There are three self-report inventories that can measure secondary trauma: the Compassion Fatigue Self-Test (CFST) for Psychotherapists (Figley, 1995), the TSI Belief Scale (TSI-BLS) (Pearlman, 1996) and the Secondary Trauma Questionnaire (STQ) (Motta et al., 2001). These inventories vary by their domain of study and targeted population. While the CFST and STQ items more closely measure trauma exposure and PTSD symptomatology, the TSI-BLS measures changes in cognitive schemas (e.g., safety, trust, esteem, intimacy and control) consistent with the author's theoretical conceptualization of vicarious traumatization. The CFST and TSI-BSL were developed to assess secondary trauma in therapists whereas the STQ was designed for both therapists and the general population.
Standardized clinical interviews specific to secondary traumatization have not been developed. However, Gulliver et al. (2002) used the Clinician Administered PTSD Scale (CAPS) in their study of secondary trauma in disaster relief clinicians. World Trade Center survivor narratives heard by the clinicians were coded as the Criterion A event and the CAPS questions were administered as it would be for primary PTSD.
A recent validational study of the CFST and TSI-BSL self-report mea-sures showed convergent validity between the CFST and TSI-BSL, moderate convergence with burnout, and strong convergence with general distress (Jenkins and Baird, 2002). The next level of measure development will likely provide norms and cutoffs for symptom intensity, that will strengthen current assessment methodology.Clinical Consequences
If trauma is contagious (Herman, 1992) and the effects of treating trauma survivors may parallel those of primary trauma, a clinician's work with patients may be adversely affected. Herman (1992) suggested that the effects on therapists may include disruptions in the therapeutic alliance, conflict with professional colleagues attempts to rescue or control patients, and violations of therapeutic boundaries.
Therapists overwhelmed by traumatic material may begin to avoid or deny their patient's experiences (Baranowsky, 2002). Alternatively, they might push patients too quickly in an effort to master their own responses. The schematic disruptions associated with vicarious traumatization (Pearlman and Saakvitne, 1995) could also impact clinical work. A clinician whose views of trust and safety have been undermined might be unable to respond effectively to traumatized patients. Researchers interviewing trauma survivors might also introduce bias into studies in their efforts to control their own exposure to trauma material. The recognition of secondary effects requires that we further investigate the implications for practitioners because we cannot assume that the practitioners' responses will not impact the care they provide.Prevention
The key components of secondary trauma prevention might be found within practice systems (Herman, 1992). Echoing this sentiment, Pearlman and Saakvitne (1995) stated that four domains are important to the prevention of secondary traumatization in mental health care providers: 1) professional strategies, such as balancing caseloads and accessible supervision; 2) organizational strategies, such as sufficient release time and safe physical space; 3) personal strategies, such as respecting one's own limits and maintaining time for self-care activities and 4) general coping strategies, such as self-nurturing and seeking connection. Thus far, no studies have evaluated the effectiveness of these prevention strategies.Training Implications
The empirical evidence indicating secondary effects in practitioners raises the immediate question of how this should be incorporated into clinician training. We have a duty to educate those entering the field to anticipate how the work will affect them and to prepare them to address these effects (Munroe, 1995).
Although secondary traumatization may adversely affect practitioners and the services they deliver, work with trauma survivors can also be immensely rewarding and has the potential to allow practitioners to grow personally and enhance their compassion, provided responses to this difficult work are used constructively.Conclusions
Treatment of posttraumatic psychological reactions in civilians became a significant public health concern in the United States after Sept. 11. This public priority should also extend to the emotional well-being of clinicians who are exposed to traumatic stimuli in their occupational duties. Just as ongoing national policy discussions explicitly recommend that health care professionals and other first responders be vaccinated in the event of bioterrorist attacks, similar consideration should be made with first-line trauma and disaster relief clinicians. If clinicians are to maintain pace with the mental health care needs of U.S. citizens living in an increasingly dangerous world then their psychological well-being must also be recognized and protected.