Dr. Levin is Assistant Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons and Medical Director, Westchester Jewish Community Services. Mr. Greisberg is staff therapist at Westchester Jewish Community Services, Hartsdale, NY. Address correspondence to: Andrew P. Levin, MD, 141 North Central Avenue, Hartsdale, NY 10530. Email inquiries to: ALevin@wjcs.com

Abstract

Although secondary trauma and burnout have been the subject of investigation in emergency workers and mental health professionals, no systematic studies have evaluated these responses in attorneys. Growing out of our collaboration with the Pace Women’s Justice Center, we designed a survey to assess the presence of secondary trauma responses and symptoms of burnout in attorneys working with victims of domestic violence and criminal defendants. Compared with two control groups consisting of mental health providers and social services workers, attorneys surveyed demonstrated significantly higher levels of secondary traumatic stress and burnout. This difference appeared related to the attorneys' higher caseloads and lack of supervision around trauma and its effects. These findings create a starting point for further study into attorney responses and methods of ameliorating the stress of work with traumatized clients.

Introduction

Over that last generation and particularly following the inclusion of Posttraumatic Stress Disorder (PTSD) in the 1980 Diagnostic and Statistical Manual of Mental Disorders--Third Edition (DSM-III), 1 the mental health field has witnessed an explosion of interest in trauma and its effects. A decade after DSM-III the mental health community began to recognize the effects of work with the trauma victim on the helping professionals themselves. 2,3 These phenomena have been labeled "Compassion Fatigue,"³ "Secondary Traumatic Stress (STS)," ³ and "Vicarious Traumatization (VT)." ²

Figley summarized the STS formulation as the "cost of caring," ³ manifested by symptoms similar to those of PTSD including re-experiencing the event witnessed, avoidance of recollections of the event, numbing in affect and function, and persistent arousal. In contrast, "Vicarious Traumatization," as conceptualized by McCann and Pearlman,² develops as a consequence of the relationship with the traumatized client during long-term individual psychotherapy. In addition to internalizing accounts of the patient's victimization with resultant effects on memory and internal imagery, the trauma therapist experiences a disruption in central schemas including assumptions about the world, trust and dependency, safety, power, independence, esteem, and intimacy. Both STS and VT degrade the professional's ability to perform her task and affect functioning in daily life beyond the job.

Quantitative research efforts on the secondary effects of trauma have focused predominantly on workers who have brief contact with the victim, e.g., disaster workers, 4 firefighters, 5 and relief workers, 6 and to a lesser extent on professionals with prolonged contact with victims, e.g., therapists.7,8,9,10,11 These studies have identified risk factors for developing STS and VT related to the nature of the trauma exposure as well as trait factors in the professional. Among emergency workers event-related risks for development of STS symptoms included identification with the dead after a disaster,⁴ degree of exposure and diminished social supports,⁶ number of distressing missions and length of service in firefighters,⁵ and work with child victims.³ In addition to the effects of caseload on mental health professionals^7,8 , a prior personal history of trauma,⁷ and prior treatment for a psychological disorder³ increased the risk of secondary trauma symptoms. Therapists with less experience were also more vulnerable to VT, with lack of supervision creating additional risk. ⁸

A small number of studies have focused on professionals in the legal arena. Follette et.al.12 found that police officers surveyed reported significantly greater symptoms of psychological distress (anxiety, depression, dissociation, sleep problems) and PTSD symptoms than mental health professionals. Although studies have characterized substance abuse13 and mental illness14 among attorneys under stress, there are no studies addressing secondary trauma symptoms or the effects of work with traumatized clients.

Despite the lack of empirical work on secondary trauma responses among attorneys, the "clinical" law literature has raised issues regarding the responses of attorneys to work with difficult and traumatized clients, particularly counter-transference and identification with the victim.15 Allegretti16 calls for increased training of attorneys in managing the "face-to-face, long-term, and intensely personal relationship" that develops between client and attorney. An understanding of this principle has recently entered into "clinical" curricula for law students. For example, at Pace Law School the clinical coursework has included readings such as Groves' article "Taking Care of the Hateful Patient,"17 and "The Difficult Legal Client," co-authored by a psychiatrist.18

In addition to symptoms of secondary trauma, helping professionals have long been known to experience "burnout." Burnout develops gradually due to the accumulation of stress and the erosion of idealism resulting from intensive contact with clients.19 The syndrome is characterized by physical symptoms such as fatigue, poor sleep and headaches, emotional changes including anxiety, irritability, depression and hopelessness, and behavioral manifestations including aggression, cynicism, and substance abuse,³ leading to poor job performance, deterioration in interpersonal relationships, and significant attrition among professionals working with traumatized populations.

In collaborating with domestic violence and criminal attorneys the author (APL) informally uncovered varying degrees of secondary trauma and burnout symptoms. To explore these phenomena further, we undertook a preliminary questionnaire survey to determine the presence of these symptoms among attorneys working with traumatized clients, compare those responses to other professionals, and identify possible risk factors.

Overview of the Study

Participants were drawn from a variety of legal and mental health agencies. Attorneys were recruited from agencies specializing in domestic violence and family law as well as legal aid criminal services. The mental health professionals, recruited from community agencies, fell into two groups: mental health professionals providing treatment and social services workers providing concrete and case management services to the mentally ill.

Participants completed a survey that combined the Secondary Trauma Questionnaire (STQ) developed by Motta, et.al,20 and items assessing burnout adapted from Figley.³ Secondary trauma questions assessed three domains: 1) re-experiencing the trauma of the person who had been traumatized in imagery, flashbacks, and nightmares; 2) avoidance of reminders of those traumas; and 3) symptoms of increased arousal including disturbed sleep, increased startle, and irritability. The burnout items included low energy, depressed mood, a feeling that work with the traumatized clients was taking over too much of life, feedback from friends that the subject had lost interest in pleasurable activities, and negative perceptions of self and work function. The survey also recorded personal and work data including number of trauma clients encountered within the last year, personal history of trauma, and history of prior treatment.

Summary of Study Outcomes

The three groups—attorneys, mental health providers, and social service workers—were of similar age and experience, and were predominantly female. The groups also did not differ in history of childhood trauma or prior history of treatment for emotional problems but the attorneys showed a higher rate of adult trauma. Caseload of traumatized clients during the prior 12 months was significantly higher for attorneys compared to both mental health providers and the social services workers. More than half the attorneys surveyed encountered 21 or greater trauma clients during the prior year whereas almost 70% of the other professionals averaged 20 or fewer clients in the same time period. Survey results demonstrated that attorneys experienced more symptoms of secondary trauma and burnout compared with both comparison groups. In addition, the attorneys were consistently higher on each of the subscales of secondary trauma. Translating these scores into symptoms, the attorneys demonstrated higher levels intrusive recollection of trauma material, avoidance of reminders of the material and diminished pleasure and interest in activities, and difficulties with sleep, irritability, and concentration.

Subjects in all three groups with a history of mental health treatment had significantly higher scores for secondary trauma and burnout. Prior childhood and adult trauma history were not predictive for any of the subjects studied. For all subjects (including the attorneys) increased client load predicted higher scores on secondary trauma and burnout.

During the course of planning and completion of the study the author (APL) heard informally from attorneys regarding their experiences. One attorney at a legal aid office representing victims of domestic violence wrote:

Discussion and Future Directions

The major finding of our study was that attorneys working with traumatized clients experience significant symptoms of secondary trauma and burnout. Second, the attorney group demonstrated higher symptom scores in all areas of secondary trauma (intrusion, avoidance, and arousal) and burnout compared to mental health providers and social services workers. Number of clients was moderately positively correlated with symptoms. This is consistent with other findings that the intensity of exposure is a risk factor for secondary trauma. ^5,6,8

In contrast, adult and child trauma were not related to intensity of response among the professionals in our study. Previous studies have not been inconsistent, identifying prior trauma as a risk factors in some samples^7,22 but not others.^9,12 On the other hand, attorneys, mental health providers, and social services workers with a prior history of mental health treatment all scored consistently higher on secondary trauma and burnout.

As to the origin of the increased secondary trauma and burnout responses among the attorneys, higher case loads alone may explain the difference. The preliminary nature of our study requires follow-up to indicate if other factors play a role in the difference. Attorneys responding at the "Think Tank" felt that in addition to their high case loads the lack of systematic education regarding the effects of trauma on their clients and themselves and the paucity of forums for regular ventilation were significant contributors to development of secondary trauma and burnout. Even among mental health professionals with advantages of education and supervision secondary trauma responses are common.^3,4,9,10,11

Both the data and the informal responses from attorneys point toward the necessity, as stressed by Silver,23 of developing educational programming for law students and attorneys regarding the effects of trauma on their clients and themselves. Future research should focus on clarifying the extent of and risk factors for secondary trauma in attorneys, judges, and allied professions. This work should form the basis for identifying the most effective interventions for reducing secondary trauma among legal professionals in order to enhance the delivery of legal services to victims of trauma.

Acknowledgements

The authors acknowledge the support and cooperation of the Pace Women's Justice Center, Victoria Lutz, Esq. Executive Director, and Drs. Stuart Kleinman and Victoria Harris of the American Academy of Psychiatry and the Law in the development and completion of this study.

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Additional Resource: National Crime Victims Bar Association. Director Jim Ferguson's email address is JFerguson@ncvc.org. He is within the National Center for Victims of Crime.