Secondary trauma

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Secondary trauma can be incurred when an individual is exposed to people who have been traumatized themselves, disturbing descriptions of traumatic events by a survivor, or others inflicting cruelty on one another. [1] Symptoms of secondary trauma are similar to those of PTSD (e.g. intrusive re-experiencing of the traumatic material, avoidance of trauma triggers/emotions, negative changes in beliefs and feelings and hyperarousal). [1] [2] Secondary trauma has been researched in first responders, [3] nurses and physicians, [4] mental health care workers, [2] and children of traumatized parents. [5]

Contents

Affected populations

Mental health care workers/social workers

Secondary Traumatic Stress (STS) impacts many individuals in the mental health field and as of 2013 the prevalence rates for STS amongst different professions is as follows: 15.2% among social workers, 16.3% in oncology staff, 19% in substance abuse counselors, 32.8% in emergency nurses, 34% in child protective services workers, and 39% in juvenile justice education workers [2] There is a strong correlation between burnout and secondary traumatic stress among mental health care professionals who are indirectly exposed to trauma and there are a multitude of different risk factors that contribute to the likelihood of developing secondary traumatic stress amongst individuals who conduct therapy with trauma victims. [1] Workers who have had a history of trauma are more likely to develop STS. Additionally, individuals who have less work support as well as less social support are at higher risk for developing STS. Lastly, as the number of patients seen by these workers increases, so do the chances of developing STS. Some of the protective factors for mental health care workers include years of experience in the profession, more time spent in self-care activities and high self-efficacy. [6]

Another social work-related profession that is impacted by secondary trauma is librarianship. Public librarians work closely with vulnerable, at-risk populations, and often experience emotional and psychological strain while doing so. [7]

First responders

Studies explain how secondary traumatic stress can negatively impact job performance in first responders which can lead to adverse outcomes not only for the first responders, but for the victims they seek to help. Job context is a greater risk factor for developing STS in first responders compared to the job content. This highlights the need for strategies targeted toward the organizational and systemic level in addition to the individual level. Organizational changes that can be addressed include work culture, workload, group support, supervision and education, and the modification of the work environment. Changes in these areas would foster resiliency for developing STS. [3]

Nurses and physicians

Similarly, research highlights the importance of psychological services for nurses and medical professionals. Services similar to the ones listed above for the first responder population were valuable for reducing secondary traumatic stress symptoms amongst medical staff working with traumatic populations in hospital settings. [4]

Children of traumatized parents

Van Ijzendoorn et al. (2003) conducted a meta-analysis of 32 studies with 4,418 participants in which they explored secondary trauma in children of Holocaust survivors. The authors found that in non-clinical studies no evidence of secondary traumatization, while clinical studies only showed evidence for secondary traumatization when additional stressors were also present. [8] [5] Intergenerational trauma or transgenerational trauma is also applied to describe the process by which parental traumatic experiences may lead to secondary trauma symptoms in their offspring, when additional stressors, such as war, famine, or displacement are present. [9] Refugee children who are exposed to these additional stressors display heightened anxiety levels, and have an increased likelihood of experiencing traumatic life events, compared with non-refugee children in the United States. [10]

Measurements

Secondary Trauma Self-Efficacy (STSE) Scale is a seven-item measure used to assess a person's beliefs about their ability to cope with barriers associated with secondary traumatic stress. The STSE measures one's "ability to cope with the challenging demands resulting from work with traumatized clients and perceived ability to deal with the secondary traumatic stress symptoms". [2] In addition to the STSE, there is the STSS. The Secondary Trauma Stress Scale (STSS), is a 17-item questionnaire that measures the frequency of secondary traumatic stress symptoms over the past month. Questions on the STSS addresses issues with intrusion, avoidance and arousal symptoms similar to those found in PTSD.

Interventions

Phipps and Byrne (2003) detail some potential treatments for STS based on the premise that STS and PTSD symptomology are similar in nature. Some brief interventions for STS include critical incident stress debriefing (CISD), critical incident stress management (CISM) and stress inoculation training (SIT). CISD is a one session exposure-based intervention aimed at reducing distress by having the client recall and explain the traumatic event to a group and a facilitator 48–72 hours after the traumatic incident. The facilitator then provides education on the reasons for the symptoms and processes of trauma in a safe environment. The seven-phase debriefing technique includes: 1. Introduction, 2. Expectations and facts, 3. Thoughts and impressions, 4. Emotional reactions, 5. Normalization, 6. Future planning/coping and 7. Disengagement. This has been shown by multiple studies to have damaging effects on the survivors and actually exacerbates the trauma symptoms present.

CISM is another one session exposure-based intervention aimed at reducing distress by having the client recall and explain the traumatic event but has a follow-up component. CISM consists of 3 phases: 1. Pre-trauma training, 2. Debriefing and 3. Individual follow-up. CISM differs from CISD in the sense that two components are added and believed to be the driving factors for symptom reduction in individuals with STS. Firstly, the pre-trauma training of Stress Inoculation training is implemented and secondly the follow-up assessments after one month.

SIT is a type of training that uses skills to lower autonomic arousal when exposed to the traumatic material. These techniques include muscle relaxation training, breathing retraining, covert self-dialogue and thought stopping. SIT provides skills to reduce trauma symptoms whereas CISD does not. These learned skills are imperative when faced with trauma symptoms and have been shown to be the most helpful type of intervention. It is recommended to implement both pre and post interventions in order to provide the best care. [11]

Bercier and Maynard (2015) explain that, to date, there is no empirical evidence to support effectiveness of interventions for mental health care workers (psychologists, social workers, counselors and therapists) who experience symptoms of STS. Although there is no empirical support for the efficacy of these interventions, there still are some interventions that are recommended for reducing symptoms of STS. Accelerated Recovery Program (ARP) has been specifically designed to treat symptoms of STS. ARP is a five-session program aimed to reduce negative arousal states that result from STS. Primary focus of STS symptom reduction has been at the individual level, but some interventions to reduce STS symptoms have been proposed at the organizational level. These organizational interventions include the provision of supervision, workshops and supportive organizational culture. [12] [6] [2]

Similar concepts

Secondary trauma is often used interchangeably with several terms that have similar meanings including compassion fatigue, vicarious trauma, [13] second victim syndrome, and job burnout. [6] Although there is an overlap in terminology, there are nuanced differences.

Compassion fatigue

Compassion fatigue refers to a reduced capacity to help as a health care professional after being exposed to the suffering and distress of their patients. [13] Secondary traumatic stress was later renamed compassion fatigue in 1995 by Charles Figley who described compassion fatigue as the natural emotions that arise as a result of learning about a significant others' experience with a traumatic event. [12] Overall, compassion fatigue is often used interchangeably with secondary traumatic stress but the difference between the two is that STS is specific to individuals who treat traumatized populations whereas CF generalizes to individuals who treat an array of other populations.

Vicarious trauma

Vicarious traumatization (VT) is defined as a transformation of a helper's inner experience that is a result of empathic engagement with a client's traumatic experiences. [12] This engagement with the client results in a shift in the cognitive schemas about oneself, the world, others. Vicarious trauma is similar to secondary traumatic stress, but individuals with VT display only one subtype characteristic of PTSD, negative changes in beliefs and feelings. VT fails to address other subtypes of PTSD symptoms (i.e. re-experiencing, avoidance, and hyperarousal). [6]

Second Victim Syndrome (SVS)

Second Victim Syndrome (SVS) was defined originally by Albert Wu in 2000, describing the impact of medical error on Health Care Providers (HCPs), especially when there has been an error or the HCP feels responsibility for the outcome. "Although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims," wrote Wu in the BMJ. [14] Susan D. Scott, PhD, RN, CPPS described a predictable phenomenological pattern that second victims experience after an adverse event: 1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. [15] SVS has been compared to PTSD affecting second victims and others further describe tertiary victims as hospital reputation and other patients due to subsequent medical errors. [16]

Job burnout

Research describes job burnout as the burnout of an individual as a resultant of additive stress and lack of accomplishment in the workplace leading to poorer work performance. [13] The concept of job burnout was originally developed to assess negative consequences of work-related exposure to a broad range of stressful situations experienced by human services employees. Job burnout is considered a symptom of STS, but STS is not a symptom of job burnout. [6]

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, such as experiencing violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

Complex post-traumatic stress disorder (CPTSD) is a stress-related mental disorder generally occurring in response to complex traumas, i.e. commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Peer support occurs when people provide knowledge, experience, emotional, social or practical help to each other. It commonly refers to an initiative consisting of trained supporters, and can take a number of forms such as peer mentoring, reflective listening, or counseling. Peer support is also used to refer to initiatives where colleagues, members of self-help organizations and others meet, in person or online, as equals to give each other connection and support on a reciprocal basis.

Compassion fatigue is an evolving concept in the field of traumatology. The term has been used interchangeably with secondary traumatic stress (STS), which is sometimes simply described as the negative cost of caring. Secondary traumatic stress is the term commonly employed in academic literature, although recent assessments have identified certain distinctions between compassion fatigue and secondary traumatic stress (STS).

Critical incident stress management (CISM) was a controversial, non-empirical, adaptive, short-term psychological helping-process that focused solely on an immediate and identifiable problem. It included pre-incident preparedness to acute crisis management through post-crisis follow-up. Its purpose was to enable people to return to their daily routine more quickly and with less likelihood of experiencing post-traumatic stress disorder (PTSD). However, after researchers showed that debriefing techniques did not decrease rates of PTSD, CISM is now seldom used and has largely been replaced with immediate psychological care techniques that do not use debriefing such as those endorsed by the CDC, Red Cross, WHO, American Psychological Association and National Center for Post Traumatic Stress Disorder (NC-PTSD). Responsible practitioners who still use CISM must eliminate debriefing steps in order to remain compliant with best practices and clinical guidelines.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

<span class="mw-page-title-main">Military sexual trauma</span> U.S. legal term for sexual assault or harassment during military service

As defined by the United States Department of Veterans Affairs, military sexual trauma (MST) are experiences of sexual assault, or repeated threatening sexual harassment that occurred while a person was in the United States Armed Forces.

Incident stress is a condition caused by acute stress which overwhelms a staff person trained to deal with critical incidents such as within the line of duty for first responders, EMTs, and other similar personnel. If not recognized and treated at onset, incident stress can lead to more serious effects of posttraumatic stress disorder.

Vicarious trauma (VT) was a term invented by McCann and Pearlman that is used to describe how working with traumatized clients affects trauma therapists. Previously, the phenomenon was referred to as secondary traumatic stress coined by Charles Figley. The theory behind vicarious trauma is that the therapist has a profound world change and is permanently altered by the interaction of empathetic bonding with a client. This change is thought to have three conditional requirements: empathic engagement and exposure to graphic and traumatizing material, the therapist being exposed to human cruelty, and reenactment of trauma within the therapy process. This change can produce changes in a therapist's sense of spirituality, worldview, and self-identity.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Childbirth-related post-traumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. This disorder can also affect men or partners who have observed a difficult birth. Its symptoms are not distinct from post-traumatic stress disorder (PTSD). It may also be called post-traumatic stress disorder following childbirth (PTSD-FC).

<span class="mw-page-title-main">Transgenerational trauma</span> Psychological trauma

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the shared family environment of the infant causing psychological, behavioral and social changes in the individual. The term intergenerational transmission refers to instances whereby the traumatic effects are passed down from the directly traumatized generation [F0] to their offspring [F1], and transgenerational transmission is when the offspring [F1] then pass the effects down to descendants who have not been exposed to the initial traumatic event - at least the grandchildren [F2] of the original sufferer for males, and their great-grandchildren [F3] for females.

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Center for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been endorsed and used by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

A moral injury is an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression on the part of themselves or others. It produces profound feelings of guilt or shame, moral disorientation, and societal alienation. In some cases it may cause a sense of betrayal and anger toward colleagues, commanders, the organization, politics, or society at large.

Compassion fatigue (CF) is an evolving concept in the field of traumatology. The term has been used interchangeably with secondary traumatic stress (STS)s. Secondary traumatic stress is the term commonly employed in academic literature, although recent assessments have identified certain distinctions between compassion fatigue and secondary traumatic stress (STS).

Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological experiences of trauma, to gain a greater sense of ownership over their bodies, and to augment their overall well-being. However, a 2019 systematic review found that the studies to date were not sufficiently robustly designed to provide strong evidence of yoga's effectiveness as a therapy; it called for further research.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Over the last fifty years, there has been an increase in the different types of media that are accessible to the public. Most people use online search engines, social media, or other online news outlets to find out what is going on in the world. This increase can lead to people easily viewing negative images and stories about traumatic events that they would not have been exposed to otherwise. One thing to consider is how the dissemination of this information may be impacting the mental health of people who identify with the victims of the violence they hear and see through the media. The viewing of these traumatic videos and stories can lead to the vicarious traumatization of the viewers.  

References

  1. 1 2 3 Cieslak R, Shoji K, Douglas A, Melville E, Luszczynska A, Benight CC (February 2014). "A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma". Psychological Services. 11 (1): 75–86. doi:10.1037/a0033798. PMID   23937082. S2CID   6963118.
  2. 1 2 3 4 5 Cieslak R, Shoji K, Luszczynska A, Taylor S, Rogala A, Benight CC (September 2013). "Secondary trauma self-efficacy: concept and its measurement". Psychological Assessment. 25 (3): 917–28. doi:10.1037/a0032687. PMID   23647049.
  3. 1 2 Kleim B, Westphal M (2011). "Mental health in first responders: A review and recommendation for prevention and intervention strategies". Traumatology. 17 (4): 17–24. doi:10.1177/1534765611429079. S2CID   71392117.
  4. 1 2 Beck CT (February 2011). "Secondary traumatic stress in nurses: a systematic review". Archives of Psychiatric Nursing. 25 (1): 1–10. doi:10.1016/j.apnu.2010.05.005. PMID   21251596.
  5. 1 2 Lambert JE, Holzer J, Hasbun A (February 2014). "Association between parents' PTSD severity and children's psychological distress: a meta-analysis". Journal of Traumatic Stress. 27 (1): 9–17. doi:10.1002/jts.21891. PMID   24464491.
  6. 1 2 3 4 5 Hensel JM, Ruiz C, Finney C, Dewa CS (April 2015). "Meta-analysis of risk factors for secondary traumatic stress in therapeutic work with trauma victims". Journal of Traumatic Stress. 28 (2): 83–91. doi:10.1002/jts.21998. PMID   25864503.
  7. ↑ Smith, Daniella L.; Bazalar, Bryan; Wheeler, Maurice (2020-05-18). "Public Librarian Job Stressors and Burnout Predictors". Journal of Library Administration. 60 (4): 412–429. doi:10.1080/01930826.2020.1733347. ISSN   0193-0826. S2CID   216228849.
  8. ↑ van IJzendoorn MH, Bakermans-Kranenburg MJ, Sagi-Schwartz A (October 2003). "Are children of Holocaust survivors less well-adapted? A meta-analytic investigation of secondary traumatization". Journal of Traumatic Stress. 16 (5): 459–69. doi: 10.1023/A:1025706427300 . PMID   14584630. S2CID   36093276.
  9. ↑ Sangalang CC, Vang C (June 2017). "Intergenerational Trauma in Refugee Families: A Systematic Review". Journal of Immigrant and Minority Health . 19 (3): 745–754. doi:10.1007/s10903-016-0499-7. PMC   5362358 . PMID   27659490.
  10. ↑ Betancourt, Theresa S.; Newnham, Elizabeth A.; Birman, Dina; Lee, Robert; Ellis, B. Heidi; Layne, Christopher M. (2017). "Comparing Trauma Exposure, Mental Health Needs, and Service Utilization Across Clinical Samples of Refugee, Immigrant, and U.S.-Origin Children". Journal of Traumatic Stress. 30 (3): 209–218. doi:10.1002/jts.22186. ISSN   0894-9867. PMC   5711415 . PMID   28585740.
  11. ↑ Phipps AB, Byrne MK (2003). "Brief interventions for secondary trauma: Review and recommendations". Stress and Health. 19 (3): 139–147. doi:10.1002/smi.970.
  12. 1 2 3 Bercier ML, Maynard BR (2015). "Interventions for secondary traumatic stress with mental health workers: A systematic review". Research on Social Work Practice. 25 (1): 81–89. doi:10.1177/1049731513517142. S2CID   72951658.
  13. 1 2 3 Huggard P, Unit G (2013). "A systematic review of the measurement of compassion fatigue, vicarious trauma, and secondary traumatic stress in physicians" (PDF). Australasian Journal of Disaster and Trauma Studies. 2013 (1): 37–44.
  14. ↑ Wu, Albert (2000). "Medical error: the second victim". BMJ. 320 (7237): 726–727. doi:10.1136/bmj.320.7237.726. PMC   1117748 . PMID   10720336.
  15. ↑ Scott, Susan (2009). "The natural history of recovery for the healthcare provider "second victim" after adverse patient events". Qual Saf Health Care. 18 (5): 325–330. doi: 10.1136/qshc.2009.032870 . PMID   19812092. S2CID   38366449.
  16. ↑ Ozeke, Ozcan (2019). "Second victims in health care: current perspectives". Adv Med Educ Pract. 10: 593–603. doi: 10.2147/AMEP.S185912 . PMC   6697646 . PMID   31496861.
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