Mental health care professionals specializing in the treatment of trauma hear tales of extreme human suffering and observe the emotions of fear, helplessness and horror registered by survivors on a consistent basis. Recent research demonstrates that these occupational duties may cause psychological symptoms in the practitioner who bears witness to the survivors' account of trauma.
Primary posttraumatic stress disorder may be diagnosed in an individual who experienced, witnessed or was confronted with a traumatic event and responded with intense fear, helplessness or horror. Intentional traumas (e.g., combat, sexual assault, terrorism and mass violence), as well as unintentional traumas (e.g., natural disasters, accidents), may cause this pervasive psychiatric condition.
Secondary trauma is defined as indirect exposure to trauma through a firsthand account or narrative of a traumatic event. The vivid recounting of trauma by the survivor and the clinician's subsequent cognitive or emotional representation of that event may result in a set of symptoms and reactions that parallel PTSD (e.g., re-experiencing, avoidance and hyperarousal). Secondary traumatization is also referred to as compassion fatigue (Figley, 1995) and vicarious traumatization (Pearlman and Saakvitne, 1995).
Secondary trauma is an understudied and controversial clinical phenomenon. In this article we will explore the controversy, review the existing literature, describe the personal and professional consequences, and address prevention of secondary traumatization.
Detractors of the secondary traumatization phenomenon in health care professionals claim that labeling clinicians with secondary PTSD is pathologizing and best described as a reaction, not a disorder. Just as most individuals directly exposed to a traumatic stressor exhibit some PTSD symptoms that abate quickly over time, many clinicians will have transitory reactions to survivor narratives. Yet in both primary and secondary trauma exposure, a small percentage of individuals will develop the full psychiatric disorder.
Research findings of primary and secondary PTSD related to the World Trade Center terrorist attacks illustrate this point. Galea and colleagues (2002) showed that in the first five to six weeks following the Sept. 11, 2001, terrorist attacks in New York City, 20% of residents living close to the World Trade Center met criteria for probable PTSD. Thus, the majority of individuals directly exposed to the terrorist attacks in New York City did not meet criteria for PTSD.
Research on secondary traumatization shows a similar prevalence pattern in mental health care professionals who treated survivors of the World Trade Center collapse (Gulliver et al., 2002). On standardized clinical interviews, many providers endorsed symptoms of PTSD linked to their exposure to survivor narratives, but most did not meet diagnostic criteria for PTSD. However, a minority of professionals met full diagnostic criteria for PTSD in the months following their exposure to survivor narratives.
A second controversial point concerns whether the PTSD DSM-IV Criterion A can include indirect exposure to a trauma. However, the definition of a traumatic stressor can be ambiguous. In fact, PTSD can occur in individuals who have been exposed indirectly to a traumatic stressor. For example, Weisaeth (1989) found PTSD in workers who were not present at the time of an industrial explosion at their workplace. More recently, Schlenger et al. (2002) reported that indirect exposure to the Sept. 11 disaster via the number of hours of television coverage watched per day on and after Sept. 11 was significantly associated with probable PTSD in individuals living outside of the terrorist attack sites. These findings show that the parameters of the Criterion A event which can precipitate PTSD are still evolving.
Review of the Literature
The current state of empirical literature on secondary traumatization among health care professionals is in its infancy. Although theorists such as Figley (1995), McCann and Pearlman (1990), and Stamm (1995) have written extensively on the phenomena of secondary traumatization, the level of corroborative data is not commensurate with the sophistication of existing theories. A recent review of Psychlit journal articles found only 17 peer-reviewed articles on secondary traumatization. Of these, only 12 contained data, and the majority of these were descriptive (qualitative) in nature.
The descriptive studies on secondary traumatization can be categorized as measure development (e.g., Jenkins and Baird, 2002; Motta et al., 2001), predictive variable studies (e.g., Adams et al., 2001; Schauben and Frazier, 1995; Wasco and Campbell, 2002) and one meta-analysis that indirectly evaluated techniques to prevent or treat secondary trauma (Everly et al., 1999).
The second category of studies explores secondary traumatization as a function of occupational roles and examines the variables that correlate with the development of symptoms. Eight studies describe the phenomena of secondary trauma among counselors with diverse training, caseloads, degrees and socioeconomic status (Adams et al., 2001; Ghahramanlou and Brodbeck, 2000; Everly et al., 1999; Iliffe and Steed, 2000; Jenkins and Baird, 2002; Schauben and Frazier, 1995; Steed and Bicknell, 2001; Wasco and Campbell, 2002). All eight studies describe a stable set of symptoms analogous to PTSD, yet a very low incidence of meeting clinical criteria (range between studies: 0% to 4%) or impairment in occupational roles was reported. This result is difficult to interpret, as the current status of the psychometric utility of available instruments decreases confidence in any conclusion, and each study used a different set of assessments. In sum, trauma counselors are likely to report some negative consequences of their work that maps onto a PTSD typology. What remains to be seen is how often this symptom profile is clinically significant and how symptoms affect patient care.
This same set of studies yields contradictory evidence about correlates of secondary trauma symptoms. The most frequently studied correlate is the therapist's personal trauma history. Jenkins and Baird (2002) found that personal trauma history correlated with secondary trauma symptoms, but Schauben and Frazier (1995) and Adams et al. (2001) did not. In addition, Schauben and Frazier found that the greater the percentage of survivors in a provider's caseload, the greater the number of secondary trauma symptoms reported.
Other factors suggested by theorists as potentially predictive of secondary traumatization include insufficient training, identification with the victims, insufficient support in the workplace, and insufficient social and familial support. Future research to further assess these characteristics is recommended.
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