In our current sociocultural climate, we have been hearing the term “trauma” discussed more frequently, not only in healthcare, but in a variety of environments and social circles. This shift signifies a changing of the guard, as there is now a social and professional movement toward recognizing the many forms of trauma and its multi-systemic impacts.
According to the National Council for Behavioral Health, approximately 90 percent of individuals receiving behavioral health services have experienced trauma and, in the U.S., approximately 70 percent of adults have experienced at least one traumatic event in their lives. In addition, the National Council states that trauma is a risk factor for the development of various behavioral health and substance use disorders.
Adopting Trauma-Informed Care Models
The aforementioned statistics highlighted the need for the behavioral health industry to adopt Trauma-informed Care (TIC) models as best practice standards.
Organizations rooted in TIC focus on addressing trauma at every level, including the individuals receiving services and all staff. Focusing on one’s trauma ensures proper interventions for individuals in care and helps prevent negative impacts on job performance and satisfaction among staff. Furthermore, research suggests a link between vicarious trauma and staff turnover, which likely contributes to workforce challenges and retention issues in human service organizations (Middleton and Potter, 2015).
Researching Vicarious Trauma in Staff
While TIC models are highly researched, less attention has been dedicated to exploring how prevention, identification and management of trauma symptoms may impact staff retention.
Research on vicarious trauma in 1990, by McCann and Pearlman, was the start of focusing on the ways clinicians were psychologically impacted by working with trauma survivors (Edmonds, 2019). Vicarious trauma is defined as the unique transformation that takes place within the therapist who empathically engages an individual’s traumatic experiences and their consequences (Branson, 2019; Pearlman & Mac Ian, 1995).
Today, vicarious trauma (VT) research has expanded to include other types of traumatic stress reactions such as secondary traumatic stress (STS) and compassion fatigue (CF). VT, STS and CF represent reactions to work-related secondary trauma exposure that can lead to emotional, cognitive and physiological responses impacting quality of life and job performance (Zerach, 2013).
More recently, literature investigating work-related primary and secondary trauma exposure has extended to different professions within behavioral health, mental health and child welfare, covering a continuum of services. These studies repeatedly indicate behavioral health staff are at an increased risk for the development of trauma reactions and reveal significant prevalence rates of VT, STS and CF in the behavioral health/mental health workforce (Ivicic & Motta, 2017; Kerig, 2019; Zerach, 2013; Salloum et al., 2019).
Traumatic Reactions Contribute to Turnover
One study examining the relationship between VT and staff turnover included nearly 1,200 child welfare workers across five organizations in four states. Results found approximately 33 percent of participants experienced varying degrees of VT; these numbers are congruent with the majority of studies examining VT in therapists. In addition, nearly 10 percent of participants endorsed “to some extent” that their personal trauma is an issue in the workplace (Middleton & Porter, 2015). Results also indicated that 50 percent of participants “often thought about leaving their organization,” and results of a structural equation model found a significant relationship between VT and intent to leave, revealing that staff with higher levels of VT were more likely to hold intensions of leaving.
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Trauma-informed Care (TIC) Guidelines also indicated that retention in behavioral healthcare is significantly influenced by an organization’s lack of attention to the realities of STS; failing to normalize trauma reactions in staff and, instead, treating them as staff failures; and not supporting staff’s utilization of personal therapy (SAMHSA 13-4801, 2014).
These findings reveal a need for more attention and interventions to address the impact of primary and secondary trauma on turnover.
Trauma-Informed Care Guidelines and Training
A core principle of TIC is safety, which includes the physical and psychological safety of individuals receiving services, as well as staff at all levels within an organization.
TIC guidelines for creating a trauma-informed organization highlight the importance of not only attending to the trauma experienced by individuals in care, but also requires that organizations develop procedures for supporting staff with personal trauma histories and those experiencing aspects of STS or VT resulting from their work (SAMHSA 14-4884, 2014). “An organizational environment of care for the health, well-being, and safety of, as well as respect for, its staff will enhance the ability of counselors to provide the best possible trauma-informed behavioral health services to clients” (SAMHSA 13-4801, p.173, 2014).
Specific suggestions for TIC training, to help employees address trauma reactions, include helping team members identify signs of STS and VT within themselves, and developing skills to implement self-care strategies shown to prevent and manage traumatic stress reactions (SAMHSA 13-4801, 2014). While these guidelines are helpful, and a necessary starting point to guide organizations in the development of TIC, there is limited research regarding specific interventions for training staff in the recognition and management of trauma reactions and outcomes related to job retention and job satisfaction.
Measuring Compassion Fatigue / Satisfaction
Much of the current research regarding interventions utilized by TIC organizations to address staff trauma have included examining changes in compassion satisfaction and compassion fatigue following completion of trauma training and trainings focused on helping staff develop trauma-informed self-care practices (TISC).
A city-wide study, conducted in Baltimore between 2015 and 2016, evaluated changes in organizational and provider specific factors following the completion of a nine-month training focusing on the six core principles of TIC, outlined by SAMHSA (Damian et al., 2017). The sample of participants included 88 staff from a number of organizations (social services, health, education and law-enforcement) serving traumatized youth, including community and residential programs.
Pre-and post-surveys measured a number of factors, including:
- Compassion fatigue (CF) includes aspects of burnout, such as feeling hopeless and ineffective with job tasks, as well as STS, which encompasses problematic reactions to others’ traumas (Damian et al., 2017).
- Compassion satisfaction (CS) is defined as “the pleasure derived from being able to do one’s work well” (Damian et al., p. 2, 2017).
Results indicated that employees reported higher levels of CS following the training, which contributed to greater empathy and camaraderie among colleagues. In addition, results revealed higher levels of CF, highlighting an increased awareness and ability to identify burnout and STS following the training. Staff also reported a greater awareness of the need to enact better work boundaries and greater self-care (Damian et al, 2017).
TISC training also has proven useful for lessening the impact of STS in staff. A study, conducted with 177 child welfare workers (primarily case managers), examined the mediating effects of TISC utilization on the relationships between burnout and STS with mental health functioning, focusing on three areas:
- Utilization of resources/supports for TIC training (e.g., stress management, trauma in individuals, helping professionals and secondary trauma).
- Organizational supervision and support practices (peer support and supervision/consultation); and
- Personal self-care (stress-management skills, work-life balance) (Salloum et al., 2019).
Results indicated that the use of self-care strategies mediated the association between burnout, STS and mental health functioning. Also, the use of organizational resources/supports mediated the effects of STS and mental health functioning, while organizational supervision and support practices did not. When STS rates were higher, there was a significant negative effect on mental health functioning, but mental health functioning was not as significantly impacted when staff utilized organizational resources (e.g., TIC training) and self-care practices.
Creating safe and healthy organizations: Literature and empirical studies reveal the high prevalence of VT, STS and CF among social service and behavioral health employees, highlighting the emphasis on TIC and the need for organizations to: 1) educate their employees about trauma and 2) attend to trauma histories and trauma reactions in staff and individuals receiving services.
Research reveals promising evidence of reduced rates of VC and STS, and increased awareness of personal trauma reactions, when staff receive TISC training, specifically the implementation of personal self-care practices and trauma-informed training that focuses on understanding manifestations of trauma in: 1) those being helped and 2) helping professionals.
Although empirical data exists regarding the negative influence of trauma reactions on staff retention, more studies are required to examine the impact of TISC on employee retention for TIC organizations. This is particularly needed in the current climate since the COVID-19 pandemic, in which we are seeing an exacerbation in behavioral health conditions and lower rates of employee retention.
The traumatic impact of COVID-19 for staff and individuals receiving services has already begun contributing to psychotherapist’s rates of VT and will likely continue for some time (Aafjes-van Doorn et al., 2020). Development of strong TIC organizations that focus on TISC practices and trainings have the potential to create safe, healthy and effective work environments where high staff retention and the use of empirically-supported practices fuels the highest standards of care for individuals served, and contributes to healthier and happier communities.
Crystal Taylor-Dietz, PsyD, is National Director of Behavior Health Services at Devereux Advanced Behavioral Health. To contact Crystal Taylor-Dietz, PsyD, email CTaylo11@devereux.org.
Devereux Advanced Behavioral Health is one of the nation’s largest nonprofit organizations providing services, insight and leadership in the evolving field of behavioral healthcare. Founded in 1912 by special education pioneer Helena Devereux, the organization operates a comprehensive network of clinical, therapeutic, educational, and employment programs and services that positively impact the lives of tens of thousands of children, adults – and their families – every year. Focused on clinical advances emerging from a new understanding of the brain, its unique approach combines evidence-based interventions with compassionate family engagement.
Devereux is a recognized partner for families, schools and communities, serving many of our country’s most vulnerable populations in the areas of autism, intellectual and developmental disabilities, specialty mental health, education and child welfare. For more than a century, Devereux Advanced Behavioral Health has been guided by a simple and enduring mission: To change lives by unlocking and nurturing human potential for people living with emotional, behavioral or cognitive differences. Learn more: www.devereux.org.
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