Trauma and the Therapist: The Experience of Therapists Working with the Perpetrators of Sexual Abuse

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2001-1

Trauma and the Therapist:
The Experience of Therapists Working
with the Perpetrators of Sexual Abuse

Lyndall Steed
Jacquie Bicknell

School of Psychology
Curtin University of Technology
Perth, Western Australia

Abstract

This study was designed to examine the existence of Secondary Traumatic Stress (STS) symptoms in a sample of therapists working with sex offenders. A further aim was to examine the relationship between STS and exposure to clients, operationalised as years of working with such clients and percentage of caseload. An Australia-wide sample of 67 therapists completed the IES-R (Weiss & Marmar, 1995) and the Compassion Fatigue Scale (CF, Figley, 1995). Findings confirmed that STS symptoms are present in this population, and that a "U"-shaped relationship exists between years of experience and avoidance such that therapists with the least and most experience experience most avoidance. This study also provided evidence of the convergent validity of the relatively new CF scale.

Trauma and the Therapist:
The Experience of Therapists Working
with the Perpetrators of Sexual Abuse

Introduction

There is a growing body of theoretical and empirical literature that recognises that engaging in therapeutic work with trauma survivors can, and does, impact on the therapist. Initially, psychological theories, research and development of effective intervention techniques, methods and processes were client focused. More recently, however, attention has turned to the caregiver as well. Early research regarding the impact on the therapist of engaging therapeutically progressed from burnout to the significance of transference and countertransference during the 1970s and 80s (Freudenberger, 1974; Johansen, 1993; Maslach, 1976; Maslach & Jackson, 1984; Singer & Luborsky, 1977). After an extensive review of the literature Stamm (1997, p. 5) commented that "the great controversy about helping-induced trauma is not, can it happen, but what shall we call it?" She concluded that there is no consistently used term regarding the impact of being exposed to traumatic material as a consequence of being a therapist. Her review revealed that there were four terms, Compassion Fatigue (CF), countertransference, Secondary Traumatic Stress (STS) and Vicarious Traumatisation (VT), most commonly used to refer to this phenomenon. When generic comments are made in this paper, the term STS will be used.

Of particular significance to this area has been the work of Figley, Pearlman and associates. McCann and Pearlman's (1990) pivotal paper outlined the life-pervasive effects of working with trauma victims and described their Constructivist Self Development Theory (CSDT). According to McCann and Pearlman, CSDT is an integrative, developmental, relational theory that forms the foundation for clinical work with survivors and the basis for conceptualising the impact of trauma therapy on the therapist. They coined the term VT that they propose describes the negative cognitive schema and behaviour changes in therapists. The work of Pearlman and associates remains largely specific to the trauma area of sexual abuse (McCann & Pearlman; Pearlman & MacIan, 1995; Pearlman & Saakvitne, 1995a,b). Pearlman and associates are clear that VT differs conceptually from STS, CF or countertransference in that such approaches focus on symptoms rather than considering the individual holistically. The VT approach focuses on the individual as a whole, which includes symptoms in the larger context of adaptation as the individual strives for meaning (Pearlman & Saakvitne). According to Pearlman & Saakvitne, aspects of the self that may be disrupted as a consequence of experiencing VT are: (1) frame of reference, (2) self capacity, (3) needs, beliefs and relationships, (4) interpersonal relationships, (5) ego resources, and (6) imagery.

Studies researching VT specifically have been emerging only in the last few years. Schauben & Frazier's (1995) qualitative and quantitative investigation of VT in 148 female therapists working with sexual violence survivors revealed that higher caseloads of sexual violence survivors correlated with: (1) more disrupted beliefs, (2) more symptoms of PTSD and (3) more self-reported VT. Pearlman & MacIan (1995) highlighted similar issues in their study of 188 self-identified trauma therapists, and found that therapists newest to the field reported more psychological difficulty (i.e. VT) than their more experienced colleagues.

Figley (1995), on the other hand, uses the term compassion fatigue to describe the impact of empathic therapeutic engagement on therapists. His work on CF evolved in relation to Post Traumatic Stress Disorder (PTSD) and recognition that therapists were known to experience symptomatology similar to that experienced by their PTSD clients. He identified the mirroring or contagion effect of symptoms from client to therapist and argued that "those who have enormous capacity for feeling and expressing empathy tend to be more at risk of compassion stress" (Figley, 1995, p.1). Noting the considerable similarity between the diagnostic criteria for primary and secondary traumatic stress disorder, he asserted that intrusions (e.g. flashbacks, recollections, dreams), avoidance (e.g. avoiding thoughts/feeling, avoiding activities, detachment from others, diminished affect) and hyperarousal (e.g. difficulty staying/falling asleep, hypervigilance, irritability), are experienced by therapists. These dimensions are represented in a measure of CF developed by Figley (1995) and the Impact of Events Scale-Revised (IES-R) (Weiss & Marmar, 1995), both of which will be used as indicators of STS for this research.

Using the measure developed by Figley, Rudolph, Stamm and Stamm (1997) demonstrated the existence of CF in mental healthcare providers. With regard to the relationship between level of training and experience of CF an inverted "U"-shaped relationship was found. That is, bachelor level and PhD level therapists were at lower risk of experiencing CF than masters level therapists. This is in contradiction to earlier research indicating that those therapists newest to the field are particularly susceptible to STS (Pearlman & MacIan, 1995). Thus the influence of level of training on VT is worthy of further exploration, in particular the possibility of a non-linear relationship.

Likewise, there is a disparity in the findings regarding the relationship between degree of therapist exposure to trauma-associated material and experience of STS. For example, Follette et al. found that the percentage of caseload relating to sexual abuse was not significant in predicting STS whereas Kassam-Adams (1995), Schauben & Frazier (1995) and Pearlman & MacIan (1995) did. The issue of exposure was highlighted by both Figley (1995) and Pearlman and associates as an issue central to their respective theories of CF and VT. The above discrepancies may be explained in terms of differing operationalisations of exposure. For example, exposure to trauma-based material could vary according to the amount of time per week spent working with trauma-based material or the overall amount of time exposed to trauma-based material (i.e. how long has the therapist been involved in trauma work). Considering the equivocal findings to date, and the theory suggesting the significance of exposure to trauma-based work, exposure, as indicated by both of these definitions will be a focal part of this study.

The overall aim of the present study is to explore the occurrence of STS in a sample of therapists working with sex offenders. The choice of this population departs significantly from much of the previous research and literature that has focused on therapists who work with victims/survivors of traumatic events. While quantifying the extent of STS, this study will also explore the relationship between STS, level of training and degree of exposure to traumatic material. In addition it will provide the opportunity to examine the convergent validity of Figley's CF scale in comparison with the IES-R.

More specifically, it is hypothesised that STS will be in evidence in this population and that those shortest and longest practicing in the field will report higher levels of STS than those with a mid-range of exposure to this type of work. That is, it is expected that the trend between STS and the number of years working with sex offenders will be quadratic. For the operationalisation of exposure in terms of percentage of caseload no predictions are made.

Regarding the convergent validity of the CF scale, it is hypothesised that there will be significant positive relationships between the CF and burnout subscales and all three subscales of the IES-R.

Method

Participants

Sixty-seven therapists (46 women, 68.7%, and 21 men, 31.3%), volunteered to participate in this study. This sample represents 38% of the 176 questionnaires distributed Australia wide to therapists working with sex offenders. Of these therapists, 43 (64.2%) were psychologists, 13 (19.4%) were social workers and the remainder represented various professions. Mean age, years of counselling experience both generally and specific to sex offending and percentage workload relating to sexual abuse are presented in Table 1.

Table 1.  Demographic Characteristics of Participants

Measures

Compassion Satisfaction/Fatigue Self-Test for Helpers. The Compassion Satisfaction/Fatigue Self-Test (Stamm 1995-1998, adapted with permission from Figley, 1995) is a 66-item measure comprising three sub-scales for compassion fatigue (23 items), compassion satisfaction (26 items) and burnout (16 items, based on burnout items from Pines (1993)). It was designed as an educational tool and warning device and thus tends to err on the side of over-inclusion (i.e. false positives). Participants are asked to rate, on a 6-point Likert scale (0 = never; 5 = very often), how frequently they have experiences characterised by statements such as, "I have beliefs that sustain me", "I am a sensitive person" and "I feel estranged from others". Pilot testing of the scale indicated that by limiting their self-report to the "past seven days" or "currently" therapists felt they would not be providing an accurate reflection of their experiences. Hence no time frame was specified. Subscale scores indicate the risk (low through to extremely high) of experiencing CF or burnout and the potential (low to extremely high) for achieving compassion satisfaction. Although still under development, examination of this measure's psychometric properties, as reported in Stamm (1996), indicated alpha reliabilities range from .94 to .86. In the present study Cronbach's alpha was .87, .78, and .91 for the CF, burnout and compassion satisfaction subscales respectively.

Impact of Events Scale-Revised. The IES-R (Weiss & Marmar, 1995) is a 22-item self report measure of the three broad domains of response to traumatic stress: intrusive phenomena, avoidant and numbing phenomena, and hyperarousal phenomena. Participants are directed to consider items with respect to "client material". A 5-point Likert scale was used (0 = not at all, 4 = extremely) to reflect the degree of distress, rather than the frequency, therapists have experienced. A subscale score of 26 or more is considered to indicate a clinically significant reaction (Weiss & Marmar). There is a large literature using the original IES (i.e. without the hyperarousal subscale) documenting its usefulness, validity and reliability (Weiss & Marman). Weiss & Marmar's development of the IES-R yielded internal consistency alphas for the Intrusion subscale ranging from .87 to .92, for the Avoidance subscale from .84 to .86 and .79 to .90 for the hyperarousal subscale. In the present study Cronbach's alphas were .86, 78, and .74 respectively.

Results

The percentage of therapists at risk of developing STS, as operationalised by CF and burnout, is shown in Table 2. Almost half the sample (46.2%) was at moderate or higher risk of compassion fatigue and approximately one fifth of the sample (19.4) was at moderate or high risk of burnout. With regard to the levels of compassion satisfaction, 97% indicated low levels of satisfaction while the remaining 3% expressed moderate levels.

Table 2. Means, Standard Deviations and
Potential Range of Secondary Traumatic Stress Measure

None of the therapists were found to exhibit symptomatology at a clinically significant level on the IES-R (i.e. scores of 26 or more). Results did, however, reveal that 15.4%, 12.5%, and 8.0% of the sample were experiencing mild levels of symptomatology in the domains of intrusion, avoidance and hyperarousal respectively.

In comparing psychologists and social workers it was found that psychologists (M = 26.95) scored significantly lower on compassion fatigue than social workers (M = 39.23). No other differences were found across disciplines. With regard to level of qualification, no significant differences were found between bachelor and masters level graduates, (Ph D graduates were excluded from this analysis because of insufficient numbers).

To determine the nature of the relationship between length of working in the field and STS trend analyses were performed with the CF and burnout subscales and the three subscales of the IES-R as dependent variables. Assumptions underlying trend analysis indicated no violations of these. Years of experience specific to working with sex offenders was divided into five proportional groups of approximately 20% each. Table 3 shows the mean and standard deviations of each dependent variable for each of the five groups. Perusal of this table will indicate that for each dependent variable there appears to be a "U"-shaped relationship. However, quadratic trend analysis revealed that the only measure for which this trend was significant was the avoidance subscale. The F ratios and concomitant p values are also shown in Table 3. To explore the possibility that years of general counselling experience or percentage of time working with sex offending clients might be a more salient factor in influencing STS, similar trend analyses were performed having divided each of the independent variables into five categories. None of these analyses yielded significant results.

Table 3.   Means and Standard Deviations of Secondary Traumatic Stress Measures According to Length of Experience in Working with Sex Offenders.

To examine the convergent validity of the subscales of Figley's CF scale a correlation matrix was computed. These results are shown in Table 4.

Table 4.   Correlations among Measures of Secondary Traumatic Stress

Discussion

The aims of this study were to explore STS in relation to therapists who work with sex offenders, to examine the relationship between STS and therapists' experience and to provide evidence of the convergent validity of the relatively new Compassion Fatigue Scale (Figley, 1995).

As expected, working with perpetrators of sexual abuse was found to have a negative impact, with 46.2% of the sample presenting at a moderate or higher risk of developing CF. As noted by Stamm (1995), the CF measure was not designed as a diagnostic tool, but was intended as an educational tool and early warning device and, as such, tends to err on the side of over inclusion. Whilst the CF measure may have over-estimated the presence of STS in this sample, utilising the measure as intended (i.e. as an early warning device), suggests that approximately half the therapists sampled need to consider the impact their work is having on them and take preventative measures to address the current indicators of STS. Burnout, which is purported to be either a predictor of STS or an indicator of untreated STS (Beaton & Murphy, 1995; Cerney, 1995; Dutton & Rubenstein, 1995; Figley, 1995; Pearlman & Saakvitne, 1995a,b; Stamm, 1995), was found with over a third of the sample presenting as a moderate (16.4%) or high (11.9%) risk. As with the other CF measure subscales, BO is prone to over-inclusion due to the educative and awareness raising feature of this measure. Nonetheless, with 38.1% of the sample recording moderate or high risk of burnout, it is clear that it needs to be taken seriously. Further support for the presence of STS to this area of work was presented by therapists' endorsements on the IES-R. Consistent with STS theory, whereby therapists are considered to experience similar reactions to their clients, but at sub clinical levels (Pearlman & Saakvitne, 1995a,b), the IES-R results indicated that 15.4%, 12.5% and 8.0% of therapists were experiencing mild disruptions in the domains of intrusion, avoidance and hyperarousal respectively.

Reflecting research findings, which suggested that therapists newest to the field were particularly vulnerable to STS and literature purporting that the effects of STS are cumulative, across time and across clients, the second aim of this study was to examine the presence of any trends in STS. Specifically, it was expected that both new and experienced therapists (as measured by their longevity in the field, specific to working with the perpetrators of sexual abuse) would report the highest levels of STS. Although presenting as expected, the quadratic trend reached significance for only one of the indicators of STS, namely avoidance. Even this finding could be refuted if strict Bonferroni corrections to the alpha rate were adhered to. However, the means shown in Table 3 clearly suggest that therapists with between two and four years' experience working with sex offenders are least vulnerable to manifestations of STS. For avoidance the newest therapists were most at risk, while for CF, burnout, intrusion and hyperarousal therapists working between nine and twelve years were most at risk. It must be borne in mind, however, that these statements are based on inspection of the means only, not statistical significance.

There are several possible reasons for the lack of statistically significant findings. First, the alteration to the measures' instructions may have compromised the data. Given that the traditional instructions ask respondents to endorse statements with regard to their experience either currently of in the past seven days, and in the present no time frame was specified, there is possible confounding between experience and reporting of symptoms. The instructions were altered following feedback from early participants who stated that if they limited their responses to the short time frame, these may not accurately reflect their experiences while working with perpetrators. Since the time frame was then not specified, their responses may reflect either current experience or a cumulative experience. However, even bearing this argument in mind, it is difficult to dismiss the consistent trend for therapists between two and four years experience to be most vulnerable to STS. There is no reason to suspect that the potential confound would effect the various groups differentially.

A second possible explanation for failure to reach statistical significance is that the study was severely underpowered. Given a larger sample it is probable that the trend analysis would have been significant, particularly for CF. In addition, the groups were not based on a priori categories but were identified ad hoc according to frequencies. However, given that this research is in such an exploratory phase pre-designation of experience categories was not possible, and even if it were, the probability that respondents would have been equally divided among them is low!

It is interesting to note that longevity as a therapist in general, rather than specific to the field of sex offending, bore no relationship to the experience of STS. It appears that, almost regardless of one's overall experience as a therapist, there is a common experience of being at considerable risk of STS when beginning work with perpetrators, this reducing somewhat by years two to four, then increasing again. Thus it seems that general experience does not provide "resistance" against STS, and that these fluctuating levels of STS are a shared phenomenon. Similarly, the percentage of client load was independent of therapists' reports of STS, and the response to this client group occurs regardless of whether one's case load is minimally or largely associated with sexual abuse.

The third aim of the study was to provide evidence of convergent validity of the CF scale (Figely, 1995). Given that measures of STS are in their infancy it is important to contribute to the discussion of their psychometric properties. From Table 4 it is clear that CF and burnout are strongly related and that there is considerably more overlap between burnout and CS than between CF and CS. In comparison to the IES-R, the CF subscale showed consistent substantial correlations with all three subscales of the IES-R. These correlations with the burnout subscale were considerably smaller, which is to be expected given the difference in the phenomena. Thus these correlations are of appropriate magnitude to suggest the validity of the CF and burnout subscales. There was minimal relationship between CS and the IES-R subscales, which attests to the divergent validity of the CS subscale.

In conclusion, this study has highlighted the relevance of STS for therapists working with perpetrators of sexual abuse. In particular, findings suggest the vulnerability of therapists newest to the field and it is suggested that organisations and colleagues recognise their needs and support them. However, the risk of STS is not limited to new therapists and it is recommended that the occurrence of STS be recognised, acknowledged and normalised as a process upon entering this field. Educational programs for staff and managers to raise awareness of this phenomenon would be beneficial and supportive supervision is mandatory. We also recommend that further studies be carried out to assess STS both in this population and those working in other areas where therapists might be exposed to traumatic material. In particular, the possibility of a relationship between STS and therapists attrition needs to be explored.

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