Experiential Avoidance and Post-traumatic Stress Symptoms Among Child Abuse Counselors and Service Workers: A Brief Report

Abstract

Professionals who counsel and serve survivors of childhood abuse may be at risk of experiencing symptoms of post-traumatic stress disorder (PTSD), which can be exacerbated by cognitive and emotional processes. It is hypothesized that (1) a significant proportion of professionals who primarily serve child abuse survivors experience elevated levels of PTSD symptoms and (2) elevated PTSD symptoms are associated with psychological inflexibility processes, specifically increased experiential avoidance, cognitive fusion, and emotion regulation difficulties. Child abuse counselors and service workers (N = 31) in a major metropolitan area were recruited for a small pilot study. Participants completed self-report measures of PTSD symptoms and levels of psychological flexibility processes. A significant proportion of counselors endorsed clinically significant PTSD symptoms (n = 13, 41.9%). PTSD symptoms were significantly associated with experiential avoidance (r = .54, p < .01) and emotion regulation difficulties (r = .51, p < .01). These associations remained significant after controlling for the personality trait of emotional stability/neuroticism. These findings suggest that PTSD symptoms may be common among child abuse counselors and service workers, and these symptoms tend to be of greater intensity when responded to in avoidant and inflexible ways.

Keywords

post-traumatic stress disorder vicarious trauma treatment of child abuse experiential avoidance cognitive fusion emotion regulation

Introduction

Exposure to childhood abuse is linked to a range of adverse outcomes, including post-traumatic stress disorder (PTSD) symptoms in adulthood (Stevens et al., 2013). Mental health clinicians who work with child survivors of abuse frequently grapple with their own direct and indirect exposure to psychological trauma (Elwood et al., 2011; Figley, 2002), and are at risk of PTSD-like symptoms (Ludick & Figley, 2017). Clinicians may respond to their own PTSD symptoms with critical self-evaluations and patterns of avoidance that could undermine the quality of services they provide (Batten & Orsillo, 2002; Figley, 2002; Scherr et al., 2015). Within the framework of Acceptance Commitment Therapy (ACT; Hayes et al., 2013), the broader psychological and functional impact of painful, albeit transient, thoughts, and emotions are hypothesized to depend on secondary reactions to those painful private events.

Complex Origins of PTSD Symptoms

Individuals can experience PTSD-like symptoms following indirect exposure to trauma and other rapid but non-life-threatening threats and losses (Hobfoll, 2014). Professionals who empathize with survivors of abuse often experience strong emotions, including frustration, fear, and shame, and may experience PTSD-like symptoms or secondary trauma (Figley, 2002; Ludick & Figley, 2017). The ACT model posits that language and cognition are inherently relational processes, and so clinicians who empathically identify with survivors of trauma could imagine themselves in situations similar to those experienced by their clients, or relate client histories of abuse to their exposure to abuse and trauma (Elwood et al., 2011; Hayes et al., 2013; Ludick & Figley, 2017). Some studies have found personal trauma exposure to be significantly associated with secondary PTSD symptoms (Bride et al., 2007) while others have not (Boscarino et al., 2004). Occupational trauma exposure, such as hours per week working with traumatized individuals and fewer years in the field (Bober & Regehr, 2006), have also been associated with secondary PTSD symptoms, although the findings are inconsistent and more research is needed (for review, see Elwood et al., 2011). This suggests that the manifestation of PTSD symptoms may not only depend on exposures to trauma but also on how those trauma exposures are framed by individual clinicians.

Cognitive Fusion and Trauma-Related Cognition

Although direct and indirect exposure to trauma tends to be ubiquitous, individuals may differ in how they respond to trauma-related memories and thoughts, and some individuals come to view trauma-related cognitions themselves to be dangerous (Resick et al., 2017). Cognitive fusion refers to a tendency to relate to one’s thoughts in a manner in which they are deemed to be true (Hayes et al., 2013). For instance, fusion with trauma-related thoughts and memories may lead individuals to experience fear and behave as if objectively life-threatening events are recurring (Cox et al., 2018). Some health care clinicians adopt assumptions that their distress is a threat to their professional competence (Adams et al., 2010; Batten & Orsillo, 2002). Fusing with these thoughts and holding them to be literally true could detract from the provision of mental health services.

Avoidant Responding and Emotion Regulation

If child abuse workers deem trauma-related cognitions and emotions to be dangerous they may also engage in experiential avoidance and attempt to avoid, escape or suppress them (Hayes et al., 2004), although this process remains untested. Processes of experiential avoidance tend to permeate culture, and many health service professionals, including mental health clinicians, vary in their tendency to negatively evaluate and rigidly respond to their upsetting thoughts and emotions (Gerhart et al., 2016; Morris & Bilich, 2017; Scherr et al., 2015). As with patient populations, studies of health care providers suggest that experiential avoidance may produce a paradox of more generally dysregulated and vacillating emotion that in turn convey risk for PTSD symptoms (Gerhart et al., 2016; Gratz & Roemer, 2004; Tull et al., 2007). Clinicians who frequently hear stories of abuse may have difficulty recognizing and understanding their emotions and attempt to avoid or impulsively escape them and thereby exacerbate the salience and severity of their PTSD symptoms.

Current Study

The current study seeks to clarify the relations between secondary trauma as measured by PTSD symptoms and psychological flexibility processes in an underexplored population, childhood abuse counselors. It was hypothesized that (1) a significant proportion of the mental health clinicians who work with child survivors would endorse elevated PTSD symptoms; and (2) professionals reporting higher levels of experiential avoidance, cognitive fusion, and difficulties with emotion dysregulation would be more prone to experiencing symptoms of PTSD. As individuals with higher levels of neuroticism experience more intense negative emotions, and may be more susceptible to secondary trauma (Karreman et al., 2013; Stevens et al., 2019), additional analyses controlled for levels of emotional stability/neuroticism.

Method

Participants and Procedure

Participants (N = 31) for the study were recruited from a nonprofit community center in a major metropolitan area as part of a pilot study to address secondary trauma in childhood abuse counselors and their colleagues. The study authors were approached by program administrators to evaluate and assess secondary trauma in their staff who treat and serve children and families affected by childhood maltreatment, which informed an acceptance-based intervention used with health care professionals (O’Mahony et al., 2016). The agency offered individual, group, and phone counseling, along with advocacy and family consultation services for survivors of childhood abuse. An email describing the study was sent to administrators at the community center who then circulated the information to approximately 40 counselors and service workers. Participants had various areas of specialization and worked with child and adult survivors of abuse or nonoffending family members. Some held administrative roles. Participants completed self-report measures to assess levels of psychological flexibility processes and their experience of PTSD symptoms.

All participants were female and held master’s degrees. Seventeen (54.8%) held degrees as social workers, and 13 (41.9%) were counselors. The mean age was 34 (SD = 8 years). The participants had worked in their field for approximately 7 years on average (SD =5 years). The study was approved by the University Institutional Review Board.

Measures

The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) is a 7-item measure designed to assess experiential avoidance. Participants utilized a 7-point Likert scale to indicate how true statements are for them (1 = never true, 7 = always true); higher scores reflect more psychological inflexibility. Scores were internally consistent in the current sample (α = .88). The Cognitive Fusion Questionnaire (CFQ; Gillanders et al., 2014) is a 7-item measure used to assess cognitive fusion, or how much behavior is regulated by cognition rather than direct experience. A 7-point Likert scale (1 = never true, 7 = always true) was used to assess how literal and believable a person views their thoughts; higher total scores reflect increased fusion with and dominance of cognitions. Scores were internally consistent in the current sample (α = .94). The Difficulties with Emotion Regulation Scale—Short Form (DERS-SF; Kaufman et al., 2016) is an 18-item scale derived from the original widely used measure of emotion regulation deficit, the Difficulties with Emotion Regulation Scale (Gratz & Roemer, 2004). Participants were asked how often they use specific strategies (e.g., impulsivity, nonacceptance, awareness) to regulate their emotions, especially when upset, using a 5-point Likert scale (1 = almost never, 5 = almost always). Scores were internally consistent in the current sample (α = .89). The PTSD Symptom Checklist—Civilian Version (PCL-C; Weathers et al., 1994) is a 17-item self-report measure of DSM-IV PTSD diagnostic criteria. Participants indicated how much they have been bothered by each symptom in the past month using a 5-point Likert scale (1 = not at all, 5 = extremely) in response to a “stressful experience from the past.” The PCL-C has demonstrated sound psychometric properties in civilian samples (Conybeare et al., 2012). Various cutoff scores have been suggested for civilian health care (e.g., 30) and veteran health care settings (e.g., 36–45) (National Center for PTSD, 2012; Walker et al., 2002). Scores were internally consistent in the current sample (α = .91). The 10 Item Personal Inventory (TIPI; Gosling et al., 2003) is a very brief assessment of personality traits identified by the Five Factor Model of Personality (FFM; Costa & McCrae, 1992). A 7-point Likert scale (1 = disagree strongly, 7 = agree strongly) is used to rate each of the 10 items that represent one of the Big Five factors (one positive, one negative). This instrument has demonstrated adequate test–retest reliability, self–other convergence, and content validity (Gosling et al., 2003). Emotional stability as determined by this scale was included in analyses as a covariate to control for high levels of trait-like sensitivity to stress and negative emotion.

Statistical Analysis

All data were analyzed using SPSS 26 (IBM, Chicago, IL). Given small sample sizes, a general tendency for psychopathology data to have non-normal distributions, and kurtotic distributions of DERS scores, Spearman correlations were computed to assess the core study question of whether experiential avoidance, cognitive fusion, and emotion dysregulation were associated with PTSD symptoms. Additionally, robust regression models utilizing Iteratively Reweighted Least Squares were computed using the “robustbase” package for R (Rousseeuw et al., 2009). These regression models included a measure of emotional stability/neuroticism as a covariate to assess whether correlations were explained by an underlying propensity to negative emotion and negativistic thinking.

Results

Means, standard deviations, and partial correlations for the study variables are presented in Table 1. The average PCL-C score of 28.5 fell below primary care screening cutoffs for PTSD (cutoff of 30; Walker et al., 2002). Thirteen participants (41.9%) reported levels of PTSD that fell at or above primary care screening cutoffs for PTSD, and of those, seven (22.6%) reported levels of PTSD symptoms that fell at or above Veterans Administration primary care screening cutoffs (cutoff between 36 and 45). PTSD symptoms were not significantly related to demographic factors such as age or years working in the profession.

Table 1.

Means, Standard Deviations, and Spearman Correlations of Study Variables.

	M	SD	1	2	3	4	5
1. Experiential avoidance	15.71	6.79
2. Cognitive fusion	22.16	8.93	.72**
3. Emotional stability	8.90	2.66	–.63**	–.74**
4. Emotional dysregulation	33.18	8.65	.72**	.62**	–.55**
5. PTSD symptoms	28.55	9.66	.54**	.48**	–.60**	.51**

Note. *p < .05. **p < .01.

Overall, results indicated moderate to strong bivariate relationships between all study variables (r = .48–.74). Experiential avoidance (r =.54, p < .01), cognitive fusion (r =.48, p < .01), and emotion dysregulation (r =.51, p < .01) were all moderately related to higher levels of PTSD symptoms. Given the high correlations between multiple measures that may map onto underlying dimensions of negative affectivity or demoralization, robust regression models were computed to control for the personality trait of emotional stability/neuroticism. After controlling for emotional stability/neuroticism, experiential avoidance (B = .57, SE =.26, p =.038) and emotional dysregulation (B = .48, SE = .21, p = .030) remained significant predictors of PTSD symptoms.

Discussion

The findings of this exploratory analysis suggest that many of the child abuse counselors who participated in this small study experienced levels of PTSD symptoms that would indicate further assessment based on primary care and Veteran Affairs screenings. This study adds to the literature by extending prior work on experiential avoidance and difficulties with emotion regulation PTSD symptoms to the study of child abuse counselors (Cox et al., 2018; Tull et al., 2007). Moreover, the findings suggest that possible linkages between experiential avoidance, general difficulties with emotion regulation, and PTSD symptoms are not simply explained by underlying levels of emotional stability/neuroticism. This implies that child abuse counselors who engage in judgmental and avoidant responses toward trauma-related thoughts and emotions may paradoxically experience an increased intensity or frequency of PTSD symptoms.

The results of the study should be interpreted within the context of its strengths and limitations. This was a theory-driven analysis of PTSD symptoms among child abuse counselors. The sample size was small and limited statistical power for multivariate analyses. In regard to diversity, the sample was relatively homogenous. Given that rates of PTSD and trauma exposure vary across populations, it is uncertain if and how these specific findings might generalize to other counselors and require further research. As in other studies of mental health professionals, the current study was not able to distinguish PTSD symptoms that resulted from personal trauma exposure from symptoms originating from occupational exposure (Elwood et al., 2011). Within the nosology of the DSM-5, a PTSD diagnosis requires the establishment of a criterion A traumatic event (Resick et al., 2017). The DSM includes the repeated exposure to trauma through one’s work as a potential source of PSTD symptoms, but other contextual factors including prior personal traumatization, discrimination, and role strains could also exacerbate symptoms similar to PTSD. As such, PCL-C scores may reflect more generalized stress reactivity rather than diagnosable PTSD. By not collecting participant’s previous trauma experiences, it is not possible to distinguish how preexisting PTSD symptoms may affect the current findings, which is a substantial limitation. Future research should assess trauma history in to better understand the role of preexisting trauma exposure and/or PTSD symptoms to secondary trauma in child abuse counselor populations.

In summary, PTSD symptoms were relatively common among this sample of childhood abuse counselors and service workers. In the current sample, processes including experiential avoidance, cognitive fusion, and emotion dysregulation were linked to higher levels of symptom severity. Clinicians and other professionals should be attentive to the possibility that similar to the experience of the clients that they serve, inflexible and avoidant reactions to upsetting thoughts, memories, and emotions could paradoxically increase their own distress. It is possible that training and supervision could foster awareness of this shared experience, support greater perspective-taking and empathy in clinical encounters, and provide insights for clinicians’ own self-care practices (Morris & Bilich, 2017). Finally, these preliminary findings also suggest that future research that focuses on transdiagnostic processes such as experiential avoidance and emotion dysregulation (Elwood et al., 2011) may help to clarify the complex origins and overlap of secondary trauma and PTSD.

Footnotes

Acknowledgments

This work was supported by the Prince Charitable Trusts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Michelle L. Miller

Authors Biographies

Michelle L. Miller, PhD, is an assistant professor of clinical psychology at Indiana University School of Medicine. She completed a postdoctoral fellowship specializing in trauma and women’s mental health at Rush University Medical Center. Her research interests focus on women’s mental health, traumatic stress, and intensive interventions.

James I. Gerhart, PhD, is an assistant professor of psychology and director of the Pain, Stress, and Symptom Management Lab at Central Michigan University. His research focuses on secondary trauma and other interpersonal dynamics of stress and trauma in the context of serious illness. He has a particular interest in developing interventions that target secondary trauma and burnout in healthcare providers.

Anissa J. Maffett, MA, is a clinical psychology predoctoral intern at Henry Ford Health System. She is currently a graduate student at Central Michigan University where she studies clinical neuropsychology. Her research interests focus on exploring the sociocultural and socioeconomic factors that impact patient quality of life and drive disparities in disease burden, brain injury recovery, and healthy aging.

Angela Lorbeck, MSTOM, MPH, LAc, Dipl OM, is a doctor of Acupuncture & Chinese Medicine in Supportive Oncology, and an assistant professor in the College of Nursing, and Department of Psychiatry & Behavioral Sciences at Rush University Medical Center. Her research interests include mindfulness meditation, and acupuncture.

Ashley Eaton England, BS, is a doctoral student in clinical psychology at Central Michigan University. She completed her undergraduate education at the University of California, Davis. She is interested in understanding how individuals cope in the context of chronic and serious illness.

Sean O’Mahony, MB, BCH, BAO, is the section director for palliative medicine at Rush university Medical Center. His research interests include workforce development and resiliency projects and health service research on interventions to lessen disparities in access to palliative medicine for vulnerable populations.

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