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BEST PRACTICES

FOR COPING WITH VICARIOUS TRAUMA

On March 14, 2007, the Office for Victims of Crime (OVC) presented a Web Forum discussion with Barbara Rubel, MA, BCETS on vicarious trauma and compassion fatigue and their effects in the workplace.  OVC's Web Forum is the perfect place for crime victim service providers and allied professionals to gain peer insight and support related to best practices in victim services.  The Guest Host Series was introduced in October 2004 to provide participants with access to national experts on topics of interest to the victim services community.  The transcript from this online session with Barbara Rubel follows:

Question:  I have been a victims advocate for only 6 months, not only do I have to learn best practices to handle my clients trauma but I have to figure out how to handle my own trauma that has emerged because of being in this position. What are best practices for this issue?

Answer: Congratulations on your new job! It has been said that knowing others is intelligence; knowing yourself is true wisdom. Only you can know what will work for you. I invite you to look at how you have coped in the past. What is your coping style? Build resiliency skills, eat well and exercise. The best ways to cope with your new role is to maintain balance between work and your personal life. Coping with vicarious trauma includes creating a therapeutic alliance with another helper and form a buddy system. Brainstorm to figure out ways to cope with your stress. Have a sense of humor when doing so. Supervision is also important. Laura, in the 6 months that you have been working, have you talked with your supervisor about what you have been experiencing? Doing so will help.

Question: Much of the discussion on coping with vicarious trauma seems to be focused on strategies that individual workers can use to identify, prevent and/or respond to compassion fatigue/burnout. Are there strategies that organizations - and the victim advocacy field in general - can use to mitigate the effects of this occupational hazard, rather than placing the onus on individual workers?

Answer: This is an important question as we must focus on professional best practices for coping with vicarious trauma. Organizations must first acknowledge that there is a risk of working with victims. Good administrative support should be in place. All new staff, when first hired, should be taught how to take care of themselves emotionally. Issues related to their own past traumas need to be addressed. Providing a supportive work environment begins by organizations determining ways of distributing workload in order to limit the traumatic exposure of any one crime victim service provider. There are funding pressures and extensive paperwork as well as frustrations with supervisors and sometimes these issues never get resolved. I think it is important to respect family concerns by having on-site childcare, if possible. Allow time off for vacations and offer health insurance that includes mental health services. Have adequate policies that educate crime victim providers. Offer excellent training as continuing education is helpful in preventing secondary trauma. Another strategy is CISM training which includes critical incident stress debriefings and defusing. To find out more information about CISM go to www.icisf.org.

Question: As a victim assistant to women experiencing domestic violence, sometimes women describe graphic acts of violence that stay with me as disturbing visual images. Do you have any suggestions for minimizing the impact of those images when they come to mind later, sometimes repeatedly? Thanks.

 Answer: You mentioned that the graphic acts of violence stay with you. These visions are absorbed and that is why I would first like to discuss compassion fatigue. Compassion fatigue is when you feel burdened, reject victims, and feel anguish for not having prevented damage or death, not having done enough, and having neglected responsibilities. Compassion fatigue is manifested by re-experiencing the traumatic event, avoidance numbing of reminders of the traumatic event, persistent arousal, and combined with the added effects of cumulative stress (burnout). Your work centers on the relief of the victims emotional suffering and that automatically includes absorbing information that is about suffering. Laurie, you wind up absorbing the suffering she felt because of domestic violence and your symptoms mimic what she is going through. Your visual images are similar to her visual images. It sounds like you would benefit from supervision, reading books on compassion fatigue, and building your resiliency. The American Psychological Association recognizes 10 ways to build resiliency: Make connections, avoid seeing crises as insurmountable, make changes, have goals, take decisive actions, self-discover, have a positive view and perspective, be hopeful and take care of yourself. Take the time to take care of yourself. Find ways to balance work and personal life so the pictures of the trauma that come to mind wont overpower you in your personal life.

Question: I have built up so many walls that I feel nothing when listening to my clients' stories. I fear I am becoming cut off from my own emotions. Does this spell trouble for me? 

Answer: By no longer listening to your clients you are attempting to protect yourself from their trauma. This is a type of silencing response where you may say I can't do anything about it. Listening won't help, so I don't want to hear about it. Or . . . I will be destroyed if I hear about the traumatic event. You may fear knowing about the terror the individual has experienced. If it could happen to the victim then it could happen to you! You may be experiencing secondary traumatic stress, which is the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. In your case - - your client. The stress results from helping or wanting to help a traumatized or suffering person and so you experience it. Secondary traumatic stress happens when you are exposed to extreme events directly experience by another and are overwhelmed by this secondary exposure to trauma. By not wanting to listen, you protect yourself from stressful stories. Talk to supportive co-workers and read books and other publications on compassion fatigue. One of my favorite resources is Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. Figley CR, ed. New York: BrunnerMazel; 1995. 

Question: Do employers bear any ethical or legal responsibility for identifying employees suffering from vicarious trauma and/or intervening to prevent further injury? 

Answer: It is the employer’s responsibility to ensure that employees are safe physically as well as mentally in the workplace. To keep employees safe they must address mental health issues. If an employee is suffering from compassion fatigue/vicarious trauma due to work related incidents then it is in the employer’s best interest to get that employee help. The employees have high self-expectations but their work suffers by chronic lateness, diminished sense of personal accomplishment and an inability to maintain balance of empathy and objectivity. I would think that very reason would make employers take notice. 

Question: In terms of DSM diagnosis, can victims of vicarious Trauma be properly given a PTSD diagnosis? If not, what alternative diagnosis or diagnoses would you suggest? Thanks.

Answer:  In terms of DSM diagnosis, victims of vicarious trauma are responding to something in their environment (being traumatized by helping a person who is traumatized) and their normal coping skills are no longer working to help them cope with the stress. It is not PTSD as they are experiencing compassion fatigue. I suggest that we do not pathologize it. However, if required for trauma purposes, an alternative diagnosis could be adjustment disorder. Some people are also diagnosed with mild adjustment disorder with anxiety disorder or adjustment disorder with depressed mood. At one of my keynotes, a professional working in the field of domestic violence, told me that she was being stalked by a clients spouse and feared for her safety. The husband felt this professional was responsible for his wife leaving him. She told me that she was diagnosed with adjustment disorder with mixed anxiety and depressed mood. She had secondary post traumatic stress and became a victim herself. After the conference, she and I, along with several other participants, went out to dinner talked about her diagnosis and experience. We complained, shared, used gallows humor, and by the end of the evening, felt renewed.  

Question: Please provide information regarding certification for bereavement counseling specialist. 

Answer: I am not familiar with a certification for bereavement counseling specialist. However, last year, I presented the Pre-Conference Specialty Workshop for the Association for Death Education and Counseling (ADEC). I met several professionals who were Certified in Thanatolgoy (CT). I was told that the CT is a foundation certification that enhances the professional designation established by your academic discipline. It recognizes your specific educational background in dying, death and bereavement. To apply to take the certification exam, you must have a bachelor’s degree and 2 years of related experience or a masters or doctorate and 1 year of verified related experience, 60 documented contact hours in Thanatology and related topics and 2 letters of support from supervisors or colleagues. Visit the ADEC website for more information: www.adec.org.  

Question: How does a manager deal with someone that is showing all the signs of "burnout", "stress", which probably stems from vicarious traumatization, but they refuse to admit it? 

Answer: A manager can deal with someone that is showing signs of burnout by first recognizing the symptoms, such as headaches, irritability, aggression, physical exhaustion from lack of sleep, emotional numbing, being jumpy and lack of concentration. Burnout is a result of frustration, powerlessness, and inability to achieve work goals (Figley, p.19). The manager can talk with the employee about these issues. Burned out employees appear callous, pessimistic, cynical, have problems in work relationships and are falling off in work performance. A manager can deal with someone that is showing burnout signs by looking at the amount and type of work being done; the caseload of distressing cases, which may be too many in number; or working over too long a period and then make workplace changes. The manager should create a Burnout Tip Sheet and give it to every employee, whether or not they are burning out. Visit http:www.helpguide.orgmentalburnout_signs_symptoms.htm for burnout in the workplace information that you can use to create a tip sheet. I have a plaque on my wall that says, Stress is when you wake up screaming and realize you haven’t fallen asleep yet. Most importantly, offer your employee an opportunity to attend a training offered through OVCTTAC. Angie McCown and I are writing an OVC training manual on Compassion Fatigue/Vicarious Trauma. Our first training is in Portland, Maine on May 22nd and 23rd. I am excited about our first training together as well as the anticipated lobster dinner. Hope to see you and your staff at future trainings. 

Question: Our staff works with a correctional population in which the victimizers are often victims themselves. Between being inundated with stories of trauma and constantly needing to maintain clear appropriate boundaries, many staff members "burn out" over a period of months or years. What are your top three recommendations for helping our staff avoid compassion fatigue so that they may continue to work effectively with our clients? 

Answer: Top three recommendations: Balance work and personal life, manage your caseload by setting priorities and apply stress reduction techniques. I am glad you brought up boundaries as I feel strongly about this issue. Time boundaries include not overworking and personal boundaries include not sharing personal problems. Being inundated with stories of trauma takes its toll. Mark, both of my parents were NYC police officers and my dad completed suicide by a self inflicted gun shot wound. I did a presentation at the FBI National Academy a few years ago and when I got back to my office, I received calls from many police officers who were struggling with issues of suicide ideation. I attempted to keep my personal boundaries by quickly self disclosing and focusing on their issues. However, I did feel as though I was experiencing compassion fatigue at the time. It sounds like your staff is experiencing burnout and traumatic stress which simply adds up to compassion fatigue. Your staff centers on the relief of victims emotional suffering and so they absorb suffering. The symptoms mimic what the traumatized person is going through. Resiliency testing during applicant screening to see if the victim service provider can bounce back and has the ability to cope with the stressors of the job may help, especially since your staff members are having difficulty so soon after being hired. A resiliency test can be taken at www.resiliencycenter.com.  

Question: What would you say is the primary or top cause for someone developing PTSD, or symptoms of PTSD through vicarious trauma? How much does ones own "worst case scenario" thoughts play into these symptoms being present or more severe? 

Answer: Symptoms of PTSD through vicarious trauma is considered Secondary Traumatic Stress Disorder (STSD). STSD happens when a person is exposed to extreme events indirectly and due to over identification with the traumatized person, is overwhelmed by this secondary exposure. STSD occurs when the exposure is to the traumatized person rather than to the traumatic event or worst case scenario. Rather than worst case scenario thoughts playing into symptoms, perhaps it is the number and variety of traumatic events that play into the symptoms. The more repetitive and cumulative of the traumatic scenarios, the more severe the symptoms, and so I would consider that, the primary cause for developing PTSD. 

Question: I was wondering what your thoughts were in regards to managing vicarious traumatization in open support groups where issues of ongoing domestic violence and past domestic violence are discussed. How do you believe the co-facilitators can provide for the safety of all the members of the group while still allowing each member to feel like they were able to share their own story and be heard by their peers? What have you found to be helpful and hurtful? 

Answer: In sharing traumatic stories, group members can experience secondary victimization. The facilitator and co-facilitator must make sure vicarious trauma is addressed at each group meeting. Facilitators provide emotional support, normalization, coping skills, information, education, advocacy and resources related to domestic violence. Most support groups begin with a welcoming statement. I have facilitated several types of support groups and always mention that listening to the stories of others in the group can be painful. I read the groups purpose/mission statement, address any old news, new news, outline the group agenda and have a discussion or activity. My groups end with a wrap up and formal closing. I provide for the safety of all group members by taking a few minutes to discuss vicarious trauma at each meeting. I recommend that you provide a handout to group participants explaining VT symptoms and ways to protect themselves. 

Question: Exercise, friends, family, hobbies, eating right are all things to help deal w/ vicarious trauma but they involve AFTER work activities. What are some things you can do while you are at work that will help? 

Answer: It is not always possible, but if you can spend a few less hours a week with traumatized people there is less chance for vicarious traumatization. Some things you can do at work are speaking with your supervisor about adjusting caseloads to include a diversity of victims you can help. Ask if your work can be diversified to include teaching, supervision and consultation rather than only working with victims. Ask if you can have supervision. Recommend that your organizations offer adequate briefing and recognize your efforts. Staff, when first hired, should be taught how to take care of themselves emotionally and issues related to their own past traumas need to be addressed. Sharon, are you satisfied with the work that you do? I would recommend that you take the Compassion Satisfaction and Compassion Fatigue Test at http://www.isu.edu/~bhstamm/tests/satfat.htm.  

Question: How can correctional personnel (teachers) best cope with vicarious trauma and compassion fatigue? I'll be teaching at the time of your presentation and hope that your responses will be archived so I can access them at a later time. 

Answer: My responses will be archived but if you want to contact me about any issues, my website is www.griefworkcenter.com and my email is griefwork@aol.com. In response to your question, correctional personnel can develop peer groups and receive on going training. Ray Flannerys study found that regular exercise, no smoking, limited alcohol use, reasonable weight control, living within ones means and social support are ways to cope with vicarious trauma. BJ, I recommend that to best cope, attempt to manage workload and use time off for leisure and fun activities. Above all else, keep a sense of humor! 

Question: How can I identify if I am a "victim" of vicarious trauma....what are the usual symptoms. Are there some symptoms that aren't as prevalent that should also send up a "red" flag? 

Answer: Vicarious trauma refers to the cumulative effect of working with victims. Compassion fatigue is a combination of secondary tramatization and burnout due to providing professional services that brings employees in direct contact with traumatized persons. Some of the symptoms are outbursts of anger, numbness, fatigue, horror, guilt, flashbacks connected to the victims your serve, exhaustion, headaches and gastrointestinal complaints. Sleep disturbances, perhaps experiencing troubling dreams is another symptom. Victim service providers have shared with me that they wake up from nightmares of the victim’s experience. The red flag is when you personally are overwhelmed because your role is to witness the victim’s horrific pain and suffering. The red flag is sent up when you focus inward and hear yourself saying or thinking, I am not acting like myself I thought I had heard the worse until now That was not something I usually do I cant listen to one more victims story and This does not sound like me. Take the Compassion Fatigue Self Test at http://www.ace-network.com/cftest.htm.  

Question: In your experience, does vicarious trauma vary according to type, e.g., sex abuse / rape trauma versus other types? 

Answer: In my experience, I have had the privilege of listening to helping professionals from many fields. Those who support children seem to have the most difficult time. There is a high turnover rate for those in child protective services. Graef & Hill (2000) note that a lot of agencies report qualified, competent applicants with child protective service backgrounds often are not available. They are overwhelmed by a child’s reactions to terror, as the reactions mimic their own response, including feeling helpless, rage, and the desire to retaliate (Coppenhall, 1995). Though other helping professions have acknowledged effects of working with victims, child protective service has not, and that creates new inexperienced workers and reassignment of cases to those already overworked. In regard to the example you mentioned, research on counselors working with survivors of sexual violence found high rates of personal experience with violence (Schauben & Frazier, 1995). Vicarious trauma (VT) is the passing on of traumatic stress by observation andor bearing witness to the stories of traumatic events. In addition to type of trauma vs. other type of trauma, we look at professionals personal issues with trauma, why helper chose that occupational setting, co-worker death, traumas related to gender, and cumulative effect of bearing witness to pain over and over again. Their history of trauma may influence how they select their clientele (Nelson-Gardell & Harris 2003; Salson & Figley, 2003). A few years ago, I wrote a 30 hour continuing education course book for Nurses, Death, Dying, and Bereavement Providing Compassion During a Time of Need, MA: Western Schools. While working on the manuscript, I tried to get my hands on research regarding Nurses and VT and compare that to other helping professions. I found that most of the research is anecdotal and there was not much research on this important topic. 

Question: What are some ways an agency can provide support for its counselors to process what they have heard and/or seen throughout the course of their work with victims?

Answer: Some ways an agency can support counselors working with victims is to provide an opportunity for ventilation, supervision, encourage creative problem solving with any issues they may be having, help delegate existing workloads if they are overwhelmed, and offer resiliency training. 

Question:  I am a clinical counselor working with adjudicated youth all male population. It gets overwhelming at times listening to details of how they have been traumatized. I find myself no matter how hard I try not to be affected particularly at home. I would like to leave my job at my job and not bring it home with me. Could you offer any helpful tips on how to avoid secondary/vicarious trauma. 

Answer: To avoid secondary vicarious trauma recognize the early warning signs. As a trained clinician you are better able than most to identify these symptoms. I would also recommend that you spend as much personal time as you can enjoying what you love to do, eat well, exercise, spend time with people that you enjoy being with, get adequate sleep, and talk to supervisor about issues that are bothering you. 

Question: Is there a difference between; compassionate fatigue, burn-out, secondary traumatic stress and vicarious trauma? 

Answer: They do all seem to blend together, don't they? First, vicarious trauma refers to the cumulative effect of working with victims. Second, compassion fatigue is a combination of secondary tramatization and burnout due to providing professional services that brings employees in direct contact with traumatized persons. Third, burnout is a state of extreme dissatisfaction with ones work characterized by excessive distancing, impaired competence and increased irritability. Secondary Traumatic Stress is a syndrome of symptoms nearly identical to Post Traumatic Stress Disorder except that exposure to knowledge about a traumatizing event is associated with the set of STSD symptoms. There is a sense of burden; depletion and self-concern; and resentment, neglect, and distress. Symptoms can occur when at least 2 people share and one person has been traumatized and one wants to help.

Question: What is the best way for a state agency to train advocates on vicarious trauma statewide? Are there any good resources, particularly for advocates in rural areas? 

Answer: I am co-authoring a Compassion Fatigue Training Manual with Angie McCown. We will be travelling across the US offering the program. Please contact OVCTTAC for more information on availability dates. 

Question: What about supervisors? Being one person removed from the survivor has caused me to miss out on meeting the client and having a chance to see that she has survived the trauma and is okay (physically at least) today. I hear so much about the victimization during debriefing. Also, there must be some fundamental tools for use in processing vicarious trauma. Exercise, long hot baths, eating right, etc. and even counseling for yourself all seem to be band aids for a larger problem? Thank you!

Answer: I agree that it appears that exercise, long hot baths, eating right, etc. and even counseling for yourself all seem to be band aids for a larger problem, but studies have shown that these suggestions help. Supervisors are removed from the survivor and often miss out on meeting the client and having a chance to see that that they have survived their trauma. Fundamental tools are in the early stages as we are only now truly recognizing the need to support supervisors and other professionals who are experiencing compassion fatigue.  

Question: Can you recommend any resources, method, or curriculum that are backed by research and considered to be effective evidence-based practice for coping with vicarious trauma?

Answer: Compassion Fatigue Self-Test (CFST) for Psychotherapists (Figley, 1995), the TSI Belief Scale (TSI-BLS) (Pearlman, 1996) and the Secondary Trauma Questionnaire (STQ) Standardized clinical interviews specific to secondary traumatization have not been developed.  

Question: Having worked with victims for a number of years, I know 'compassion fatigue' (Charles Figley) can pose serious problems. I also know finding support within non-profit organizations can be just as challenging. Any suggestions? 

Answer: That is a major challenge! These non profits must be educated about compassion fatigue and its risks. Offer your supervisor information about compassion fatigue, secondary trauma, and burnout and work with human resources to see how much staff is burning out and leaving their jobs. Is it cost effective to educate their staff? Are they recognizing the symptoms of staff burnout and its effects on the people they serve? If they realize their staff is burning out they may be more apt to support them. 

Question: The post-September 11th era has dealt with tremendous trauma from such an unprecedented event. What do you recommend to health and law professionals in coping with the pain of the victims as well as your own personal experiences? 

Answer: I was teaching Crisis Intervention at Brooklyn College during the weeks following Sept. 11th. The Secretary in our Department was shattered when she heard the news as her son worked in the World Trade Center. His body was never found. My world was shattered that day as well or at least my sense of safety. So, to cope, I remain thankful for what I can be thankful for, spend time with my family, pray, and attempt to keep a sense of humor, exercise, spend time with my close friends and travel. Law and health professionals will cope in their own way. Professionally, I also recommend that they continue getting training.  

Question: Through my work as a Domestic Violence Advocate I have been given the opportunity to reflect on my own traumas, while working with women in crisis. Unfortunately I often feel emotionally exhausted. Is possible to be in your own process of healing and be the support person for others in there own? I question if this is can really be sustainable.

Answer: It really is not possible until you personally work through your issues. I recommend that you speak to your supervisor, get help for your own process and when you are ready, begin helping others. 

Question: I am an Advocate, I find myself dreaming throughout the night, regarding my participants, and the actions throughout the day, what can I do, after my work day is over, so I can go home and sleep, and not dream about my day? 

Answer: I think this is one of the most frequently asked questions in all of my workshops and trainings. What I find amazing is that when it is asked a handful of arms are raised into the air as participants want to offer their advice. So based on their responses . . . have a cup of hot tea, take a long hot bath, read a book unrelated to your field, go on line and play Boxerjam (whatever that is), read jokes, do a crossword puzzle, say a prayer, call a friend that you have not spoken to in a long time, create a journal, have sex, or listen to your favorite music. A few weeks ago a male police officer raised his hand and informed the crowd that he just started crocheting before he went to bed. So, find what works for you and sleep well.  

Question: I serve as Regional Director for Latin America at a faith-based NGO that does human rights cases. My field staff are not well versed with the concept of vicarious trauma, but definitely suffer its effects. Can you recommend some self-care practices that I could implement from a distance? Thank you. 

Answer: I’d like to recommend the following self-care practices that you could implement from a distance (but hopefully not too far in the distance) which are based on Figleys work Improve training, recognize and normalize STS symptoms, own your own personal trauma history, provide a supportive work environment, limit work hours, and offer debriefings. However, being that you are faith based, I would also recommend recognizing faith, religion, and spirituality to cope with vicarious trauma. Too often I am told not to mention faith when instructing, but it is significant to many people who are dealing with the effects of trauma. Help your staff to affirm their spiritual identify and to continue working on their spiritual growth as they listen to stories that absorb into the heart, mind and spirit. 

Question: I work in Victim Services in corrections, and I work with parole officers and the parole board on a regular basis. These positions bring evidence of secondary trauma of their own to me, from working with offenders and victims both. Do you have suggestions for how to respond? 

Answer: In working with corrections, parole officers, the parole board, offenders and victims themselves, I can understand how you can recognize evidence of secondary trauma. I would suggest that you vent to your supervisor, a co-worker or a mental health professional. Does your supervisor recognize that vicarious trauma is real? You need to process your reactions to lessen the risks. Find a nonjudgmental listener and read what you can on this important topic. Pearlman and Saakvitne, (1996) have developed an assessment tool to determine the contributing factors of vicarious trauma. They want you to look at personal as well as professional factors. Personally, they ask you to look at the nature of your work and ask these questions: Do I have choice and control over my work, am I doing the kind of work I like for which I feel I like, for which I feel well suited, for which I feel competent and talented? Does this work match my values and beliefs? Is there balance and variety in my caseload and work? Are there certain clients with whom I especially enjoy working? Why? With which clients do I struggle the most? Professionally, you can ask yourself, Do I have enough organizational support? Do I have collegial support within my organization, within my profession, among collateral providers? Am I getting enough helpful supervision? These questions may help you identify the source of your vicarious traumatization in corrections.  

Question:  I am a Victimology major planning to go into victim counseling. Counseling classes have explained the concept of compassion fatigue and burnout. But, I am concerned with the effects of anger. I get angry at the inhumanities committed against humanity and want to do something, but am helpless. How do you control the anger so it does not control your life? 

Answer: I wish you much success in this field and appreciate your asking me about controlling anger so it does not control your life. A study by Yale School of Management, Professor Barsade and Gibson of Fairfield University showed that 1 in 4 Americans feel at least somewhat angry at work. You have yet to enter the workforce and already show signs of being angry. Helping professions and students are human! We feel . . .we react . . . we cry . . . and sometimes we get ANGRY! We must use anger constructively and it sounds like you are self aware. While studying for my red belt in Tae Kwon Do I was asked to break a board, and did so. It was on the same day that I helped two victims. I realized that I was extremely angry with the perpetrator and so breaking the board became a way for me to channel my anger. Other ways could be less physical such as journaling your feelings and thoughts, or singing. Several victim service providers have told me that they sing whenever they can to help them with their stress. So put your radio on, and SING . . . or talk to yourself and use strategies that work for you to calm down and deal with your anger. I wish you much success and hope that my response helped you to feel less helpless.  

Question: Frequently experts in a single condition have accumulated many credentials, but have very little actual experience in the systems they seek to give advice to. Do you think it is important to have hands on knowledge of context, good practice, and the resilience which flows from such experience, or is expertise as an outsider sufficient? 

Answer: Hands on knowledge would be beneficial but is not always possible. So, expertise as an outsider is acceptable as long as that person recognizes the uniqueness of the profession they are assisting. An outsider should focus on intervention that best meets that particular profession. Anyone offering advice must be well versed in traumatic death, burnout, vicarious trauma and traumatic stress and have tools for transforming trauma and treating compassion fatigue. That person must recognize the pain of helping and the psychological injury of helping professionals and then be able to modify what they know to the particular population they are assisting. 

Question: To what degree may we assume that vicarious trauma and compassion fatigue are in place, as a baseline stressor, for American citizens who regularly view information about the war in Iraq? How can human service professionals address this static anxiety with the people we serve? 

Answer: Watching TV is a stressor as it exposes Americnas to trauma. I think we should assume that vicarious trauma and compassion fatigue are in place, as a baseline stressor for Americans who regularly watch television shows about Iraq. According to Figley's (1995a) Secondary Traumatic Stress (STS) theory, persons who work directly with or have direct exposure to trauma victims on a regular basis are just as likely as the primary victims to experience traumatic stress symptoms and disorders. People can be traumatized without actually being physically harmed or threatened with harm. They can be traumatized simply by learning about the traumatic event (p.4). Secondary trauma is defined as indirect exposure to trauma through a firsthand account or narrative of a traumatic event. Whether the stressor is a television program about the war or a victim sharing his or her story, it is still a stressor that can cause anxiety as well as anger, fear, nightmares, irritability, and loss of control. Address the anxiety by educating those you serve. They may not even recognize how their TV viewing habits are effecting them until you point it out.  

Question: What practices can be utilized by an agency or individual practitioner to minimize the effects of vicarious trauma on professionals treating offenders and victims of domestic violence? 

Answer: The best practices would be based on a few core questions. Why did the practitioner enter this career? Is he or she a victim or offender of domestic violence? Has he or she addressed issues related to victimization prior to entering the domestic violence field? Though there is little research on counselors who work with domestic violence, Saakvitne and Pearlman, 1996 recommend the following: provide respite for staff such as adequate time off, have realistic case loads, provide qualified supervision, and recognize the severity and pervasiveness of the clients traumatic experiences and after effects, work with staff to address signs of VT, provide continuing education, vacation time and personal psychotherapy opportunities.  

Question: I would like to know what we as individual social worker's can do to reduce the amount of work related stress with respect to vicarious trauma. 

Answer: It is crucial that after identifying the source of the stress, you identify the stress response in order to implement strategies to cope with it. In previous postings, I listed several ways to reduce the amount of work related stress. So, I would like to, if I may, focus on the theme of Awaking the Heart, which is also discussed in the book, Mass Trauma and Violence: Helping Families and Children Cope, by N.B. Webb. Awaking the Heart is a spiritual practice that allows social workers to be touched by their clients’ stories and pain and to remain open (Welwood, 2000). Rather than experience vicarious trauma because of the heartfelt story, the social worker remains open, which is to stay with that shakiness, to stay with a broken heart, with a rumbling stomach, with the feeling of hopelessness . . . that is the path of true awakening (Pema Chodron, 2001, p. 211). Therefore, I would recommend that you focus on being empathetic with an open heart to prevent vicarious trauma.  

Question: How do you find support despite working in a minimally supportive work environment? 

Answer: Can you find support outside of the office? Speak with other professionals in your field, a good friend, family member or mental health professional. If your organization is not recognizing vicarious trauma, they are probably not recognizing other issues such as layoffs, benefit cutbacks, downsizing, restructuring, interpersonal conflicts and external agency conflicts. Many professionals like yourself are dealing with stressors of inadequate job training, lack of referral agencies, funding pressures, frustration with criminal justice system, irregular work schedule and extensive paperwork. So, identify your social support and reach out to them.  

Question: I supervise therapists who provide crisis counseling to sexual assault victims during the medical/evidentiary exam following the crime. The counselor hears a detailed account of the sexual assault. Any tips for helping them cope with the effects of vicarious traumatization that comes from hearing these horrific stories? 

Answer: I would like to recommend 2 tips. First, be supportive. A recent study found that rape victim advocates felt supported by their organization if the advocate was encouraged to call backup, had flexible hours, was allowed to attend training, conferences, and workshops, had weekly case meetings, and individual clinical supervision. Feeling supported will help them with VT. Second, in a previous post, I responded to a students question about anger. I would like to focus on the issue of anger as a tip for self care. Rape victim advocates must identify their reactions to what they hear and studies show that anger is a common reaction in professionals helping sexual assault victims. A recent study on rape victim advocates found that on the individual level, 49 of the anger responses were associated with reactions to attitudes, actions or statements from criminal justice personnel, including police officers, judges, detectives, defense attorneys, and prosecutors, while 11.3 of the advocates had anger responses directed toward the perpetrators of the assault. The results on the extra-individual level indicated that 38.7 of the participants were angry at the inefficiency and insensitivity of the court system, and 18.3 were angry at other systems like the hospitals. 15 of the extra-individual anger focused on societal attitudes toward women and rape and 14 were angry at the brutality of rape in general. Hope these two tips help (Wasco, S. & Cambell, R., Reactions of Rape Victim Advocates, 2002).  

Question: What awareness and educational programs are there to help supervisors and managers become aware of this issue as well as knowing about how to best help their direct reports to deal with the issue?

Answer: Awareness and educational programs are: the Green Cross Academy of Traumatology in Florida; website: www.traumatologyacademy.org; the Sidran Institute in Maryland; website: www.Sidran.org; Traumatic Stress Institute Center for Adult & Adolescent Psychotherapy, LLC and Trauma Research, Education,& Training Institute, Inc. in Connecticut; website: www.tsicaap.com; info@tsicaap.com; Institute of Rural Health in Idaho; website www.isu.edubhstamm; www.isu.eduirh. Also, OVC is offering a brand new 2 day training on Compassion Fatigue/Vicarious Trauma. I co-authored the training with Angie McCown. Contact OVC for more information. 

Question: I just started in my job as an immigration case manager, and even though that by the client comes to me she would have already been helped by the staff at the women crisis centers, I too feel may have to help them (even if it is in some small way); how can I prepare myself to deal with it? I do care about them and do not want to let them down and want to be prepared for most situations, even if they never come to be, thank you.

Answer: You mentioned that by time the clients comes to you, they would have already been helped by staff but you feel you have to help them (even if it is in some small way). Skovholt (2001) maintains, Helping professionals often want so much to help that they get caught up in wanting to make a big difference for many people. Veteran practitioners often learn that satisfaction can consistently come only if the helper reduces expectations and focuses on small changes. This approach is often more empowering for the client or patient and is a form of practitioner self-care. First prepare yourself to deal with your feelings. Spend time with family and friends, talk with supportive co-workers, read books and other publications on compassion fatigue, read online resources and attend workshops or classes. To prepare yourself to help them, read books and journal articles and get training. 

Question: In one of the previous discussions you recommended reading books on compassion fatigue. Is there a specific book that you would recommend? 

Answer: There are two I recommend equally: Treating Compassion Fatigue (2002) by Charles Figley and A Clinical Guide to the Treatment of the Human Stress Response (2002) by George Everly and Jeffrey Lating. 

Question: I work with the families of Homicide victims. I have found that most families prefer to tell the surviving children of the victim what happened, themselves, without professional assistance. In my opinion, in many cases, this makes the initial trauma worst for the kids. Is there a general method that I could suggest for families to use, even though, every Homicide incident is different. 

Answer: Recommend that they use the correct words (ex. dead, homicide). Speak at the correct age and developmental level so the child will understand; Go slow; Be honest; Allow the child to ask questions; offer them a handout on children and grief and what to expect from birth to age 3, age 5 - 9, and adolescent and teenager responses. Offer a few suggestions for immediate rituals they can perform with their child, and offer assistance regarding the child's participation at the funeral.

Question: Traumatic events such as the Vietnam War reportedly had more victims dying from suicide than from combat. These traumas were of course witnessed and taken to heart by the professionals aiding them. Are there any special government programs to aid the professionals that will have to deal with the veterans of the current war? 

Answer: One early scientific study indicated The estimated risk for PTSD from service in the Iraq war was 18 percent. You can find out about programs that help these veterans through Operation Iraqi Freedom.  

Question: Is keeping a journal a good idea, when working with survivors of Domestic Violence? 

Answer:  Keeping a journal is an excellent idea as it will help the victim clarify thoughts. Journal writing helps writers process the homicide. I also recommend that you offer suggestions on books that they can read about homicide, traumatic grief, and loss as well as working in their journal. For book resources: www.centeringcorp.com.

Question: I would like to know how you can prevent vicarious trauma in the work place. 

Answer: Prevention: Organizations must acknowledge that there is a risk of working with victims; Good administrative support; Include resiliency testing in applicant screening; Teach all new staff how to take care of themselves emotionally; Provide a supportive work environment; Determine ways of distributing workload in order to limit traumatic exposure; Adjust caseloads to include diversity of victims; Create a buddy system; Offer (CISM): Critical incident stress debriefings and defusing and offer excellent training.  

Question: As a victim/witness advocate in a prosecutor based program for the past 20 years, I sometimes find myself losing patience with some victims of domestic violence-who have continually been involved in the court system sometimes with more than one offender, and yet they refuse to seek counseling, leave the offender, take advantage of community resources or change their pattern of relationships. Repeatedly, they will contact the police to have the offender arrested and then once charges are filed, they are hostile and refuse to cooperate. While I am "used to this", I find it very frustrating at times. What is the best approach to take in talking with these particular victims who put you in a no-win situation? 

Answer: I was a bereavement counselor for hospice for several years. I recall someone saying to me, Why work with those who are terminally ill... it's a no win situation. What that statement attempted to do was negate all that I did to support those in need of help. It is an interesting comment, a no-win situation as it appears to me you have been winning for the past 20 years serving victims of domestic violence. You win when you provide education and support. You win when you take the time to empower victims as they attempt to cope with their situation. You win when they take the time to listen to you and accept literature and telephone numbers. Whether they accept the support or not, focus on the fact that you win each time you share your expertise, compassion, listening skills, education, and advocacy and you win when they chose not to. You win because you are doing the job that many cannot and will not do!  

Question: One way I work with my staff during trainings and after is to remind them that it is ok not to think about your clients or your work all the time. Many staff, those new and experienced, have this notion that they need to be on and available to everyone who needs them 24/7. Those that like to help often take that on in their personal lives as well as their professional lives and it's very easy to lost track of yourself that way. Or people come to identify themselves as "helpers" and then don't allow themselves a break. I just don't think that is healthy. I think it's ok and necessary to say to allow yourself to turn it off. What are your thoughts on that?

Answer: I did a keynote a few weeks ago and asked those in attendance to pick up their water glasses. I asked them to keep holding the glasses while I spoke. After two minutes, I could sense that their arm was getting tired. I asked them to keep holding the glass of water while I continued on. After 5 minutes I asked if they were getting tired of holding the glass of water and the resounding answer was, YES! I then asked them to put the glass down and explained that the water represents their work and the people they serve. They have to put it down. If they hold the glass for a short time and periodically put it down, it is not heavy. However, the longer they hold it, without rest, the harder it is to hold. So, during your staff training try the exercise and explain why it is so important for them to put their glass down when they can. 

Question: Please explain the difference between primary and secondary PTSD (or Compassion Fatigue/Vicarious Traumatization and PTSD). Thank you. 

Answer: In PTSD, the individual has been exposed to a traumatic event in which the event that involved actual or threaten death or serious injury, or a threat to the physical integrity of self or others. The four most common characteristics of PTSD are visualization- flashbacks; reenactment- trauma unconsciously acted out to restore power and control; fear of intimacy, pain, loss of control, victimization associated with relationships; and a sense of hopelessness. The event itself involved fear, helplessness or horror. The duration of the disturbance is more than one month and causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Figley (1995a) refers to Secondary Traumatic Stress (STS) as the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person (Figley, 1995b, p. 10). The pathological response of being exposed to another's traumata is called Secondary Traumatic Stress Disorder (STSD). STSD is a syndrome of symptoms nearly identical to PTSD except that exposure to knowledge about a traumatizing event is associated with the set of STSD symptoms which is seen in the unsuccessful, maladaptive psychological and social stress responses where there is a sense of burden; depletion and self-concern; and resentment, neglect, and distress.  

Question: I respond to victims of DV and sexual assault in hospital emergency rooms and have noticed that in the 4 years I've been doing it, I have developed a pattern of getting lightheaded as soon as a victim of SA is prepped for the internal exam. I have no previous negative experiences with gynecologists, SA, etc. and still feel fully able and willing to do the work that I do. I have no other problems except the lightheadedness, but it seems too coincidental that it always happens at the same point in the exam, to not be something significant. Any ideas or suggestions?

Answer: Being that you have had no history of sexual abuse or negative experiences with gynecologists, I would expect that your responding physically at the same point is very similar to reactions in those who at the same point see the sight of blood and feel queasy, or if they see a mouse, they startle, etc. 

Question: I just took the CF Self Test from ACE. I scored a 40 (high risk) for Compassion Fatigue, and a 38 (high risk) for burn out. Now what do I do? 

Answer: Read through the various responses throughout this discussion that recommend how to cope with CF and Burnout . . . go on line and read the various articles on CF . . . and talk to your supervisor when you get to work. 

Question: There is a predominant belief promoted about the role of mental, legal or health professionals regarding their having to detach themselves from their clients in order to aid them. Do you think this belief has contributed to the denial of the existence of vicarious trauma? Professionals often feel guilty about letting their get in the way of their work even though it’s normal and humane. 

Answer: Creating boundaries by detaching is healthy. By detaching you allow yourself to maintain your boundaries. I don't believe it contributes to denial of VT. You are right -- Their feelings are normal and they are not abnormal if they cannot detach. I recommend you read the following site that goes into great detail about detachment and guilt: http://www.coping.org/control/detach.htm#What.

Question: Do you often see vicarious trauma in staff that work in hospice? 

Answer: It does occur. However, studies show that there is a higher occurrence of VT in domestic violence or sudden violent loss than cancer or anticipatory loss.

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