Introduction
Trauma psychology, as one of the newest fields in psychotherapy, has evolved through crisis theories, empirical research, and the development of crisis intervention and crisis management methodologies. Under the DSM-IV-TR, diagnostic options in the realm of trauma psychology that manifested through anxiety were generally limited to Phobias, Panic Disorder, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Acute Stress Disorder, and Posttraumatic Stress Disorder (American Psychiatric Association, 2000). What happens when a client is encountered who does not present with any specified phobias, has an absence of panic attacks and compulsions, has not directly experienced powerful traumatic event as required by Acute Stress Disorder and Posttraumatic Stress Disorder, but has pathology too significant for a diagnosis of Generalized Anxiety Disorder? How do we address a client whose exposure to trauma is indirect, frequent, and cumulative?
It has been well documented that police officers are in an inherently stressful profession, facing a significant risk of violence and direct exposure to traumatic events on a daily basis. Police officers in field services are expected to quickly respond to scenes where they have the misfortune of witnessing both the actions and the aftermath of interpersonal violence and cruelty (Tovar, 2011). As such, these officers have a significant opportunity to experience, witness, and/or confront traumatic events that meet the exposure requirements for both Acute Stress Disorder and Posttraumatic Stress Disorder (American Psychiatric Association, 2000). One of the protective factors for police officers is the ability to distance themselves from the experiences, documenting their observations in reports, moving on to the next call for service, and leaving yesterday’s experience in the past when possible. However, the aftermath of the incident does not stop there, and is then passed on to a criminal investigator who must process the details of the interpersonal violence or traumatic event. The field services officer may see a significantly traumatic call a few times per month, a few times per week, or even once per day interspersed among routine traffic stops, noise complaints, and other non-traumatic events. The detective who specializes in a particular category or type of crime is compelled to focus on what may be perceived as an infinite series of traumatic events. While the detective may not experience the traumatic events directly, she will, by nature of her duties, re-experience each event over and over again as the investigation is completed and the pieces of the criminal puzzle are put together in anticipation of a trial before a judge and jury.
Background
According to the DSM-IV-TR, Acute Stress Disorder and Posttraumatic Stress Disorder are similar in the requirement of direct exposure to one or traumatic events followed by clinically significant disturbances in the areas of avoidance, intrusion, and arousal. Acute Stress Disorder tends to have an immediate onset with a duration of no more than four weeks where Posttraumatic Stress Disorder may have either an acute or a delayed onset and will last for more than one month (American Psychiatric Association, 2000). Some commenters have discussed a need to consider secondary or vicarious traumatization amongst Acute Stress Disorder and Posttraumatic Stress Disorder within anxiety disorders. Kanno (2009) discussed how the symptoms of secondary traumatic stress parallel those seen in Acute Stress Disorder and Posttraumatic Stress Disorder, with the obvious difference in that secondary traumatic stress is experienced by people who are affected by the trauma of others, and recommended inclusion of secondary traumatic stress in the development of the DSM-V.
Secondary traumatic stress, while not discussed in the DSM-IV-TR, is not a relatively new concept to the field of trauma psychology, though it is still in need of attention and research. McCann and Pearlman (1990) described vicarious traumatization as being the pervasive, cumulative, and permanent effects that empathetic engaging with traumatic materials of clients had on mental health professionals. Figley (1995) used the terms “compassion fatigue” and “secondary traumatic stress” as a psychological disorder experienced by professionals working with, and family members of, people suffering from Posttraumatic Stress Disorder. Where vicarious traumatization focuses on cognitive phenomenon, secondary traumatic stress focuses on symptomology that parallels that of Posttraumatic Stress Disorder (Baird & Kracen, 2006). By 2003, a significant body of research had been developed regarding direct exposure to trauma yet very little research focused on professionals who work with the victims of trauma, even though the risk of burnout among those professionals was thoroughly identified (Salston & Figley, 2003).
Cieslak, et al. (2013) conducted a meta-analysis of 38 cross-sectional and 3 longitudinal studies of secondary traumatic stress that were conducted between 2001 and 2012 in which they found a significantly strong association between secondary traumatic stress and job burnout (weighted r = .69). However, the included studies were dominated by mental health and healthcare professionals (87.8%) and included only two studies of professionals involved in the criminal investigation of traumatization.
Compared to mental health and healthcare professionals, there is a dearth of research on the effects of secondary traumatic stress on criminal investigative professionals even though the risks are well documented. Catanese (2010) documented that a minimum of sex professionals are exposed to one sex offender’s criminal activity. Just as multiple traumas can have a cumulative effect on Posttraumatic Stress Disorder, it is theorized that the same exists for secondary traumatization. In contrast to the field services officers, there is a distinct lack of recovery time between cases for specialized investigators (Catanese, 2010).
While the roles of forensic interviewers of abused children and criminal investigators differ, we can anticipate some correlation between occupational stressors between these two groups. Perron and Hiltz (2006) studied factors related to burnout and secondary trauma among forensic interviewers working for child abuse evaluation centers throughout the United States. They found a moderate inverse relationship between organizational satisfaction and burnout (r = -.31, p < .05) as well as a slight inverse relationship between organizational satisfaction and secondary trauma (r = -.25, p < .1). No significant relationships were found between either burnout or secondary trauma and the number of forensic interviews conducted or the length of employment as a forensic interviewer. The findings of Perron and Hiltz would allow us to hypothesize that professional satisfaction would also mediate and reduce the risks for burnout and secondary trauma amongst police investigators.
In fact, Perez, Jones, Englert, and Sachau (2010) cited Perron and Hiltz when they sought to assess burnout and secondary traumatic stress among law enforcement investigators frequently exposed to child pornography. They found that the total amount of time an investigator worked with child pornography was moderately correlated with secondary traumatic stress (r = .39, p < .05) but the number of child pornography cases was not significantly related to either secondary traumatic stress or burnout. Job satisfaction had a strongly inverse relationship to secondary traumatic stress (r = -.50, p < .01) and burnout (r = -.49, p < .01). Perez, et al.’s (2010) findings were similar to Perron and Hiltz’s (2006) findings, however, the criminal investigators scored higher than the forensic interviewers on several measures. Those differences may be explained by the fact that forensic interviews are often semi-structured, time-limited, and objective while investigations are more dynamic and time-intensive (Perron & Hiltz, 2006; Perez, et al., 2010).
The development of an exceptional investigator takes a significant amount of time, money, training, and experience that cannot be otherwise replicated (Catanese, 2010), yet some of the research in the area of secondary traumatic stress among police investigators is conflicting. Catanese (2010) reported that prolonged exposure to sexual investigations was associated with higher levels of secondary trauma and cynicism and recommended rotating investigators out of high exposure positions every few years. In contrast, Powell and Tomyn (2011) did not find any significant effect on overall life satisfaction among child abuse investigators from years in service, number of interviews with child abuse victims, and number of interviews with child sexual offenders. They specifically denounced Catanese’s earlier recommendation and further offered that forcing exceptional and dedicated investigators out of a position could itself create significant psychological distress. Perron and Hiltz (2006) found similar results to Powell and Tomyn in their study of burnout and secondary trauma among forensic interviewers. Their findings showed that the number of interviews conducted and the length of employment did not have a significant relationship with either burnout or secondary trauma.
The growing body of research involving primary traumatic stress and secondary traumatic stress has not gone unnoticed. The American Psychiatric Association released the updated DSM-V in 2013, which removed Acute Stress Disorder and Posttraumatic Stress Disorder from the anxiety cluster to place them with other disorders in a new category for Trauma- and Stressor-Related Disorders. One of the more significant changes to the diagnostic criteria for Posttraumatic Stress Disorder was to include multiple pathways for exposure to traumatic event(s) – including direct exposure, in person witness exposure, secondary exposure through a close family member or close friend, and “experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains, police officers repeatedly exposed to the details of child abuse)” (American Psychiatric Association, 2013, p. 271).
Our Client
Let us consider the case of “Jacen” as we continue. Jacen was recruited to an urban police agency shortly after completing a bachelor’s degree from the local campus of the state’s university system. During a short tenure as a patrol officer, Jacen showed significant talent in investigations and promoted quickly into a detective capacity. After some months working as an undercover narcotics detective, Jacen was assigned to investigate a sudden upsurge of juvenile heroin cases. Over the next few years, Jacen was isolated from other officers and investigators, worked varying hours with frequent days exceeding 14 hours at work, investigated approximately three dozen heroin overdose deaths involving adolescents, and filed federal organized crime cases against a half dozen adult drug dealers who were ultimately linked to the overdose deaths. Jacen was single, had a history of trauma (bullying and suicide attempts) from his own childhood, and was the subject of intermittent harassment from supervisors who were intimidated by his talent and abilities and could not reconcile their personal biases that developed after they learned that Jacen identified as homosexual.
Jacen went through a series of small crisis events that were never resolved and were countered only by transcrisis states. He developed pervasive symptoms of intrusion, arousal, and avoidance symptoms consistent with psychological trauma. While the arousal symptoms manifested both from secondary trauma caused by his caseload and the primary trauma caused by sexual harassment, the intrusion symptoms were primarily related to the secondary trauma and the avoidance symptoms were primarily related to the sexual harassment. Jacen’s direct supervisor increased his frequency and level of anti-homosexual remarks both in Jacen’s presence and directed at Jacen. After the supervisor blamed his own insubordination to the chief of police’s orders on Jacen, the situation erupted into an explosive encounter between Jacen and his direct supervisor in a high-traffic hallway at police headquarters with over a dozen police witnesses. In a final attempt to avoid the growing conflict, Jacen locked himself in his office and began typing a letter of resignation from the law enforcement agency. It is here where we will presume that a crisis worker has been asked to make contact with Jacen in his office.
Approach and Psychological First Aid
In this case, initial contact may not be expected from Jacen, as such, contact should be initiated in a nonintrusive and helpful manner with overarching concerns for safety. The crisis worker should approach casually and request that everybody in the initial conversation, including Jacen, agree to remove his or her firearm and other weapons in order to talk unarmed. Safety for the crisis worker, Jacen, and any other persons in the building is paramount given Jacen’s police training and immediate access to weapons (James & Gilliland, 2013). Stabilization of the emotional aspects of the situation should be initiated by assuring Jacen that, at least temporarily, there is an understood physical and psychological separation from his supervisor. The crisis worker or another police supervisor whom Jacen respects can make these assurances and should enforce them (Brand, 2013).
Once the crisis worker feels that the situation is stabilizing and Jacen is able to engage in discussions, the crisis worker should begin to define the crisis and gather information as to Jacen’s perceptions of his needs and concerns. The crisis worker should use open-ended questions and allow catharsis while providing guidance and promoting mobilization (James & Gilliland, 2013). The crisis worker should utilize resiliency-focused language that builds strength and helps to reframe Jacen’s perspective from that of a victim to that of a survivor. For example, instead of saying, “Oh, that’s horrible!” in response to hearing about the supervisor’s actions the crisis worker could say, “I’m so glad you told somebody! It’s not your fault that he acts that way.” (Brand, 2013). The crisis worker’s overall approach should be nondirective and/or collaborative, unless Jacen’s response indicates a need for directive action (James & Gilliland, 2013).
Ethicolegal Considerations
In order to gain trust and rapport with Jacen, the crisis worker must assure Jacen of the confidentiality and clearly define the limits of confidentiality in their discussions. While the crisis worker may be employed or contracted by the police agency, the crisis worker must understand that Jacen is the client and deserves as much confidentiality as can be ethically afforded. Outside of spoken plans to harm himself or another, everything discussed during the intervention should remain confidential between Jacen and the crisis worker (American Psychological Association, 2010).
Impact Assessment
We will consider a projective assessment of Jacen using Triage Assessment Form as described by James and Gilliland (2013) with additional influence from the Developmental-Ecological Perspective offered by Collins and Collins (2004).
Affective Domain. Jacen presents with primary affective impairment in the anger/hostility domain likely due to the sexual harassment, secondary affective impairment in the frustration domain with contributions from the totality of the traumatic experiences, and a potential for tertiary affective impairment in the sadness/melancholy domain due to the impact of the traumatic caseload. Impairment severity is marked (scale score 8) (James & Gilliland, 2013).
Behavioral Domain. Jacen’s behavioral domain shows a mixture of approach, avoidance, and immobility with low impairment (scale score 3). Continued exposure to the direct trauma and secondary trauma without intervention and/or treatment would be likely to exacerbate the behavioral domain (James & Gilliland, 2013).
Cognitive Domain. Jacen would appear to present with a psychological transgression and a threat to social relationships (coworkers) in the cognitive domain. The continuous exposure to both primary and secondary trauma may have had significant impact on Jacen’s self-identity and sense of emotional well-being. The escalations pose a threat to social relationships within the workplace and a threat to continued employment with the law enforcement agency if not mitigated and properly handled (James & Gilliland, 2013).
Developmental Domain. Jacen presents on the cusp of the exploration stage and the realization stage. Career roles have likely been well established, but are also threatened due to the primary trauma and secondary trauma exposures occurring in the workplace. Leadership and creative accomplishment roles are on the horizon, if not already present, and are also threatened by the traumatic experiences (Collins & Collins, 2004).
Ecological Domain. Jacen presents with some impairments within his primary social support ecosystem. He is single, lives alone, and has potentially become detached from extended family and friends due to his caseload at work. Treatment goals will need to include a reduction within the anger/hostility subdomain so that social support can be strengthened and maintained (Collins & Collins, 2004).
Projective Effects
Removing Jacen from the effects of his caseload and his supervisor would potentially have the short-term effects of mitigating the on-going, chronic crisis and allow Jacen to de-escalate into a transcrisis state.
Risk Factors, Resiliency, and Recommendations
Stress is well known to the law enforcement profession, and hundreds of studies into the occupational stress of law enforcement have been conducted over the past 4 decades. Risk factors for stress-related disorders among law enforcement professionals tend to include a combination of organizational stressors, external stressors, personal stressors, and task stressors. Examples of individual stressors common to the law enforcement profession include hostile supervisory practices, bureaucracy, work-life conflict, shift work, risk of violence, frequency of emotionally demanding interpersonal encounters, high workloads, lack of adequate recognition, lack of autonomy, poor social support, and conflict due to interagency collaborations (Perez, Jones, Englert, & Sachau, 2010).
The National Child Traumatic Stress Network (2011) recommends formal assessment of secondary traumatic stress through the Professional Quality of Life measure (ProQOL) both for acute incidents and for tracking changes among trauma exposed personnel over time. Jacen is screened through his employer’s Employee Assistance Program using the Professional Quality of Life (ProQOL) version 5 to assess compassion satisfaction, burnout, and secondary trauma using 10 items per category on a Likert scale of 1 through 5, generating linear scalar ranges from 10 to 50 (Hudnall Stamm, Higson-Smith, Hudnall, Piland, & Stamm, IV, 2009). His compassion satisfaction scale score of 37 shows that he has above-average professional satisfaction. His burnout scale score of 37 is above average and indicates a moderate cause for concern. His secondary traumatic stress scale score of 47 is significantly above average and indicates a significant cause for concern (Hudnall Stamm, Higson-Smith, Hudnall, Piland, & Stamm, IV, 2009). The employee assistance program coordinator made a psychological referral with 6 sessions pre-paid through the EAP, which could be followed up through Jacen’s insurance benefits.
Jacen’s compassion satisfaction shows a significant potential for resiliency and the ability to return from burnout. Jacen’s age and education level provide further opportunity for resiliency. He may be able to draw upon coping methods used to get past traumatic childhood experiences in forging a path through the present stressors (James & Gilliland, 2013).
Jacen’s treatment should be trauma-focused and include cognitive behavioral interventions as well as relaxation training such as the use of mindfulness techniques. During the initial phases of treatment, considerations should be given for caseload adjustment, changes in job assignment, and changes in supervision (The National Child Traumatic Stress Network, Secondary Traumatic Stress Committee, 2011).
As treatment is scaled down and Jacen returns to work, a number of adjustments in the workplace could help support resiliency and prevent a recurrence of the events that developed into the crisis. Increasing opportunities for professional efficacy, such as regularly bringing attention to the importance of the work of crimes against children investigators, can foster a sense of accomplishment among Jacen and other investigators (Perez, Jones, Englert, & Sachau, 2010). Training in recognizing signs of distress, burnout, and traumatic stress for supervisors and co-workers may help develop an early warning system for the future (Perez, Jones, Englert, & Sachau, 2010). Such warning signs may include hypervigilance, minimizing, diminished creativity, chronic exhaustion, fear, guilt, a sense of persecution, dissociations, numbing, cynicism, grandiosity, and addictions (Hangartner, 2013). Creating a system that encourages a balanced caseload, flexible scheduling, nutrition programs, and encouraged exercise also have shown to have preventative abilities in support of worker resiliency (The National Child Traumatic Stress Network, Secondary Traumatic Stress Committee, 2011).
Future Research and Epilogue
Greater research is needed in the impact of secondary traumatic stress on crimes against children investigators. To date, the only empirical research conducted in this area was recently completed by Perez, Jones, Englert, and Sachau (2010). Brough (2004) suggests that research be conducted to assess the differential impacts of primary traumatic stress, secondary traumatic stress, and organizational stressors among emergency services professionals. Such research can inform policy makers on best-practices for prevention, early identification, and intervention in order to foster resiliency, compassion, and effectiveness among professionals who spend the majority of, if not the totality of, their professional lives encountering significant traumatic experiences.
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© 2013 – 2014, Jeremy Liebbe. All rights reserved.
