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

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

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.

“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)

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).

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).

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

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.

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).

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

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

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

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)

Definitions

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

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).

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.

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.

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.

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.

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).

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.

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.

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.

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).

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.

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

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

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.

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

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

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.

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

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

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

Evaluating Professional Quality of Life Scale: http://www.proqol.org/uploads/ProQOL_5_English_Self- Score_3-2012.pdf

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

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.

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

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

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.

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”

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

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)

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

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

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)

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

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

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

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.

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, 2002. pp. 155-170. 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), 371-389. 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), 350-363.

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), 31- 52. 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), 227-243. Maslach, C. and Jackson, S. E. (1981). The measurement of burnout. Journal of Occupational Behavior, 2, 99-113. Maslach, C. (1976). Burn-out. Human Behavior, 5 (9), 16-22. 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, 131-149.

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), 336-341. 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), 545-553. 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, 150-177. 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, 2011. Rothschild, B. & Rand, M. (2006). Help for Helpers. NY: W.W. Norton & Company, Inc.

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: www.dynamicharmony.com 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), 309- 323. Zimering, R., Gulliver, S.B.; Knight, Jeffrey; Munroe, James; Keane, Terence M.; Journal of Traumatic Stress, Vol 19(4), Aug, 2006. pp. 553-557.

Web Resources Websites on CF http://www.breathofrelief.com/ http://www.compassionfatigue.org/ http://www.headington-institute.org/Default.aspx?tabid=2648