Expert Answer:SOCW6333 Walden self-care and Wellness program: Ph


Solved by verified expert:Due 03/19/2019Reflect on work environments you have experienced. Choose one organizational practice that promoted self-care and wellness and one practice that inhibited self-care and wellness. Consider the self-care and vicarious trauma implications of each. Post a brief description of one organizational practice from your experience that promotes self-care and wellness and one practice that inhibits self-care and wellness. Explain the outcome of each experience, then explain the impact these practices had on you personally and professionally. Be specific. Finally, explain how these practices may or may not impact the development or perpetuation of vicarious trauma.ReferencesMorrissette, P. J. (2004). The pain of helping: Psychological injury of helping professionals. New York, NY: Taylor & Francis.Chapter 7, “Vicarious Traumatization” (previously read in Weeks 2 and 3)Hernandez, P., Engstrom, D., & Gangsei, D. (2010). Exploring the impact of trauma on therapists: Vicarious resilience and related concepts in training. Journal of Systemic Therapies, 29(1), 67–83.Sansbury, B. S., Graves, K., & Scott, W. (2015). Managing traumatic stress responses among clinicians: Individual and organizational tools for self-care. Trauma, 17(2), 114-122. doi:10.1177/1460408614551978Steinlin, C., Dölitzsch, C., Kind, N., Fischer, S., Schmeck, K., Fegert, J. M., & Schmid, M. (2017). The influence of sense of coherence, self-care and work satisfaction on secondary traumatic stress and burnout among child and youth residential care workers in Switzerland. Child & Youth Services, 38(2), 159-175. doi:10.1080/0145935X.2017.1297225


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Original Article
Managing traumatic stress responses
among clinicians: Individual and
organizational tools for self-care
2015, Vol. 17(2) 114–122
! The Author(s) 2014
Reprints and permissions:
DOI: 10.1177/1460408614551978
Brittany S Sansbury1, Kelly Graves2,3 and Wendy Scott2
There is a growing interest in conceptual frameworks related to preventing stress responses among mental health
clinicians working with survivors of trauma. The following paper comprehensively compares and contrasts vicarious
traumatization with compassion fatigue (i.e. secondary trauma), and it considers how these two traumatic stress
responses can lead to professional burnout. It reviews the historical development and empirical support related to
the effects of trauma work on clinicians, and it provides practical guidelines for both individuals and organizations to
protect clinicians from traumatic stress responses.
Vicarious trauma, burnout, compassion fatigue, clinician self-care
There is growing attention to the prevalence of trauma
and its negative consequences. A myriad of research
studies have shown that trauma can chronically and
pervasively impact multiple developmental areas,
including social, cognitive, psychological, and biological development across the lifespan.1–3 Recent
research has documented that trauma exposure can
impact at the DNA level, as children who were exposed
to trauma showed signs of biological aging (‘‘wear and
tear’’) on DNA sequences called telomeres, which are
responsible for aging and progression of disease
states.4,5 In addition, the financial costs of childhood
trauma are astronomical-approximately $4379 per incident2 and $103.8 billion per year in the United States.6
If one expands statistics to both human-made and natural disasters, authors elaborate that over nine million
deaths and 7000 traumas occurred around the world
between 1951 and 2000.7
Although the field has been looking intensively at
the impact of trauma on clients, we know less as a
field about the impact of trauma-specific treatment on
the ‘‘helpers’’. As many as 24 million or 8% of US
residents will experience a traumatic stress response
during their lives; but the rate is an estimated 15%8
to 50%,9 potentially nearly six times higher, among
mental health workers. Traumatic exposure responses,
in general, have been referred to as the ways in which
the ‘‘world looks and feels like a different place to you as
a result of your doing your work’’.10 Trauma work
demands that clinicians are astutely aware of the core
principles of trauma-informed care, namely safety,
empowerment, trust, collaboration, and choice.11
Every action that a clinician takes must be consistent
with these core principles as trauma-informed treatment has been shown to be more beneficial than the
usual standard of care. Given the intensity of traumaspecific treatment, clinicians also must maintain
self-care practices to manage their own traumatic
stress responses. The next section compares and contrasts vicarious traumatization with compassion fatigue
(i.e. secondary trauma).
University of Memphis Institute on Disability, University of Memphis,
Center for Behavioral Health and Wellness, North Carolina A&T State
University, NC, USA
Department of Human Development and Services, North Carolina A &
T State University, NC, USA
Corresponding author:
Brittany S Sansbury, The University of Memphis Institute on Disability,
Ball Hall 100, Memphis, TN 38152 USA.
Sansbury et al.
Vicarious traumatization
Compassion fatigue
In the 1990s, Pearlman and colleagues defined vicarious traumatization as ‘‘the transformation that occurs
within the therapist (or other trauma worker) as a
result of empathic engagement with clients’ trauma
experiences and their sequelae’’.12 The transformation
occurs when managing trauma among clients results in
altered memory systems and cognitive schemas associated with five need areas: safety, dependency or
trust, power, esteem, and intimacy.13 When these
disruptions occur, clinicians demonstrate increased
vulnerability or awareness of how fragile life can be
and can become suspicious or distrusting of others.
These experiences can prompt unexplainable changes
in affect, like anger or sadness, which can complicate
how an individual interacts with both colleagues in the
work environment as well as in interactions within
their personal lives.14 The incidence and severity of
clinician symptomology depends on how salient the
need area is in his or her life.11 For example, a
person who struggles with trust, is more likely to
relive reports from a client about being betrayed or
violated in family incest. These need areas also can be
particularly salient for clinicians who have their own
traumatic histories.12
More recent theory and research broadens the
concept of vicarious traumatization to include
countertransference, empathy, and emotional contagion.14 Related to countertransference, clinicians
who fail to contain reactions to client emotion are susceptible to changes in their own belief systems,14,15
reduced awareness, and increased defensiveness.
Related to empathy, the ability to connect with client
suffering helps the clients, but also increases
vicarious trauma if clinicians cannot ‘‘manage’’ the
empathic process.14
Finally, emotional contagion involves unconsciously reliving the trauma of a client, beyond
simply attempting to understand it with empathy.
Older studies support the ‘‘catching’’ of depression16
and anxiety symptoms by clinicians who seek to mimic
or parallel clients’ affect.17 The capacity to put oneself
in the emotional world of others can assist a trauma
worker in learning about them. Nonetheless,
emotional contagion is most dangerous when a
lack of self-awareness gives way to an unconscious
and prolonged shift from personal views to
clients’ traumatic affect. Interviews with trauma
clinicians confirm several life areas impacted by vicarious traumatization such as seeing the world in a
negative way, feeling unsafe, reduced sense-of-self,
reduced connection to work, less interest in others,
and increased negative affect.18,19 This collection
of stress responses is a hallmark of vicarious
Figley20 coined the term secondary traumatic stress to
denote suffering acute emotional crisis due to interaction with trauma survivors, whether in personal relationships or the therapeutic alliance. Early on, the
author renamed this adverse psychological functioning
to compassion fatigue to reduce stigma against traumatic stress responses among professionals.21 Figley
identified three domains to explain the concept:
(1) re-experiencing content from a client’s story;
(2) avoidance and numbing toward potential triggers;
and (3) burnout.20 The first component refers to physical symptoms like sleep disturbance and gastrointestinal issues. A clinician also can endure emotional
changes (the second component) such as unreasonable
irritation, anxiety, or guilt. The third component is the
behavioral component, which includes symptoms such
over-eating or substance abuse. The last two components, pertaining to affiliations at work and with
peers, involve clinicians psychologically or physically
separating themselves from others. This withdrawal
may result in difficulty performing tasks and consequently loss of relationships. Compassion fatigue
differs from vicarious trauma in that compassion fatigue can occur with little to no contact with clients,
whereas vicarious trauma only occurs when interacting
directly with traumatized clients.
Maslach and Jackson22 popularized the concept of
burnout as an occupational syndrome in systems of
care characterized by high demands and little support.
Burnout is a gradual and progressive process that
occurs when work-related stress results in emotional
exhaustion, an inability to depersonalize client experiences, and a decreased sense of accomplishment.23 This
traumatic stress response is globally affiliated with prolonged strain at work, not simply contact with clients
who have experienced trauma. It is the principal assertion of this paper that burnout can emerge after
extreme cases of either vicarious traumatization or
compassion fatigue.24 Recent reports on helping professionals’ mental health provide empirical evidence of
this triangular relationship.25–30
A report of 782 police officers, firefighters, and medical responders indicates a correlation between vicarious traumatization and burnout.25 There is an inverse
relationship between their role clarity and intrusive
thoughts (r ¼ .23, p < .01), avoidance (r ¼ .31, p < .01), and emotional arousal (r ¼ .26, p < .01). Predictability at work has a moderate association with these three symptoms of vicarious traumatization (r ¼ .09, .16, .18, p < .01). A second study with 10 child welfare workers further corroborates the 116 relationship between the traumatic stress response and job-related psychological withdrawal.27 It recognizes countertransference and poor coping strategies, which are historically linked to vicarious traumatization, as precursors for burnout. Another set of studies attributes significant variance in mental health outcomes to the positive relationship between compassion fatigue and burnout. For example, Meadors et al.29 write that burnout is responsible for nearly 32% of variance in the incidence of traumatic stress response for a group of 167 healthcare providers (r ¼ .56, p < .01). Vilardaga and collegues30 investigated how work-related variables impact burnout for addiction counselors. A set of factors, namely job control, coworker support, supervisor support, salary, workload, and tenure, account for considerable variance in traumatic stress responses. Specifically, the results demonstrate that these mediators for compassion fatigue explain 27% of the variance in counselors’ emotional exhaustion, 16% of the variance in their depersonalization, and 22% of the variance in their sense of accomplishment at work. Psychological demand is positively associated with distress, depression, and burnout (R2 ¼ .22, F ¼ 8.68, p < .01), with burnout showing the strongest association amongst the other mental health outcomes. Assessing traumatic stress responses Because burnout can emerge after extreme cases of vicarious traumatization or compassion fatigue, it is essential that clinicians, supervisors, and the organizations they work for monitor such symptoms. There are several measures to quantify the incidence and severity of traumatic stress responses by clinicians, and these scales allow clinicians to track and monitor symptoms of vicarious traumatization, compassion fatigue, and burnout. Accordingly, they serve as a first line of defense in managing traumatic stress responses as it allows for the first essential step (as described in more detail below), namely awareness of traumatic stress responses. Commonly used assessments include: The Traumatic Stress Institute Belief Scale (TSI-BSL) is an 80-item standard assessment for vicarious traumatization. The TSI-BSL evaluates a clinician’s impairment in self- and social-need areas such as safety, trust, control, esteem, and intimacy.31 Its 80 items prompt him or her to respond on a 6-point Likert scale, where higher scores indicate more disruption in the memory system and cognitive schemas. The resulting composite scale has a reported internal consistency reliability of .98, and its 10 subscales possess Cronbach alpha ratings that range from .77 for other-control to .91 for self-esteem. On average, trauma clinicians and Trauma 17(2) other mental health professionals score 166.83 on the TSI-BL,13 indicating little to no impairment, yet it remains unclear how to differentiate simpler adjustment challenges from clinical symptomology in need areas. The Compassion Fatigue Self-Test for Psychotherapists
(CFST) is a 40-item scale including items on both compassion fatigue (CFST-CF) and burnout (CFST-BO)
for a total composite score.32 Its items allow trauma
clinicians and staff members to respond on a 5-point
Likert scale, where higher scores indicate more stress
response from trauma work. The internal consistency
reliability ratings have Cronbach alphas ranging from
.86 to .94.
The Professional Quality of Life Scale (ProQoL)33 has
30 items and represents attempts to combine earlier
subscales on compassion satisfaction with compassion
fatigue.33 Its 2002 version has three discrete subscales:
the compassion satisfaction items evaluate the pleasure
a trauma clinician derives from his or her work; the
compassion fatigue items evaluate potential distress
due to exposure to client cases; and the burnout items
evaluate feelings of hopelessness and less sense of
accomplishment. The subscales allegedly possess relatively high internal consistency reliability, ranging from
.72 to .87. The ProQol asks trauma clinicians to answer
all 30 items using a 6-point Likert scale, with higher
scores indicating more psychological impairment.
According to Stamm,33 clinician scores above a 17 on
the compassion fatigue subscale or a 27 on burnout
subscale reflect the highest risk for severe traumatic
The Maslach Burnout Inventory is a 22-item self-report
survey with three subscales: the emotional exhaustion
(EE) items refer to a clinician being strained mentally
and emotionally; the depersonalization (DP) subscale
evaluates his or her ability to differentiate self from
client experiences; and the personal accomplishment
(PA) items assess gratification and sense of efficacy
from work.22,34 The PA subscale is reverse-scored,
whereas higher scores on the EE and DP items indicate
burnout. The entire assessment includes 22 items with
7-point Likert responses. Its composite internal consistency reliability is .91, with Cronbach’s alphas for the
subscales from .81 to .92.
It is worth noting that burnout and compassion fatigue scales have presented difficulties in past empirical
studies that attempted to validate them conceptually.21,29 Specifically, there is some evidence that the
domains are not reliably related to work with individuals who experience trauma. There are two assumptions to draw from this problem. Clinicians may
report immediate and heightened affect after sessions
with their clients, even if they appear only minimally
Sansbury et al.
impacted by changes in their belief systems over time.
Lastly, one can also assume that other scales could
identify risks and symptoms better than the CFST or
ProQol. If compassion fatigue is a construct largely
focused on theory and unseen changes in cognition,
applied research to monitor measurable traumatic
stress for clinicians can benefit from utilizing more
psychometrically established assessments.
Practical guidelines for individuals and
There is a need for more practical guidelines that
can unify the conceptual frameworks related to preventing traumatic stress response. As Lipsky and
Burk describe:
‘‘There is a difference between feeling tired because you
put in a hard day’s work and feeling fatigued in every cell
of your being. Most of us have experienced a long day’s
work and the reward of hard-earned exhaustion. . .That is
one kind of tired. The kind of tired that results from
having a trauma exposure response is a bone-tired,
soul-tired, heart-tired, kind of exhaustion. . .’’ (p.110).10
There are positive consequences to traumaspecific work such-as when providers gain a sense of
accomplishment from helping someone achieve a goal,
heal from a difficult situation, or develop a pathway for
recovery. In a 2012 New Delphi study, focus groups
with 102 paramedics and first-responders in the UK
National Health Service confirmed that knowing what
happens to survivors or learning how better to assist
impacted families provided more satisfaction. They
reported being unsatisfied with the status quo, implying
that their service inspired them to improve the quality
of care for those affected by trauma.35
Inversely, there are also negative consequences of
therapeutic work, some of which are at the conscious
level, and some are unconscious. As Hilfiker36 states,
‘‘All of us who attempt to heal the wounds of others will
ourselves be wounded; it is, after all, inherent in the relationship’’. The primary question is: how can people in
the helping field work toward facilitating the healing of
others while limiting the negative impact on themselves? We propose that the answer to that question
has multiple levels of responsibility. Both individuals
and organizations have a responsibility to create an
environment of wellness and support.
Practical guidelines for individuals
When considering the ways in which clinicians can
actively work to prevent burnout, it is important to
understand that the process of preventing burnout is
an active one. The clinician is not a passive recipient
in which all the stress gets wiped away by breaks or
organizational magic wands. Instead, the clinician
must be actively involved in a process of self-care.
Readers are encouraged to review the 16 signs
of trauma exposure responses as outlined in Trauma
Stewardship: An Everyday Guide to Caring for Self
While Caring for Others,10 for specific examples of
the ways in which trauma responses ‘‘show
themselves’’ in the everyday lives of clinicians. Here,
we have reviewed and synthesized a four-step
process for clinicians to utilize on their journey to
Step 1 – Know thyself. Clinicians must be aware of
their own arousal states. Rothschild and Rand24 indicate that ‘‘we are most vulnerable to compassion
fatigue or vicarious traumatization when we are
unaware of the state of our own body and mind’’. This
is the first step to creating an individual climate of selfcare. Mindfulness regarding the ‘‘status’’ of one’s body
and autonomic nervous system activity, otherwise
known as arousal awareness, is a core tenet of
‘‘knowing thyself.’’
Step 2 – Commit to address the stress. The first step
should be closely followed by the second one of knowing or learning how to manage various identified arousal states (i.e., reducing stress). This requires
recognizing that distress may, at times, be present at a
somatic level. Clinicians should pay attention to their
own body posture, facial expressions, muscle tensions,
breathing patterns, and other bodily sensations.24
Particularly during the process of joining with the
client and providing empathy while the client is sharing
emotional content, it is quite possible for clinicians to
start unconsciously mimicking the somatic feelings of
their clients. It is thereby essential for clinicians to
develop the skills in which they can dually monitor
the somatic experiences of not only their client but
also of themselves.
Part of this monitoring process may be to understand boundaries not only in terms of work-life
balance, but also within the therapeutic context. For
those who are healing from trauma, this modeling
opportunity can be strong therapeutic material that
can set the stage for how they can set appropriate,
healthy boundaries in other relationships. For clinicians, the concept of boundaries also extends to physical space. Simple adjustments can be made that can
create a sense of safety, such as altering the space
between the client and therapist chair or the room
layout. Clinicians also can create personal space
through eye contact. Hodges and Wegner documented
that simply changing your gaze from a client to something else, even if momentarily, can assist clinicians in
regulating their own emotional responses to the
client.36 Wilhelm Reich37 has since coined the term
ocular defense to describe this process. Addit …
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