set of guidelines that focuses on reducing the effects of secondary trauma, utilizing
interventions that are validated through research to reduce secondary trauma. The development
of comprehensive guidelines will necessitate further research, but based on current knowledge
that emerged from research, several recommendations can contribute to future guidelines.
Secondary trauma as an organizational issue. Organizations must recognize
secondary trauma as an inherent risk within international development organizations that address
psychosocial needs in disaster-affected communities. Secondary trauma is a natural and
common response to hearing traumatic stories that can cause lasting harm to professionals.
SECONDARY TRAUMA
30
Organizations have a responsibility to shape a culture and implement practices that support
international development professionals in their work.
Administrative stresses. Minimizing administrative stresses and bureaucracy can help
alleviate the strain that international development professionals face. Work with survivors of
trauma is highly stressful, so efforts should be made to mitigate all other work-related stresses.
Reporting structures, job descriptions, and work expectations should be clearly communicated
and understood.
Internal social support. Organizations should design internal structures that encourage
social support. International development professionals should be placed on teams that work
collaboratively to implement programs. Cohesive teams will help support each other in decisionmaking, stress management, and secondary trauma reactions. Creating formal structures of
support, such as group consultations, as well as internal mechanisms to address conflicts will
help insure that teams operate effectively.
External social support. Creating opportunities for international development
professionals to remain connected to external social support systems is important. Organizations
should work creatively to offer family-accompanied posts when security situations are stable. In
situations in which security risks are too great, organizations should encourage frequent
communication with family and friends and periodic opportunities to spend time together.
Education to family members about risks and stresses within the work may help them provide
understanding and support.
Education. Providing education about secondary trauma is essential in order for
international development professionals to recognize the symptoms in themselves and others.
The education should be implemented throughout the employment experience, beginning with
SECONDARY TRAUMA
31
hiring and orientation and continuing at regular intervals during employment and at the end of an
assignment before returning home. Because of higher risks associated with newer employees to
the field of trauma (Way et al., 2004), more intensive education should be provided to employees
with less trauma-based experience.
Clinical supervision. Regular clinical supervision should be provided to all international
development professionals who work with survivors of trauma. Clinical supervision will provide
employees with an opportunity to process their reactions to the work and support them in their
clinical decision-making. It is also an opportunity for supervisors to watch for signs of
secondary trauma and support the international development professionals in utilizing positive
coping methods.
Needs of national staff members. National staff members face increased risks of
secondary trauma compared to expatriate staff members (Cardozo et al., 2005; Musa & Hamid,
2008), so they may have heightened need for support to mitigate the effects of secondary trauma.
As members of communities impacted by disasters, they may share similar experiences and
identify with the beneficiaries they are serving, increasing their risks of secondary trauma.
Organizations can provide specialized education, ensure national staff members receive regular
clinical supervision, and limit workloads, so they have sufficient time to spend with family and
friends. Lastly, organizations should be attentive to the economic pressure that national staff
members may face to continue to remain in positions even though working with trauma survivors
may cause emotional harm. Transitioning overwhelmed national staff members into positions
that do not involve direct work with survivors of trauma may be beneficial.
Security. International development professionals are regularly exposed to health and
security risks such as accidents, political unrest, diseases, intentional violence, and loss of life.
SECONDARY TRAUMA
32
Organizations must anticipate risks and implement preventive measures. In addition, they must
have comprehensive plans to address security and safety incidents, and all staff members must be
trained on the procedures.
Workload and time away. Lastly, organizations must manage the workloads of
international development professionals, so their work is achievable. Living within communities
that have tremendous needs, international development professionals may feel pushed to work
beyond the point that is healthy, so organizations need to take an active role in narrowing work
expectations in order to preserve the ability of professionals to sustain their work long term. In
addition, they must support international development professionals taking time away from the
disaster site for rest and relaxation breaks and home leaves.
Further Research
Interventions that address secondary trauma among trauma professionals within the field
of international development are rich areas for further research. Researchers should explore the
effectiveness of various interventions and their impact on secondary trauma. As research
expands within the field, the development of guidelines with interventions that are validated for
effectiveness will become more realistic. Some specific interventions that may impact secondary
trauma include the quality and frequency of clinical supervision, structure of jobs, amount of
exposure to traumatic material, degree of structure and processes for addressing risks, types of
social support mechanisms, and amount of time away from the worksite.
The relationship between the type of disaster and secondary trauma warrants further
research. Exploring differences in secondary trauma levels between natural and human-made
disasters may illuminate the need for different types of interventions. In human-made disasters,
such as wars and genocide, people caused the trauma to one another out of fear, greed or hatred.
SECONDARY TRAUMA
33
In earthquakes, hurricanes, and tsumanis, acts of nature cause the destruction. Research on
visibility and level of resources provided to respond to a disaster may impact secondary trauma.
Exploring differences between high profile and well-resourced disaster recovery efforts, such as
tsunami relief of 2004 compared to poorly resourced recovery efforts such as the ongoing war in
Congo, may reveal the need for specialized approaches.
National staff members hold a unique role in supporting international development
efforts. In many cases, they may have experienced the same tragedies as the beneficiaries they
are supporting. Additional research on the differences between expatriate staff members, whose
work in the region is generally time-limited, and national staff members who are part of the
communities they serve, is essential in designing effective programs that address secondary
trauma. Also valuable is further research that explores cultural and regional differences in
secondary trauma and responses to intervention strategies.
Summary
International development professionals, who respond to disasters and contribute toward
the healing of survivors of trauma, face risks of secondary trauma that can harm the emotional
health of professionals, undermine the quality of work provided to survivors, and limit the ability
of international development organizations to fulfill their missions. Organizations have an
obligation to address the risks of secondary trauma, just as they plan for security threats.
Ultimately, the field needs a comprehensive set of standards that are adopted by all international
organizations working with trauma that mitigate the risks of secondary trauma. Included in the
paper are a beginning set of recommendations encompassing administrative stresses, social
support, education, security risks, clinical supervision, specialized needs of national staff
members, and workload. Further research on the effectiveness of interventions intended to
SECONDARY TRAUMA
address secondary trauma in international development organizations will build on the current
recommendations.
34
SECONDARY TRAUMA
35
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