Secondary trauma among social workers treating trauma clients: The role of coping strategies and internal resources

Abstract

This study explores the association between coping strategies (problem-focused, emotion-focused, and avoidance), internal resources (dispositional optimism and mastery), demographic and work characteristics, and secondary trauma symptoms among 160 social workers in public agencies treating clients who were victims of trauma. A hierarchical regression analysis revealed that emotion-focused and avoidance coping strategies, previous history of exposure to a traumatic event, and high exposure to traumatic material through clients were associated with increased levels of secondary trauma, while dispositional optimism, mastery, and steady supervision on a weekly basis were associated with a reduction of those symptoms. Theoretical and clinical implications of the findings are discussed.

Keywords

Coping strategies optimism and mastery secondary trauma social workers

Introduction

Treating trauma survivors exposes therapists to difficult accounts of these clients’ profound emotional expressions of fear, grief, rage, horror, pain, injustice, cruelty, hopelessness, suffering, and posttraumatic symptoms. Research over the past two decades has found that these ongoing, intense therapeutic encounters may cause psychological distress and psychopathology among therapists as well (e.g. Adams and Riggs, 2008; Adams et al., 2001; Bride, 2007; Hesse, 2002; Wasco and Campbell, 2002). Various terms have been suggested in this context to describe the emotional consequence of therapy with trauma victims, including secondary traumatization and compassion fatigue (Figley, 1995), and vicarious traumatization (McCann and Pearlman, 1990). While differing in phenomenology and manifestations, the terms essentially describe the negative impact of bonding with a trauma survivor and exposure to the survivor’s traumatic encounters (McCann and Pearlman, 1990; Pearlman and Saakvitne, 1995), commonly regarded as secondary trauma (ST).

ST refers to the consequences of indirect exposure to the details of a traumatic event through the direct victim. The traumatic account usually includes vivid verbal descriptions of the occurrence itself or of intrusive thoughts, images, dreams, and flashbacks about the trauma. Thus, when significant others such as therapists extend emotional support to survivors in an attempt to understand and empathize with them, they often incorporate the traumatized person’s feelings, experiences, and even memories (Figley, 1995). Research literature has demonstrated that the symptoms characterizing ST are essentially similar to those of the survivor’s posttraumatic stress disorder (PTSD) symptoms, such as re-experiencing the traumatic event, avoidance, or hyper-arousal, although the severity of the symptoms tends to be lower (Gilbar et al., 2012; Weinberg, 2013). In examining ST among therapists, the literature has identified numerous unique risk factors, such as insufficient or inappropriate training and supervision; a high caseload level and, in particular, a high proportion of clients who are trauma survivors; low socioeconomic status; identification with victims; personal history of trauma; insufficient support in the workplace; and insufficient social and familial support (Adams et al., 2001; Everly et al., 1999; Ghahramanlou and Brodbeck, 2000; Iliffe and Steed, 2000; Jenkins and Baird, 2002; Schauben and Frazier, 1995; Steed and Bicknell, 2001; Wasco and Campbell, 2002).

The therapist’s ability to adjust to this emotional distress is highly dependent on his or her coping strategies and resources, which represent behavioral and cognitive efforts to deal with stressful encounters and modify adverse aspects of the environment, as well as minimize internal threats induced by stress (Carver and Connor-Smith, 2010; Lazarus, 1999, 2006; Lazarus and Folkman, 1984). Lazarus and Folkman (1984), in developing the transactional stress model, classified coping modes by function as either problem-focused (PF) or emotion-focused (EF), thereby delineating coping as dealing mainly with the problem or with its emotional and physiological outcomes, respectively. Carver et al. (1989) added an additional coping strategy – avoidance, which aims to ignore or avoid the problem and its emotional consequences (Carver and Conner-Smith, 2010; Skinner et al., 2003). Research has shown PF coping strategies to be more effective than EF and avoidance strategies in terms of neutralizing negative emotional reactions and improving performance levels (Ben-Zur, 2009; Zeidner and Ben-Zur, 1994). In the realm of traumatic experiences, coping strategies have been examined among survivors and their spouses (Carmelo et al., 2008; Gil, 2005; Gilbar et al., 2010, 2012; Silver et al., 2002; Weinberg, 2011). However, while therapists working with trauma clients may use coping efforts in an attempt to regulate their own emotional reactions to the traumatic encounter, to the best of our knowledge no research has examined such relationships. To bridge this gap, this study aims to explore the relationship between coping strategies and ST among social work therapists treating trauma clients.

Intrinsic in the coping process are the individual’s internal resources, considered to be a significant factor in influencing the coping process (e.g. Hobfoll, 2001; Lazarus and Folkman, 1984; Moos and Schaefer, 1993; Pearlin, 1999). Studies of natural and human-made disasters (Norris et al., 2002) have shown that high levels of personal resources are related to lower distress and lower PTSD symptoms, while resource loss is found to be related to high PTSD levels. The current study focuses on two such internal resources – dispositional optimism and mastery. Recent research has pointed to the importance of both dispositional optimism and mastery as key resources while facing stressful situations (Ben-Zur, 2008; Segovia et al., 2012; Sumer et al., 2005). Lazarus (1999), Lazarus and Folkman (1984), and Moos and Schaefer (1993) perceived personal characteristics such as dispositional optimism and sense of control or mastery as antecedents that affect people’s appraisals of their capacity to cope with stressful encounters, as well as their subsequent coping efforts, leading to lower short-term distress and better long-term life satisfaction and health.

Dispositional optimism is defined as the generalized expectancy that good outcomes will occur when confronting major problems (Scheier and Carver, 1985). This personal quality is considered to be a determinant of sustained efforts to deal with problems, in contrast to turning away and giving up. Higher levels of optimism have been related to better coping with life events, including well-being in times of stress and distress (Besser and Zeigler-Hill, 2014) and adversity (Carver et al., 2010), and better responses to traumatic events (Prati and Pietrantoni, 2009), including illness (Ben-Zur and Debi, 2005; Carver et al., 2003; Kivimäki et al., 2005), disasters (Samoon et al., 2010), terrorism (Ai et al., 2006), and war trauma (Thomas et al., 2011; Weinberg et al., in press).

Mastery refers to the extent to which one regards life events as being under one’s own control, in contrast to adopting a fatalistic outlook (Pearlin and Schooler, 1978). It is also defined as inner feelings of strength, and as the capacity to cope with and overcome obstacles by relying on one’s own efforts (Hobfoll et al., 2002). Research literature has demonstrated that mastery is associated with lower levels of anger and depressive moods (Ennis et al., 2000), PTSD (Ben-Zur, 2008), decreased caregiver stress (Mausbach et al., 2007), and lower levels of negative affect and higher levels of positive affect (Ben-Zur, 2002). Survivors of natural disasters showed that high levels of perceived mastery and optimism were related to lower distress and intrusions (Sumer et al., 2005).

However, despite empirical evidence suggesting that coping contributes to the explanation of PTSD and ST among those who were directly and indirectly exposed to traumatic events (Gil, 2005; Gilbar et al., 2012; Kanninen et al., 2002; Weinberg, 2011), its role in the particular context of the ST of therapists who treat trauma survivors has not yet been examined. Thus, based on the theoretical framework of the coping with stress model (Lazarus, 1999, 2006; Lazarus and Folkman, 1984), and the literature relating to the significance of optimism and mastery as coping resources, the following hypotheses were posited:

H1. High levels of PF coping strategies among social work therapists who treat trauma survivors will be associated with low levels of ST severity symptoms.

H2. High levels of EF and avoidance coping strategies among social work therapists who treat trauma survivors will be associated with high levels of ST severity symptoms.

H3. High levels of dispositional optimism and mastery among social work therapists who treat trauma survivors will be associated with low levels of ST symptoms.

Method

Sample

The study population consisted of social work therapists in Israeli public agencies treating clients who were victims of trauma. Inclusion criteria for participation in the study were an MA or BA degree, and weekly treatment of at least three clients who were trauma survivors.

Recruitment took place in seven treatment centers – two general mental health centers and five centers for treating trauma survivors specifically. Each center provided a list of all social work therapists eligible for participation in the study. Overall, 200 therapists met the inclusion criteria, and 160 (80%) completed the study questionnaires and comprised the final study sample.

The sample consisted of 134 (83.8%) female and 26 (16.3%) male social workers, with a mean age of 32 years (standard deviation (SD) = 8.63 years). The majority (53.8%) had an MA degree. Mean number of years in the profession was 10 years (SD = 12.3 years). A total of 50 (31%) participants reported a history of exposure to a traumatic event. A total of 90 (56%) reported being under steady supervision on a weekly basis, 38 (23.8%) reported irregular supervision, and 32 (20.2%) reported lack of supervision. The mean number of clients per therapist was 19.4 (SD = 22.9), and the mean number of clients who were trauma survivors per therapist was 11.2 (SD = 13.94). No statistical differences in demographic and work characteristics were found between those participating and not participating in the study.

Measures

Secondary traumatization

ST was evaluated using the PTSD Symptom Scale-Self Report (PSS-SR) (Foa et al., 1993). The PSS-SR is a 17-item self-report questionnaire aimed at assessing the level of posttraumatic stress symptoms over a period of the preceding 2 weeks. Each item corresponds to 1 of the 17 Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM IV-TR) (American Psychiatric Association (APA), 2000) diagnostic criteria for PTSD. The severity of each item is rated on a 4-point Likert scale ranging from 0 = not at all to 3 = very much. The total severity score is calculated as the mean of the respondents’ ratings on the 17 items. The purpose of the questionnaire in this study was to examine ST symptom severity based on the average overall score of the questionnaire, and not for a clinical diagnosis of ST. Participants were asked to refer to the questionnaire in the context and as a consequence of their therapy sessions with their traumatized clients. The PSS-SR was found by its originators (Foa et al., 1993) to be internally consistent and highly correlated with widely used instruments assessing specific reactions to trauma. The Cronbach’s α coefficient for the scale in this study was .92.

COPE scale

Coping strategies were measured by a short 30-item Hebrew version of the COPE scale (Carver et al.,1989). The shortened version contains 15 coping strategies, each represented by the sum of 2 items (Zeidner and Ben-Zur, 1994). Respondents indicate the extent to which each of the 15 strategies is used. Responses are rated on a 4-point scale, ranging from 0 = not at all to 3 = great extent. The strategies are active coping, planning, seeking instrumental social support, seeking emotional social support, suppression of competing activities, religion, positive reinterpretation and growth, restraint coping, acceptance, ventilation of emotion, denial, mental disengagement, behavioral disengagement, alcohol/drug use, and humor. Based on a factor analysis, three main subscales were used: PF coping (including active coping, planning, and suppression); emotion-support coping (including instrumental and emotional support, and ventilation); and avoidance coping (including behavioral and mental disengagement, denial, and alcohol/drug use). The Cronbach’s α coefficients for the three subscales in this study ranged from .83 to .91.

Mastery

Mastery was examined using the mastery scale developed by Pearlin and Schooler (1978). The scale contains seven items ranging from 1 = not appropriate to 7 = very appropriate, with a high score indicating a high level of mastery. Hobfoll and Walfisch (1984) reported a test–retest reliability of .85 or above, with reasonable internal reliability levels, α = .75. The Hebrew version showed satisfactory internal reliability levels in various Israeli samples (e.g. Ben-Zur, 2003; α = .69–.80). The Cronbach’s α coefficient for the scale in the present study was .83.

Dispositional optimism

Dispositional optimism was examined using the Life Orientation Test (LOT; Scheier and Carver, 1985). This scale consists of eight items rated on a 1–5 scale (1 = disagree to a large extent; 5 = agree to a large extent), with a high score indicating an optimistic tendency. The internal reliability and test–retest of the original version were satisfactory (α = .76, test–retest = .79; Scheier and Carver, 1985). The Hebrew version (Zeidner and Ben-Zur, 1994) was used in various Israeli studies with satisfactory reliabilities. In the present study, the Cronbach’s α coefficient for the scale was .86.

Demographic and work characteristics

A questionnaire addressing demographic and personal work characteristics, covering gender, age, education, place of birth, and history of exposure to trauma was used. Questions about work characteristics included number of years in the profession, number of clients who are trauma victims, perceived level of exposure to traumatic material through clients (high, medium, low), stability of supervision (every week, from time to time, lack of supervision), and treatment approach (psychodynamic, supportive, cognitive-behavioral, or rehabilitative).

Procedure

Following approval by the ethical committee for research with human participants, welfare, and health sciences, University of Haifa, a letter was sent to the participants explaining the importance of the research and requesting their consent. All participants completed the questionnaires voluntarily. No compensation was offered for participation in the study.

Results

An independent sample t-test analysis showed that female participants reported a significantly higher level of ST (M = 0.68; SD = 0.56; t = 2.4; p < .01) than males (M = 0.30; SD = 0.42), and participants with a history of a traumatic exposure (M = 0.81; SD = 0.36) reported higher levels of ST symptoms than those with no such history (M = 0.41; SD = 0.44).

An analysis of variance (ANOVA) analysis with Duncan post hoc revealed that participants who reported a lack of supervision (M = 0.71; SD = 0.56) had higher levels of ST symptoms than those who reported steady supervision (M = 0.39; SD = 0.22) or irregular supervision (M = 0.45; SD = 0.24). No statistically significant differences were observed regarding treatment approach.

A Pearson correlation analysis showed a positive correlation (r = .28; p < .001) between the use of EF coping strategy and level of ST symptoms, and a positive correlation (r = .22; p < .001) between avoidance coping strategy and ST symptoms. No statistically significant correlation was found between the use of PF coping strategies and level of ST symptoms. Negative correlations were found between levels of ST symptoms and dispositional optimism (r = −.23; p < .001) and mastery (r = −.19; p < .01). A positive correlation (r = .34; p < .01) was found between number of clients who were trauma survivors and level of ST symptoms. A positive correlation (r = .27; p < .01) was also found between perceived level of exposure to traumatic material through clients and levels of ST symptoms.

The associations posited in the research hypotheses were examined using a hierarchical regression analysis in which the level of ST symptoms was entered as the dependent variable. In order to control for demographic and personal variables, gender and personal work characteristics (therapists’ trauma history, supervision, number of clients who were trauma survivors, and perceived level of exposure to traumatic material) were entered respectively in block 1. Coping strategies (PF, EF, and avoidance) were entered in block 2, and internal resources (dispositional optimism and mastery) were entered in block 3.

As shown in Table 1, levels of ST symptoms were found to have a positive association with a history of traumatic exposure, lack of supervision, high level of perceived exposure to traumatic material through clients, high use of EF coping strategy, high use of avoidance coping strategy, and negative association with dispositional optimism and mastery. The entire model was found to explain 32 percent of the variance in level of ST symptoms.

Table 1.

Hierarchical regression analysis of level of symptoms of secondary trauma (ST) and research variables (N = 160).

	B	SE	Beta	R²/F
Block I – personal and work characteristics
Gender (male = 0; female = 1)	.02	.01	.8
Trauma history (no = 0; yes = 1)	.04	.01	.9*
Supervision (yes = 0; no = 1)	.07	.03	.11**
Number of clients who are trauma victims	.05	.02	.04
Perceived level of exposure to traumatic material through clients	.10	.06	.10*	R² = .14; F = 3.91***
Block II – coping strategy
Problem-focused coping strategy	.02	.01	.07
Emotion-focused coping strategy	.14	.08	.12***	R² = .18; F = 4.56***
Avoidance coping strategy	.12	.07	.11**	R² = .18; F = 4.56***
Block III – internal resources
Dispositional optimism	−.09	.04	−.9**	R² = .32; F = 5.11***
Mastery	−.09	.05	−.8*	R² = .32; F = 5.11***

SE: standard error.

∆2 – 1 = .04; ∆3 – 2 = .14.

p < .5; **p < .1; ***p < .01.

Discussion

The main aim of this study was to examine the association between coping strategies (PF, EF, and avoidance) and internal resources (dispositional optimism and mastery) with ST symptoms among social work therapists treating trauma survivors. As anticipated, EF and avoidance coping strategies were found to be positively associated with higher levels of ST symptoms. These findings are consistent with previous research demonstrating the relationship between EF and avoidance coping strategies and trauma exposure (Gil, 2005; Gilbar et al., 2012).

Furthermore, the study findings implicate maladaptive coping strategies such as EF and avoidance as playing a negative role in dealing with ST not only among spouses of trauma survivors (Gilbar et al., 2012), but also among therapists who treat trauma survivors. Surprisingly, however, no association was found between PF coping strategies and therapists’ ST. This discrepancy intensifies when taking into account that PF coping strategies are known for their capacity to help deal with stress and trauma more effectively (Ben-Zur, 2009; Weinberg et al., 2014; Zeidner and Ben-Zur, 1994). Thus, it would be expected that social workers, as professionals, would adopt PF coping strategies in dealing with their own emotional distress and ST induced by their relationship with trauma survivors. A possible explanation may lie in the interaction between social workers’ characteristics and different coping strategies. Given that all the participants in the study were trained therapists with in-depth academic knowledge and many years of experience, it is likely that they address emotional states on a regular basis. Therefore, when confronting their own ST as related to the therapeutic context, emotional coping strategies may seem more natural and intuitive than PF coping strategies, circumstances which lead them to engage with more EF and avoidance coping strategies and less PF coping strategies.

These findings suggest an important coping mechanism among social workers who treat trauma survivors, which has not yet been reported. Specifically, they point to the importance of the awareness of effective coping strategies not only for survivors during therapy sessions, but also for the therapist himself or herself. Such findings have clinical and practical policy implications which constitute a tangible contribution to therapists treating trauma survivors, namely enhanced education and training in coping strategies for therapists. Within this framework, it is advisable to enhance an awareness of maladaptive coping strategies and ST, while strengthening PF strategies and skills.

As anticipated, the study revealed that the internal resources of dispositional optimism and mastery were associated with a reduction of ST symptoms among the social work therapists. While previous studies generally examined dispositional optimism and mastery in the context of direct exposure to stressful events and traumatic exposures (Ben-Zur, 2008; Prati and Pietrantoni, 2009; Samoon et al., 2010; Sumer et al., 2005; Weinberg et al., in press), demonstrating the association between these internal resources and reduced emotional distress, the current study extends this knowledge about the role that dispositional optimism and mastery may play among therapists who were exposed indirectly and suffer from ST symptoms. More specifically, the relationship between dispositional optimism and mastery and ST shows that when the social worker faces his or her own emotional distress, such as ST symptoms, internal resources may contribute to better coping and fewer ST symptoms. Moreover, taking into account that ST extends beyond social workers and may affect the entire family system (spouses, children, etc.), the study findings can be relevant or transferable to other contexts as well.

Finally, in deepening the understanding of the association between personal and professional characteristics and ST, in accordance with previous research, the study demonstrated that a previous history of exposure to a traumatic event, and high exposure to traumatic material through clients, are associated with increased levels of ST, while steady supervision on a weekly basis is associated with decreased levels of ST (Adams et al., 2001; Ghahramanlou and Brodbeck, 2000; Jenkins and Baird, 2002; Steed and Bicknell, 2001). Notably, these findings contradict Bober and Regehr’s (2006) study which failed to find an association between supervision and ST among therapists treating trauma victims. A possible explanation for this discrepancy might be the differences between the study samples. While in the present study all the therapists were trained and experienced social workers, in Bober and Regehr’s (2006) study social workers comprised only 46 percent of the sample. Thus, possibly the participants reacted to and incorporated supervision differently.

The findings in this study provide further evidence of the importance of directing the attention of therapists who treat trauma survivors towards coping strategies and internal resources with regard to the development of ST symptoms. Together, these findings reinforce the theoretical concept that adjusting to psychological distress is highly dependent on coping strategies, resources, and personal characteristics which contribute to modifying adverse aspects of the environment as well as minimizing internal threats induced by stress (Carver and Conner-Smith, 2010; Lazarus, 1999, 2006; Lazarus and Folkman, 1984).

Limitations

Several methodological limitations should be mentioned. Since the study was conducted at a single time point, cause and effect relationships are hypothetical. Arguably, not only do coping strategies and resources affect ST levels, but those with high levels of ST symptoms tend to use ineffective coping strategies, be less optimistic, and view their control level as limited. Furthermore, the research was conducted in a specific population, namely social workers treating trauma survivors in public agencies. In addition, the relatively small sample size may limit the relevance of the findings to broader populations.

Nevertheless, the findings of the study are valuable in highlighting specific characteristics of therapists treating trauma survivors in public agencies which may heighten the risk for the development of ST symptoms. The study emphasizes the importance of reducing emotional coping strategies such as EF and avoidance while increasing PF coping strategies. Social work therapists are also encouraged to utilize the internal resources of dispositional optimism and mastery, found to be key elements associated with less ST. In addition, a previous history of exposure to a traumatic event, high exposure to traumatic material through clients, and steady supervision should be considered when confronting ST.

Future investigations involving assessment at two time points are recommended in order to broaden the understanding of coping strategies and internal resources and their effect on ST. Moreover, future studies should also further explore the characteristics of the traumatized clients. Additionally, deepening the linkage and association between the social worker’s ST and the clients’ primary trauma characteristics is recommended. Finally, studies involving therapists of trauma survivors should examine additional aspects of internal as well as external resources and their influence on coping strategies and emotional distress. Within this framework, addressing the clients’ and the social workers’ unique social contexts is recommended.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author biographies

Michael Weinberg is a social worker and lawyer, head of trauma studies at the School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel. His research focus is coping and posttraumatic stress.

Sharon Gil is a clinical social worker, psychotherapist, and clinical supervisor; senior lecturer; head of the MA and supplementary programs; head of the unit for treating adult male survivors of sexual abuse, The Interdisciplinary Clinical Center, School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.

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