Addressing Secondary Traumatic Stress
Emerging approaches in child welfare
By Julie Collins
I thought I was doing well as a child welfare supervisor of one of the highest-risk areas in Ottawa, Canada. But that changed when I began having dreams--nightmares, really. As a manger for a unit of 10 child and family workers, I was struggling with cases that I could not assign. The workers had at least 30 cases already, many of which were extremely challenging. As I began having the repeating nightmare, I took it as a warning sign to get the cases assigned and badgered my director to get other units to take the cases. But every night for two weeks, I had the same nightmare. I would see a young child around age 2 being sexually abused. It made me feel incompetent, because I could not stop it from happening. I would wake myself up, and then sit for hours with the images repeating in my mind. I did not share them with anyone, as I felt they were a reflection of weakness and inability to cope. Shaken by the nightmares and the intense situation at work, I found it difficult to stay focused.
When I finally transferred the last case, I thought the nightmare would end, but it happened again that night. When I went to work the next morning, I found out that a toddler had been brutally abused and murdered, then placed in a trash bin. The victim was part of an open case in another unit, but was the biological child of a mother in an open case in our unit--one that we had been intensely monitoring. What followed was an extremely difficult period of time for the already overwhelmed staff. As I have become familiar with literature on the effects of exposure to traumatic stress, I wish I would have known about it at that time. This situation had a significant impact on me, particularly because it touched my own early traumatic experiences. Many years later, I still cannot speak about the circumstances of the death of this child without my eyes welling up. But I am not alone.
While there has been little research of the effects of exposure to trauma specifically on the population of child welfare workers, a recent survey was done with a sample of workers in the Administration for Children's Services (ACS) office in New York City as part of a collaboration between ACS and the Mount Sinai School of Medicine (MSSM). The study found that one week after what workers identified as their most distressing work-related event, 60% reported clinically significant post-traumatic stress disorder (PTSD) symptoms. Of that 60%, half the workers continued to experience clinically significant PTSD symptoms an average of 2.15 years later. The study demonstrated that exposure to traumatic stressors is frequent for CPS workers and can cause persistent distress.
Learning More About Secondary Traumatic Stress
Secondary Traumatic Stress (STS) is the result of exposure to trauma experienced by others, generally within a workplace context. Symptoms of STS are often indistinguishable from those found in individuals as a response to a traumatic event they experienced directly. Listening to stories or reading documents describing a traumatic event can have an impact. According to Chris Siegfried, Network Liaison at the National Child Traumatic Stress Network-UCLA, symptoms of STS include "fatigue or illness, cynicism, irritability, reduced productivity, feelings of hopelessness, anger, despair, sadness, feelings of re-experiencing the event, nightmares, anxiety, avoidance of people and activities, or persistent anger and sadness." First responders from other fields, such as firefighters and emergency response workers, have been shown to experience STS as a result of their work. "Such experts as [Brian] Bride view STS as an occupational hazard of providing direct services to traumatized populations," says Siegfried.
Through the National Child Traumatic Stress Network (NCTSN), the federal government has been putting resources into the study of the impact of trauma and treatment modalities that work. The NCTSN has a wealth of information and resources that could be helpful to the child welfare field on evidence-based and promising treatment approaches for traumatized children. A core component of these approaches is building the resilience of the child. This same concept of building resilience skills is being used to help those experiencing STS.
Why This Matters for Child Welfare
"STS is one of the most pervasive and influential factors in child welfare, and yet few recognize its impact on the nature of the work, the ability of people to stay and prosper in the field, and the world view of the people who labor every day to serve this nation's children," says Charles Wilson, Director at the Chadwick Center for Children and Families in San Diego, California, which is part of the NCTSN. "Child welfare is in the business of trauma and needs to be taking care of its workforce to address this."
Child welfare workers are particularly at risk for developing STS, since they are exposed daily to people who have experienced trauma while trying to meet the often onerous administrative requirements of their job. "STS is believed to lead workers to use more sick leave, and to create lower morale and less effective workers, which can then result in poorer outcomes for children and families," says Erika Tullberg, Assistant Commissioner for the New York City ACS, a CWLA member agency, and Children's Trauma Institute Co-Director. "One of the reasons child case workers prematurely leave their jobs is thought to be exposure to STS," says Siegfried. "As Beth Hudnell-Stamm has pointed out, feelings of professional isolation, larger case loads, and frequent contact with traumatized people can exacerbate effects of STS." Professional isolation has been identified as a major risk factor for developing STS. "Traumatic stress can make staff ashamed about their strong reactions and uncomfortable about burdening colleagues or loved ones with their pain," says Siegfried.
While the workforce crisis has prompted much study about issues such as recruitment and retention, burnout, lack of supervisory support, workload, and training, less attention has been given to STS and its impact on the workforce and the organization as a whole. This is changing slowly, however, as exciting work has begun to address this gap.
What Is Needed?
CWLA recently reached out to a sample of public child welfare agencies to obtain a better understanding of what they are doing regarding STS. Of the 25 states responding, there seemed to be a growing recognition among them that STS is an issue, but there is a definite gap between this recognition and what is being done in practice. Of the small group of states doing STS-related work, most focus on providing crisis response and debriefings after a major event, such as the death of a worker or a death on an open case, or offering Employee Assistance Programs (EAPs). An even smaller number indicated they were providing a one-time training on what STS is and how to recognize it, along with prevention tools. There were only a few that indicated they were providing support groups or working towards a multileveled systemic approach.
In reaching out to some of the key individuals delivering training and providing consultation to public agencies around STS, it is clear that training, or having an EAP program and crisis debriefing, is not enough. The solutions need to be more systemic, with leadership and organizational support. "It needs to be a multileveled response that addresses the physical, emotional, spiritual, and psychological well-being of the staff," says Michael Schultz, Director of Special Review and Staff Support at the Connecticut Department of Children and Families. Tullberg echoes these sentiments. "The agencies need to take ownership of addressing the impact and equipping the workers to be able to effectively manage, given the reality of the exposure to STS. This should not be an issue that an individual worker needs to solve themselves," she says.
What Is Being Done?
The Resilience Alliance Project
The ACS-MSSM Children's Trauma Institute (CTI) has been working to develop a comprehensive response to appropriately address STS in child welfare workers. A recent NCTSN grant through SAMHSA, as well as the Annie E. Casey Foundation, Casey Family Programs, and ACS, has enabled CTI to build on previous work regarding the impact of trauma from the events of September 11, 2001, on New York City's child welfare staff.
CTI has developed resilience-focused interventions integrated into child welfare practice, while scientifically evaluating their effectiveness. "The Resilience Alliance Project was developed to address STS and reduce attrition among Child Protective Services staff," says Tullberg. "What we have found is that child welfare is a stressed system--staff stress, client stress, and management stress--all related to trauma." They found workers were impacted on many levels, such as an overall loss of perspective, impacting the ability of workers to assess safety and risk, distrust among colleagues and supervisors, increased absenteeism, decreased motivation, and increased attrition. Tullberg indicated that systemic pressures can exacerbate these responses, resulting in a negative feedback loop. "Often the proposed solutions to poor casework practice such as training, new protocols, and increased oversight exacerbate the problem as much as they help," she says.
To address these issues, the Resilience Alliance Project focuses on decreasing stress on the worker through enhancing resilience skills and increasing social support. "Our intervention seeks to provide skills that have the effect of a 'psychological Hazmat suit' for child welfare staff," says Claude Chemtob, CTI Co-Director and Clinical Professor of Psychiatry and Pediatrics at MSSM. The average person does not get exposed to traumatic circumstances as frequently as child welfare workers. "Such toxic levels of exposure are considered the nature of their work and an occupational stress," Chemtob says. The approach focuses on preventing the effects of STS by building on the resilience of workers.
The skills-focused resilience intervention, developed by Chemtob and his colleagues, uses three prisms to view CPS work. The first is optimism, where workers are provided with skills to focus on the best possible outcomes and reframe challenging situations positively. Increasing optimism offsets negativity associated with recurrent trauma exposure. The second prism, mastery, focuses skills to regulate negative emotions associated with child protection work and promotes self-care. The third prism, collaboration, encourages mutual support between workers, supervisors, and clients together toward the best interest of the child. Tullberg emphasizes that the resilience approach provides workers with the skills to deal with job-related stress proactively. "The project is helpful because it lets you know that you are not the only one dealing with stressful situations pertaining to the job," says one participant. "It gives the person hope that maybe things will improve because someone else has experienced it and they are still here."
"The impact of STS over time tends to break down the ability of workers to collaborate and work together. People exposed to trauma have a harder time coming together for a common purpose in the face of stress and danger," Chemtob says. The results from this pilot indicate that participating staff had significantly greater optimism, more job satisfaction, were better able to handle stress, had less burnout, decreased attrition among new workers, and had fewer overdue cases. Anecdotal feedback from supervisors indicates that workers who had done the intervention had a higher quality of work than those who had not.
The intervention was done as a parallel process for new workers and supervisors. Supervisors received the same materials and sessions as the workers, but practiced the skill-building activities in relation to their supervisory work. "We found that supervisors had similar levels of distress as the workers," says Rohini Luthra, a Psychologist and Clinical Instructor at the Child and Family Resilience Program at MSSM.
This project indicates that targeted interventions can reduce STS effects on individual and occupational dimensions, but interventions require administrative and leadership-level support as well as staff-level buy-in. From CTI's post-September 11 work, they learned that doing three to four trauma sessions without providing skills and follow-up was not enough. As a result, the Resilience Alliance Project includes 12 sessions of prevention intervention, and workers are provided with booster sessions as a follow-up. According to Tullberg, the Resilience Alliance has become part of their office and way of working.
There has been such a positive response from participants in the pilot program that workers throughout the department have asked to receive the prevention intervention. "[The project] has taught me to deal constructively with daily challenges as an ACS worker, to be more flexible and open to change," says one participant. The current goal is to make this available to all ACS workers.
Connecticut Department of Children and Families
The Connecticut Department of Children and Families (DCF) is another CWLA member agency addressing STS among child welfare staff, with the help of a Children's Bureau workforce grant the department received around retention. According to DCF's Schultz, a licensed psychologist, DCF has focused its efforts on both training and organizational-level infrastructure that provide supports to address the impact of STS. The DCF Training Academy and the Division of Special Reviews and Staff Support have teamed to put together a training and support package to deal with work-related stress for child welfare workers, supervisors, and support staff. "We focus our training on helping workers know what [work-related stress resulting from STS] is, and what the signs are and effective ways to protect themselves," Schultz says. He points out that they use the language of work-related stress rather than trauma, as workers respond better. He reports that the approach focuses on empowerment and wellness to reduce the effects of STS, burnout, and compassion fatigue. By drawing on the research and learning from participants, they have developed an approach that teaches strategies on three levels: professional, personal, and organizational.
The key professional strategies are described as the "ABCs": awareness, balance, and connection. Participants learn to recognize STS as an occupational hazard; focus their empathy on strengths and resilience; fully utilize supervision; build an internal support team; limit exposure to traumatic material outside of work; and acknowledge the importance of aligning their choice of workplace with their professional values. Personal strategies include nurturing healthy relationships outside of work; seeking activities that instill beauty, comfort, hope, meaning, and joy; being aware of the individual's threshold; learning to respond rather than react; and focusing on self-care and self-nurturing activities.
Organizational strategies require management and leadership buy-in, which sends the message that the agency recognizes the hazards of the job. Organizational strategies reflective of this are having balanced caseloads for workers; cultivating a team-oriented working environment of competency, safety, and trust; providing effective and respectful supervision and consultation; cultivating healthy community partnerships and joining in actions to prevent abuse and neglect; and offering access to flexible scheduling and adequate vacation, sick time, and personal leave for workers to deal with stress. The department already has many of these strategies in place.
Schultz reports that they have been conducting qualitative analysis, which they use to revise their overall approach. As in an effective therapeutic intervention, DCF has participants evaluate as they go along to make sure that what is being provided is addressing their needs. They use this feedback and qualitative analysis to refine what is being done and inform senior leadership regarding organizational supports needed. Supervisory staff receive summary reports of the feedback, detailing recommended actions that participants believe would enhance the working environment.
The Connecticut DCF has been building a multileveled systemic approach to addressing STS through such efforts as adding materials on STS to the pre-service training for all new staff, team-building forums, special training for supervisory staff, special sessions for past and present military and a DCF Military Impact Awareness Team that offers support and education, mentoring programs for new staff, and a statewide Worker Support and Threat Assessment Team.
As initiatives like these take hold within each child welfare system, it will be interesting to see what the overall impact will be for retaining their workforce and how that might improve outcomes for children and families. With this national focus of the importance of addressing STS, there is greater potential for the broader child welfare field to realize the importance of a multileveled systemic approach towards building a resilient workforce.
Jaime Dohn, a former CWLA intern, contributed to this article.
Julie Collins is CWLA's Director of Practice Excellence.
To comment on this story, e-mail firstname.lastname@example.org.
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