Week 11, DQ 1

Social Work in Mental Health

ISSN: 1533-2985 (Print) 1533-2993 (Online) Journal homepage: www.tandfonline.com/journals/wsmh20

Hidden trauma victims: Understanding and preventing traumatic stress in mental health professionals

Hanae Kanno & Martha M. Giddings

To cite this article: Hanae Kanno & Martha M. Giddings (2017) Hidden trauma victims: Understanding and preventing traumatic stress in mental health professionals, Social Work in Mental Health, 15:3, 331-353, DOI: 10.1080/15332985.2016.1220442

To link to this article: https://doi.org/10.1080/15332985.2016.1220442

Published online: 24 Mar 2017.

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Hidden trauma victims: Understanding and preventing traumatic stress in mental health professionals Hanae Kanno, PhD, MSW, MA and Martha M. Giddings, PhD, LCSW

Department of Social Work, Valdosta State University, Valdosta, Georgia, USA

ABSTRACT Mental health professionals, including social workers, are often exposed to the traumatic experiences of clients in their work with victims of violence, crime, and disaster. Given their empa- thetic engagement with traumatized victims, they may experi- ence severe emotional reactions such as terror, grief, and rage. Empirical evidence identifies these emotional reactions as “trau- matic stress” including burnout, Traumatic Countertransference (TC), Vicarious Trauma (VT), and Secondary Traumatic Stress (STS)/ Compassion Fatigue (CF). In this study, the history and definition of each traumatic stress are examined, and differences among them are explored. Preventive strategies for reducing traumatic stress in mental health professionals are discussed.

KEYWORDS Burnout; Compassion Fatigue; mental health professionals; preventive strategies; Secondary Traumatic Stress; Traumatic Countertransference; traumatic stress; trauma victims; Vicarious Trauma

For the past decade, the annual total of victims of violence and serious crime on average (domestic violence, rape, sexual assault, robbery, and aggravated and simple assault) was 6,623,500 in the United States (Bureau of Justice Statistics, 2003–2012). In 2014, Children’s Advocacy Centers served over 315,000 child victims of sexual abuse nationally, providing victim advocacy and support to these children and their families (National Children’s Alliance, 2013–2014). During the past decade, the United States became one of the top 5 countries that are most frequently impacted by natural disasters (Guha-Sapir, Hoyois, & Below, 2014). Due to both the prevalence and traumatic outcomes of violence, crime, and disaster, mental health professionals such as social workers are quite likely to work with victims of these traumatic life events. Not surprisingly, social workers and other mental health professionals are likely to spend much of their time listening empathically to clients’ trauma histories as well as specific, trau- matic life events. In the process, social workers may encounter visual evidence of physical injuries to clients as well as psychological scars and emotional damage related to traumatic, and often horrific, experiences. Just as these experiences are overwhelming to the client at the time of the

CONTACT Hanae Kanno [email protected] Dewar College of Education and Human Services, Department of Social Work, Valdosta State University, 1500 North Patterson Street, Valdosta, GA 31698. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wsmh.

SOCIAL WORK IN MENTAL HEALTH 2017, VOL. 15, NO. 3, 331–353 http://dx.doi.org/10.1080/15332985.2016.1220442

© 2017 Taylor & Francis

trauma, the subsequent retelling and reliving of these experiences during clinical interviews can be extremely stressful and anxiety-provoking for clinicians. Clinical interviews can also be highly stressful because traumatic stories are often told as if they are happening in the moment, with descriptions and images so vivid that they assail the senses of the practi- tioner. Human beings’ typical responses to situations involving extreme fear and terror include fight, flight, freeze, or collapse (van der Kolk, 2014, p. 80), and yet clinicians must sit calmly, projecting empathy as they listen intently to what may be highly distressing content. The current article will explore the impact of trauma-related practice on mental health profes- sionals including social workers.

A growing body of research affirms the fact that work with trauma victims and the process of listening empathically to trauma victims impact those who are trained to help them. Canfield (2005) notes that traumatic images may remain with social workers who may reexperience the images after sessions have ended. Additionally, social workers may experience strong emotional reactions such as grief, rage, and outrage over time (Canfield, 2005), and they may become exhausted by trying to connect empathically with these clients. As a result of intensive interactions with traumatized clients (potentially along with their own exposure to direct trauma), mental health professionals themselves may be exposed to a phenomenon that is called traumatic stress (Figley, 1995; McCann & Pearlman, 1990). Figley (1995) recognized that social workers and other mental health professionals are “indirect victims of trauma” through their exposure to clients’ trauma (possibly impacted by their own trauma), and he wrote that those assisting traumatized populations will, at some point in their personal and professional lives, experience some degree of trauma symptoms (Robinson-Keilig, 2014). In a national study of 275 social workers, over half of those employed in mental health were found to be affected by traumatic stress in their personal and professional lives (Ting, Jacobson, Sanders, Bride, & Harrington, 2005).

Until the 1980s, minimal attention was given to the impact of traumatic stress on helping professionals. In 1983, Figley recognized “stress disability” among crisis workers such as police, firefighters, emergency technicians, and other emergency workers assisting families of victims from catastrophes in which the stress resulted from exposure to traumatized populations. However, it was not until the 1990s, that social workers and other mental health workers were identified as “hidden victims” of trauma in our society (Stewart & Hodgkinson, 1994). During this decade, research attention was finally directed to stress that occurs in clinical practice when therapists work closely with trauma victims. The traumatic stress experienced by these work- ers has been variously recognized as Vicarious Trauma (VT) (McCann & Pearlman, 1990) or Secondary Traumatic Stress (STS)/Compassion Fatigue (CF) (Figley, 1995) in the fields of social work and mental health. Others had

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previously identified similar symptoms of stress called burnout (Maslach, 1976, 1982) or Traumatic Countertransference (TC) (Danieli, 1981, 1984).

The current review article defines traumatic stress as occupational stress faced by helping professionals assisting traumatized populations such as VT, STS/CF, burnout, and TC. In this review, the background and definitions of various types of traumatic stress (e.g., VT, STS/CF as well as burnout and TC) will be examined, and differences among these types of stress will be explored. Lastly, preventive strategies for reducing traumatic stress will be considered. The unique contribution of this article includes a review of literature that has been published worldwide over the past 41 years (1974– 2015) including attention to the various types of traumatic stress. Additionally, this review covers not only the literature on the background and nature of each traumatic stress, but it also includes common prevention and intervention methods for each type of stress. Less attention in the literature has been given to an in-depth consideration of both elements. Each term has been clarified in more detail than in previous reviews, and it is hoped that mental health professionals may be able to better identify the type of traumatic stress to which they are being exposed. Awareness and recognition of this problem can lead to the development of best practice strategies for reducing practitioner stress and preventing the emergence of traumatic stress.

Background of traumatic stress in trauma work

Burnout

The term burnout was coined as symptoms of exhaustion, fatigue, and disengagement by human service workers in demanding work environments requiring intense client care by Freudenberger (1974) and Maslach (1976, 1978). In the 1980s, Maslach (1982) elaborated on the nature of burnout by defining it as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among mental health professionals. Burnout is a response to the chronic emotional strain of deal- ing extensively with other human beings, particularly when they are troubled or having problems” (Maslach, 1982, p. 3). Based on his definition, the Maslach Burnout Inventory (MBI) was developed to measure symptoms of burnout (Maslach & Jackson, 1981). Workers who spent more time in the direct care of clients with difficult problems were more likely to show burnout symptoms. While several researchers recognized the most salient features of burnout as chronicity, acuity, and complexity which were beyond the coping abilities of the professional (Freudenberger, 1974, 1975; Maslach, 1976, 1982; Maslach & Jackson, 1981), others recognized these as environ- mental stressors such as role ambiguity and workload (Duquette, Kérowc,

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Sandhu, & Beaudet, 1994; Firth, McIntee, McKeown, & Britton, 1986; Firth, McKeown, McIntee, & Britton, 1987).

Studies of direct exposure to trauma increased in the 1980s because of the growing awareness and recognition of the need for better medical treatment and benefits for Vietnam veterans as well as supporters of sexual assault/ domestic violence victims that were associated with the second wave of the American feminist movement. With increasing trauma research, the 1990s reflected a greater number of burnout studies among mental health profes- sionals who were treating specific groups of trauma victims such as Holocaust survivors, Vietnam veterans, and sexual assault survivors. Research showed that mental health professionals who worked with trauma survivors exhibited a unique distribution of burnout scale scores (Edwards & Miltenberger, 1991; Savicki & Cooley, 1994). Although personal accomplish- ment scores on the burnout scale remained stable, emotional exhaustion and depersonalization scores on the same scale were higher and more compact than in the normative human service sample. Other evidence suggested that a client’s unresolved trauma, the experience of being an auditory witness to the details of traumatic client material, and global emotional reactions to abuse appeared to increase workers’ vulnerability to burnout (Aguilera, 1995; Brown & O’Brien, 1998; Maslach & Leiter, 1997; Neumann & Gamble, 1995; Savicki & Cooley, 1994). Studies of burnout in trauma work further increased in 2000, and researchers began to use the Compassion Fatigue Scale (CFS) (Figley, 1995), which will be described later to measure burnout in mental health professionals assisting traumatized clients.

Traumatic Countertransference (TC)

Along with exploring burnout among professionals who treated trauma survivors, since the 1980s some researchers have studied Traumatic Countertransference (TC) (Herman, 1992; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). Countertransference was defined as “1) thera- pists’ affective, ideational, and physical responses to their clients and their materials, and 2) the therapists’ defenses against the affects, intrapsychic conflicts, and associations aroused by the former” (Pearlman & Saakvitne, 1995, p. 23). TC is the defensive reaction triggered by therapists’ trauma clients such as avoidance (denial or detachment) or overidentification (idea- lization or guilt) based on the therapists’ own life experiences or unresolved trauma (Wilson & Lindy, 1994). TC can occur in clinicians specific to their treatment with traumatized clients which mainly appeared in studies con- ducted in the 1980s (Herman, 1992; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). For example, Danieli produced a groundbreaking study (1981, 1984) of therapists’ reactions to clients who had survived the Holocaust. According to Danieli (1981, 1984), clinicians who were

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Holocaust trauma survivors defended themselves more frequently against listening to the Holocaust experiences of their clients compared to clinicians who were not Holocaust victims. Clinicians who were Holocaust trauma survivors reported 49 TC themes including defensiveness, numbing, denial, avoidance, and overidentification in response to the survivors’ stories. Benedek (1984) explored the TC feelings of clinicians who work with victims of natural and human disasters, and he identified the following common therapist responses to working with these trauma victims: crying, rage, shame, guilt, fear of offering premature interpretations or unrealistic recom- mendations, and activation of a therapist’s own unresolved traumas (Benedek, 1984). Among therapists working with Vietnam veterans suffering from Post-Traumatic Stress Disorder (PTSD), Lindy (1987) found TC themes that were similar to themes identified by Danieli (1981, 1984).

In the 1990s and the 2000s, trauma researchers continued to focus on descriptions of therapists’ TC (Beck & Buchele, 2005; Dalenberg, 2000; Davies & Frawley, 1994; Figley, 1995; Gedo, 2013; Herman, 1992; Maroda, 1991; Pearlman & Saakvitne, 1995; Sexton, 1999; West, 2013; Wilson & Lindy, 1994). They asserted that these types of reactions can lead to empa- thetic strain. TC was measured by Assessment of Countertransference Scale (ACS), which assesses 23 feelings of TC in three factors: closeness, rejection, and indifference (de Moura Silveira et al., 2012; Eizirik et al., 1991).

Vicarious Trauma (VT)

Despite the usefulness of the constructs of burnout and TC, other tools are needed to determine the occupational stress that is unique to those working with traumatized populations. Many of the effects observed in mental health professionals resembled the traumatic stress effects reported by the survivors with whom they worked (Courtois, 1993; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995). McCann and Pearlman (1990) and Pearlman and Saakvitne (1995) suggested that therapists who work with survivors of various types of victimization are at risk for work-related stress reactions. McCann and Pearlman (1990) coined the term VT, to assess occupational stress specific to those working with traumatized populations. VT is defined as disruptions to important beliefs that individuals hold about themselves, other people, and the world, and the process through which the trauma therapists’ cognition and inner experience is negatively transformed as a result of empathetic engagement with clients’ trauma (McCann & Pearlman, 1990; Pearlman, 1999; Pearlman & Saakvitne, 1995). This term includes accounts of violence, rape, or childhood sexual abuse (Herman, 1992), and it results when disruptions to cognitive schemas manifest in five areas: safety, trust, esteem, intimacy, and control (Canfield, 2005; Pearlman & Saakvitne, 1995). Symptoms of VT include safety concerns, sensory imagery

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disruptions, difficulties with relationships, distrust of others, changes in world-view, and tendencies to withdraw from primary relationships (Harris, 1995; van Dernoot Lipksy, 2009). Trauma researchers describe pervasive changes in cognitive schemas that occur in mental health profes- sionals over time as a result of their work with traumatized clients (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995).

The Trauma Stress Institute Belief Scale (TSI Belief Scale) (Pearlman, 1996; Pearlman & MacIan, 1995) is used to measure VT. In a major VT study, Pearlman and MacIan (1995) administered a self-report questionnaire including the TSI Belief Scale to a non-random sample of 788 self-identified trauma therapists. Less time on the job and participation in personal therapy to address trauma work contributed significantly to lower scores on the TSI Belief Scale. Approximately 66% of respondents with a personal trauma history revealed greater disruptions in cognitive schemas than those with no history (Pearlman & MacIan, 1995). In another study on VT of female psychologists and rape crisis counselors, the percentage of survivors on therapists’ caseloads was significantly correlated with self-reported accounts of VT and higher TSI scores (Schauben & Frazier, 1995).

Secondary Traumatic Stress (STS)/Compassion Fatigue (CF)

As studies of direct exposure to trauma increased in the 1980s, Figley (1983, 1985, 1988) and Sparks (1982) began to recognize the unique effects that direct exposure to traumatic events had on therapists. Figley (1983) reported that therapists providing direct service to families traumatized by the victi- mization of a family member could experience traumatic stress symptoms similar to those of the trauma victims. The more this problem has been recognized, the more researchers have begun to investigate how the phenom- enon impacts the personal and professional lives of therapists who work with trauma survivors (Courtois, 1988, 1993; Figley, 1988). After the term VT began to be used (McCann & Pearlman, 1990), other terms of traumatic stress specific to trauma workers’ psychological and behavioral symptoms, STS/CF, were introduced by Figley (1995).

Although the term CF had already appeared in the literature to describe the experience of nurses’ exposure to trauma (Joinson, 1992), the term STS/ CF gained recognition with the publication of Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized by Figley (1995). Since that time, the term has been used frequently in the literature. Figley (1995) defined STS/CF as the behaviors and emotions that naturally result from knowing about the trauma experi- enced by another and caring for or wanting to help the suffering individual. Figley (1995) believed that those exposed to STS/CF suffer from intrusive thinking, periods of avoidance and/or numbing, and persistent arousal just as

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those diagnosed with PTSD. Therapists with STS/CF may avoid hearing traumatic materials, experience traumatic imagery related to the traumatic materials, and suffer from physical symptoms in the form of sleep distur- bance, headaches, gastrointestinal problems, or heart palpitations (Clark & Gioro, 1998; Figley, 1995). The symptoms of STS/CF are nearly identical to the symptoms of PTSD. The main difference between STS/CF and PTSD is that STS/CF is thought to be less severe and to involve a faster rate of recovery (Figley, 1995).

In addition to Figley (1995), Schauben and Frazier (1995) found that therapists with a high percentage of sexual violence survivors on their case- loads reported more PTSD-like symptoms than those with fewer survivors (Schauben & Frazier, 1995). Moreover, Chrestman (1995/1999) and Kassam- Adams (1995) in attempts to test STS/CF, found that the level of exposure to trauma survivors’ stories is associated with increased symptoms of intrusion and avoidance.

Figley (1995) developed the Compassion Fatigue Self-Test for Psychotherapists (CFST), which is used to measure STS/CF. This self-report test has two subscales that work to explain the dimensions of STS and burnout (Figley, 1995). Also, the Impact of Events Scale (IES) (Horowitz, Wilner, & Alvarez, 1979; IES-R; Weiss & Marmar, 1997) and Secondary Traumatic Stress Scale (STSS) (Bride, 1999, 2007) have been used frequently to measure the symptoms of STS/CF.

Differences among the terms used to describe traumatic stress

In the above section, the definition, history, and empirical support for the various types of traumatic stress (burnout, TC, VT, and STS/CF) were explored. Disparities among the different concepts will be addressed in the following section.

Differentiating STS and CF

Figley (1995) used the terms, STS and CF interchangeably and suggested that the two concepts refer to the same phenomenon. He preferred CF as a reference term because it has a more accessible framing and connotation (Baranowsky, 2002; Figley, 1995, 2002). Although Figley (1995) stated that CF more aptly described the stress and fatigue that compassionate profes- sionals may feel from functioning in their line of work, the literature com- monly references both terms.

In contrast, Stamm (1997) argues that STS and CF are different constructs. Stamm (1997) suggests that CF is a more general term that describes the overall emotional and psychological fatigue that helping professionals experi- ence because of their chronic use of empathy to treat suffering clients (Figley,

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1995, 1999). For mental health professionals that treat trauma victims, STS may contribute to their overall feeling of CF; however, helping professionals who treat populations other than trauma victims (such as the mentally ill) also have CF without experiencing STS (Newell, 2008). CF, a term with a broader definition than STS, includes the symptoms of both STS and burnout (Newell, 2008; Stamm, 1997). In fact, Figley’s (1995) CFST includes the two subscales of CF and burnout.

Differentiating STS/CF and VT

Since the term, STS/CF, first appeared in 1995, researchers have debated differences between STS/CF and VT. The definition of STS/CF (Figley, 1995) has strong similarities to the definition of VT offered by McCann and Pearlman (1990); however, there are differences in the conceptualization of the two. Figley’s conceptualization of STS/CF does not specifically focus on cognitive symptoms as does Pearlman’s conceptualization of VT. Figley emphasized psychological and behavioral symptoms (1995) that directly link with the symptoms of PTSD (Baird & Kracen, 2006). In contrast, Pearlman’s conceptualization and framework for VT involves disruptions in cognitive schemas or beliefs about self and others based on the Constructivist Self-Development Theory (McCann & Pearlman, 1990; Pearlman, 1998; Pearlman & Saakvitne, 1995). Therefore, STS/CF is grounded in the field of traumatology, and emphasizes clinically observable DSM-V, PTSD-based symptoms of relatively sudden onset. In comparison, VT, a theory-driven construct, emphasizes more gradual, covert, and permanent changes in cognitive schema (Baird & Jenkins, 2003; Figley, 1995).

Differentiating STS/CF, VT and burnout

The key differences between STS/CF, VT and burnout relate to the cause of each traumatic stress. Burnout not only includes those working with trau- matized clients, but it also results from practitioners’ interactions with difficult clients including those who are not traumatized (Canfield, 2005; Iliffe & Steed, 2000; Schauben & Frazier, 1995). Burnout can arise from large caseloads, work isolation, a lack of control, insufficient rewards, unfairness, and other bureaucratic factors (Maslach & Leiter, 1997). While STS/CF is an acute psychological response and VT describes more gradual changes in cognitive schema, burnout may be the “final common pathway of continual exposure to traumatic material” (McCann & Pearlman, 1989, p. 134). Moreover, STS/CF and VT may not be related to workplace conditions (Figley, 1995). However, Figley (1995) labels burnout as a “collection of symptoms associated with emotional exhaustion” in relation to the workplace (p. 11). Another major difference between the concepts is that STS/CF is

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based on the diagnostic conceptualization of PTSD (Pearlman & Saakvitne, 1995) whereas VT is based on cognitive disruptions (McCann & Pearlman, 1990), although burnout does not usually lead to PTSD symptoms and cognitive disruptions. Some empirical evidence supports differentiation of the constructs of STS/CF, VT, and burnout. In a study of counselors that treat sexual violence survivors (Schauben & Frazier, 1995), counselors with a higher percentage of sexual violence survivors on their caseloads reported more symptoms of STS/CF and VT. However, working with survivors was not related to counselor burnout (Schauben & Frazier, 1995).

Differentiating STS/CF, VT, and TC

Trauma researchers have attempted to differentiate STS/CF, VT, and TC (Pearlman & Saakvitne, 1995). First, STS/CF and VT are “longer-term nega- tive reactions to a client’s traumatic materials compared to traumatic coun- tertransference which is viewed as a ‘shorter-term’ response than STS/CF and VT (McCann & Pearlman, 1990). STS/CF and VT occur over time, are cumulative based on numerous therapeutic relationships, and will emerge through TC (Pearlman & Saakvitne, 1995). Secondly, unlike TC, a reaction that should only occur within the context of psychotherapy (Figley, 1995; Sexton, 1999), STS/CF and VT may occur in anyone involved in a relation- ship with a traumatized person (e.g., therapist, family member, friend, and coworker), and is not limited to therapeutic interactions that are seen in psychoanalysis (Newell, 2008). Third, TC which emerges from working with traumatized clients does not necessarily lead to conditions of STS/CF or VT in clinicians (Pearlman & Saakvitne, 1995).

Figure 1 summarizes the relationships and differences among each term of traumatic stress based on previous trauma studies and theories indi- cated by trauma researchers such as Figley (1995), McCann and Pearlman (1989), and Pearlman and Saakvitne (1995). TC may occur at the first point on the pathway of therapeutic relationships between helping profes- sionals and their clients following Pearlman and Saakvitne (1995) who mentioned that STS/CF and VT would emerge through TC. In other words, if helping professionals do not deal with TC, they may develop the symptoms of VT, cognitive distortions, and/or the symptoms of STS, similar to PTSD symptoms (Pearlman & Saakvitne, 1995). If they do not deal with VT or STS/CF well, helping professionals may develop symp- toms of burnout. Burnout may be the final pathway through accumula- tions of trauma exposure whereas VT or STS/CF is an acute response which may lead to burnout if untreated (McCann & Pearlman, 1989). Theoretically, however, the symptoms of CF consist of both symptoms of STS and burnout although STS and CF refers to almost same phenomenon and are used interchangeably (Figley, 1995). VT, STS, CF, and burnout can

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occur in any context to anyone who plays the role of a helper in their relationships; the contexts do not have to be in therapeutic relationships (Newell, 2008). In contrast, TC can occur in only therapeutic relationships (Figley, 1995; Sexton, 1999).

Common preventive strategies for traumatic stress

Researchers that have explored the various types of traumatic stress (e.g., STS/CF, VT along with burnout and TC) have suggested a number of strategies to prevent traumatic stress in helping professionals (Pryce, Shackelford, & Pryce, 2007). All levels of workers need adequate workplace support in order to identify and mitigate risk factors associated with traumatic stress. The following recommendations are offered as empiri- cally-based strategies for preventing traumatic stress in social workers, mostly from the administrative perspective (Joslyn, 2002; Nelson-Gardell & Harris, 2003). Additionally, because some social service organizations do not recognize concerns about traumatic stress prevention, workers must take the initiative of inoculating themselves to remain healthy. In terms of stress prevention within organizations, Dershimer (1990) has emphasized the key role played by administrators of social service agencies in respond- ing to worker stress.

Figure 1. Relationships and differences among each term of traumatic stress.

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Administrative actions that can mitigate traumatic stress in workers

It can be argued that human service administrators have an ethical respon- sibility to ensure the well-being of their staff in addition to their mandate to provide efficient and effective consumer services. However, this lofty goal seems somewhat incongruous in regard to current agency practices which appear to be driven more by funding cutbacks, the mantra of “doing more with less,” high levels of staff turnover, increasing consumer demands for services, cutbacks on client services, and the ongoing search for new funding streams. Whereas agencies must focus on these factors to ensure their survival, Dershimer (1990) highlights the critical role that administrators play in terms of maintaining a healthy workforce by their awareness of traumatic stress prevention and by their provision of support for the emo- tional needs of their workers. One key trauma prevention strategy involves the establishment of worker support systems which include regular super- visory meetings to provide workers with emotional outlets for processing trauma-specific work experiences. Studies reveal a correlation between higher degrees of employee supervision and lower levels of traumatic stress (Bonach & Heckert, 2012; Choi, 2011; Creamer & Liddle, 2005; Ewer, Teesson, Sannibale, Roche, & Mills, 2015; Hodgkinson & Shepherd, 1994; Lybeck- Brown, 2002; Naturale, 2007; Slattery, 2003).

Despite the recommendation for increased worker support systems, many trauma workers do not receive adequate levels of weekly supervision that provide them with psychosocial support. Workers may receive regular administrative supervision emphasizing their work responsibilities, but less attention is given to the provision of supervisory meetings convened to help them process the emotional impact of their work with traumatized popula- tions. Because of this deficit in worker support, employees are not taught critical coping skills such as how to maintain healthy boundaries with clients so as to avoid traumatic stress (Badger, 2001). Badger (2001) suggests that the organizational use of one or more of the commonly-used stress indices can help administrators to monitor employees’ trauma levels which facilitates supervisory or worker self-identification of high levels of stress. Importantly, younger, less-experienced trauma workers showed higher levels of traumatic stress in a number of studies (Badger, Royse, & Craig, 2008; Creamer, 2002; Creamer & Liddle, 2005; Ghahramanlou & Brodbeck, 2000; Good, 1996; Joubert, Hocking, & Hampson, 2013; Sprang, Craig, & Clark, 2011; VanDeusen & Way, 2006). Elevated trauma scores can be helpful to indivi- dual workers, but in the case of large-scale human tragedies such as 9/11, these scores can quickly identify workers in need of increased emotional support or triage.

Kanno (2010) explored New York City social workers who assisted in the 9/11 crisis. More than half of a sample of social work supervisors reported

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that they did not discuss their reactions to 9/11 with their own supervisors. A major reason for this omission had to do with the fact that these workers had to function in their supervisory roles in order to assist their supervisees in responding to the 9/11 stressors. Not surprisingly, these supervisors experi- enced the stress of their front-line workers as well as their own personal sense of trauma without receiving upper administrative and supervisory support. It is imperative for administrators to establish proactive supervisory plans to target the emotional and psychosocial needs of all levels of staff because of the increasing occurrence of major community crises and natural disasters. To function during serious crises, all staff must be given a structure in which to process their own traumatic experiences and monitor their own psycho- logical health.

Peer support groups (system)

A second administrative strategy that is focused on prevention and mitiga- tion of worker trauma involves establishment of peer support groups or support systems to address the needs of traumatized employees. These groups can be established within human service and other organizations, and they have the potential to strengthen employee cohesion and encourage staff members to function as a team in responding to trauma. The presence of peer support groups provides an outlet for staff members who are experi- encing strong emotional responses to their work.

Peer support has been found to buffer the level of traumatic stress experi- enced by mental health professionals (Bonach & Heckert, 2012; Bride, Jones, & MacMaster, 2007; Choi, 2011; Kanno, 2010; Pulido, 2012; Slattery, 2003). According to these studies, although many helping professionals did not talk about their trauma experiences with supervisors, they did talk with peers, and the availability of peer support contributed to reducing their personal levels of traumatic stress. In fact, peer support may provide the most expedient way to reduce traumatic stress among employees.

Valent (1995) suggests that helping professionals must process their experiences of traumatic stress through treatment teams, consultation with colleagues, and debriefing meetings so that they can analyze their clients’ traumatic experiences more objectively and intervene with clients more effectively, having learned to separate their own traumatic responses from those of their clients. Sharing traumatic experiences with peers as well as exploring the emotional impact of these experiences during team meetings may effectively reduce worker stress. The team approach to dealing with stress is particularly important because some trauma workers are unable to share their experiences with outsiders who do not understand fully the nature of their work and do not know how to help them. Issues of client confidentiality also make sharing with outsiders problematic (Pryce et al.,

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2007). Agency colleagues who are engaged in conducting the same type of trauma work can best understand and validate each other’s experiences without compromising client confidentiality.

Ideally, workers involved with traumatic clients should be employed in a caring, tension-free environment, although this description does not neces- sarily fit the frenetic pace and workload that exists in many human service organizations. Germain (1982) has written at length about the importance of social support, and she points to network support (the individual’s feeling a part of a group whose members share the same interests and concerns) as being necessary for buffering individual stress (Cutrona & Russell, 1990; Lind, 2000). By providing workers with network support, administrators can help them deal more effectively with their own traumatic stress. In practice, cohesive network support, including more casual friendships, tends to be developed informally through social and recreational activities. Administrators have the authority to create supportive opportunities for the staff to form networks using strategies such as group lunches or wellness events that meet the needs of staff. Despite the fact that formal peer support groups may play a positive role in maintaining the well-being of those who treat trauma victims, the reality is that this type of basic staff support is not often viewed as an agency priority, and preventive strategies designed to promote the mental health of staff members are often viewed as less impor- tant than other more pressing agency concerns.

Creating rotation systems among trauma workers

A third strategy for maintaining the mental health of workers involves the use of a rotation system to give trauma workers a fair and reasonable case- load to ensure that trauma exposure is equitable across staff. Empirical evidence suggests that helping professionals exposed to a higher number/ percentage of traumatized clients or materials experience higher levels of traumatic stress (Brady, Guy, Poelstra, & Brokaw, 1999; Chrestman, 1995/ 1999; Creamer, 2002; Ewer et al., 2015; Kanno, 2010; Meyers & Cornille, 2002; Pinsley, 2000; Robinson-Keilig, 2014; Simonds, 1996; Wee & Myers, 2002). One such preventive strategy involves reducing each worker’s level of trauma exposure as well as trauma caseload reduction, if possible. In fact, there is evidence that reducing the number of hours worked with victims of child maltreatment encouraged hospital child protection professionals to remain in their jobs (Bennett, Plint, & Clifford, 2005).

Educational/training sessions for trauma work

A fourth administrative strategy involves development of in-service educa- tional/training sessions to educate workers about the specialized skills they

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need to responsd to trauma victims as well as self-case skills to protect themselves. Training and education sessions may offer a protective factor for workers (Chrestman, 1999; Ewalt, 1991; Flarity, Gentry, & Mesnikoff, 2013; Frazer & Sechrist, 1994; Haviland, Sonne, & Woods, 1995; Perrin et al., 2007; Salston & Figley, 2003). The results of two studies indicate that most workers do not receive adequate training for their work with traumatized populations (Ewer et al., 2015; Kanno, 2010).

The use of training and educational sessions can teach workers the skills and techniques needed to cope more effectively with the traumatic stress reflected in their clients. For example, trauma workers can learn “self-care techniques” such as physical, social, and emotional self-care (Pryce et al., 2007). Physical self-care activities include adequate sleep, rest, exercise, and good nutrition to contribute to workers’ physical well-being. To support social self-care, workers learn to develop diverse sources of social support through relationships with spouses, children, friends, and colleagues. Interactions and activities with those who represent sources of support have been found to promote positive psychological states and reduce negative states (Cohen, 2002; Pryce et al., 2007). Trauma workers also can be taught emotional self-care by assessing their feelings and reactions to their trauma work using one of the traumatic stress scales such as the CFST scale by Figley (1995). Considering the fact that many workers join the helping professions because of their own life experiences, including their own trauma history (Pryce et al., 2007), workers can learn to assess their trauma history which tends to increase their vulnerability to traumatic stress symptoms. Further, workers can learn how their own personal trauma impacts their work with traumatized clients. Other coping skills include the use of humor and laugh- ter which have been recognized as effective ways of coping with horrific situations that workers witness or hear their clients describe (Moran, 2002; Pryce et al., 2007). Finally, agency training and workshops on music therapy (Wlodarczyk, 2010) and art therapy (Landis, 2010; Van der Vennet, 2002) have proven to be effective in reducing traumatic stress.

The authors suggest that social service administrators should consider empirically-based evidence which strongly suggests trauma workers need to develop effective coping strategies. Likewise, administrators should consider the development of both short- and long-term strategies for monitoring, reducing, or preventing high levels of traumatic stress in their workforce. Educational sessions on trauma-related topics appear to lead to better mental health outcomes for helping professionals.

Empowering workers to begin to deal with their own traumatic stress

Whereas human service administrators are in a pivotal position to develop programs to monitor or reduce high levels of traumatic stress in workers, this

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type of worker support often is not provided. Research continues to identify the risks and the impact of traumatic stress on mental health workers. If organizations are unwilling to assist workers exposed to high levels of trauma, individual workers are still in a position to empower themselves to acquire the coping skills needed to maintain their psychological and social health and to learn to take care of themselves. Several strategies will be presented in the next section.

External supervisory and peer support Trauma workers may consider non-agency supervision from competent supervisors who are not a part of the organization. Staff members also may choose to attend external peer support groups in which they can discuss the work that they are doing with trusted colleagues who can, in confidence, help them respond to their high levels of interpersonal stress and to develop effective coping strategies. Informal support has been identified as the stron- gest predictor of prevention of traumatic stress in forensic interviewers from children’s advocacy centers (Bonach & Heckert, 2012).

Formal psychotherapy/counseling Trauma workers also may elect to participate in formal psychotherapy or counseling provided by qualified clinicians knowledgeable about the impact and possible outcomes of trauma exposure. Likewise, they may choose to join a formal support group external to their workplace in order to receive professional help for traumatic stress (Pryce et al., 2007).

External training and education specific to trauma work Another alternative for workers is to seek continuing education programs on trauma so that they become more knowledgeable about the topic. Training sessions and workshops are offered by most professional associations, and now, many educational programs are presented online, through DVDs, or through webinars that can increase workers’ knowledge about a topic without their having to leave the workplace. The goal of such activities is for trauma workers to acquire a significant understanding of trauma and to develop coping skills and strategies that they can use to protect their emotional and mental health.

Conclusion

The depth of the current literature review suggests that it is critical for all human service employers, staff, and professionals to have a clear understanding of the nature of traumatic stress. Whereas trauma can cause debilitating pro- blems in clients, traumatic stress can likewise cause significant impairment in workers. The literature strongly suggests that traumatic stress among clinicians

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who treat severely traumatized victims is not only a workplace issue, but it is an ethical issue in terms of workers being given adequate education and training about the potential impact of traumatic stress, prevention strategies to minimize trauma encountered in the workplace, and remediation strategies in the form of workplace support, supervision, peer support, and in more serious cases, referral to therapy and counseling services.

Administrative strategies for identifying, planning, remediating, and preventing traumatic stress were presented. Clearly, agency administrators have the ability to respond to the needs of their traumatized employees, and administrative strategies are extremely important. Traumatic stress has the potential to adversely affect the job performance of trauma workers causing resignations, and leading to a high job turnover rate (Baird & Jenkins, 2003; Beaton & Murphy, 1995; Harris, 1995). If administrators are unwilling to respond to the needs of their workers in regard to the emergence (or is occurrence better) of traumatic stress, social service agencies are likely to continue to experience these personnel problems. Further, the constant shift in caseloads leaves traumatized clients even more vulnerable to mental health problems. The prevention strategies that were described have been found to be effective in reducing worker stress and in positively impacting agencies.

If social service agencies continue to fail to respond to the needs of their workers, human service professionals are encouraged to begin to learn about their own vulnerabilities to traumatic stress and to take proactive steps to manage their own high levels of stress. In particular, some mental health professionals who assist witnesses and survivors of traumatic events tend to be exposed to many of the same traumatic events as their clients and require assistance with their own trauma (Boscarino, Figley, & Adams, 2004). In fact, many of the previous studies indicated that personal trauma history is strongly correlated with workers’ increasing traumatic stress (Follette, Polusny, & Milbeck, 1994; Ghahramanlou & Brodbeck, 2000; Good, 1996; Kassam- Adams, 1995, 1999; Wrenn, 2005). Workers may need to advocate for and pursue strategies of self-care in order to maintain their own mental health.

Despite the many studies that have been carried out in the area of trau- matic stress, few provide strong empirical evidence indicating the effective- ness of specific treatments for preventing traumatic stress in workers (Flarity et al., 2013; Gentry, Baggerly, & Baranowsky, 2003; McNamara, 2010). Clearly, more rigorous empirical work is needed to successfully identify the effectiveness of specific treatments (Bercier & Maynard, 2015; Novoa & Cain, 2014). Data from two studies (Bearse, McMinn, Seegobin, & Free, 2013; Bober & Regehr, 2006) indicate that some mental health professionals did not utilize preventive activities and faced barriers in seeking self-care strate- gies. Additional studies of these barriers are needed to identify effective solutions.

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Implementation of preventive strategies may enable both agency adminis- trators and individual workers to avoid the pitfalls of traumatic stress and, in turn, to improve the support and care provided to traumatized clients. Since society focuses more on assisting victims of direct trauma, less attention has been given to the indirect trauma faced by social workers and other profes- sionals. Mental health professionals have been called the “hidden victims” of society (Stewart & Hodgkinson, 1994). Trauma workers must learn to recog- nize their own strengths as well as their very real limitations, both as helping professionals and as human beings.

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