Running Head: APPLYING HIGH RELIABILITY PRINCIPLES



Reducing the Impact of Secondary Trauma in

International Development Organizations that Serve Trauma Survivors

Deb Ekeren

Saint Mary’s University Of Minnesota

Schools of Graduate & Professional Programs

In partial fulfillment of the requirements for GM689

Instructor: Janet Dunn

August 21, 2010

Table of Contents

Chapter One: Introduction 3

Purpose 3

Significance 3

Scope 4

Terms 5

Chapter Two: Literature Review 7

Secondary Trauma: Definition Clarification 7

Factors Affecting Secondary Trauma 9

Organizational Strategies for Addressing Secondary Trauma 12

International Development Context 18

Organizational Models of Staff Support 22

Summary 26

Chapter Three: Recommendations 28

Lessons Learned 28

Recommendations 29

Further Research 32

Summary 33

References 35

Reducing the Impact of Secondary Trauma in

International Development Organizations that Serve Trauma Survivors

Chapter One: Introduction

Purpose

In this paper, I explore organizational approaches to lessen the risks and impact of secondary trauma on trauma professionals in the field of international development in order to provide recommendations for organizations providing psychosocial support.

Significance

Trauma professionals working in the international development sector are involved in responding to natural and human-made disasters, and they work closely with the human impact of the disasters. By providing basic needs and ongoing development support, staff members are exposed to tragic stories of trauma and vulnerability. Over time, the exposure to traumatic experiences can cause emotional, mental, spiritual and sometimes physical harm to trauma professionals. Secondary trauma, as defined by Figley (1995), “is the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other - the stress resulting from helping or wanting to help a traumatized or suffering person” (p.7). Trauma professionals in international development face high risk of exposure to direct and indirect threats and trauma. Nearly a third of international development professionals displayed clinically significant symptoms of emotional distress (Erikkson, Kemp, Gorusch, Hoke, & Foy, 2001). The compound effect of stress and burnout result in problematic factors for organizations through high rates of turnover, high risk of accidents and illnesses, diminished decision-making skills, reduced efficiency, high risk of self-destructive behavior, and heightened tendency to become either over-involved with beneficiaries or apathetic (Ehrenreich, 2006). In order for organizations that work with trauma to achieve their missions of helping communities recover from tragic events, the effects of secondary trauma must be examined and addressed.

As a human resources professional in an international development organization that serves trauma survivors, I am aware of the complexities of hiring and maintaining a healthy, stable, and productive workforce. The organization for which I work delivers psychosocial support in post-conflict and refugee-receiving countries for survivors of torture and war trauma. The organization employs expatriate trauma psychologists from around the world who provide training and supervision to staff members hired locally as counselors. Most direct counseling is provided by national staff members, but both staff groups are exposed on a daily basis to traumatic stories and material.

Understanding effective organizational approaches to secondary trauma will help my organization and others in the field of international development develop effective practices that support trauma professionals who are asked to work in a difficult field. Specifically, identification of practices will illuminate ways in which international development organizations can increase retention of trauma professionals, strengthen dynamics within workforces, position organizations as leaders in staff care practices, and ultimately, provide high level of care to survivors of trauma.

Scope

This paper explores research on secondary trauma, generally, with a focus on organizational practices that support trauma professionals in their work. The paper will offer recommendations on practices targeted specifically to international development settings. While significant research has been published on practices that individual professionals can utilize in order to manage their risks of secondary trauma, content on individual approaches will remain outside of the scope of this paper. Also, the paper will focus on recommendations for the psychosocial sector in the field of international development. International development staff members in other sectors such as microfinance, rule of law, and water and sanitation are exposed to risks associated with secondary trauma, but the needs may be less specialized than for professionals who are responsible for addressing emotional needs of trauma survivors.

Terms

Compassion fatigue. Compassion fatigue is a term that blends the concept of secondary trauma with burnout (Adams, Boscarino & Figley, 2006).

Compassion satisfaction. Compassion satisfaction is the amount of fulfillment that trauma professionals derive from their work

Debriefing. As used in this paper, “debriefing” refers to a structured meeting following a difficult incident in which reactions to the event are discussed.

Expatriate staff members. In the international development field, the term refers to staff members hired to work in a country other than their home country.

International development. The term refers to the international sector involved in humanitarian work, disaster assistance, and ongoing development.

National staff members. The term refers to employees hired to work in their home country.

Posttraumatic stress disorder. The term refers to a set of symptoms following the exposure to traumatic situations, including personal experiences, witnessing events, or learning about traumatic events. The disorder is characterized by intrusion, avoidance, and arousal (American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision).

Psychosocial support. The term refers to an approach in the international development sector that encourages healing and resiliency development in communities by addressing psychological and social support needs.

Secondary trauma (secondary traumatic stress or compassion fatigue). The term refers to a set of psychological symptoms that mirror posttraumatic stress disorder as a result of exposure to people who have suffered from trauma. The stress is the result of empathizing with survivors (Figley, 1995).

Self-care. The term refers to mechanisms that increase trauma professionals’ physical, intellectual and social functioning, so they can approach their work in a healthy, optimistic manner.

Trauma. The term refers to an emotional and or physical wound that causes lasting and substantial damage to the psychological development of a person (Alexander, Eyerman, Giesen, Smelser & Sztompka, 2004).

Trauma professionals. The term refers to psychologists, social workers, counselors, and other professionals who address emotional healing of survivors of trauma.

Vicarious traumatization. The term refers to cumulative and permanent changes that take place in trauma professionals’ views of themselves, others, and their world, as a result of exposure to traumatic stories or materials (McCann & Pearlman, 1990).

Chapter Two: Literature Review

The review of literature on organizational practices to address secondary trauma in international development organizations that serve survivors of trauma begins with a review of the concept of secondary trauma. Due to limited research on factors affecting secondary trauma within international development organizations, research from domestic organizations that serve survivors of trauma is used to build an understanding about factors associated with secondary trauma and organizational interventions that can lessen its impact. Research on the international development field is reviewed next, including prevalence of secondary trauma, risks associated with international development, and successful interventions for secondary trauma. Finally, several models of good practice in the field of international development are reviewed for recommendations that mitigate the impact of secondary trauma.

Secondary Trauma: Definition Clarification

Psychologists, social workers, and other mental health professionals whose work involves listening to the stories of trauma survivors face a risk of secondary trauma. The concept of secondary trauma was defined by Figley (1995) as the emotions and behaviors that are the result of exposure to traumatic stories experienced by another person. He further elaborated that secondary trauma is the result of empathizing with the person who has suffered trauma. The impact can mirror the symptoms of posttraumatic stress disorder experienced by primary survivors of a trauma, including re-experiencing, hypervigilance, avoidance, and numbing (American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision).

Secondary trauma can hinder the ability of trauma professionals to carry out their work to their full potential. Pearlman and Saakvitne (1995) identified that secondary trauma can cause cynicism and despair, undermining the ability of trauma professionals to share hope with their clients. In addition to impacting professional work, secondary trauma can bleed into the personal lives of trauma professionals. Killian (2008) argued that in order for professionals to address the needs of trauma survivors, they must be healthy, committed, and psychologically present.

Researchers demonstrated the prevalence of secondary trauma among trauma professionals (Birck; 2001; Conrad & Kellar-Guenther, 2006; Way, VanDeusen, Martin, Applegate, & Jandle, 2004). Among child protection workers in Colorado, almost 50% had a high or extremely high risk of secondary trauma (Conrad & Kellar-Guenther, 2006). Fifty seven percent of therapists who treated torture survivors in Germany reported a high level of secondary trauma (Birck, 2001). Trauma professionals who treated survivors of sexual abuse and sexual offenders reported high levels of secondary trauma with 52% of providers reporting clinically significant risk for secondary trauma (Way et al.).

Researchers built on the concept of secondary trauma and introduced several other related concepts: vicarious traumatization, burnout, and compassion fatigue. McCann and Pearlman (1990) introduced vicarious traumatization, a concept that advanced the definition of secondary trauma and included profound and harmful psychological effects that alter the way in which professionals see themselves, others and the world. The changes are the result of trauma professionals integrating the traumatic experiences of clients into their personal memory. The impact is cumulative, pervasive and permanent for trauma professionals (Baird & Kracen, 2006).

Burnout was differentiated from secondary trauma as the response to long-term exposure to challenging interpersonal situations. Characteristics of burnout include emotional exhaustion, depersonalization, and reduced feelings of personal accomplishment (Maslach, Schaufeli & Leiter, 2001). Burnout can develop in a variety of stressful environments, including situations that are not related to trauma.

Compassion fatigue is a term that blends the concept of secondary trauma with burnout (Adams, Boscarino & Figley, 2006). Trauma professionals who have secondary trauma and face intense workplace stress over a long period of time may develop compassion fatigue. In some of the research, compassion fatigue was used interchangeably with secondary trauma, and in other research the term included symptoms of burnout (Figley, 2002; Killian, 2008).

For the purpose of this paper, secondary trauma refers to the set of symptoms associated with repeated exposure to traumatic stories of clients. The differences between the concepts secondary trauma, vicarious traumatization, and compassion fatigue are not significant for the focus for this paper. Other researchers have applied a similar approach and used the terms interchangeably (Baird & Kracen, 2006; Figley, 1999; Killian; 2008; Pross, 2006).

Factors Affecting Secondary Trauma

A growing body of research has emerged exploring factors that contribute to secondary trauma. Contradictory conclusions have been reached about some demographic, workplace, and environmental factors and their relationship to secondary trauma. The diversity of results reinforces the need for further research to understand factors that impact secondary trauma.

Trauma history. Concerns have emerged about the predisposition to secondary trauma based on personal experiences of trauma. Several research studies demonstrated that trauma professionals who have their own personal trauma histories face an increased risk of secondary trauma (Baird & Kracen, 2006; Buchanan, Anderson, Uhlemann, & Horwitz et al., 2006; Killian, 2008). Contradictory results were found among trauma professionals who worked with violence and sexual violence that indicated personal history with trauma was not associated with secondary trauma (Bober & Regehr, 2006; Schauben & Frazier, 1995; Way et al., 2004).

Tenure in the field and age. The relationship between length of time working in the field of trauma and secondary trauma is another factor that has been explored by researchers. For trauma professionals focusing on sexual violence, shorter time in the field was associated with increased risk of secondary trauma (Way et al., 2004). Trauma professionals who were newer to the field showed more distress than experienced professionals. Older counselors reported lower levels of distress than younger counselors (Bober & Regehr, 2006). International development workers in Darfur who were older reported lower impact of secondary compared to younger workers (Musa & Hamid, 2008). The correlation between age and length of time in the field is important to recognize. Older staff members and those who have been in the field for a longer period of time may be more effective at managing the emotional challenges of working with trauma. Trauma professionals who are not able to develop effective coping mechanisms may choose to leave the field.

Exposure to trauma. Inconsistent results were shown for the relationship between the amount of exposure to trauma survivors and secondary trauma. (Baird & Kracen, 2006; Birck, 2001; Bober & Regehr, 2006; Buchanan et al., 2006; Eidelson, D’Alessio, & Eidelson, 2003). Exposure can encompass hours with traumatized clients and percentage of trauma survivors on a caseload. In an exploration of 16 research articles and dissertations on secondary trauma published between 1994 and 2003, Baird and Kracen (2006) found evidence on both sides of the hypothesis. They found persuasive evidence linking the amount of exposure to traumatic material of clients and an increased risk of secondary trauma. They also found reasonable evidence to the contrary that increased exposure was not associated with increased risk of secondary trauma. Research not included in the meta-analysis showed similar contradictory findings. Among trauma professionals working with torture survivors, long hours spent with traumatized clients did not increase the risk of secondary trauma (Birck). In contrast, increased levels of secondary trauma were associated with caseloads comprised predominantly of trauma survivors among 280 Canadian mental health workers (Buchanan et al.). Diversified caseloads with a combination of trauma survivors and mainstream clients was viewed as an important factor in low levels of emotional stress among psychologists working in New York following the September 11 terrorist attack (Eidelson, D’Alessio, & Eidelson, 2003). Bober and Regehr (2006) found similar results among 259 therapists; the amount of time spent counseling survivors of trauma was directly associated with secondary trauma. Researchers have not found a clear relationship between secondary trauma and exposure to traumatic material.

Compassion satisfaction. The amount of fulfillment that trauma professionals derive from their work is another factor that has been researched in relation to secondary trauma. The term compassion satisfaction refers to the amount of satisfaction gained from helping clients heal who have endured suffering (Radey & Figley, 2007). A high level of compassion satisfaction among children protection workers was associated with a low level of secondary trauma (Conrad & Kellar-Guenther, 2006). The results supported a theory by Stamm (2002) that compassion satisfaction may be a protective factor against secondary trauma. Finding strategies that raise the level of fulfillment that trauma professionals gain from their work may minimize the risks of secondary trauma.

Work culture. Aspects of work culture were related to secondary trauma. Killian (2008) observed that two factors were closely associated with secondary trauma: a therapist’s sense of powerlessness and work drain. The sense of powerlessness encompassed feelings that social support systems were impeding the healing of clients, leaving the therapist feeling frustrated and hopeless. Work drain encompassed a high level of stress that carried over into time therapists spend away from work. Work environments that address powerlessness and work drain will be better positioned to mitigate the effects of secondary trauma.

Social support. The final factor considered was the association between social support and secondary trauma. Social support can include relationships with colleagues, family, and friends, encompassing relationships at work and in the personal lives of therapists. Trauma professionals working with trauma survivors identified social connections with peers as an important component in managing their work stress (Killian, 2008). A strong association was demonstrated between social support systems and satisfaction with trauma-oriented work, in a quantitative analysis conducted as part of the same study. Reduced stress and increased satisfaction mitigated risks of secondary trauma. Among psychologists working in New York City following the September 11 terrorist attack, a high social support environment contributed to low levels of stress and an increase in positive feelings about their work (Eidelson et al., 2003). Social support appears to serve as a protective factor against the effects of secondary trauma.

Organizational Strategies for Addressing Secondary Trauma

Secondary trauma is a risk that is inherent in working with trauma survivors. Much of the research in the field has focused on specific practices that individuals should employ in order to manage personal risks related to secondary trauma (Bell, Kulkarni, & Dalton, 2003). An alternative perspective holds that within organizations that serve survivors of trauma, secondary trauma is an occupational hazard that requires organization-wide strategies. Organizations have an obligation to create a safe work environment and a culture that promotes healthy behaviors. A review of research will identify key practices that organizations can utilize in order to mitigate the effects of secondary trauma.

Culture. A culture reflects the values and priorities of an organization. For organizations that serve survivors of trauma, the culture must embrace trauma-related stresses as legitimate and expected, and the stresses are the shared responsibility of the organization and the individual (Sexton, 1999). Creating a culture of openness and acceptance is a useful method to mitigate other potentially difficult characteristics of organizations that serve survivors of trauma. Addressing conflicts, providing clear roles and job descriptions for trauma professionals, and promoting cooperation are additional components of culture that should be enhanced in organizations (Hormann & Vivian, 2005). Deliberate efforts aimed at strengthening the culture will result in organizations that are better able to address secondary trauma.

Administrative stresses and their relationship to secondary trauma warrant examination. Cultures of bureaucracy amplify feelings of disempowerment and helplessness and increase risks for secondary trauma (Sexton, 1999). Minimizing administrative stresses can have positive outcomes related to secondary trauma. Killian (2008) recommended that administrative stresses can be reduced by providing trauma professionals with opportunities for decision-making on workplace issues. The recommendation was based on research that an increased sense of control and input increased compassion satisfaction (Killian).

Lastly, building a culture that reflects on the meaning and values of the work can be protective against secondary trauma. Providing opportunities and a culture that welcomes reflection about the impact of working with trauma can help sustain trauma professionals in their careers (Fischman, 2008; Hormann & Vivian, 2005; Trippany, Kress, & Wilcoxon, 2004). Also, building a culture of positivity is protective against secondary trauma. By encouraging trauma professionals to focus on strengths and successes of their clients, instead of disappointments, compassion satisfaction increases (Radey & Figley, 2007). Creating a supportive culture can foster a positive environment and reduce the risk of secondary trauma.

Trauma caseload. Limiting the number of trauma survivors within a caseload is a strongly recommended practice (Bell et al., 2003; Pross, 2006; Trippany et al., 2004). Researchers found a direct relationship between longer hours spent counseling trauma survivors, a decrease in compassion satisfaction, and an increase of secondary trauma (Bober & Regehr, 2006; Killian, 2008). Diversifying caseloads with clients with varying levels of symptoms was a useful strategy at strengthening the ability of trauma professionals to remain optimistic (Radey & Figley, 2007). Allowing staff members to work part-time in trauma and part-time seeing mainstream populations, possibly in a different environment, was another strategy offered (Pross, 2006). Composition of caseloads and hours spent counseling trauma survivors are two critical factors that organizations must address.

Education and training. Enhancing the knowledge of trauma professionals is a widely endorsed practice for organizations. Providing education to trauma professionals about secondary trauma can reduce the risks of developing symptoms (Bell et al., 2003; Campbell, 2007; Fischman 2008; Radey & Figley, 2007; Trippany et al., 2004). Training on secondary trauma should be viewed holistically and integrated throughout the employment experience, beginning with interviewing and continuing with the hiring process and regular professional development (Bell et al.). Researchers have recommended different types of interventions: comprehensive psycho-educational training (Fischman, 2008), training on techniques to address secondary trauma individually (Bell et al.), training on therapeutic self-awareness (Pross, 2006), and targeted education following a high-intensity situation (Paton,, 1997). Researchers also emphasized the value in providing training on topics outside of secondary trauma that increase the competency of trauma professionals and counteract feelings of hopelessness that can be a characteristic of secondary trauma (Campbell, 2007; Schauben & Frazier, 1995). Investing in education and training may help organizations reduce the risk of secondary trauma.

Formal social support. Designing an environment and structure in which colleagues are supportive of one another is closely tied to increasing the satisfaction that trauma professionals gain from working with trauma survivors (Killian, 2008). Beginning with the configuration of workforces, organizations can shape environments that encourage group support by implementing team treatment models that share the weight of survivors’ stresses across a group of professionals and create a sense of shared responsibility (Sexton, 1999). Team members can support each other in secondary trauma reactions and reduce the risk of isolation. Specifically, group case consultation was recommended as a strategy for processing experiences formally on a regular basis among peers (Bell et al., 2003; Sexton, 1999; Trippany et al., 2004; Way et al., 2004). The process can be useful for sharing new perspectives, clarifying distortions, and empathizing with the emotional responses of colleagues (Bell et al.). Despite the benefits of group case consultations, some possible risks should be anticipated, including a tendency toward conformity in thinking, potential for traumatizing other team members, and hesitancy of some group members to share their vulnerabilities (Bell et al.; Sexton, 1999). With carefully supported facilitation, group case consultations can support trauma professionals in reducing their risks of secondary trauma.

Informal social support. Creating a culture of informal peer support can reduce the risks of secondary trauma. Killian (2008) advocated for creating physical space and allocating time for regular interactions that promote relationships among colleagues. Bell et al. (2003) acknowledged the importance of trauma professionals having time with each other to celebrate personal milestones, participate in team-building activities, and connect on staff retreats. Building into an organization a diverse range of formal and informal social support mechanisms will strengthen factors that protect against secondary trauma (Holmqvist & Andersen, 2003).

Supervision. Providing clinical supervision to professionals who work with trauma survivors is a strongly recommended practice for reducing the impact of secondary trauma (Bell et al., 2003; Holmqvist & Anderson, 2003; Killian, 2008; Sexton, 1999; Trippany et al., 2004). Clinical supervision provides trauma professionals with an opportunity to reflect on their work, remain grounded in trauma theory, gain objective feedback, and explore their risks associated with secondary trauma (Sexton, 1999). Baird and Kracen (2006) found some evidence that clinical supervision served as a protective factor against secondary trauma. Organizational culture and values surrounding clinical supervision will impact the level of effectiveness. Bell et al. advocated for the separation between evaluative supervision and clinical supervision, in order to build trusting relationships in which trauma professionals feel comfortable expressing their vulnerabilities and fears without concerns about how their feelings will impact their employment. Clinical supervision can serve as a supportive mechanism to help trauma professionals remain in the field of trauma and provide high quality care to survivors, while minimizing risks associated with secondary trauma.

Self-care and coping strategies. Self-care and coping mechanisms are important considerations related to secondary trauma. Emotionally negative coping and self-care practices, such as denial, avoidance and venting, were associated with a high level of work stress, while positive coping strategies, such as reduced workload, supervision, and social support, were associated with a low level of stress (Killian, 2008). Cultivating self-care practices has been viewed as an individually-oriented pursuit for trauma professionals that includes a broad range of activities supporting their rejuvenation from stresses of trauma work. A potential risk with organizations supporting self-care is transferring the responsibility for trauma reactions to trauma professionals, rather than the organization sharing the responsibility (Bober & Regehr, 2006; Killian, 2008). Implementation of practices related to self-care should reflect the shared accountability.

Specific activities remain the responsibility of individuals, but organizations can play a role in creating a culture that encourages trauma professionals to pursue positive self-care. Providing benefits and employee programs can support positive self-care activities. Recommended practices for organizations include providing health insurance with coverage for mental health care (Bell et al., 2003), mindfulness practices (Bell et al.; Berceli & Napoli, 2006), stress management training (Bell et al.), paid time away from work (Trippany et al., 2004; Way et al., 2004), and physical wellness programs (Radey & Figley, 2004).

Very little research has been conducted to determine the relationship between specific self-care practices and secondary trauma (Radey & Figley, 2007). Bober and Regehr (2006) studied 259 therapists and analyzed the relationship between time devoted to perceived useful practices and secondary trauma scores. Specifically, they examined leisure activities, self-care, supervision, and other professional activities outside of direct trauma counseling, including research and educating others. They found no association between time devoted to the practices and a reduction in symptoms of secondary trauma. The research calls into question long held beliefs about the correlation between self-care and secondary trauma. Further research that validates the findings could create significant shifts in thinking about caring for trauma professionals.

International Development Context for Secondary Trauma

While the international development field shares the same challenges inherent in trauma work within domestic environments, the international development field introduces further complexities. Staff members are working and living in communities that have suffered human or natural disasters, and they are exposed to a broad range of risks and threats. Emanuel and Ursano (1999) identified four categories of risks that people working in disaster areas face. Physiological risks include physical exertion, accidents, diseases, intentional violence, and loss of life. Psychological risks are actual or perceived threats of harm, exposure to trauma survivors, and isolation from social support, which can result in secondary trauma and burnout. Occupational risks include overwhelming responsibilities attached to a position and inability to put limits around work. Organizational risks emerge with role conflicts, tension between personal and organizational needs, and conflicts within work teams.

While studies on exposure to risks among international development professionals are limited, researchers revealed that international development workers are regularly exposed to serious risks that impact individuals and organizations. (Augsburger et al., 2007; Cardozo et al., 2005; Jones, Müller & Maercker, 2006). Among international development professionals working in Kosovo after the end of the conflict, expatriate staff members experiences on average 2.8 traumatic events, and national staff members experienced 3.2 (Cardozo et al.). Traumatic events included sniper fire, threats to life, murder of a family member or friend, separation from family, and handling dead bodies. Among international development workers from Germany who were placed around the world, 47% experienced and 7% witnessed a traumatic event during their service (Jones et al.). International development workers in Darfur and Chad experienced a high level of stress (Augsburger, 2007). More than half of staff members reported they felt physically stressed within the previous two weeks. Just less than half reported they were emotionally stressed, and a third felt they were mentally stressed. The highest level of stress was associated with exposure to trauma (41.1%), separation from family (40.3%), workload (29.2%), fear of traumatic events (27.8%), and moral dilemmas (25%). Risks and stresses are present at high levels among international development workers.

Limited research has been conducted on secondary trauma among international development workers, but the significance of secondary trauma was demonstrated. Approximately 30% of expatriate international development workers identified significant symptoms of posttraumatic stress disorder and 51.3% reported partial symptoms (Eriksson et al., 2001). Among 53 international development workers in Darfur, 25% reported high levels of secondary trauma and 50% showed psychological distress (Musa & Hamid, 2008). All international development workers in Gujarat, India, reported at least one symptom of secondary trauma, while 8% met the full criteria for posttraumatic stress disorder (Shah, Garland, & Katz, 2007). Among Israeli social workers who responded to terrorist attacks, nearly half reported high or extremely high levels of secondary trauma, and less than a quarter reported low to moderate levels of symptoms (Cohen, Gagin, & Peled-Avram, 2006). High level of secondary trauma among international development workers reinforced the importance of organizations' taking comprehensive measures to mitigate the impact.

Researchers who compared secondary trauma prevalence between expatriate and national staff members reported that national staff members showed higher levels of trauma than expatriate staff members (Cardozo et al., 2005; Musa & Hamid, 2008). National staff members are generally part of the communities in which they are working, and they may have experienced events similar to the trauma survivors they are serving. Among national staff members, separating primary trauma from secondary trauma was a challenge cited by several researchers (Musa & Hamid, 2008; Shah et al., 2007). Secondary trauma involves not only exposure to traumatic material but also empathy with a survivor of trauma. National staff members may identify more closely and empathize with survivors because they share the same community and cultural identity compared to expatriate employees (Cardozo et al.). In a meta-analysis of 177 studies of disaster victims, highest risks for emotional trauma were reported by women, ethnic minorities, people of low socioeconomic status, and people from traumatized communities (Norris, Byrne, & Diaz, 2001). All international development workers face risks for secondary trauma, but national staff members may face more pronounced risks. International development organizations need to examine the potential risk of trauma within their workforce and take protective measures to limit further exposure.

Addressing secondary trauma within international development organizations necessitates understanding the relationship between secondary trauma and various interventions. Social support was a prominent factor in literature on secondary trauma. Within the international development context, the importance of social support was validated. Among returning humanitarian workers, social support was a protective factor against posttraumatic stress disorder symptoms and exposure to traumatic events (Eriksson et al., 2001). International development workers with high exposure to traumatic events reported lower levels of posttraumatic stress disorder if they had a high level of social support. The lowest levels of posttraumatic stress disorder were reported among international development workers who had the lowest exposure to traumatic events and the highest levels of social support. Cardozo et al. (2005) examined the relationship between communication with family and mental health outcomes for international development workers in Kosovo and found that inadequate communication with family members, for both expatriate and national staff members, resulted in poorer mental health outcomes. Among German international development workers, social support was found to mitigate the effects of posttraumatic stress disorder. In particular, international development workers who experienced a traumatic event had fewer symptoms of posttraumatic stress disorder when they received social support in the form of social acknowledgement as a victim (Jones et al., 2006). The research about social support and secondary trauma implies the need for organizations to integrate social support mechanisms into their culture and operations. Actions that create team cohesion, provide opportunities for employees to communicate with family members, and offer education among team members about how to support their colleagues may prove valuable to reducing the prevalence and impact of secondary trauma within international development organizations.

Debriefing is another intervention addressed within the literature on secondary trauma. Specifically, debriefing following traumatic events has been a practice widely endorsed by mental health practitioners, yet research conducted on the practice revealed that was ineffective and, in some cases, harmful (Devilly, Gist, & Cotton, 2006). Within international development organizations that serve survivors of trauma, witnessing and experiencing trauma is an anticipated and regular occurrence, so organizations must operate with practices that are safe and effective. Following exposure to highly traumatic events, specialized interventions may be necessary. Devilly et al. (2006) conducted an extensive review of research on debriefing and offered a model for addressing traumatic experiences that was grounded in research-validated practices. First, organizations should develop plans and train all staff members on procedures for handling traumatic events, such as safety measures and communication plans. Second, organizations should provide immediate support that emphasizes natural social supports and resilience, including connecting individuals impacted by trauma with family and other social support networks and providing clear information. Third, psychological interventions should take place, as needed, and at graduated levels of assistance. Depending on the response of the individual affected by trauma, specialized psychological services may be necessary. The model emphasizes building on the healing approaches that are most helpful for the individual impacted by trauma. Gelder and Berhoff (2002) advocated for special efforts to minimize the traumatization of other staff members, with specific emphasis placed on the protection of national staff members. Utilizing support resources rather than relying on staff members working at the same program site will reduce the spread of trauma responses. As demonstrated in the prevalence data, traumatic events are a part of international development work, and organizations must have clear plans in place to address trauma for individuals and organizations.

Organizational Models of Staff Support

Three widely adopted standards were developed for international development organizations that offer some recommendations for the care of staff members: Interaction’s PVO Standards (Interaction, 2007), Code of Good Practice in the Management and Support of Aid Personnel (People in Aid, 2003), and IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Inter-Agency Standing Committee, 2007). Most of the practices were developed with the goal of improving the productivity and effectiveness of international development organizations or addressing the well-being of staff members. While not addressing secondary trauma in a comprehensive manner, the practices include recommendations that are relevant to the care of staff members working in trauma. The review of organizational models also includes recommendations offered by two researchers: Ehrenreich (2006) and Fawcett (2000).

In order to mitigate the effects of secondary trauma, organizations should consider a systemic approach to managing staff members that encompasses all aspects of the organization and should last throughout the employment life cycle (Wilson & Gielissen, 2004). As a starting point, organizations need to develop a culture of well-being in which the health of staff members is a strategic priority (Ehrenreich, 2006; People in Aid, 2003). Within a supportive culture, the relationship between the well-being of staff members, quality of care to trauma survivors, and fulfillment of the mission will be widely understood. Organizations must allocate sufficient financial resources for staff well-being by establishing a budget specifically for the care of staff members (Fawcett, 2002; People in Aid, 2003), and develop comprehensive policies and plans in order to address emergencies, security issues, and crises that are inevitable in international development work (Ehrenreich, 2006; Fawcett, 2002; IASC, 2007; Interaction, 2007; People in Aid, 2003). Comprehensive plans deliver a message to staff members than their safety and care are serious concerns.

Deliberate care in hiring and training staff members will help to mitigate the impact of secondary trauma. Fawcett (2002) argued the importance of a comprehensive hiring process that explores psychiatric history, resiliency, strength of social and team skills, previous field experiences, and leadership style of potential staff members, in addition to technical competencies. Focusing on protective factors for secondary trauma will help to mitigate some risks from the onset. Once hiring decisions are made, international development staff members should have a thorough orientation covering all policies, plans, risks, and supportive measures offered by the organizations (Ehrenreich, 2006; IASC, 2007; People in Aid, 2003). Clarity about expectations and systems will reduce ambiguity and limit the likelihood of poor decision-making by staff members. Orientation is the first opportunity for training, but it should not be the only experience. Ongoing training and development on security, stress management, team cohesion, technical expertise, and leadership training focusing on organizational stress management should be part of a comprehensive plan (Fawcett, 2002; People in Aid, 2003). Ongoing training will help build skills that are essential for effective operations.

International development staff professionals need to work in a context in which they can be successful and supported while completing difficult work. The quality of leadership and management was emphasized in the literature as an important protective factor in managing the stress of international development staff members (Ehrenreich, 2006; Wilson & Gielissen, 2004). Leaders can promote clarity and purpose in day to day work, and they are critical in supporting a culture of well-being. Fostering leadership that is attuned to the complex dynamics in an international work environment and possess the skills necessary to implement changes when needed can make a significant impact in shaping a culture. Clearly defining job descriptions and reporting relationships will help to clarify expectations (Ehrenreich, 2006; Fawcett, 2002; People in Aid, 2003). Organizations working in communities with high emotional needs should introduce clearly defined job descriptions, and organizational structures can mitigate feelings of being overwhelmed because of lack of clarity.

In order to manage exposure to traumatic material and limit the stress of staff members, organizations need to attend to the hours staff members work. Organizations should provide limits around the number of work hours on a regular basis (IASC, 2007; People in Aid, 2003). Living in an isolated environment, surrounded by unmet needs in the community, can create significant pressure on international development professionals to work more than is healthy. Organizations must provide time away from the work site and require staff members to use this time at regular intervals (Fawcett, 2002; IASC, 2007; People in Aid, 2003). Time away provides staff members with an opportunity for relaxation, rejuvenation, and reduction in stress.

Providing a culture in which international development staff members feel supported involves a comprehensive approach. Team cohesion is an important part of supporting staff members in international development (Ehrenreich, 2006; IASC, 2007, Wilson & Gielissen, 2004). Team members can provide regular feedback and support, and they can serve as a safety net that allows trauma professionals to work intensively with survivors of trauma in difficult environments.

Organizations must support international development professionals with benefits designed to addressed the unique needs of trauma-oriented field work. Access to mental health resources is a critical measure of support when working with trauma survivors (Ehrenreich, 2006; Fawcett, 2002; IASC, 2007). Some organizations are large enough and can provide the resources internally. Other organizations may need to utilize international employee assistance programs. Organizations should address unhealthy living or coping strategies, such as alcohol use (IASC, 2007). Resources for mental health care should support staff members in implementing healthy strategies for responding to traumatic work. Following highly traumatic incidents, organizations should have clear plans that provide comprehensive support (IASC, 2007).

Providing ongoing support is an important role that organizations should play. Organizations should allow employees to communicate with family members, friends and other social support networks on a regular basis (Fawcett, 2002; IASC, 2007). Encouraging employees to utilize their social supports systems will help build resiliency.

Finally, organizations should provide comprehensive debriefing at the end of employment and provide resources to help staff members through their transition (Ehrenreich, 2006; IASC, 2007; People in Aid, 2003). Debriefing will provide employees with an opportunity to reflect on their feelings and experiences and allow the organization to offer education about the challenges of re-entry. Organizations will benefit from hearing the experiences of staff members, and their feedback may provide useful recommendations to improve organizational functioning.

The standards developed for international development organizations offer a starting point for addressing the effects of the secondary trauma. Further recommendations that are grounded in research will assist in the development of a comprehensive plan. Supporting international development professionals working with trauma survivors requires a multi-faceted approach in order to mitigate the effects of secondary trauma.

Summary

Secondary trauma is the result of repeated exposure to traumatic stories of survivors of trauma that can cause emotional harm to trauma professionals and undermine the quality of their work, and it represents a serious risk for professionals who work in the field of international development. In addition to facing risks associated with trauma work, international development professionals are exposed to risks inherent in post-disaster environments, and they are usually working in areas removed from family and friends. Organizations have an obligation to treat secondary trauma as an occupational risk and address it through organizational measures, rather than relying on trauma professionals to be solely responsibility for their reactions to the work. A number of interventions were recommended in the literature, including creating a culture that recognizes secondary trauma risks, managing caseloads and work expectations, providing education, building systems of social support, providing clinical supervision, planning and managing high trauma events, and supporting self-care practices. Several models of organizational standards were reviewed that provide a framework for a model focused specifically on secondary trauma in international development organizations.

Chapter Three: Recommendations

Tragic events such as wars, earthquakes, genocide, terrorism, and famines, initiate international responses with teams of international development professionals responding to the needs of affected communities. International development professionals who address the psychological needs of communities following human-made and natural disasters face risks due to repeated exposure to tragic stories of loss, violence, and threats. Secondary trauma is the reaction that trauma professionals may experience by empathizing with survivors of traumatic events, and it can result in symptoms that mirror posttraumatic stress disorder. International development organizations have an obligation to address the risks of secondary trauma among their staff members, in order to protect their emotional health, ensure that quality of care to beneficiaries remains high, and fulfill their mission of healing communities impacted by tragic events.

Current research on secondary trauma and international development provided clarity on some factors that impact secondary trauma and interventions that are useful at mitigating its effects within organizations that address trauma. Some of the interventions included creating a culture that recognizes secondary trauma risks, managing caseloads and work expectations, providing education, building systems of social support, providing clinical supervision, planning and managing high trauma events, and supporting self-care practices. The research encompassed interventions that can lead to a comprehensive model to reduce the effects of secondary trauma within international development organizations that serve trauma survivors.

Lessons Learned

I was surprised to discover the limited amount of research that has been conducted within the field. Several prominent international agencies, institutions, and international development networks have promoted awareness about the emotional risks faced by international development professionals, so I anticipated that I would find more studies that explored interventions. Perhaps the newness of secondary trauma with only 15 years of research and the recentness of its recognition to the field of international development can explain the limited amount of research. Another possibility is that funding is limited for research on internal practices within organizations. The result is that effective practices may not be studied or findings disseminated broadly. Finally, for a field in which there is limited research, the true need is for conducting primary research. With additional time and resources, I would have valued the opportunity to contribute to the field with new findings that move the field closer to effective solutions that mitigate the effects of secondary trauma.

Recommendations

Standards of practice such as the People in Aid’s Code of Good Practice and InterAction’s PVO Standards provide a model of comprehensive guidelines that international development organizations can implement. I recommend the development and implementation of a parallel set of guidelines that focuses on reducing the effects of secondary trauma, utilizing interventions that are validated through research to reduce secondary trauma. The development of comprehensive guidelines will necessitate further research, but based on current knowledge that emerged from research, several recommendations can contribute to future guidelines.

Secondary trauma as an organizational issue. Organizations must recognize secondary trauma as an inherent risk within international development organizations that address psychosocial needs in disaster-affected communities. Secondary trauma is a natural and common response to hearing traumatic stories that can cause lasting harm to professionals. Organizations have a responsibility to shape a culture and implement practices that support international development professionals in their work.

Administrative stresses. Minimizing administrative stresses and bureaucracy can help alleviate the strain that international development professionals face. Work with survivors of trauma is highly stressful, so efforts should be made to mitigate all other work-related stresses. Reporting structures, job descriptions, and work expectations should be clearly communicated and understood.

Internal social support. Organizations should design internal structures that encourage social support. International development professionals should be placed on teams that work collaboratively to implement programs. Cohesive teams will help support each other in decision-making, stress management, and secondary trauma reactions. Creating formal structures of support, such as group consultations, as well as internal mechanisms to address conflicts will help insure that teams operate effectively.

External social support. Creating opportunities for international development professionals to remain connected to external social support systems is important. Organizations should work creatively to offer family-accompanied posts when security situations are stable. In situations in which security risks are too great, organizations should encourage frequent communication with family and friends and periodic opportunities to spend time together. Education to family members about risks and stresses within the work may help them provide understanding and support.

Education. Providing education about secondary trauma is essential in order for international development professionals to recognize the symptoms in themselves and others. The education should be implemented throughout the employment experience, beginning with hiring and orientation and continuing at regular intervals during employment and at the end of an assignment before returning home. Because of higher risks associated with newer employees to the field of trauma (Way et al., 2004), more intensive education should be provided to employees with less trauma-based experience.

Clinical supervision. Regular clinical supervision should be provided to all international development professionals who work with survivors of trauma. Clinical supervision will provide employees with an opportunity to process their reactions to the work and support them in their clinical decision-making. It is also an opportunity for supervisors to watch for signs of secondary trauma and support the international development professionals in utilizing positive coping methods.

Needs of national staff members. National staff members face increased risks of secondary trauma compared to expatriate staff members (Cardozo et al., 2005; Musa & Hamid, 2008), so they may have heightened need for support to mitigate the effects of secondary trauma. As members of communities impacted by disasters, they may share similar experiences and identify with the beneficiaries they are serving, increasing their risks of secondary trauma. Organizations can provide specialized education, ensure national staff members receive regular clinical supervision, and limit workloads, so they have sufficient time to spend with family and friends. Lastly, organizations should be attentive to the economic pressure that national staff members may face to continue to remain in positions even though working with trauma survivors may cause emotional harm. Transitioning overwhelmed national staff members into positions that do not involve direct work with survivors of trauma may be beneficial.

Security. International development professionals are regularly exposed to health and security risks such as accidents, political unrest, diseases, intentional violence, and loss of life. Organizations must anticipate risks and implement preventive measures. In addition, they must have comprehensive plans to address security and safety incidents, and all staff members must be trained on the procedures.

Workload and time away. Lastly, organizations must manage the workloads of international development professionals, so their work is achievable. Living within communities that have tremendous needs, international development professionals may feel pushed to work beyond the point that is healthy, so organizations need to take an active role in narrowing work expectations in order to preserve the ability of professionals to sustain their work long term. In addition, they must support international development professionals taking time away from the disaster site for rest and relaxation breaks and home leaves.

Further Research

Interventions that address secondary trauma among trauma professionals within the field of international development are rich areas for further research. Researchers should explore the effectiveness of various interventions and their impact on secondary trauma. As research expands within the field, the development of guidelines with interventions that are validated for effectiveness will become more realistic. Some specific interventions that may impact secondary trauma include the quality and frequency of clinical supervision, structure of jobs, amount of exposure to traumatic material, degree of structure and processes for addressing risks, types of social support mechanisms, and amount of time away from the worksite.

The relationship between the type of disaster and secondary trauma warrants further research. Exploring differences in secondary trauma levels between natural and human-made disasters may illuminate the need for different types of interventions. In human-made disasters, such as wars and genocide, people caused the trauma to one another out of fear, greed or hatred. In earthquakes, hurricanes, and tsumanis, acts of nature cause the destruction. Research on visibility and level of resources provided to respond to a disaster may impact secondary trauma. Exploring differences between high profile and well-resourced disaster recovery efforts, such as tsunami relief of 2004 compared to poorly resourced recovery efforts such as the ongoing war in Congo, may reveal the need for specialized approaches.

National staff members hold a unique role in supporting international development efforts. In many cases, they may have experienced the same tragedies as the beneficiaries they are supporting. Additional research on the differences between expatriate staff members, whose work in the region is generally time-limited, and national staff members who are part of the communities they serve, is essential in designing effective programs that address secondary trauma. Also valuable is further research that explores cultural and regional differences in secondary trauma and responses to intervention strategies.

Summary

International development professionals, who respond to disasters and contribute toward the healing of survivors of trauma, face risks of secondary trauma that can harm the emotional health of professionals, undermine the quality of work provided to survivors, and limit the ability of international development organizations to fulfill their missions. Organizations have an obligation to address the risks of secondary trauma, just as they plan for security threats. Ultimately, the field needs a comprehensive set of standards that are adopted by all international organizations working with trauma that mitigate the risks of secondary trauma. Included in the paper are a beginning set of recommendations encompassing administrative stresses, social support, education, security risks, clinical supervision, specialized needs of national staff members, and workload. Further research on the effectiveness of interventions intended to address secondary trauma in international development organizations will build on the current recommendations.

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