mental health AIDS

Winter 2008 Newsletter / Volume 9, Issue 2

For Whom the Tell Tolls: Curbing the Cost of Giving & Getting Distressing, HIV-Related News (Part 1)

"There is a cost to caring. Professionals who listen to clients' stories of fear,
pain and suffering may feel similar fear, pain and suffering because they care."
                                                                                                                      ---- Figley, 1995, p. 1
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In their recent systematic summary of literature on the sociobehavioral dimension of HIV counseling and testing, Obermeyer and Osborn (2007) observe that

[m]uch is expected of providers "on the front lines," but little is known about how they cope. In addition to practical difficulties, they must deal with their own emotional issues regarding HIV. ... They may be reluctant to be tested and themselves suffer stigma ...; they may fear contamination and feel helpless, pessimistic, and doubtful of their ability to provide care. ... This makes it difficult to communicate with clients and encourage them to adopt appropriate behaviors. Conversely, good rapport between providers and clients is an important determinant of patients' acceptance of clinic-based interventions, including testing. ... Attention should therefore be directed at providers to define the needed services and ascertain the training, time, and resources necessary to deliver them. (p. 1768)

On this point, Myers et al. (2007) offer "a first step to identifying the challenges and stress that test providers experience related to delivering an HIV-positive test result" (p. 1018). The investigators conducted a thematic analysis of interview data from 24 providers of HIV counseling and testing services. The sample included physicians as well as counselors who worked at anonymous testing sites in Ontario, Canada.

Myers and colleagues found that,

as with other healthcare professionals communicating 'bad news', HIV test providers experience an impact when delivering a positive HIV test result; however, this impact varies and is influenced by contextual factors such as history with the test recipient ... . Implicit in the assessment of the impact of delivering an HIV-positive test result is the assumption that a positive result is 'bad news'. While a small number of the test providers indicated that they felt no or little impact of delivering the HIV-positive test result because the diagnosis is 'not the end of the world', most indicated it was difficult as it was anticipated that the test recipient would (or did) find the news distressing. (p. 1017)

With regard to approaches used by these providers to manage the impact of delivering a positive test result, "several coping strategies were employed, some active and some passive. The active strategies were focusing on the test recipient and use of social support. The literature suggests that 'shutting down' or depersonalisation (one of the dimensions of burnout), the use of dark humour (another manifestation of depersonalisation of the client/patient) and the use of alcohol or snack foods are not as adaptive ..." (p. 1018).

Trauma Tied to HIV

It is not only when clinicians must convey distressing news that their own coping mechanisms come into play. In the HIV-related clinical encounter, a clinician's coping mechanisms are also called upon when the client reveals distressing, if not traumatic, life experiences that precede and/or follow from the detection of that individual's positive serostatus.

Indeed, according to Radcliffe et al. (2007), "HIV-infected adults have been found to present with high rates of ... [posttraumatic] stress (10.4% to 42%). ... Posttraumatic stress disorder [PTSD] has been linked both to receiving the HIV diagnosis itself as well as to other life stressors associated with HIV such as a history of sexual abuse and assault. ... Strikingly, symptoms of posttraumatic stress have been found to persist for long periods of time postdiagnosis, with one study reporting posttraumatic symptoms even after 8 years, on average, postdiagnosis" (p. 502). In their own study of posttraumatic stress and trauma history among teens and young adults living with HIV/AIDS who were predominantly male and African American, Radcliffe and colleagues found that

93% of the sample report[ed] ... that receiving a diagnosis of HIV was experienced as traumatic. Of these, 13.3% met criteria for [PTSD] in response to HIV diagnosis, while an additional 20% showed significant ... [posttraumatic] stress symptoms. Even greater rates of posttraumatic stress were reported in response to other trauma, with 47% of youth surveyed reporting symptoms of posttraumatic stress in response to such traumatic events as being a victim of a personal attack, sexual abuse, or being abandoned by a caregiver. (p. 501)

Such revelations can exert an impact on clinicians who journey with clients through their HIV-related pain and suffering. In 1994, "Gabriel reported that group therapists who experienced the death of group members from AIDS were experiencing symptoms such as 'death imprints', 'indelible images' and 'psychic numbing' (pp. 170, 172)" (in Dunkley & Whelan, 2006, p. 110). More recently, Smith (2007) presented a series of anecdotal reports supporting his contention that "[m]any persons living with HIV/AIDS experience severe traumas that pose considerable challenges to the self-care strategies of mental health providers" (p. 193).

This is the first of a two-part series. Part 1 tackles the terminology used to describe how clinicians are thought to be affected by their work with trauma survivors. This section also summarizes literature on approaches to recognizing and alleviating the dangers facing clinicians practicing trauma-related psychotherapy. Part 2 (to be presented in the Spring 2008 issue of mental health AIDS) will expand on the current state of qualitative and quantitative research in this area and offer emerging evidence for the positive consequences of this work for clinicians.

Mind Your Phraseology!

A whole host of constructs has been used to describe the impact on clinicians of their work with trauma survivors; among the most prominent are countertransference, burnout, vicarious traumatization (VT), compassion fatigue, and secondary traumatic stress (STS). Unfortunately, "there still exists a lack of conceptual clarity in the literature ... [that] has made it difficult to use the literature to inform practice and training" (Baird & Kracen, 2006, p. 181).

A term familiar to mental health professionals, "countertransference involve[s] the therapist experiencing strong responses within the psychotherapeutic relationship in relation to the client. This can include emotional and behavioural responses (both conscious and unconscious) to ... patient[s], the material they bring to therapy, reenactments, and transference" (Sabin-Farrell & Turpin, 2003, p. 454).

"In terms of countertransference, the counsellor's personal characteristics determine his or her response to the client's trauma, while burnout1 places emphasis on the characteristics of the stressor ... . By comparison, ... [in conceptualizations of VT,] the counsellor's response to the client's trauma material ... [is thought to be] formed by aspects intrinsic to the individual therapist as well as characteristics of the situation ..." (Dunkley & Whelan, 2006, p. 108).

First coined by McCann and Pearlman (1990), VT "is the process through which the therapist's inner experience is negatively transformed as a result of empathic engagement with clients' traumatic material ..." (Canfield, 2005, p. 88). Moreover,

[a] therapist's VT is evident across all relationships in her/his personal and professional life and is permanently transformative. It is different from countertransference in that countertransference is temporarily linked to a particular period, event, or issue in the therapeutic process or in the therapist's life. [VT] represents changes in the most intimate psychological workings of the therapist's self. Invariably such change shapes countertransference reactions. As a therapist experiences increasing levels of VT, ... [countertransference] responses become stronger and/or less available to conscious awareness. This interaction creates a spiral with potentially disastrous results for treatment. In addition, increased VT can have dire consequences for the therapist's personal and professional life, including loss of personal relationships and in some instances, preventable job or career changes ... . (Canfield, 2005, pp. 87-88)

Importantly, "VT can be seen as a normal response to ongoing challenges to a helper's beliefs and values but can result in decreased motivation, efficacy, and empathy" (italics added; Baird & Kracen, 2006, p. 182).

As described by Dunkley and Whelan (2006), "trauma can disrupt the counsellor's cognitive schemata [i.e., intrapsychic structures] in one or more of five fundamental need areas: safety (feeling safe from harm by oneself or others), trust/dependency (being able to depend on or trust others and oneself), esteem (to feel valued by others and oneself and to value others), control (the need to be able to manage one's own feelings and behaviours, as well as to manage others[']), and intimacy (feeling connected to others or to oneself)" (pp. 109-110). "[S]pecific areas of disruption will differ for different individuals depending on which area is more or less salient for them as a reflection of their unique life experiences" (p. 111).

According to Baird and Kracen (2006), STS "refers to a syndrome among professional helpers that mimics [PTSD] and occurs as a result of exposure to the traumatic experiences of others" (p. 182). The term was first used by Figley (1995), who also referred to this syndrome as compassion fatigue. "The focus here is not specifically on cognitive phenomenon (as in cases of VT), but on a wider syndrome of experiences quite directly linked to the symptoms of PTSD. In addition, the precipitating experience(s) of the helper can be of quite short duration ... . This kind of exposure is both qualitatively and quantitatively different from the experience of a psychotherapist bearing witness to years of sexual abuse" (Baird & Kracen, 2006, pp. 182-183). STS is also different from burnout;

[t]he key difference … lies in the cause, since both conditions are characterized by depression, insomnia, loss of intimacy with friends and family, and both are cumulative.

[STS], however, is the direct result of hearing emotionally shocking material from clients, while burnout can result from work with any client group. Treating traumatized clients involves assisting them in managing PTSD symptoms, helping them tell their stories of traumatic events, and providing a safe place where feelings of helplessness, anger, and fear can be expressed. Since [STS] symptoms are considered a normal reaction to engagement with traumatic material, many therapists will experience STS, and some are likely to experience it for extended periods of time ... . Self-care practices are preventative and can reduce the likelihood that STS symptoms will develop into STSD. The difference between [STS] reactions (STSR) and [STS] disorder (STSD) lies in the duration of the symptoms experienced by therapists. Symptoms under one month [in] duration are considered normal, acute, crisis-related reactions. Symptoms that last for six months or more following the triggering event reflect [STSD] ... . STSD is a syndrome nearly identical to PTSD except that exposure to a traumatizing event experienced by one person becomes a traumatizing event for the second person, be it a family member, friend, mental health professional, or some other helper. (Canfield, 2005, pp. 84-85)

"Based on the diagnostic conceptualisation of ... PTSD ..., the symptoms [of STSD] include reexperiencing, avoidance or numbing reminders, and persistent arousal ... . Unlike [VT], [STSD] gives limited attention to context and aetiology, restricting its focus to observable symptoms ... . [VT] involves a consideration of the individual as a whole and places the observable symptoms in context ..." (Dunkley & Whelan, 2006, p. 109).

"Who Counsels the Counselors?"2

According to Bober and Regehr (2006),

[t]heorists in the area of secondary or vicarious trauma recommend a variety of strategies for reducing levels of symptoms and disruption. Several authors point to the importance of maintaining a balance between work and personal life ... . Seeking psychotherapeutic treatment to assist with countertransference issues related to unresolved events in ones' personal history and secondary trauma … [is] recommended ... . Peer consultation, supervision, and professional training to reduce the sense of isolation and increase feelings of efficacy are suggested ... . Finally, stemming from the association between exposure and symptoms, reducing the number of trauma cases is frequently suggested ... . These strategies are mirrored by therapists participating in qualitative studies and in anecdotal reports by therapists whose suggestions include peer support, physical activity and self-care, reading and watching TV shows or movies that are nonviolent, limiting their trauma counseling workload, and political activism ... . (pp. 2-3)

A number of these prevention and intervention strategies may also be incorporated into an agency's administrative response to the VT of its workers (see sidebar). Additionally, several approaches to recognizing and alleviating VT – a single-session VT group model for agency-based trauma workers (Clemans, 2004), certified compassion fatigue specialist training (Gentry, Baggerly, & Baranowsky, 2004), and a mindfulness-based trauma prevention program (Berceli & Napoli, 2006) – were identified in recent professional literature. As of yet, findings from rigorous evaluation of these approaches do not appear to have been published.

– Compiled by Abraham Feingold, Psy.D

References

Baird, K., & Kracen, A.C. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counselling Psychology Quarterly, 19(2), 181-188.

Berceli, D., & Napoli, M. (2006). A proposal for a mindfulness-based trauma prevention program for social work professionals. Complementary Health Practice Review, 11(3), 153-165.

Bober, T., & Regehr, C. (2006). Strategies for reducing secondary or vicarious trauma: Do they work? Brief Treatment & Crisis Intervention, 6(1), 1-9.

Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work, 75(2), 81-101.

Clemans, S.E. (2004). Recognizing vicarious traumatization: A single session group model for trauma workers. Social Work with Groups, 27(2-3), 55-74.

Dunkley, J., & Whelan, T.A. (2006). Vicarious traumatisation: Current status and future directions. British Journal of Guidance & Counselling, 34(1), 107-116.

Figley, C.R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C.R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1-20). New York: Brunner/Mazel.

Gabriel, M.A. (1994). Group therapists and AIDS groups: An exploration of traumatic stress reactions. Group, 18(3), 167-176.

Gentry, J.E., Baggerly, J., & Baranowsky, A. (2004). Training-as-treatment: Effectiveness of the certified compassion fatigue specialist training. International Journal of Emergency Mental Health, 6(3), 147-155.

McCann, I.L., & Pearlman, L.A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131-149.

Myers, T., Worthington, C., Aguinaldo, J.P., Haubrich, D.J., Ryder, K., & Rawson, B. (2007). Impact on HIV test providers of giving a positive test result. AIDS Care, 19(8), 1013-1019.

Obermeyer, C.M., & Osborn, M. (2007). The utilization of testing and counseling for HIV: A review of the social and behavioral evidence. American Journal of Public Health, 97(10), 1762-1774.

Radcliffe, J., Fleisher, C.L., Hawkins, L.A., Tanney, M., Kassam-Adams, N., Ambrose, C., & Rudy, B.J. (2007). Posttraumatic stress and trauma history in adolescents and young adults with HIV. AIDS Patient Care & STDs, 21(7), 501-508.

Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23(3), 449-480.

Smith, B.D. (2007). Sifting through trauma: Compassion fatigue and HIV/AIDS. Clinical Social Work Journal, 35(3), 193-198.

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 1 For more information on interventions designed to address burnout, go to the Tool Box entitled "Sustaining Stamina at the Interface of HIV & Mental Health Practice" in the Winter 2005 issue of mental health AIDS.

 2 Obermeyer & Osborn, 2007, p. 1768.

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Kicking It Upstairs

Bell, Kulkarni, and Dalton (2003) drew from multiple sources to offer a number of prevention and intervention strategies that merit consideration as an agency's administrative response to the vicarious traumatization of its workers. Four areas – organizational culture, workload, work environment, and education – of the seven identified by Bell and colleagues are briefly discussed here:

• Organizational culture – An organizational culture that "normalizes" the effect of working with trauma survivors can provide a supportive environment for ... workers to address those effects in their own work and lives. It also gives permission for ... workers to take care of themselves. ... A supportive organization is one that not only allows for vacations, but also creates opportunities for ... workers to vary their caseload and work activities, take time off for illness, participate in continuing education, and make time for other self-care activities. Small agencies might signal their commitment to staff by making staff self-care a part of the mission statement, understanding that ultimately it does affect client care. Administrators might also monitor staff vacation time and encourage staff with too much accrued time to take time off. Self-care issues could be addressed in staff meetings, and opportunities for continuing education could be circulated to staff. (p. 466)

• Workload – Research has shown that having a more diverse caseload is associated with decreased vicarious trauma ... . Such diversity can help the ... worker keep the traumatic material in perspective and prevent the formation of a traumatic worldview ... . Agencies could develop intake procedures that attempt to distribute clients among staff in a way that pays attention to the risk of vicarious trauma certain clients might present to workers. When possible, trauma cases should be distributed among a number of ... workers who possess the necessary skills [to provide care] ... . In addition, ... workers whose primary job is to provide direct services to traumatized people may benefit from opportunities to participate in social change activities[.] ... Such activities can provide a sense of hope and empowerment that can be energizing and can neutralize some of the negative effects of trauma work.

Organizations can also maintain an "attitude of respect" ... for both clients and workers by acknowledging that work with trauma survivors often involves multiple, long-term services. Organizations that are proactive in developing or linking clients with adjunct services ... will support not only clients, but also decrease the workload of their staff ... . Developing collaborations between agencies that work with traumatized clients can provide material support and prevent a sense of isolation and frustration at having to "go it alone." (p. 466)

• Work environment – A safe, comfortable, and private work environment is crucial for those ... workers in settings that may expose them to violence[.] ... Although it is more of a challenge in certain settings, protecting workers' safety should be the primary concern of agency administration. Paying for security systems or security guards may be a necessary cost of doing business[.] … [Also], agencies may consider developing a buddy system for coworkers so that if one worker is threatened by a client, another can summon the police [or other assistance].

In addition to attention to basic safety, ... workers need to have personally meaningful items in their workplace. These can include pictures of their children or of places they have visited, scenes of nature or quotes that help them remember who they are and why they do this work. ...

Agency administrators can encourage staff to make these small investments in their work environment. By placing inspiring posters or pictures of scenic environments (rather than agency rules and regulations) in the waiting rooms, staff meeting rooms, and break rooms, the organization can model the importance of the personal in the professional. In addition, workers also need places for rest at the job site, such as a break room that is separate from clients ... . With a space such as this, the organization could address the self-care needs of staff by providing a coffee maker, soft music, and comfortable furniture. (pp. 466-467)

• Education – Trauma-specific education also diminishes the potential of vicarious trauma. Information can help individuals to name the experience and provide a framework for understanding and responding to it. ...

Efforts to educate staff about vicarious trauma can begin in the job interview ... . Agencies have a duty to warn applicants of the potential risks of trauma work and to assess new workers' resilience ... . New employees can be educated about the risks and effects associated with trauma, as new and inexperienced workers are likely to experience the most impact ... . Ongoing education about trauma theory and the effects of vicarious trauma can be included in staff training ... and discussed on an ongoing basis as part of staff meetings. Agencies can take advantage of ... workshops ... at professional conferences ... by sending a staff member for training and asking that worker to share what he or she has learned with the rest of the staff. This information provides a useful context and helps ... workers to feel more competent and have more realistic expectations about what they can accomplish in their professional role. ...

Learning new ways to address clients' trauma may also help prevent vicarious trauma. Theories, such as constructive self-development theory ... on which the theory of vicarious trauma is based, maintain a dual focus between past traumas and the client's current strengths and resources. Working from a theoretical framework that acknowledges and enhances client strengths and focuses on solutions in the present can feel empowering for client and worker and reduce the risk of vicarious trauma. (p. 467)

The three remaining areas highlighted by Bell and colleagues – group support, supervision, and resources for self-care – will be discussed in the Spring 2008 issue of mental health AIDS.

Reference

Bell, H., Kulkarni, S., & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society, 84(4), 463-470.

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