1. Sarah Hessenauer, PhD University of Wisconsin – Whitewater
Assisting Interns, Staff and Colleagues in Detecting Secondary Traumatic Stress and Vicarious Trauma
Sarah Hessenauer, PhD
University of Wisconsin – Whitewater

2. Rules for Self-Care
When social workers are exposed to traumatic stories and / or situations, it may cause uncomfortable thoughts and responses.
If you start to feel uncomfortable, take care of yourself. Stand up, take a walk, take deep breathes, employ relaxation techniques, take a break, talk to others, or do whatever works best for you! -Take care of yourself
Be mindful of your feelings
Be respectful to others

3. Examples
A colleague called to tell me about an incident where staff were talking about a death of a client the night before. Two students were in the room as the staff basically said “too bad” and went about their meeting. The colleague admitted they paid no attention to their co-worker who had been the direct worker nor to the students involved who may have never experienced this in their past.
A student in her internship called to state that the agency had been put on alert due to a threatening call, but that they told her to go ahead with her group. During her group, an alarm sounded and she had no training on how to handle the situation.

4. “Often we are not aware we have brought home an un- welcome visitor unless we notice that we are agitated rather than relaxed, have trouble sleeping, or pick a useless fight with our partner and make a connection” (Rothschild & Rand, 2006)
“A profession cannot successfully retain its workforce when issues of personal safety go unaddressed” (NASW & University of Albany, 2006)

5. Social Workers and Trauma Work
Social workers have higher rates of burnout than other helping professionals, such as occupational therapists (Brown, 2008).
In a study of British social workers 74% were experiencing high levels of anxiety (Lloyd et al., 2002)
62% of experienced Child Protective Service workers scored high on a measure of emotional exhaustion. (Anderson, 2001)
In a study by Meyers & Cornille, (2002), of CPS workers interviewed, 82% reported a trauma prior to working in the CPS field, and 77% reported trauma while on job (versus 76% of American adults).

6. Social Workers and Trauma Work Cont.
In 1995, Beaton & Murphy reported social workers experience physiological and physical symptoms, some extending to serious illnesses, and ultimately a higher mortality rate among controls (Figley, 1995).
In one study 17.7% of caseworkers suffered from secondary traumatic stress, while only 15.2% of Vietnam Vets reported post traumatic stress disorder (Kulka et al, 1990).
About 48% of the total workforce in the United States experiences high levels of personal distress as a result of their work (Strozier & Evans, 1998).

7. Self-Care
Social work self-care requires proper functioning at least three neuropsychological symptoms:
Interpersonal empathy
Rothschild and Rand (2006) cite Stern who said “we have the capacity to experience what others experience” and “empathy is an integral, necessary tool of our work” (p. 10).
Impact of motor neurons – brain cells reflect the activity of another’s brain cells (p.42)
Balance in autonomic nervous system and arousal regulation
Clear thinking relying on the balanced functioning of all brain structures

8. Stress
Stressors are situations, conditions, people or things that have the potential to trigger the stress response in us.
Stress can be protective; stress helps us adapt to situations and is important for survival.

9. Impact of Stress
If we allow stress reactions to build, they accumulate and their impact spreads beyond our work life into home and relationships.
Research shows that about 20% of professional helpers are greatly impacted by taking on negative energy from their clients or patients (Thivierge, 2011).

10. Top 10 Signs You Are Too Stressed
You find yourself hoping to get the flu just so you can stay in bed for a day
Your children shutter in fear when your bosses name is mentioned
You have wondered if your cell phone would float when you hurled it into the rive
You start using a pencil instead of a pen to put dates with your partner in your schedule
Medical journals or case files have become “light bedtime readings”
Your best friends think you have moved away since they have not hear from you in so long
You consider Red Bull a part of a balanced diet
You fall asleep during trips to the dentist office, because it is the only time you put your feet up
You are too tired to remember the name of your dog
It takes you six days of vacation to even begin to feel relaxed, and six minutes back at your office to make you forget that you took a vacation
Volk, Guarino, Grandin & Clervil, 2008

11. Cognitive Stress Signs
Stress Reactions
Physical Stress Signs
Cognitive Stress Signs
Headaches
Exhaustion
Teeth grinding
Negative rumination
Insomnia
Inability to focus on a task
Irritability, anger
Reduced libido
Muscle tension
Reduction in joy
Gastric disturbance
Mental fatigue
High blood pressure
Feelings of futility
Rapid heartbeat
Devaluing of co-workers

12. How Is Your Life Affected By Stress?
How does your body react to stress?
How is your personal life affected by stress?

13. Student Specific Stressors
Beginning workers
Role conflicts
Expectations of field and academic learning
Nature of field setting
Population served
Supervisors lack of attention to students’ emotional reactions; current emphasis on an education model rather than on a growth model (Litvack, Bogo, & Mishna, 2010)

14. Definitions

15. Trauma Exposure to a situation in which:
The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
The person’s response involved intense fear, helplessness or horror
PTSD (Post Traumatic Stress Disorder)
An anxiety disorder in which one may experience nightmares, flashbacks, heightened arousal, etc., related to a traumatic event.
APA, 2000

16. Trauma
Figley (1995) suggested that PTSD should be called primary post-traumatic stress disorder, whereas the same symptoms appearing secondarily to the victim care in helpers should be called secondary traumatic stress disorder (exposure to the traumatized person rather than to the traumatic event itself).

17. Re-Traumatization
The individual having experienced their own traumatic event may develop symptoms that are reactivated by hearing the client tell their story of trauma.

18. Secondary Traumatic Stress
Zimering, Munroe, and Bird Gulliver (2003) identify secondary traumatic stress as “indirect exposure to trauma through a firsthand account or narrative of a traumatic event” (n.p).
Bober and Regher (2005) stated that secondary traumatic stress has symptoms similar to PTSD; however the trauma is due to working with someone else who has experienced the direct trauma and not the social worker.

19. Secondary Trauma and the Brain
1990’s, research began to look at the role of mirror neurons in the brain and their association with Compassion Fatigue (which will be discussed further). There is some speculation that the contagiousness of laughter and yawning may be connected to the function of the mirror neuron. There is a mimicking response observed, that may be triggered by these mirror neurons. The mirror neurons reflect the activity of someone else’s brain cells (Rothschild, 2006).
Mimicking can work both ways.

20. The Brain and Countertransference
“Unconscious attunement to and absorption of victims’ stresses and traumas” (Figley, 2002, p. 19)
Not easily accessible via words
Intrusive type countertransference leads to loss of boundaries, over-involvement, reciprocal dependency, and pathological bonding
Avoidance type countertransference leads to withdrawal, numbness, intellectualization, denial.

21. Vicarious Trauma
McCann and Pearlman (1995) identified vicarious traumatization (VT) as the transformation that occurs when an individual begins to change in a manner that mimics a client’s trauma-related symptoms (experience in social workers’ nervous systems).
Vicarious traumatization tends to be the result of repeated exposure to traumatic stories which results in a change in the social workers thinking / core beliefs.
The social worker begins to interpret and relate to the world in a new manner and his/her inner experience is altered by exposure to trauma work (Figley, 2002, p. 157).

22. Vicarious Trauma
VT emphasizes the way the therapist’s experience of the self is altered in terms of identity, world view, spirituality, self capacities, ego resources, psychological needs, and the sensory system. Moreover, VT disrupts the therapist’s sense of safety, trust, esteem, intimacy, and sense of control (Pearlman & Saakvitne, 1995).
In effect, VT resembles the effects of trauma on the client. Over time, the therapist is changed as a consequence of empathic engagement in clients’ stories of sadism, cruelty, betrayal, neglect, abandonment, and exploitation.

23. Vicarious Trauma
In psychotherapy with traumatized individuals, it has to be assumed that our subjectivity, including our organizing principles, are altered by VT.
First, vicarious trauma weakens the therapist’s capacity to be emotionally flexible and available to the client’s emotional needs, that is, to provide a holding environment and to sustain affective attunement through empathic immersion in the client’s subjective experience.
Second, the intersubjective field of the client–therapist is always shaped by the therapist’s emotional experience of this relational domain, in addition to the client’s experience.

24. Compassion Satisfaction
Compassion satisfaction is about the pleasure you derive from being able to do your work well.
For example, you may feel like it is a pleasure to help others through your work and that we provide them with some relief, growth or healing.

25. Compassion Fatigue
The term compassion fatigue has been around since 1992, defined by both Johnson and Kottler (Figley, 2002).
Compassion fatigue is experienced by caregivers who are overly focused and upset by the cumulative trauma of those they are trying to help.
The symptoms are similar to those of post traumatic stress disorder (PTSD).

26. Compassion Fatigue Defined
Compassion Fatigue is defined as the social workers decreased ability to be empathic or able to “bear the suffering of clients” and is “the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced or suffered by a person” (Figley, 1995, p. 7).
Siegel, 2010, indicates it affects our ability to be fully “present” with our clients. Our past, especially histories of trauma, restrict our plateau’s and create valenced states that bias how we will view certain situations. When we sense danger, we cannot activate the social engagement system or self- engagement system. It will cause us to disengage from our clients.

27. Compassion Fatigue Examples
A female case manager working with women who have been sexually assaulted assumes that all men she encounters are unsafe
Staff working at an eating disorder center start to believe that 100 lbs. is a good weight for an adult female
Someone you have supervised for years has developed a recent habit of checking with you before making any decisions, questioning whether his actions have any value to the clients he once felt confident working with
Adapted from Volk, Guarino, Grandin & Clervil, 2008

28. Compassion Fatigue Symptoms
Excessive Blaming
Bottled Up Emotions
Isolation from Others
Poor Self-Care
Diminished Sense of Safety
Nightmare
Difficulty Maintaining Boundaries
Exhaustion
Apathy
Sadness / Depression
Aggression towards Others
Decreasing Sense of Competency
Questioning Personal Values

30. Burnout
The state which occurs when stress reactions reach a crisis point. More commonly experienced by staff and caregivers in response to continual exposure to other peoples pain.
Health may be suffering or outlook on life becomes negative.
It grows over time and unlike Compassion Fatigue, burnout is caused by stress and hassles, such as paperwork/phone calls, rather than over-empathizing with the trauma of those you work with.
It is the predictable, cumulative effect from the impact or overload of their work.

31. Unaddressed burnout can lead to compassion fatigue.
Remember the instructions from the flight attendant, “If the cabin loses air pressure, oxygen masks will drop from the ceiling. Please put on your own mask before assisting others.”
Help yourself before you can help others
Adapted from Volk, Guarino, Grandin & Clervil, 2008

32. Burnout Physical symptoms include: Emotional symptoms include:
fatigue, low energy
poor sleep and headaches
irritability
Emotional symptoms include:
anxiety and depression
hopelessness
aggression and cynicism
substance abuse

33. Other Warning Signs
Baranowsky (2002) identifies other warning signs as:
Wishing the client would just get over it.
Using anger or sarcasm with clients.
Blaming a client for their problems.
Fearing what the client will want to talk about.
Using humor with a client to minimize his / her problems.

34. Organizational Symptoms of Compassion Fatigue
High absenteeism
Constant changes in co-workers relationships
Inability for teams to work well together
Desire among staff members to break company rules
Outbreaks of aggressive behaviors among staff
Inability of staff to complete assignments and tasks
Inability of staff to respect and meet deadlines
Lack of flexibility among staff members
Negativism towards management
Strong reluctance toward change
Inability of staff to believe improvement is possible
Lack of a vision for the future

35. Cost of Not Addressing
Job performance decreases in terms of productivity
Mistakes increase
Office morale drops
Work relationships suffering
Personal life suffers, increased risk for substance abuse
Can lead to problems with health
Isolation from support networks
Decreased sense of self esteem and confidence
High staff turn over ($)
Increase use of sick leave ($)
Lack of collaboration with other offices

36. Risk Factors for Social Workers
Caseload
History of personal trauma
Lower level of trauma training
Lack of control over work schedule
Lack of organizational support
Poor self-care

37. Evaluating Professional Quality of Life Scale:
Score_ pdf

38. Mean scores of PROQOL Subscale UWW BSW N=49
Prior BSW Study (Knight, 2010)
N=42
Research Participants
(Stamm, 2005)
N=1000 (Mental health professionals)
Compassion Satisfaction
43.65/43.89
41.3 37
Secondary Traumatic Stress
18.19/17.37
11.2 13
Burnout
19/17
18.5 22

39. NASW Code of Ethics
We have an ethical responsibility to engage in appropriate and responsible self-care.
The NASW Code of Ethics states that “a social worker’s ethical behavior should result from their personal commitment to engage in ethical practice.”
Ongoing self-care is the foundation of that “commitment” to ethical practice.
We need to identify our secondary trauma and vicarious trauma so that we can address to prevent related negative consequences.

40. Protective Factors for Social Workers
Job satisfaction and personal gratification protect us
Management of vital functions (sleep, food, recreation) (Yassen, 1995)
Proper training, including helpers’ ability to read and care for their own stress responses
Training in safety/debriefing after “traumatic” event
Balanced number/level of trauma clients in your caseload
Relationships with others that convey cooperation and respect
Benefits that allow for time-off, vacation, and mental health care
Good self-care
Good boundaries

41. Meyers & Cornille’s Study Recommends:
Improved training
Recognize and normalize secondary traumatic stress
Owning personal trauma history
Recognize gender differences (recognize how males and females react differently after being exposed to abuse)
Coping strategies
Handling on-the-job victimization
Providing a supportive work environment
Limiting work hours
Personal care

42. Caregiving Organizations
“Holding Fast” – Kahn (2005)
What is Object Relations?
How people internalize and externalize their relationships with others.
“Good enough” others.
What is a Caregiving Organization?
Those agencies whose primary task is the effective providing for people seeking healing, growth, learning or support form another.
Relationships are based on premise that growth, healing, and learning involves risk and vulnerability on part of those we treat.
Caregivers must contain (absorb thoughts and feelings), provide empathic acknowledgement, and provide an enabling perspective (take over others ego functioning until they can do this on their own). Each of these require a unique set of skill and sophistication, along with stamina. Stress is an inevitable by product.

43. Caregiving Organizations (Cont.)
Object Relations view of self-care in organizations
“the quality of care given to care seekers depends on the extent to which caregivers are emotionally ‘held’ within their own organizations…the institution as a whole becomes therapeutic and its members model caretaking behaviors toward one another”
“the extent to which caregivers are emotionally held within their own organizations is related to their abilities to ‘hold’ others”
Leadership in Caregiving Organizations
Create strong vision and mission which supports resiliency
Supervision is key – allow staff to explore issues
Leaders become ultimate attachment figures – contain emotion and model appropriate behavior
Leaders must assist with change
“Leaders must hold lightly, hold firmly, and hold courageously”

44. Helping Student / Interns
Discuss strategies to address any potential violence prior to student starting: help student to potential situations, teach safety education, help students understand rights, and discuss fears
Address students over-identification (distorted reality) and low sense of coherence (confidence) (Ying, 2009)
Offer agency debriefing and support to students after a stressful situation
Critical incident stress debriefing
Counseling referral as needed
Schools should provide training for field educators on client violence issues

45. Self-Care Defined
“A person’s emotional and psychological capacity to cope with demands across time, circumstance, and setting’ (Ashford, Lecroy, & Lortie, 2006)
Self-care enhances well-being and involves purposeful and continuous efforts that are undertaken to ensure that all dimensions of self-care receive the attention that is needed to make the person fit to assist others (Moore, Bledsoe, Perry & Robinson, 2011)

46. Self-Care Strategies How do you care for yourself?
What are the benefits?

47. Tools
Self-Care Assessment Tool: Self-Care
Organizational Self-Care Checklist

48. Self-Care Strategies at Work
Seek supervision and guidance
Peer consultation about clients
Regular lunch breaks
Taking short breaks at work
Utilize Employee Assistance Programs
(Eastwood, C.D. & Ecklund, K, 2008)

49. General Self-Care Strategies
Acknowledge your work will affect you
“Know thyself”
Obtain trauma training
Learn about burnout
Mixed literature on this however, many of us know the fact but do not live it.
Seek consultation and supervision
Seek professional help when needed
“Heal old pain”
Get proper nutrition, sleep, and exercise
Use humor to relieve tension
Develop realistic expectations about your role
Examine self-talk

50. General Self-Care Cont.
Build a strong support network
Balance between personal and professional life
“Sick days versus wellness days”
Pursue leisure activities
Moderate caffeine / alcohol use
Maintain professional contacts
Meditation and body therapy (yoga, massages, etc.)
Reflect
Evaluate and set new goals
Be kind to yourself

51. Other Ideas Attending cultural events Hobbies
Take medications as prescribed
Take trips for pleasure
Volunteer
Journal
Church / worship services

52. How to Help Others
When approaching your colleagues about their stress, compassion fatigue or burnout---make sure to have this conversation while they are not distracted or overly stressed.
Identify stress-relief solutions such as retreats and workshops.

53. Resources
Baird, K. & Kracken, A. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counseling Psychology Quarterly, 19(2): 181–188.
Baranowsky, Anna B.; In: Treating compassion fatigue. Figley, Charles R. (Ed.); New York, NY, US: Brunner-Routledge, pp
Bober, T. & Regehr, C. (2006). Strategies for Reducing Secondary or Vicarious Trauma. Brief Treatment and Crisis Intervention 6 (1); 1-9.
Criss, P. (2010). Effects of client violence on social work students: a national study. Journal of Social Work Education, 46 (3),
Figley, C. R. (Ed.) (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. NY: Brunner/Mazel.
Figley, C. R. (2001). Renewing Spirits: Lessons From Thirty Years of Trauma Work, Invited keynote address to the William Wendt Center for Loss and Health Conference on Illness, Grief & Trauma, Washington, DC, October 6.
Figley, C. R. (Ed.) (2002). Treating Compassion Fatigue. New York: Brunner- Routledge.
Harr, C. & Moore, B. (2011) Compassion fatigue among social work students in field placements. Journal of Teaching in Social Work, 31(3),

54. Resources
Kabat-Zinn, J. (1994). Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, New York: Hyperion
Knight, C. (2010).Indirect trauma in the field practicum: Secondary traumatic stress, vicarious trauma, and compassion fatigue among social work students and their field instructors. Journal of Baccalaureate Social Work, 15(1),
Kulka, R. A.,Schlenger, W. E.,Fairbank, J. A.,Hough, R. L.,Jordan, B. K., Marmar, C. R.,Weiss, Daniel S. (1990). Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans readjustment study. Philadelphia, PA, US.
Litvak, A., Bogo, M., & Mishna, F. (2010). Emotional reactions of student in field education: an exploratory study. Journal of Social Work Education, 46(2),
Maslach, C. and Jackson, S. E. (1981). The measurement of burnout. Journal of Occupational Behavior, 2,
Maslach, C. (1976). Burn-out. Human Behavior, 5 (9),
McCann, I. L. and Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3:2,

55. Resources
Miller, K. I., Stiff, J. B., & Ellis, B. H. (1988). Communication and empathy as precursors to burnout among human service workers. Communication Monographs, 55(9),
Moore, S.E., Bledsoe, L.K., Perry, A.R., Robinson, M.A. (2011) Social work students and self-care. Journal of Social Work Education, 47 (3),
Morrisette, P. J. (2004). The Pain of Helping: Psychological Injury of Helping Professionals. NY: Brunner-Routledge.
Pearlman, L A. & Saakvitne, K. W. (1995). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorders in those who treat the traumatized, NY: Brunner/Mazel.
Pierson, J.E. Vicarious Trauma and Self-Care. Retrieved from: dhss.delaware.gov/si08/files/si09_1314_vicarioustrauma_selfcare.pdf, April 10,
Rothschild, B. & Rand, M. (2006). Help for Helpers. NY: W.W. Norton & Company, Inc.

56. Resources
Siegel, D. (2010). The mindful therapist: a clinician's guide to mindsight and neural Integration (1st ed). New York: W. W. Norton & Company.
Stamm, B.H. (2005) The ProQol Manual. Lutherville, MD: Sidran Press.
Thivierge, R. (2001). Healing from Secondary Trauma and Vicarious Trauma. Retrieved from: on April 5, 2011.
van der Kolk, B. (2005). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society (1st ed). Guildord Press. New York: New York.
Ying, Y (2009). Contribution of self-compassion to competence and mental health in social work students. Journal of Social Work Education, 45(2),
Zimering, R., Gulliver, S.B.; Knight, Jeffrey; Munroe, James; Keane, Terence M.; Journal of Traumatic Stress, Vol 19(4), Aug, pp

57. Web Resources Websites on CF http://www.breathofrelief.com/