CHAPTER 3:
The Risks of Treating Sexual Trauma:
Stress and Secondary Trauma
in Psychotherapists

"This chapter addresses the potential risks to a therapist when treating sexually traumatized clients...In fact, the trio of gender, personal trauma history, and exposure to sexually traumatized clients was predictive of reported intursion and avoidance symptoms."
-From the opening quote of chapter 3 (Secondary Trauma Stress, 2nd edition)

Experiences of clinicians provided much evidence of the phenomenon of STS, several authors put forward conceptualizations of dynamics of indirect trauma experienced by therapist. (ex. compassion fatigue and vicarious trauma) The emphasis here is on the strength of the experience on the helper, and the likelyhood that "Trauma is contagious"
When the client has experienced violence, especially if the traumatic experience and post-traumatic responses are the focal point of the clients' therapy, therapist may find themself forced to look at the reality of some of the terrible things that can happen in this world. Acknowledging this reality can prove to be a strain on the therapists' adaptive assumption of personal invulnerabilty, and their perception of the world as a meaningful and comprhensible place could be challenged. This challenge, clearly, would have an adverse effect on a sense of safety and stablility in daily living.

In his essay "Sitting with the shattered soul" (1991), which is about treating survivors of severe abuse, K. Steele stated: "all the therapists I know who do this work have been blindsided at least once by the horror of it. Their own vulnerablity, their helplessness in the face of such abuse is staggering." As we will see in this chapter, the studies that have been done indicate the reality and accuracy of this statement is clear, if often overlooked, at least until recently.
Chapter is intended to be a brief report on a study examing the relationship btween therapists' level of exposure to sexually traumatized clients and the therapists' own report of PTSD symptoms or general work stress symptoms.
The Study was designed to sample a variety of experiences with a range of sexual trauma exposure in their clinical work, in order to determine a relationship between exposure to such issues and the level of stress or secondary trauma symptoms reported. Also included in the study was exposure to other difficult client issues. This was in an attempt to test for possible alternatives for adverse effects by many different forms of difficult or clinical work.

See table 1 on page 40 for a summary of the work settings and professional disciplines represented in this test.

To examine the potential contribution of situational and/or environmental factors to the therapists' stress, the following factors were also included in the test:
workload
use of clinical supervision hours
a rating of technical and emotional support available at work
personal trauma experience (childhood and adulthood)

See table 2 on page 41 for details of the six types of trauma asked about in this study.







In this study, exposure to sexual trauma issues was defined as the reportaed percentage of the therapists' caseload that had presented these issues. (This was done both over the past year and over their the course of their careeer as a therapist) Participants were asked to estimate the percentage of their caseload that had presented any of six different categories of clinical problems or diagnoses in therapy. What was reported was as follows:

(From most to least)
depression and other mood disorders
sexual assault or abuse issues
personality disorders
substance abuse
schizophrenia and other psychotic disorders
other post-trauma reactions (besides the trauma of sexual cases)

Two outcome measures were included in the study:
Personal Strain Questionaire (PSQ) - a measure of general work-related stress and psychological stress
Impact of Event Scale (IES) - a measure of trauma symptoms commonly found in PTSD (post traumatic stress disorder)

PSQ:

Resuts for this sample of therapists reported levels of symptoms similar to those of a norm group of 900 workers in various professions.
The only factor found to be associated with general work symptoms was at the level of support in the workplace reported by therapists. (higher support ratings were associated with lower stress levels)
General measure of work stress not correlated with sexual trauma issues in therapy or any other client problems or diagnoses.
Not predicted by any other situational or individual characterstics of therapists (ex. years of experience or current workload)

IES:

Nearly half of the participants scored in the "high" range, which would suggest a need for clinical attention in traumatized persons
Therapists were reporting intrusive and avoidant symptoms in relation to their work with clients ("I had waves of strong feelings about it" "Pictures about it popped into my head" "I tried not to think about it" )
Would support the notion that this line of work does indeed have an impact on therapists
Central finding of IES was that the level of PTSD symptoms in therapists was with the level of exposure to sexually traumatized clients.
Cumulative career exposure also correlated with more recent(past year) exposure.
Therapists with a higher percentage of of clients with sexual trauma issues in their caseload tended to report more PTSD symptoms themselves

The hypothesis that exposure to other difficult client diagnoses and problems would also account for the therapists' trauma symptoms was not supported by the data.

To measure the potential importance of cognitive appraisal as a mediating variable in producing secondary trauma, therapists were asked to rate the personal impact on each of the six client issues. Two issues stood out for having the highest average ratings:
sexual assault or abuse
personality disorders



Workplace chacterstics (ie workload, availablity of supervison and support in workplace) were not found to be related to of PTSD symptoms reported by therapists.

Certain Individual characterstics were also looked at in this study:
age
gender
years of clinical experience
personal history of trauma

Of these characteristics, only gender and personal history of trauma were related to therapists' level of symptoms. Gender and overall history were correlated, with more female therapists reporting trauma. Interestingly, gender and childhood trauma were not stronlgy correlated.

Regression analyses were used to examine how therapist gender, personal trauma history, and exposure to sexual trauma clients may contribute in combination to therapists' PTSD symptoms. Gender and trauma history proved to be significant predictors of PTSD symptoms in therapists. When exposure to clients with sexual trauma was entered (gender and personal history partialled out), the predictive value still proved significant. All three also proved significant in predicting PTSD symptoms.

Closer examination of correlations btween PTSD symptoms and various types of personal trauma history reported by therapists revealed only childhood incidence of trauma stood out as being strongly associated with PTSD symptoms in the therapist from his or her work with clients. Replacing overall trauma history with childhood trauma history, the regression model then suggests that trauma in childhood can account for the bulk of contributing factors in therapists' trauma history to later development of PTSD symptoms form this line of work.

The concept of secondary or vicarious traumatization implies a specific effect of trauma therapy on the therapist:
akin to intusion an avoidance phenomena of post -traumatic stress responses in direct trauma survivors
is distinct from "burnout" or other forms of occupational stress. *

*ie "burnout" has to do with the feeling of physical fatigue and being emotionally drained from the work, where vicarious trauma is more intrusive - it's like "reliving" the clients trauma, or possibly having the clients' trauma trigger some personal trauma history issue.

Two concepts in particular are consistent with the concept of vicarious (secondary) traumatization:
general occupational stress symptoms (PSQ) was not related to the stressor of exposure to sexually traumatized clients.
exposure to other difficult types of client diagnoses was not related tothe intrusion and avoidance phenomena of PTSD measured by the IES.

These results strengthen the argument for a model of secondary trauma rather than generic occupational stress or burnout in accounting for therapists' responses to trauma clients.

Clearly suggested by this study, there is a distinct need for further examination of the role of gender and personal trauma history (especially in childhood trauma) as factors which contribute to the development of PTSD symptoms related to the feild of therapy with trauma clients. Regressiom analyses show that each of these factors has a degree of impact independantly, we can also see these factors are also interrelated in therapist's reports of trauma-like symptoms.






Women were more likely to report a personal history of trauma then men, and tended to report a higher percentage of caseload involving clients with sexual trauma issues.
Interpretaiton of result limited - only 25% of the sample in study were male
Therapists with personal history of trauma tended to present a higher overall career of trauma clients

Though more study needed, seems like that gender and past history may be related to:
self selection into trauma work
therapists' percieved vulnerablity to the type of trauma material presented by clients
the ways in which the therapist experiences his or her working relationship with trauma clients

NOT wise to conclude that secondary trauma is a risk primarily for women. SImilar results were found in male therapists dealing with combat trauma clients in the Veterans Administration.

Childhood trauma appears to more closely associated with secondary trauma symptoms in the therapist.
Possible that childhood trauma more likey to produce peronality dynamics or vulnerabilities than adult trauma that increase an individual's susceptbility to indirect trauma.
again, more study is needed to support this hypothesis.

Commonly held hypothesis is personal trauma history relates to therapists reaction to clients' trauma whne therapist has similar experiences, which may lead to counter-tranference reactions. (Not supported by current study. Therapists' sexual assault or abuse history correlated with exposure to sexual trauma clients, by itself this does not relate significantly to PTSD symptoms.

To truly support the above hypothesis, more studies are required in specific realms of trauma and how the therapist reacts to the client in relation to his or her own past trauma history.

This, and other recent studies build a growing base of evidence which support the idea that therapists who treat trauma survivors are tehmselves vulnerable to secondary trauma symptoms. For better understanding of how this works, careful attention is required. We have an ethical duty as well to promote quality servicces to our clients by evaluating the effectivenss of our self care and specific coping efforts.

On a final note, there is tremendous potential for positive effects of doing trauma work:
personal growth
spiritual connection
hope and repect for human resiliency
These also deserve to recieve attention, since they are the factors mostlikely to retain talented and effective therapists in this important work.


GLOSSARY:

Ethical Duty: Duty or obligation as it pertains to morality.