CHAPTER 1: INTRODUCTION
Post-traumatic stress disorder occurs after experience with a traumatic or terrifying event where there was either physical or bodily harm, or the victim was threatened. Some of the events that may lead to this condition may include sexual or physical assault, the death of a loved one, war, disaster, accidents etc. and tend to cause intense fear, tension, and helplessness. Considering that the ailment manifests itself in the form of mental images and events, the consequences may last for a long time and it may require the help of a professional or the family to help a person overcome this. More to this is the fact that the condition can be passed on to people who are in close proximity to the victim and may include the families, emergency personnel and rescue workers. Hence, on this context, the secondary traumatic stress may be defined as the result of behaviors and emotions that arise from the knowledge about an event encountered by a person or from the trial to help a person affected by trauma (Figley, 1995)
Numerous studies have been conducted on the effect of post-traumatic stress disorder on social workers. The studies have mainly focused on the measures that might be required so as to protect the same staff, such as in the case of social workers of the 9/11 attack, the survivors of the Holocaust and their children, the spouses of the victims of rape and assault and the people working as counselors for victims. In this case, it has been stated that these people may indicate signs of posttraumatic stress through the secondhand exposure of trauma histories of others (Pulido, 2007).Considering the September/11 attack, social workers were subjected to secondary traumatic stress mainly because of trying to help the victims of the attack.
The environment in terms of the society and community and the events leading to traumatic events are the main factors that may increase or decrease the vulnerability of an individual to the secondary traumatic stress.
Research has indicated that mental health social workers who specialize in disaster management are particularly at a very high risk of secondary traumatic stress. These people are subjected to various disaster issues at a single time and in new surroundings. As matter of fact, different types of disasters have different capabilities of exposing a social worker to secondary traumatic stress. Events that have a higher probability of occurring such as in the case of tsunami, have lesser effects than events that have very little probability of occurrence, such as in 9/11 (Pulido, 2007).If the natural disaster occurs by an intentional and deliberate act, the probability of these professional being subjected to this disorder increases by threefold (Creamer & Liddle, 2005).
Purpose of the Study
This paper focuses on social workers and the ability to get affected by secondary traumatic stress syndrome. Considering that there are different varieties and types of social workers, the main emphasis will be on social workers in the clinical field and the exposure to secondary traumatic stress. These professionals may be exposed to simultaneous effects of trauma and hence it is important to put them into consideration.
Another aspect in post-traumatic stress to be considered is whether the gender of a clinical social worker has anything to do with secondary traumatic stress. It may be wise to consider that both men and women have different emotional capabilities and are different in terms of empathic connections to other people. It is this that is the underlying factor in trying to understand whether the different genders have different capabilities of being affected by post-traumatic stress syndrome in the field of clinical social work.
Significance of the Study
To begin with, the mental health professionals and the people who are involved in training have to understand the impact of the line of work on individuals. In this aspect, each field that exposes an individual to secondary traumatic stress has to come up with measures that will be preventive All these measures require proper implementation and supervision. Furthermore, clinicians who are to a large extent exposed to these risks need proper assessment, supervision, and training to ensure that they are not exposed to this condition. These people are the most exposed to stress because of these traumatic experiences and by ensuring that they are regularly attended to, the effects might be prevented.
The second factor is the provision of recommendations on the assurance to clinical workers that the administration and agency support their activities. This may require that these management bodies take part in organizational training and management of secondary traumatic syndrome so as to boost the support of their workers. The clinical staff feels at a better position to use these methods on themselves when there is recognition that the systems are very effective.
There should be a methodology designed so that the clinical staff can manage future disasters in a better way. The ability to understand encountered disasters and design the methodology on how to effectively counter it is likely to have a soothing effect on the staff particularly for future purposes.
CHAPTER 2: REVIEW OF LITERATURE
The first line of treatment for people who have come across traumatizing events is the mental health services. Traumatic events often lead individuals to professional experts such as psychologists and psychiatrists.This is regarded as a form of medication. It has been estimated that in a community, 94% of people seeking mental health reported at least one traumatic event. On the other hand, psychiatric hospitals report at least 64% of traumatic events. (McFarlane, Bookless, & Air, 2001).
It is this interaction between traumatized victims and mental therapies that exposes these professionals to the risk of a secondary traumatic syndrome. The details of the traumatic events that are mainly centered on violence, war, accidents and are vividly described to the therapists which results into an emotional connection. In a survey that was conducted on 446 female psychotherapists, 72% indicated an exposure rate of ‘frequently’ or ‘sometimes’. Another separate survey of 221 mental health professionals, the exposure rate was described as moderate by 45.2% while 24.2% reported a profound exposure to traumatic events (Kadambi & Truscott, 2004). It is this exposure to these traumatic materials that has been regarded as an occupational hazard to these healthcare professionals.
The last 15 years have produced remarkable discovery on the effects of this exposure to therapists and mental health care experts. Various names have been used to describe this type of disorder: secondary victimization, compassion fatigue, secondary traumatic stress, vicarious traumatization among others. This indirect form of exposure manifests itself in different ways such as the functioning, disorders and even clinical symptom.
Furthermore, not only is this disorder limited to mental health workers, various professionals who work with trauma victims are also people of interest. Some of these professionals include firefighters, policemen, nurses, domestic violence advocates etc. These professionals in one way or another get exposed to traumatic events \and are likely to develop secondary traumatic stress. However, the group of professionals that is most vulnerable to this disorder is that of the mental health therapists.
Mental health therapists and workers are most vulnerable to secondary traumatic disorder because of empathic engagement with the client and the amount of exposure associated with the traumatic event. (Figley, 1995). On this note, it is important to note that secondary traumatic stress disorder disregards these primary victims and tries to describe the people: family, people, friends’ personnel etc. that come into contact with them. It furthermore describes the indirect effect of these traumatic events on the emotional and physical characteristics of this personnel and people. In effect, the symptoms of these secondary victims may be similar to those of the primary victims and may include intrusive imagery that may be related to the primary traumatic events (Courtois, 1988).
Figley’s Trauma Transmission Model
Figley (1995), tried to investigate the process through which secondary traumatic stress occurs. In his analysis, he found out that the key players in this transfer of trauma are exposure and empathy. Exposure in the sense of getting acquainted with the traumatic event and empathy which creates an emotional connection. In the model, compassion stress is the stress connected to the victim’s traumatic event while compassion fatigue is the physical, mental and social state exhaustion associated with the stress. In this effect, the ability to have a healthy relationship with the victim depends on various factors that include: empathic ability, empathic concern, and empathic response. These factors combined with the satisfaction of helping trauma victims determine the level of compassion stress. This process of empathic engagement determines the vulnerability to secondary traumatic stress.
This unique term is used in identifying the symptoms that are observed in therapists’ treating trauma victims and survivors (McCann & Pearlman, 1990). Empathic engagement with the victims results in a change in the inner experience of the therapists and may end up causing painful disruptions to his or her sense of meaning, connection, identity, beliefs, psychological needs, and interpersonal relationships. The main cause of this disorder is the permanent engagement with various trauma victims.
The causes of vicarious traumatization may include direct exposure to trauma victims and their description of the event, reading and professional presentations related to trauma and supervision of trauma cases (Rosenbloom, Pratt, & Pearlman, 1995).The major symptom that indicates vicarious traumatization is disruptive imagery in the sense that the therapists are able to create mental images of the traumatic events of their clients subsequently altering their own. As a result, there are significant changes in the psychological and interpersonal functioning of their brains (McCann & Pearlman, 1990).The manifestation of these traumatic experiences of the victims can occur to the therapist in form of flashbacks and dreams which may result in changes in emotion.
Social Workers in the Clinical Field and Exposure to Post Traumatic Stress Disorder
Mental Health Social workers
This is a group of health professionals who are mandated with the responsibility of providing help and mental support to many fragile people who might be at the point of suicide. In this respect, 28 to 33% of these mental health workers have come across patients with fatal client suicide behavior while over 50% have come across patients with non-fatal client suicidal behavior. This may present a difficulty in trying to describe the reaction of a social worker considering that they display different characteristics in response to the patients.
Many cases have been documented that go on to indicate that secondary traumatic stress is more prevalent among mental health workers who are in contact with traumatized patients. One of the most common behavior and reaction among this group of professionals is the fatal and nonfatal client suicidal behavior. The behavior is, in fact, the most stressful among this group of professionals and is defined as the suicide attempt or suicide completion by any victim. The disorder seems to rubs onto the professional and various cases have been reported. It is therefore imperative to establish the residual effects of these effects on the health professionals.
The increase in mental health delivery by social workers has reportedly increased the exposure to 33% (Ann & Keilg, 2010).In this respect, mental health social workers tend to feel more about the personal reactions of the trauma victims than any other mental health professional such as psychologists and psychiatrists. Furthermore, because of the personal caregiving according to the victim, these professionals have additional feelings and reactions which to some extent may mean that they experience secondary post-traumatic syndromes. Some of the emotions that they show include sadness, shock, disbelief, irritability, and other personal feelings.
The defense mechanism is an unintentional and unconscious response to a traumatic event while coping with these traumatic events is conscious and intentional. Therefore, it has been a concern if the coping mechanism is bound to change over time. These mechanisms have been described as either positive or negative; repressive or avoidant and problem focused or emotionally focused. This does not indicate that these mechanisms are exclusively used but are in most circumstances used simultaneously. A mental social health worker who may have experienced suicidal and non-suicidal client behavior may try to suppress his/her emotions and this might lead secondary traumatic stress behavior.
The reaction and the perceptions of mental health workers are directly related to the encounter with clients with suicidal behavior. The study purports that 52.5% of this class of social workers experience fatal and non-fatal client behaviors in comparison to any other type of mental health professionals such as psychiatrists and psychologists. On the aspect of gender, men experienced more avoidant reactions and behaviors while women might be more inclined towards intrusive reactions and an increased level of secondary traumatic stress.
In an examination that was conducted on mental health social workers who had come in contact with clients expressing suicidal behaviors, most displayed reactions such as sadness, irritability, depression, and anger all on a personal level and on the professional level. These effects of the clients seemed to rub onto the emotions on the social worker on a professional level and included the feeling of failure in professionalism and the blame to oneself. All these behaviors displayed were on a short-term lease but the long-term effects displayed included long-term guilt as well as a change in the clinical practice (Courtois, 1988). In another attempt to fully understand these sort of behaviors, studies were conducted on another set of mental health social workers who had come in touch with patients who displayed symptoms of fatal client suicidal behaviors. The most prevalent reactions from the social health workers included avoidance, intrusion, shock, anger towards the patients and the agencies involved, self-blame, as well as isolation and justification. The study was conducted on mental health social workers with agency support and those without this support and the final conclusions drawn were that those with agency support felt these effects at a much lower level.
On this note, it is imperative to understand the coping mechanisms that these social health workers use to overcome the trauma of suicidal clients. These coping behaviors can either be classified as either positive and adaptive or negative and maladaptive (Aldwin & Yankura, 2004).In this respect, the positive behaviors have no adverse effects and are mainly aimed at helping reduce anxiety and stress while also improving the situation without any harm. The positive behaviors may include exercise, mediation, seeking social support among others. On the other hand, negative behaviors may include substance abuse which is just a measure to reduce stress on a short term. These short-term goals end u worsening the situation further.
Considering the stress relieving strategies, on the part of the mental social health workers, the best used coping behaviors were: decreasing the attachment to the behavior and responsibility, talking with the colleagues and the agencies and accepting the possibility of suicide in the lifetime of a human being. On the aspect of gender, men and women have different coping strategies with women indicating that talking with colleagues is the most effective method, unlike men who only see talking to colleagues and concentrating more on work as an effective method only after returning to work (Farberow, 2005).
In another study that was basically conducted on psychology interns, it was found out that the support accorded to an individual by the supervisory staff was more important than the support given by peers, family, and friends (Arvay, 2001). The study furthermore goes on to state that without this supervisory help, the clinician survivor is at most times left with guilt, anxiety, self-doubt, shame which may subsequently lead to questions regarding the professionalism and his/her competency. On this aspect, it is important to note that increasing the supportive roles of agencies and providing procedures that that help in dealing with client suicidal behaviors the mental social worker improves the coping mechanism and responses.
The 9/11 social workers
It is important to look at the 9/11 terrorist attack considering that it brought about serious mental health issues across the country but particularly so to the families and survivors of the attack. After the attack, there were various mental health social workers who were rallied to help support for all these people and considering that they were exposed to the pain and suffering of other people, later on, there were indications of secondary traumatic stress syndrome.
This terrorist attack can basically be considered the blueprint for the establishment of the management framework of mental health social workers. This is particularly so because this group has indicated high levels of posttraumatic stress, particularly because there was no effective supervision nor coping mechanisms that were provided as a guide.
The terrorist attack was unique in that there had been no other similar case prior to this. In this, the clients’ own stories interacted with the clinicians own stress levels and terrorist concerns, subsequently raising the secondary traumatic stress beyond the simple additive effects (Pulido, 2007).In this case, the experiences of these social workers were completely different. There were various issues involved with the social work such as: dealing with families who had lost relatives, in other circumstances people who had fled the burning towers, and the people who were indirectly affected. Furthermore, it is wise to note that between the searching for friends and families, DNA testing, searching and planning memories and funerals for the remains of other people there must have been a major toll taken on these social workers.
The mental preparedness of the health workers during this period may be described as not so good considering that most of them had not been properly trained on disaster mental counseling and had no experience or clue whatsoever on how to handle the new cases brought to them by the affected. Furthermore, because of the long-term exposure of these health workers to the same stories over and over again, intrusive, avoidant and hyperarousal symptoms became evident on these social workers (Pulido, 2007). Finally, when the mental weight increased, the stories are said to have become even more painful to hear. The emotional repercussions that are described thereafter include anger and irritability, during and after the sessions. In other circumstances, some social workers got so emotionally attached to the victims that they would eventually break down into tears and often described the effect of listening to all those victims was like a re-experience of their trauma.
In the long run, particularly after the event had passed, there were varied intrusive smells that would tend to give these social workers a reminder of 9/11, ranging from olfactory smells to blue skies, which would give an impression that there was a probability of something nasty happening. It is this emotional attachment to the event that has been described as a scar to these health workers and tends to distort their lives. With this incident came the avoidant symptoms of the social workers and include: feeling numb about the event or doubting its occurrence and avoiding the world trade center. On the other hand, hyperarousal symptoms that have been associated with the social health workers most particularly surround traveling and safety issues particularly on bridges, subways or even planes.
On the professionalism aspect, the health social workers maintained a sense of doubt in the sense that they felt that they did not provide enough help to the victims of this tragedy. It is because of this doubt that these social workers had an increased sense of anxiety considering how they failed in the provision of these services. Finally, other social health workers had become prone to anger particularly because even though the time devoted to the clients was enough, there was little that they could do. All the above-stated effects eventually had an effect of physical and mental exhaustion to these workers. (Pulido, 2007)
Most of the social workers do not experience this emotional rollercoaster during the time of service. It is reported that in the case of the 9/11 tragedy, the social workers maintained their emotional and physical balance during the time of service and it is after the disaster was over that the symptoms of secondary traumatic stress became evident. In respect to the years after the incident that the symptoms started showing, some indicated that they managed to avoid the emotional attachment for about two years after the event while others described the numbness went to over three years.
Gender and Secondary Traumatic Stress
Gender and secondary traumatization syndromes have been largely ignored. It is with this effect that some studies have been conducted to try and indicate the difference in susceptibility of the two genders of mental health professionals to secondary traumatization. Considering the clinicians who treat traumatized clients, it has been estimated that female professionals are more susceptible to this disorder (Ann & Keilg, 2010).
In one study, gender has been described as a major predictor for intrusion symptoms. This study was primarily focused on the roles that gender, prior trauma and age after prior trauma play in the development of secondary traumatic stress. To begin with, a total of 39.3% of female participants and 33.3% of male participants reported a history of assaultive trauma (Ann & Keilg, 2010).
It is also important to consider that most women may be subject to traumatic events which may subsequently lead to their secondary traumatic syndromes in their line of work. Furthermore, on the study conducted, Post hoc analysis found that female gender was a statistically significant unique predictor, explaining 1.2% of a variance in intrusion symptoms (American Psychiatric Association, 2000). Prior studies that found no association between gender and secondary traumatic stress/vicarious trauma symptoms failed to separate out particular symptom categories.
The study tried to explain the possibility of a prior trauma acting as a sensitizing factor in on the later development of secondary traumatic stress/vicarious trauma in women professionals (Arvay, 2001). On the contrary, regardless of the gender, assaultive trauma history can play a big role in the development of secondary traumatic syndromes. In eventuality, being female along with having an assaultive trauma history predicts more severity of symptoms on any case of secondary traumatic syndromes (Briere, 1995)).
Lastly, on a model developed specifically to assess the frequency of intrusion, avoidance, and arousal symptoms associated with secondary traumatic stress/vicarious trauma resulting from working with traumatized population, the sample selected was primarily composed of white females particularly on master’s level social science having worked in the field of social science for approximately 15 years. Of this group, 15.2% displayed clinical levels of secondary traumatic stress/vicarious trauma (Bride, 2007).This is particularly a major boost in trying to establish the role that gender plays not only on women professionals but on the general population.
The term traumatic is relative in the sense that a traumatic experience to one person may be a different experience for another person. In this respect, the ability of an individual to cope with an event and his/her own perception is what determines if it is traumatic. The perception of a traumatic experiences varies from individual to individual and the people who perceive events as traumatic are the likely victims of mental disorders such as post-traumatic stress disorder, Acute Stress Disorder, Major Depression, Anxiety, and substance abuse.
In turn, the events seem to rub onto the mental care professional considering the vivid descriptions of traumatic events, human cruelty and other emotionally oriented descriptions. This exposure to such descriptions has further on been regarded as an occupational hazard.This varied exposure to traumatic events may lead to various changes to these mental therapists because of the emotional connection. More to this, the symptoms of secondary traumatic stress include cognitive schema disruption, post-traumatic stress disorder symptoms and interpersonal disruption (Collins & Long, 2003).
Studies have gone an extra mile to prove that between 5% and 15.2% of therapists experience vicarious traumatization and secondary traumatic stress basically at the clinic level (Adams & Riggs, 2008). This can result in negative implications for the clients because the therapists will try to distance themselves and poor judgment
CHAPTER 3: METHODOLOGY
The methodology for this research will take place as a systematic review of relevant literature, and proposed methodology for field research incorporating survey or questionnaire tools: 1) an unstructured, open-ended survey of social workers and 2) a Likert Scale questionnaire for respondents that will add quantitative data among those reporting experience with SPTS symptoms. Survey and questionnaires will be anonymous, and care will be taken to carry all necessary Institutional Review Board (IRB) protocols for research involving human subjects (NIH, 2016; IRB, 2017).
The systematic review of literature will focus primarily on mental therapists with little consideration for the other professions involved in the mental care sector. The aim of this literature is to form the foundation of the research and will most likely be combined with the practical aspect of this field of work. A more important aspect to be studied will be the manifestation of SPTS on the mental health therapists and the 9/11 social workers.
Literature research will utilize specific keywords to find highly relevant data on precise study inquiries, backed by empirical or consensus-based evidence and published in professional journals. A special effort will be made to find highly reliable research findings that have withstood scrutiny in peer review publications or presentations
The systematic review of the relevant literature will give basic knowledge on the problem of Secondary traumatic stress among social workers and will give insights into this research. More to this is that the study may be centered on gender and the difference in the vulnerability of the two genders. On this aspect, the primary focus will be on female social workers of which study has indicated might be more vulnerable.
The first inclusion criteria are on the membership roles of social workers. The study will be aimed at about 500 social workers who played an active role in the National Association of Social workers. The group will be limited to at least 19 years work experience. The group is required to identify the people who had major practice in mental health. This selection criterion is on the basis that this group is likely to have personal contact with the victims and would be more open about the experience.
A second criterion will include a Likert Scale questionnaire on which they can mark, on a scale of SPTS symptoms or manifestations of shock, from one to nine, the level of difficulties they experienced with respect to the intense exposure they record in the open-ended survey.
The third aspect to be included in the research is the aspect of gender. Considering that there are different levels of vulnerability for both male and female, the ratio of participation will be 50:50.In this, there is likely to be discernible differences in the observations.
Finally, the aspect of the 9/11 workers has to be included. The study will focus on their experiences during and after the 9/11 incidence. Furthermore, the body that was mandated with the responsibility of these workers will have to be consulted to provide basic information about the frameworks employed for social workers before and after the event.
(1) Secondary Post Traumatic Stress; (2) social worker; (3) mental therapists; (4) 9/11; (5) mental health; (6) treating SPTS; (7) Shock; (8) trauma; (9) suicidal behavior.
The class of social workers that has not been registered to any association of social workers will be neglected. The aspect of mailing questionnaires is likely to give the study a hectic time if the address is not in any database. More to this exclusion is the fact that social workers not affiliated with any association are likely to provide wrong and unreliable information particularly on themselves.
On to the aspect of registered social workers, the availability of this group will influence the inclusion into the study. Some of the social workers may not be available for interviews or questionnaires or might not be willing to participate in the study. It is thus very important to include only the class of social workers willing to partake in the study
Limitations of the Study
To begin with is the access to computers and online interviews and questionnaires. Some of the social workers could not respond through email because of the difficulty in accessing internet and online services. This was a limitation to the amount of data collected.
The non-random selection of the clinical workers is likely to have a bias implication on the studies. The selection of social workers was focused on the national association of social workers which limited the scope of the study team. A more inclusive approach need to be considered for all the workers that deal with secondary traumatic stress.
Finally, the probability of the data being biased has to be considered. Some questionnaires involved personal questions that the respondents might have deliberately given false information. Such questions might involve sexuality, sexual interest, and sexual satisfaction
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CHAPTER 1: INTRODUCTION