The research literature is replete with data demonstrating that professionals who work with clients experiencing traumatic stress symptoms are at risk of developing their own trauma responses, particularly if they have potent indirect exposure to distressing trauma details (Henzel, Ruiz, Finney et al., 2015). The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) identifies repeated and extreme indirect trauma exposure as a qualifying Criterion A event for consideration of posttraumatic stress disorder (PTSD) in professionals. Despite its clear framing as a clinical syndrome, best practice recommendations for addressing secondary traumatic stress in the literature have historically fallen into the domains of self-care, wellness and health promotion, with little application of evidence-based trauma interventions to the problem of secondary traumatic stress in practice (Molnar, Sprang, Killian, et al., 2017).
Indeed, the message to clinicians seems to be to work harder at self-care on your own time so you can withstand the toxic effects of your work life. Based on what we know about the biopsychosocial response to trauma, this self-care-only approach represents a mismatch between the problem and the applied intervention, so that the underlying trauma condition may be unrecognized and undertreated. Additionally, these perspectives focus primarily on the individual, while the organizational context goes largely unaddressed (Sprang, Ford, Kerig, & Bride, 2019). That is unfortunate because organizations that under-respond subject their workers to high doses of exposure with no options to titrate the impact, or those entities who enact punitive strategies toward employees with secondary traumatic stress may undermine a worker’s attempts to adapt and recover from secondary trauma symptoms (Bloom, 2010). This is further supported by research that indicates that highly functional organizations are those with reciprocal and dynamic healthy agency practices and procedures, emotionally well employees, and positive unit and worker outcomes (Gil-Beltrán, Llorens, & Salanova, 2020).
In recognition of the transactional nature of individual and organizational processes central to the issue of addressing secondary traumatic stress, there has been a call for assessment approaches at two levels. This includes: 1) measures that clearly target the clinical constructs of secondary traumatic stress so that trauma-focused, evidence-based interventions can be delivered when appropriate, and, 2) tools that operationalize organizational role and responsibility in building and maintaining secondary trauma informed workplaces (Sprang et al., 2019). To this end, the following strategies are proposed.
Organizational Assessment
The Secondary Traumatic Stress Organizational Assessment (STSI-OA; Sprang, Ross, Miller et al., 2017) is a 40-item organizational assessment tool that categorizes secondary traumatic stress prevention and intervention activities into five domains: resilience building strategies, the promotion of physical and psychological safety in the workplace, utilization of secondary traumatic stress-focused policies and practices, healthy leadership practices, and organizational efforts at reducing secondary traumatic stress including evaluation and monitoring. The STSI-OA defines an organization's role in addressing secondary traumatic stress by outlining a series of policy, practice and training activities that would lead an organization toward being secondary trauma-informed. By using this tool, an organization can address this problem in the workplace in a manner that is tailored to the unit’s unique characteristics and needs. This data can be used as a blueprint for organizational change and has been implemented in systems transformation projects with agencies that are seeking to become secondary trauma responsive as part of their trauma-informed care initiatives.
The STSI-OA has high internal consistency at .97 for the total score, and excellent Cronbach’s alpha scores, ranging from .88 (Promoting Safety) to .94 (Resiliency Building Activities and Leadership Practices). Test-retest reliability at 90 days is good at .81. The STSI-OA is available in English, Spanish and Hebrew. A pandemic version is also obtainable (STSI-OAP). All can be accessed via a free download at www.uky.edu/CTAC
Individual Assessment
The Secondary Traumatic Stress Scale (STSS) for DSM-5 (B. Bride, Personal Communication, October 5, 2017) is a 21-item measure used to assess the professional’s self-reported symptoms of secondary traumatic stress in four domains that map directly onto the DSM-5 depiction of PTSD: intrusion, avoidance, alterations in mood and cognition, and alterations in arousal and reactivity. A five-point Likert scale was used to determine the frequency of symptoms with a score of one representing never and five signifying very often. Possible scores on the STSS range from 21 to 105, with higher scores indicating greater levels of secondary traumatic stress. The STSS has demonstrated good validity and reliability across studies of varied groups of professionals.
The STSS anchors measurement clearly within the confines of a trauma syndrome, so high scores in a symptom cluster(s) would clearly indicate those individuals who should be more thoroughly evaluated for the appropriateness of an evidence-based trauma treatment. The STSS for DSM-5 is currently available in multiple languages. A pandemic version is also available via a free download. Both versions and can be found at https://www.stsconsortium.com/resources-for-individuals-1
The Professional Quality of Life 5 (ProQOL 5; Stamm, 2010) is a 30-item self-report measure of the positive and negative effects of working with individuals who are experiencing traumatic stress operationalized into three subscales: compassion satisfaction, compassion fatigue and burnout. Items in the Compassion Satisfaction domain capture positive feelings derived from professional work (e.g., peer connections, making a contribution, etc.). The Compassion Fatigue construct considers burnout, which is defined by the items as negative feelings (cynicism, fatigue, loss of job satisfaction) about work due to high workload or a non-supportive environment. Embedded in the Compassion Fatigue construct are items related to secondary traumatic stress, which tap into some of the DSM-5 domains for PTSD. The primary distinction between the burnout and secondary traumatic stress scales center on items related to fear, which are in the secondary trauma item set only. In this way, the ProQOL 5 anchors the phenomenon of secondary traumatic stress into a fear response framework.
The ProQOL 5 demonstrates good construct validity across studies and studies demonstrate little shared variance between the Compassion Fatigues scales of burnout and secondary traumatic stress, underscoring the distinct nature of the subscales. Therefore, while the ProQOL is not a diagnostic tool, it can be used to distinguish burnout from a trauma-related condition like secondary traumatic stress. Scores on the compassion fatigue subscale range from 10 to 50 with higher scores indicating higher levels of distress. If secondary traumatic stress symptoms are high (e.g., 43 or above), further evaluation is necessary to determine if a trauma condition exists. The Professional Quality of Life 5 is available in 26 languages and can be downloaded for free, with permission, from https://proqol.org/ProQol_Test.html
To illustrate this approach, consider this real-life case example (pseudonyms used). Mary has been a therapist at a community mental health center for six years. After attending a professional development session on secondary traumatic stress, she noticed signs that indirect trauma exposure was having an impact on herself and her coworkers. She discussed her observations with her clinical director, Dr. Smith, who agreed there was cause for concern. Dr. Smith collaborated with an external partner to administer the STSI-OA (to assess organizational functioning), the STSS (to determine whether secondary traumatic stress was a problem in the organization) and the ProQOL (to assess burnout and compassion satisfaction). All employees of the organization were surveyed anonymously. The evaluation revealed a low mean score on the STSI-OA (67), indicating the organization was not viewed as addressing the problem adequately, individual average scores on the STSS that were in the high range (48), and burnout scores (23) that were within normal limits. From an organizational perspective, the safety domain of the STSI-OA was ranked the poorest, with employees reporting low sensitivity to issues related to physical and psychological safety. Mary and Dr. Smith realized there was considerable work to be done to get a handle on the significant problem of secondary traumatic stress in their workplace.
Using the items and domains of the STSI-OA as a guide, the organization took some immediate action. First, a safety assessment was conducted, where workers identified areas of work where they felt psychologically or physically safe. Based on employee feedback, a defined protocol was developed (with staff input) to guide provider care following a critical incident like a client suicide, child fatality or wide-scale disaster. Additionally, Dr. Smith implemented a low impact processing approach where employees were trained on ways to process difficult client encounters without sharing graphic trauma details with one another. Employees were coached on how to provide and access healthy peer support on high-exposure days and to enhance their skills in managing ruminations so they could disconnect from their work at the end of the day. A roster of external providers who were able to provide trauma-focused interventions for secondary traumatic stress were added to the organization’s employee assistance program so that those with high levels of secondary traumatic stress could get professional attention. After one year of data-driven activity, the measures were re-administered. Although short of their goal of a STSI-OA score of 125, this community mental health center noted a 28% increase in their STSI-OA scores, and notably, a 21% reduction in their average secondary traumatic stress scores. To ensure sustainability of their gains, the group began to formalize their efforts into policy so these practices would be integrated into the fabric of the organization.
Using this two-pronged approach to assessing secondary traumatic stress in individual workers and organizations can not only benefit employees, but likely client engagement and outcomes as well.
About the Author
Ginny Sprang, PhD, is a professor in the College of Medicine Department of Psychiatry at the University of Kentucky (UK) and the executive director of the UK Center on Trauma and Children. She is the principal investigator of the SAMHSA-funded Category II Secondary Traumatic Stress Innovations and Solutions Center under the National Child Traumatic Stress Initiative and chair emeritus of the Secondary Traumatic Stress Collaborative group for the National Child Traumatic Stress Network. Dr. Sprang’s work investigates child trauma, the commercial sexual exploitation of minors, and secondary traumatic stress. Her work involves the creation of translational tools as well as development and implementation of evidence-based practices to treat those exposed to traumatic experiences.
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