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January 09, 2017 Articles

The Hidden Cost of Empathy: How to Address Secondary Trauma Stress in a Child Law Office

By Tamara Steckler and Vicki E. Light

In February 2006, a staff attorney in the Legal Aid Society's Juvenile Rights Practice (JRP) in the Bronx contacted the director of social work to discuss feeling overwhelmed by the sadness she was experiencing as a result of her work representing children in Family Court. The director quickly acknowledged that she was not alone in her reaction. Indeed, there is a term in the field of psychology for what she was feeling: secondary trauma stress (STS). This conversation began a discussion about how JRP could start educating its staff on identifying STS and explore ways to address it personally and professionally. This article describes the underlying conditions leading to STS, the history of how JRP designed its model for assisting staff, and a description of that model.

The Creation of an STS Committee at the Legal Aid Society
New York City's Legal Aid Society is the nation's oldest and largest private, not-for-profit organization providing free legal assistance. The society represents over 300,000 clients each year through a network of 25 offices, and it provides a comprehensive range of legal services in three practice areas: civil, criminal, and juvenile. The staff of JRP, which includes 350 attorneys, social workers, investigators, paralegals, and support staff, represents more than 30,000 children annually in the five boroughs of New York City's Family Court in child welfare, termination of parental rights, persons in need of supervision, and juvenile delinquency petitions. As a result, staff must deal with traumatic and emotionally charged cases affecting children and their parents and caretakers every day.

The need for an organizational response to identify tools to manage the vicarious trauma and stress that JRP staff experience seems obvious. It was in 2008 that the idea of establishing a programmatic plan to address these experiences began to be developed. Following a retreat with 25 interdisciplinary members of JRP staff that led to a charge from JRP's attorney-in-charge to develop a plan to address this issue, JRP's Secondary Trauma Stress Interdisciplinary Committee was formed. The committee has gone on to develop a comprehensive approach to assessing and dealing with STS within JRP, an approach that may serve as a model for other organizations.

What Is Secondary Trauma Stress?
To address STS in the work place, it is necessary to understand what STS is and how it is linked to vicarious trauma and burnout. Stress is defined as a mentally or emotionally disruptive or disquieting influence, which can arise from positive or negative events. Stress emerges over time. Each new stress builds on the unresolved past stress, compounding the effect of additional stress. Trauma is any shock that creates substantial damage to the psychological health of the individual. Traumatic stress is the strain on the human mind and body from a specific major event that shocks, stuns, and horrifies.

Vicarious trauma can occur from witnessing and hearing traumatic events experienced by others. Staff who experience vicarious trauma absorb the sight, sound, touch, and feel of the stories told by the victim. The trauma experienced by the client creates distress in the helper, which may cause such symptoms as minor sleep problems, hyper-arousal, intrusive thoughts, recurring dreams, and avoidance or emotional numbing. These experiences can cause the helper to question his or her beliefs about the kindness of others and the safety of themselves or others.

STS is also known as compassion fatigue. It is a combination of exposure to trauma and empathy. It is defined as the behavior and emotions resulting from knowing about a traumatizing event experienced by someone close. It becomes an emotional weight experienced when helping or wanting to help a traumatized person. Some factors that contribute to STS seen in JRP are the chronic nature of this type of work and its stressors, the helper's own experiences with trauma triggered by hearing about the clients' trauma, the lack of control over work life, experiencing the pain of clients, the difference between expectations and reality, the difference between how staff perceive their job and how clients and their families perceive it, and a sense that showing emotions, especially for attorneys, is seen as a weakness. Further along the continuum, unresolved STS can lead to burnout.

Examples of STS in the Work Place
As members of a law practice representing children in neglect and abuse cases, persons in need of supervision proceedings, and delinquency proceedings, staff listen to clients talk about the trauma that they have experienced or been exposed to in their lives. Hearing about traumatic experiences over and over, staff sometimes become desensitized to it. Other times, staff relive it with clients as they describe their trauma. Here are two examples of STS from JRP staff.

In the first example, a social worker is assigned to assist an 18-year-old child welfare client. An immigrant, with limited family or friends to visit him and a very severe mental health diagnosis, he seems to be in crisis on a regular basis. Since being assigned to the case, the social worker has visited the client in numerous hospitalizations and placements. In addition, she fields calls from him nonstop, sometimes up to six times a day. The client does not like his current placement and, since being there, has been continually swallowing items. On one particular day, the social worker is informed that the client has somehow managed to swallowed pushpins and has just been released from the emergency room.

From that moment on, the social worker becomes anxious and nervous anytime the phone rings, fearing that the client has had a serious emergency. She also begins to question her social work skills. Her feelings transfer to other cases, as she begins to anticipate the worst for her clients. The social worker is hesitant about discussing this with her supervisor for fear of being seen as "weak" or unable to handle difficult clients.

In a second example, an attorney is assigned a delinquency case and is representing an 11-year-old boy accused of sexually abusing his 5-year-old cousin. The attorney feels the weight of this case on a number of levels: the young ages of those involved, the impact she feels that the case is having on both families, the increasing demands of the client's mother, and knowing that she may need to cross-examine a 5-year-old child.
The attorney finds that she is thinking about the case outside of work. The attorney has a 5-year-old child of her own and begins feeling concerned about her own child's safety, though she never before experienced these worries. She thinks about the case obsessively and becomes teary eyed when doing daily tasks.

Developing a Model
The STS committee decided that its first order of business was to determine the nature and scope of the problem, and so in 2010 it developed a survey to identify what contributes the most to STS and vicarious trauma reactions in its staff. Based on the results of the survey, the committee developed trainings and protocols to address the identified problems. To measure the effectiveness of these initiatives and to identify continuing needs, the committee created and released a follow-up survey in 2014.

The data set in these surveys included 223 survey takers in 2010 and 228 in 2014, which was a 65 percent response rate. Each survey was composed of two sets of 30 questions. The first set asked demographic and work-related questions tailored to reflect the particular nature of the individual's specific work. The second set consisted of the standard set of questions from the most current version of the Professional Quality of Life Scales. B. Hudnall Stamm, Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL) (2009). The measure—developed with data from over 3,000 individuals—has been used since 1995 and has been revised multiple times. The ProQOL measures levels of compassion satisfaction, burnout, and compassion fatigue. It is the "most commonly used measure of the negative and positive effects" of helping others who have experienced or are "experiencing suffering and trauma."

The data in both surveys were analyzed to determine whether STS varied depending on the length of time at JRP, borough, practice area (child protective or delinquency), and discipline area (attorney, manager, social worker, paralegal, or support staff). Using those criteria, the only genuine distinction the committee found was an elevated level of STS for staff attorneys. The 2010 survey results using the ProQOL reflected that, compared with the JRP-wide average, attorneys scored lower on compassion fatigue, higher on STS, and slightly higher on burnout. However, the results revealed that all disciplines, except for support staff, were experiencing levels of STS above normal limits. Staff attorneys were the only discipline experiencing burnout above normal limits.

The committee was also able to compare the results from 2010 and 2014 using the ProQOL set of questions, which revealed a decrease in STS and burnout, and an increase in compassion satisfaction. In that regard, there were lower levels of "feeling trapped" by the job and being overwhelmed by high caseloads than in 2010. In addition, levels of satisfaction in choosing this work trended higher in 2014 than in 2010. Responses to the JRP-specific questions revealed positive trends as well, including an increase in feeling respected by coworkers and a greater ability to speak more openly and candidly with supervisors about stress. More respondents reported in 2014 that they felt their clients' safety and well-being did not rest primarily on their shoulders. For instance, although more staff reported regularly checking emails outside of work hours, fewer gave clients their personal contact information.

JRP's Approach to Addressing STS
Once the committee obtained the results of the first survey and identified that staff were experiencing STS, JRP developed a comprehensive plan. First, the committee decided to conduct trainings on STS to educate staff on its symptoms and techniques for managing it. From the committee's review of social science literature, it became clear that in order to prevent and manage STS, staff needed knowledge, recognition, and responses from three category groups: personal, institutional, and professional.

Personal techniques for managing STS. To address the personal element, JRP trained staff in the importance of self-care, the primary objective being to do no harm to yourself when helping others. To achieve that goal, the individual needs to prioritize his or her own physical, social, emotional, and spiritual needs. The training also emphasized the need to be aware of the physical manifestations of STS—in particular, empathic resonance (a tendency to experience the same feelings as the client, e.g., anger, sadness), hyper-arousal, and hypersensitivity (a tendency to overreact to stimuli).

In discussing personal responses to STS, the trainers explained that the best approach is to become one's own advocate and to remember the basics: sleep, eat, exercise, and laugh. It is vital to balance home and work. That means maintaining reasonable work hours and cultivating healthy intimate and family relationships. Attention to physical health is another important component. Spirituality or daily meditation (or both) may be helpful, as may be counseling and professional help.

To manage stress, the team of STS-trained individuals taught colleagues a number of stress management techniques, including breathing and mindfulness exercises, centering and guided imagery, biofeedback, and progressive relaxation.

Mindfulness in the workplace is a very useful strategy for addressing STS. Mindfulness is defined as having "moment-to-moment awareness without judgment," and it can be characterized with these three words: intention, attention, and attitude. Mindfulness in the workplace means being present and attentive to the task at hand, while also implementing skills to effectively cope with both short- and long-term stress. According to Ruth Crocker, an expert on recovery from trauma and personal tragedy, managers who practice mindfulness state that it improves their ability to encourage a calm and stable work environment. In addition, research has linked mindfulness meditation to boosts in productivity level, decreasing work-related stress levels, and promoting self-care. Ruth Crocker, PhD, The Benefits of Mindfulness, July 27, 2014.
The committee suggested several tips on practicing mindfulness and self-care:

• The "STOP" technique: Stop, Take a few breaths, Observe, and Proceed. When a project brings on feelings of being stressed and overwhelmed, take a short break (one to five minutes), focus on one task at a time, and practice mindful listening during meetings. Elisha Goldstein, PhD, "Stressing Out? S.T.O.P.," Mindful, Aug. 2013.
• Smartphone apps for meditation and calming such as Calm, Headspace, Happier, Digipill, Spirit/Junkie, and Buddhify.
• Reserving time for activities that are personally meaningful: contact with nature, spirituality, creative expression, volunteer work, hobbies, or whatever other interests or endeavors nurture the individual's personal needs and growth.
• Encouraging attendance at professional meetings outside the firm or office.

Institutional techniques for managing STS. The JRP attorney-in-charge, managers, and staff all recognized the need to address STS in the workplace and to implement measures to create a safe and supportive environment. In that regard, management agreed to ensure regular supervision and peer and individual support, especially during times of crisis, and to balance caseload size and workload. They also agreed to encourage attendance at continuing professional education on all topics, to address the effects of STS and other job issues, and to undertake coalition building with other system players. The broader Legal Aid Society management team has committed to continue to promote a healthy work setting, educate staff on policies and procedures, provide better access to leaders and supervisors, and maintain adequate human resource policies. They provided a method for seeking counseling and professional help (through a hotline number and contracted agency), and created awareness of these issues during staff recruiting.

The STS committee also worked with JRP supervisory staff to develop techniques to reduce STS among frontline staff. The supervisors strive to create an open and nonjudgmental professional space in which to identify pertinent cases, discuss issues, validate reactions, and encourage self-care. Good supervision techniques should include dedicated time to address supervision needs, creating a collaborative and mentoring relationship, offering constructive feedback, and being open to self-reflection and self-exploration. Supervision at JRP includes both appreciation and recognition, critical elements of developing a supportive environment.

One of the approaches that the committee and management developed was the Critical Incident Protocol, also known as crisis debriefing. The protocol was developed to create a procedure that allows those involved with an incident such as the death or serious injury of a client, threats to personal or communal safety, or the unexpected death of a colleague, to process the event and reflect on its impact. Under this protocol, managers and employees identify the traumatic event, share current responses, and validate and normalize those reactions. The supervisors are to monitor STS reactions in employees and share self-caring ideas with employees. Both sides are encouraged to practice one stress management technique together and encourage self-care.

The committee and management also developed a screening tool for staff recruiting considerations, for both long-term employment and internships. The tool begins during the hiring process with informing candidates of the inherent stresses of the job, describing the caseload and clients involved, explaining the support and supervision in place, and exploring the candidate's ability to handle stress.

Professional techniques for managing STS. The committee created professional responses within the offices to address STS. It did so based on its recognition of the emotional toll this kind of work can take and understanding the need for setting boundaries and limits given the particular time constraints and resources available. It has encouraged individual daily goal setting and self-evaluation as well as making "worker care" a team activity to help each other maintain good work boundaries.

As part of its professional response to STS, the committee has conducted JRP staff trainings and intern trainings, presented at national conferences and law school public interest forums, developed the Critical Incident Protocol, implemented De-stress and Digest meetings, and conducted surveys regarding STS in the offices. The STS committee is continuing to disseminate information and resources and will continue to address future concerns and to develop or revise protocols as needed.

The goal of the committee is to build resilience and increase compassion satisfaction. Resilience is how a person recovers (bounces back) from stress and trauma. Resilience is related to the delicate balance between the factors and defenses that protect against cumulative stress (prevention and management). It is based on having and employing coping skills that allow for continued stress resolution. It can be inherited or innate, but resilience can also be learned and developed. Compassion satisfaction allows for the perceived stress to be associated with higher compassion and job satisfaction. Workers who are in the same setting who report higher job satisfaction also report less stress. Job satisfaction is associated with higher levels of social support, autonomy, and effectiveness.

STS and vicarious trauma are obvious "occupational hazards" in direct service legal work. If not addressed, STS and vicarious trauma affect not only the professional but also the clients with whom that professional is working. It may affect one's ability to empathize and respond to clients, process information, and make decisions. A professional suffering from STS may be apt to avoid "stressful" questions and less likely to identify clients' past trauma, and, therefore, less able to intervene appropriately. The professional also may become hypervigilant and focus on small details to the detriment of the client's overall history, situation, and concerns, also resulting in less effective intervention. Cues may be misread, important information not explored, facts skewed to fit assumptions, incorrect conclusions made, and ineffective responses provided.

Thus, it is essential that direct service legal professionals be prepared for this aspect of the work early in law school. Awareness is key in preventing and addressing STS and vicarious trauma before they cause burnout or have a detrimental impact on client representation. Empathy brings people to this work, but that same empathy causes them to be deeply affected by their clients' personal traumas. The awareness of STS and its effects, knowledge of what STS is, recognition that we are experiencing STS in our field of work, and learning appropriate responses can mitigate the impact of STS and vicarious trauma.

The issues of trauma, empathy, and awareness must be normalized. There needs to be an open discussion of how to deal with clients' legal and personal crises in a way that supports both the client and the legal professional. It is crucial that professionals come to this work with realistic expectations, self-awareness, and acknowledgement of their own personal trauma histories and coping strategies. Mentors and supervisors need to create a supportive environment in which these issues can be raised. It is incumbent on public interest legal providers to create an awareness of these issues to support both current and future attorneys.

The work of the JRP Secondary Trauma Stress Interdisciplinary Committee, in collaboration with managers at JRP, provides a model for other public interest legal providers and law schools interested in responding to the concerns raised by STS and vicarious trauma. By providing STS training for interns and new staff, encouraging ongoing office discussions and disseminating information on the issue, implementing a Critical Incident Protocol, engaging in community outreach and presentations, and convening central meetings to discuss practice issues and innovative responses, the model provides a menu of institutional responses to STS designed to increase awareness, address workplace issues, provide stress outlets, and encourage self-care and professional care.

Keywords: litigation, children's rights, secondary trauma stress, vicarious trauma, public interest legal providers

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