The Secondary Trauma & Empathic Strain Toolkit

THE SECONDARY TRAUMA & EMPATHIC STRAIN TOOLKIT

Developed by Françoise Mathieu, M.Ed., CCC., RP Executive Director, TEND

MULTIPLE EXPOSURE: INCREASED RISK

Personal Vulnerabilities Socio-Cultural Context

Working Work-related Conditions Traumatic Grief/Loss

Direct Exposure Systems Failure

Indirect Trauma Empathic Strain

Image courtesy of Dr. Leslie Anne Ross, UCLA

Indirect Trauma Secondary or Vicarious trauma is caused by an indirect exposure to trauma: you are not in actual danger, you are not at the scene of the traumatic event seeing first-hand the results of a shooting rampage or an accident. Instead, those stories are described to you verbally, in writing or through audio or video recordings. Secondary traumatic exposure can happen through counselling a client who is retelling a story of abuse, reading case files, debriefing a colleague or a client, sitting in court and hearing graphic testimonies or watching a disturbing movie or traumatic news footage. Many first responders such as firefighters and paramedics are at risk of developing primary trauma in addition to the secondary trauma they are exposed to in the line of duty.

Empathic Strain (Compassion Fatigue) Compassion fatigue, now more commonly referred to as Empathic Strain (ES) refers to the profound emotional and physical exhaustion that helping professionals and caregivers can develop over the course of their career as helpers. It is a gradual erosion of all the things that keep us connected to others in our caregiver role: our empathy, our hope, and of course our empathy - not only for others but also for ourselves. When we are suffering from Empathic Strain, we start seeing changes in our personal and professional lives: we can become dispirited and increasingly bitter at work, we may contribute to a toxic work environment, we are more prone to work errors, we may violate confidentiality and lose a respectful stance towards our students and colleagues. We become short-tempered with our loved ones and feel constant guilt or resentment at the never-ending demands on our personal time.

Systems failure Grappling with roadblocks in the systems that we work with. Feeling angry and/or frustrated about a lack of resources, disagreeing about someone’s eligibility for a service, there are many examples of systems failure. One result of facing these numerous challenges is moral distress. Moral distress occurs when we are told to do things that we fundamentally disagree with or are morally opposed to. When our values conflict with what is required by law or other rules and regulations.

Working Conditions Working conditions are profoundly affected by our workplace relationships, sense of trust, quality of communication, perceptions of fairness, workload, who we directly report to, overall workplace climate, rewards, recognitions and many other factors.

Socio-cultural Context The socio-cultural context of the community, state or country that we live in can profoundly impact our daily levels of stress. Being a member of a minority group and having to navigate discrimination or safety concerns on our way to and from work and even in the workplace. The current political climate, media, being exposed to cyber bullying etc.

ASSESS YOUR PHYSICAL & PSYCHOLOGICAL RESILIENCE

Adapted from: Saakvitne, K. W., and Pearlman, L. A. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. New York, NY: W.W. Norton. & Loehr, J., and Schwartz, T. (2003). The Power of Full Engagement: Managing Energy, Not Time, Is the Key to High Performance and Personal Renewal. Free Press.

Instructions: X Indicate what you already do 0 Circle what you wish you did more often

Body I eat regularly, eating when hungry and stopping when full I maintain a healthy weight I eat lots of vegetables and fruits throughout the day I choose whole grains, non-processed fruits, and limit my sugar intake I have healthy snacks with me in my office, on the road, and at home I drink at least 8 cups of fluid (water or other healthy options) throughout my day I use the stairs whenever possible I walk or cycle to meetings, appointments, and other outings whenever possible I use work breaks or lunchtime to stretch, go for a walk, or take an exercise class I do activities that strengthen my muscles, bones, and improve posture 2-3 times a week I do stretching and balancing activities 2-3 times a week I accumulate 150 minutes of active living/increased heart rate every week I get regular preventative and required health care I do physical activities that I find fun I make sure to get enough sleep I limit the amount of screen time I engage in I take regular vacations or time off

Mind I play challenging games or puzzles I am curious and like to learn new things I break out of my normal routine or do things that are out of my comfort zone I read literature that is unrelated to work I do things that I am not an expert at or in charge of

Heart I practice deep breathing during stressful times like short deadlines, traffic jams, etc. I have people I can share things with I practice receiving from others

I nurture intimate relationships I deal with situations directly I take time for myself everyday I volunteer for something that I feel is worthwhile I see the class as half full, rather than half empty I know when and how to say “no” I accept other people’s differences and the things I cannot change I treat myself with loving kindness as I would speak to someone I care about I allow myself to cry when needed I smile and laugh daily I engage in play regularly

Spirit I take time to self-reflect I know what my values are I have a sense of purpose in life I seek to make a contribution in life I have hope I am aware of the non-material aspects of life I identify what is meaningful to me and notice its place in my life I take time to meditate/pray/contemplate I have experiences of awe I connect with things larger than myself e.g. nature, spiritual group, etc.

REFLECTION Which section has more circles than X’s for you?

MAKE A COMMITMENT Highlight one statement that you indicated you ‘wish you did more often’ and make a plan to incorporate that activity/statement into your day.

IDENTIFYING YOUR BIG THREE WARNING SIGNS

Write down three warning signs that you are getting overloaded with stress (could be physical, emotional or behavioural):

THE WINDOW OF TOLERANCE

From: Ogden, P., Minton, K., and Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York, NY: Norton. Siegel, D.J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, NY: Guilford Press. Image credit: St. Michael’s Hospital, Toronto, ON. Mindful Awareness Stabilization Training (MAST).

REFLECTION

What am I like when I am stressed, upset or overwhelmed?

Are these hyper or hypo arousal symptoms?

What am I like when I am the best version of myself?

STRATEGIES TO REMAIN HEALTHY & COMPASSIONATE

RECOMMENDED RESOURCES

TEND Covid-19 Resources:

www.tendacademy.ca/covid19/

TEND Covid-19 Articles:

This is a Marathon, Not a Sprint: Strategies to Address Wear & Tear in Helping Professionals during Covid-19: www.tendacademy.ca/marathon-not-sprint-covid19/

Dealing with Stress & Uncertainty: www.tendacademy.ca/dealing-with-stress/

Leaders are People too: Staying Well During Covid-19: www.tendacademy.ca/leaders-are-people-too/

Today, Spare a Thought for The Call Centre Operators: www.tendacademy.ca/spare-a-thought-for-call- centre-operators/

Videos:

Feet on the Floor: Grounding Strategy: www.tendacademy.ca/feet-on-the-floor/

Ten Strategies for Managing Compassion Fatigue & Secondary Trauma: www.youtube.com/watch?v=zy3MkhGyOrQ

Empathic Strain/Compassion Fatigue, Secondary Traumatic Stress & Burnout:

Borysenko, J. (2011). Fried: Why Your Burn Out and How to Revive. Carlsbad, CA: Hay House.

Mathieu, F. (2012). The Compassion Fatigue Workbook: Creative Tools for Transforming Compassion Fatigue and Vicarious Traumatization. New York, NY: Routledge.

Remen, R. N. (1996). Kitchen Table Wisdom. New York, NY: Riverhead Books.

Rothschild, B. (2006). Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma. New York, NY: W. W. Norton.

Saakvitne, K. W., and Pearlman, L. A. (1996). Transforming the Pain: A Workbook on Vicarious Traumatization. New York, NY: W.W. Norton.

Stamm, B.H. (Ed.). (1999). Secondary Traumatic Stress: Self-care Issues for Clinicians, Researchers and Educators. (2nd Ed.). Lutherville, MD: Sidran Press.

van Dernoot Lipsky, L. & Burke, C. (2009). Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. San Francisco, CA: Berrett-Koehler.

Resources Specific to Secondary Trauma & Culture, Race and Historical Trauma:

Compiled by the National Child Traumatic Stress Network (NCTSN)

Webinars:

Cultural Implications of Secondary Traumatic Stress: National Child Traumatic Stress Network Webinar: https://learn.nctsn.org/enrol/index.php?id=234

STS Webinar Series: https://www.nctsn.org/trauma-informed-care/secondary-traumatic-stress

It's Not All Black and White: Working with African-American Families in Post-Katrina New Orleans: National Child Traumatic Stress Network Webinar: https://learn.nctsn.org/enrol/index.php?id=351

Publications:

Implicit Bias Tests: https://implicit.harvard.edu/implicit/takeatest.html

Comas-Diaz, L.C., Hall, G.N., and Neville, H.A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. American Psychologist, 74 (1), 1-5.

DeGruy, J.A. (2005). Post Traumatic Slave Syndrome: America’s Legacy of Enduring Injury and Healing. Joy DeGruy Publications Inc

Evans-Campbell, T. (2008). Historical trauma in American Indian/Native Alaska communities: A multilevel framework for exploring impacts on individuals, families, and communities. Journal of Interpersonal Violence, 23(3), 316–338.

Sandeen, E. and Moore, K.M. (2018). Reflective Local Practice: A pragmatic framework for improving culturally competent practice in psychology. Professional Psychology: Research and Practice, 19(2), 142-150.

Risk Habituation:

Bosch, D. (2020) Risk Habituation: The Next Covid-19 Danger, Headington Institute.

Bosh, D. (2020) Managing Emotions during a Pandemic: Understanding the effects of uncertainty, Headington Institute. Gawande, A. (2009) The Checklist Manifesto: How to Get Things Right, New York: Picador.

Haynes, T. (2018) Dopamine, Smartphones & You: A battle for your time: http://sitn.hms.harvard.edu/flash/2018/dopamine-smartphones-battle-time/

Stress & Immune System:

Borysenko, J. (1997). Minding the Body, Mending the Mind. Boston, MA: Da Capo Press.

Fisher, P. (2016). Resilience, Balance & Meaning Workbook. Victoria, BC: Fisher & Associates Solutions Inc.

Maté, G. (2003). When the Body Says No: The Cost of Hidden Stress. Toronto, ON: Knopf Canada.

van Dernoot Lipsky, L. (2018). The Age of Overwhelm: Strategies for the Long Haul. San Francisco, CA: Berrett-Koehler.

Books on Organizational Health:

Fisher, P. (2016). Resilience, Balance & Meaning Workbook. Victoria, BC: Fisher & Associates Solutions Inc.

Fisher, P. (2015). Building Resilient Teams. Victoria, BC: Fisher & Associates Solutions Inc.

Posen, D. (2013). Is Work Killing You? A Doctor’s Prescription for Treating Workplace Stress. Toronto, ON: House of Anansi Press.

Pfeffer, J. (2018). Dying for a Paycheck: How Modern Management Harms Employee Health and Company Performance – and What We Can Do About It. New York: HarperCollins.

Trauma and the Body:

Burke Harris, N. (2019) The Deepest Well: Healing the Long-Term Effects of Childhood Adversity.

Nakazawa, D. J. (2015). Childhood Disrupted: How Your Biography Becomes Your Biology. New York, NY: Atria Books.

van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. New York, NY: Viking.

Critical Incident Stress Debriefing/Psychological First Aid

Collins, P. (2019) https://www.blueline.ca/psychological-debriefing-are-we-doing-more-harm-than- good-6321/

Mitchell, R. (2018) The Harmful effects of Critical Incident Stress Debriefing (CISD): Why police departments should stay up to date on evidence-based practices. The American Society of evidence- based policing.

Rose, S. C., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews.

Sijbrandij, M. et al (2006) Emotional or educational debriefing after psychological trauma in British Journal of Psychiatry, 189, 150-155.

Remote PFA during a covid-19 outbreak: https://pscentre.org/?resource=remote-psychological-first- aid-during-the-covid-19-outbreak-interim-guidance-march-2020

Canadian red cross PFA online course: https://www.redcross.ca/training-and-certification/course- descriptions/psychological-first-aid/psychological-first-aid-–-caring-for-others

NTSN Psychological First Aid online course: https://learn.nctsn.org/course/index.php?categoryid=11 NCTSN (2006) Psychological First Aid Field Operations Guide

Schwartz Center webinar: “Managing Traumatic Stress: Evidence-based guidance for organizational leaders” with Dr. Neil Greenberg, Professor of Defense Mental Health, King's College London https://www.youtube.com/watch?v=k0CNWgUqBkM&feature=youtu.be

Grounding Skills & Tools to Manage Exposure:

Graham, L. (2013). Bouncing Back: Rewiring Your Brain for Maximum Resilience and Well-being. Novato, CA: New World Library.

Work/Life Balance:

Richardson, C., (1999). Take Time for Your Life: A 7 Step Program for Creating the Life You Want. New York,

Websites/Apps:

CALM: https://www.calm.com

Hanson, Rick: Just One Thing: Simple practices for resilient happiness. Free newsletter: https://www.rickhanson.net/writings/just-one-thing/

Moment Screen time App: https://inthemoment.io

Neuroscience simply explained: https://www.neuroscientificallychallenged.com/search?q=cortisol

Other Blog Posts by F. Mathieu

Coming home to Secondary Traumatic Stress: August 2019 https://www.tendacademy.ca/coming-home-to-sts/

Breathe, Reset, Refuel, Rinse, Repeat: January 2019 https://www.tendacademy.ca/breathe-reset-refuel/

Three Simple Guidelines for Healthy Living: September 2018 https://www.tendacademy.ca/three-simple-guidelines-health-living/

Disappoint Someone Today: July 2018 https://www.tendacademy.ca/disappoint-someone-today/

Free Tools and Assessment Measures

1) Secondary Traumatic Stress in Child Welfare Practice: Trauma-Informed Guidelines for Organizations

The Chadwick Center for Children & Families at Rady Children's Hospital San Diego released a set of trauma-informed guidelines with concrete strategies for approaching secondary traumatic stress (STS) in 2016. While these guidelines were created for intended use within child welfare systems, they may be easily adapted into other child-and family-serving organizations.

These guidelines were created as part of the Chadwick Trauma-Informed Systems Dissemination and Implementation Project (CTISP-DI), supported by funding from the Substance Abuse and Mental Health Services Administration (SAMHSA). The guidelines highlight strategies and approaches to STS throughout 4 phases in the life of a child welfare worker (or other child-and family-serving

professional), including the hiring phase, first 3 months on the job, the cumulative effect over time, and critical incidents.

Link: https://ctisp.files.wordpress.com/2017/01/stsinchildwelfarepractice-trauma- informedguidelinesfororganizations.pdf

Source: Chadwick Trauma-Informed Systems Dissemination and Implementation Project. (2016). Secondary traumatic stress in child welfare practice: Trauma-informed guidelines for organizations. San Diego, CA: Chadwick Center for Children and Families.

2) Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA)

The STSI-OA is an assessment tool that can be used by organizational representatives at any level to evaluate the degree to which their organization is STS-informed, and able to respond to the impact of secondary traumatic stress in the workplace. The STSI-OA identifies specific areas of strength, and opportunities to implement STS informed policies and practices. The results of this tool can be used as a roadmap for future training and implementation activities in the area of STS and trauma-informed care.

-For a copy: www.uky.edu/CTAC -For electronic scoring: www.STSInformed.com -Contact Ginny Sprang, Ph.D. for more information at [email protected]

3) Using the Secondary Traumatic Stress Core Competencies in Trauma-Informed Supervision

The STS Supervisory Competencies is a tool that was developed by NCTSN. Individuals and organizations can use it as a benchmark of the competencies needed to provide effective STS supervision and it is also a map to resources that can help address gaps in those competencies.

https://www.nctsn.org/resources/secondary-traumatic-stress-core-competencies-in-trauma-informed- supervision-self-rating-tool https://www.nctsn.org/sites/default/files/resources/fact- sheet/using_the_secondary_traumatic_stress_core_competencies_in_trauma- informed_supervision.pdf

4) Low Impact Debriefing Tool

“Low impact debriefing” or “Low impact processing” is a strategy that was developed by Françoise Mathieu and Robin Cameron in 2008 to address the risk of emotional contagion and secondary traumatization when debriefing and/or discussing difficult traumatic details with colleagues and loved ones. Four simple steps are suggested to pause and reflect on the content that each of us needs to

share when discussing difficult material. It was originally published in Mathieu’s 2012 book “The Compassion Fatigue Workbook”.

This infographic and postcard can be reprinted and used in your workplace:

https://www.tendacademy.ca/wp-content/uploads/2019/03/Low-Impact-Debriefing-2019.pdf

Instructions for the ProQol (Professional Quality of Life) Scale

The ProQol is a quick and free 30 question self-assessment test that was designed by Dr. Beth Stamm to assist helping professionals in evaluating their current levels of burnout, secondary traumatic stress and compassion satisfaction.

There are two ways to take this self-assessment test:

1) A digital version 2) A pencil and paper version

1) ProQol digital version: The Provider Resilience App

Name of app: Provider Resilience Source: National Center for Telehealth & Technology Where to get it: App store Specs: Requires iOS 11.0 or later. Compatible with iPhone, iPad and iPod touch and Android. Pros: Free; quick and no risk of error in scoring Cons: Requires downloading an App & creating a login; provided by an external agency - The United States National Department of Defense.

2) ProQol pencil and paper version:

Name of test: ProQol V. 5 Source: Stamm, B.H. 2009 Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5. Where to get it: https://www.tendacademy.ca/category/proqol-self-test/ Pros: Free; no digital devices required Cons: Downloading & printer required; More time consuming to take than digital version; high risk of calculation errors converting raw scores to actual scores.

Disclaimer:

“The most important aspect about interpreting the ProQOL is that it is not a diagnostic test. There are no official diagnoses in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) or in the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV-TR, 2000). The body of research on burnout and posttraumatic stress disorder indicates a close kinship with each to depression. While this is useful information, depression is a general term that also

is a specific diagnosis of a mental disorder and is widely and officially recognized by both the medical and the mental health communities. Therefore, it is impossible, and grievously inappropriate, to diagnose depression or any other disorder from the result of the ProQOL. What the ProQOL can do, from a diagnostic perspective, is to raise issues to address with use of appropriate diagnostic procedures. For example, as noted above, both burnout and PTSD are frequent “co-travelers” with depression. A high score on either burnout or secondary traumatic stress, or a high score on both with a low score on compassion satisfaction, can be an augury of clinical depression that deserves treatment. Clearly the disorder most commonly associated with secondary trauma is PTSD. In fact, the DSM-IV-TR PTSD A1 criteria specify that the event may happen to self or to others. Additionally, it specifies that a person’s reaction must involve fear, helplessness, or horror. However, what it does not specify is when one has “experienced, witnessed, or was confronted” with the threat to another. Despite this parallel of compassion fatigue and/or secondary trauma to PTSD, it cannot be overemphasized that these issues are a natural consequence of trauma work and not necessarily pathological in nature (Figley, 1995; Larsen & Stamm, 2008; Stamm, 1999). Given these concerns, the ProQOL can be a guide in regard to an individual’s or organization’s balance of positive and negative experience related to doing either paid or volunteer work. For an individual or an organization, high scores on compassion satisfaction are a reflection of engagement with the work being done.” Excerpted from: Stamm, B.H. (2010). The Concise ProQOL Manual, 2nd Ed. Pocatello

More information can be obtained at by reading the Proqol Manual: https://proqol.org/uploads/ProQOLManual.pdf

MORE RESOURCES AVAILABLE AT TENDACADEMY.CA/RESOURCES