Secondary traumatic stress among alcohol and other drug workers. Philippa Ewer, Katherine Mills, Claudia Sannibale, Maree Teesson, Ann Roche

Transcription

1 Secondary traumatic stress among alcohol and other drug workers Philippa Ewer, Katherine Mills, Claudia Sannibale, Maree Teesson, Ann Roche

2 Trauma and PTSD among clients AOD clients Dore et al. (2012). Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug and Alcohol Review; 31:

3 Types of trauma Situations in which a person experiences, witnesses, or is confronted with a situation in which they fear for their own or another s safety. Event % Total Witnessed serious injury/death 68 * Threatened with a weapon, held captive, kidnapped 64 Seriously physically attacked or assaulted 55 Involved in a life threatening accident 50 * Great shock other person 42 Sexually Molested 31 * Raped 25 * Involved in a fire, flood, other natural disaster 24 Other extremely stressful event 21 Tortured or the victim of terrorists 8 Direct combat experience in a war 4 Mills et al. (2005). Post traumatic stress disorder among people with heroin dependence in the Australian Treatment Outcome Study Drug and Alcohol Dependence, 77,

4 Trauma informed care Recommended that assessing for trauma history among clients be part of routine clinical practice. A history of trauma exposure may be integrally linked with the person s current AOD use (can provide a framework for understanding current situation). The presence of a trauma history also indicates that further investigation is required to determine whether the person may have symptoms of PTSD. Marel C et al. (2016). Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (2nd edition). Sydney, Australia: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales. Marsh A et al. (2012). Trauma-informed treatment guide for working with women with alcohol and other drug issues (2nd ed).perth, Australia: Improving Services for Women with Drug and Alcohol and Mental Health Issues and their Children Project

5 Trauma-related symptoms Reactions following exposure to a traumatic event are varied, and can include anxiety or fear-based symptoms, aggression or anger-based symptoms, or dissociative symptoms. Most commonly PTSD: Re-experiencing: unwanted and intrusive memories, recurrent dreams or nightmares, or flashbacks. Avoidance: memories, thoughts, feelings, or external reminders of the event (e.g., people, places or activities). Negative cognitions and mood: distorted sense of blame of self/others, feeling detached from others or less interest in activities, inability to remember key aspects of the event. Arousal: Aggressive, reckless, self-destructive behaviour, sleep disturbances, hypervigilance, or increased startle response.

6 Trauma-related symptoms Can be difficult to manage, particularly if symptoms exacerbated when stop using/reduce use But how does the affect workforce?

7 Secondary Traumatic Stress (STS). emotions resulting from knowledge about a traumatising event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatised or suffering person (Figley, 1999, p. 10). Also referred to as vicarious traumatisation

8 Secondary Traumatic Stress (STS) Similar symptoms to PTSD: o Intrusive cognitions about client s disclosures o Avoidant responses o Physiological arousal o Distressing emotions o Functional impairment

9 Secondary Traumatic Stress (STS) Until recently, considered distinct from PTSD because of the nature of the traumatic event (i.e. exposure to a traumatised individual s retelling of a traumatic event, as opposed to experiencing/witnessing the event oneself). The most recent revision to the DSM has included exposure to aversive details of the event(s) in the course of professional duties as a qualifying event.

10 Secondary Traumatic Stress (STS) Documented among clinicians in a variety of fields: mental health, child welfare, domestic violence and sexual assault counselling, and social work. Viewed as an occupational hazard for clincians working with traumatised populations (Pearlman, 1999) US study (Bride, Hatcher & Humble, 2009) o 225 AOD counsellors o 19% currently experience STS What about STS in the Australian AOD workforce?

11 Aims 1. Prevalence of secondary traumatic stress (STS) among AOD workers in Australia 2. Factors associated with the presence of STS Ewer et al. (2015). The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug and Alcohol Review, 34(3),

12 Methods Anonymous online survey Distributed through main AOD professional bodies (eg DANA) Target population: o AOD workers in Australia Inclusion criteria: o Aged 18 years or over o Currently working in an AOD setting

13 What did we measure? Demographics Professional characteristics Client profile (trauma history) Secondary Traumatic Stress Scale (STSS) past week Trauma history (CIDI v 2.1) PTSD (PCL) past week Depression, Anxiety & Stress (DASS) past week

14 Sample characteristics (n=412) NT 4% WA 5% SA 4% QLD 22% NSW 37% Population: >100,000: 58% 1,000-99,000: 36% : 3% <200 3% VIC 21% ACT 7% TAS 4%

15 Sample characteristics Total (N=412) % Female 70.5 Mean age (SD) 44.3 (10.7) % Indigenous Australian 3.7 % Completed tertiary education 98.5 Median years working in AOD (range) 10.0 ( ) Median years working in mental health (range) 9.0 ( )

16 Sample characteristics Other 27% Nurse 22% Social worker 7% Counsellor 20% Case worker 12% Psychologist 12%

17 Client trauma experiences % Clients who have experienced Total (N=412) Any type of traumatic event - Median (range) 80.0 (1-100) Physical abuse as a child - Mean (SD) 55.3 (24.1) Sexual abuse as a child - Mean (SD) 46.0 (23.0) Physical abuse/assault as an adult - Mean (SD) 45.0 (26.7) Was sexually molested as an adult - Mean (SD) 25.0 (0-99) Witnessed someone being badly injured or killed- Median (range) 25.0 (0-100) Was raped as an adult - Median (range) 20.0 (0-90) Life threatening accident Median (range) 20.0 (0-90) Threat with weapon, held captive, kidnapped Median (range) 15.0 (0-100) Natural disaster Median (range) 5.0 (0-100) Combat experience or war Median (range) 1.0 (0-95) Tortured or victims of terrorists Median (range) 0.0 (0-50)

18 Aim 1: Prevalence of STS 18

19 Prevalence of STS Prevalence Current Study US Study No difference between males/females or occupation.

20 STS symptoms in past week % Intrusive thoughts about clients 55.5 Difficulty sleeping 34.3 Difficulty concentrating 33.5 Avoidance of clients 30.2 Irritability 29.7 Emotional numbing 29.2 Diminished activity level 27.7 Detachment from others 23.6 Cued psychological distress 22.1 Foreshortened future 20.9 Avoidance of people, places, things 19.2 Hyper vigilance 17.0 Inability to recall client information 15.8 Easily startled 15.1 Cued physiological reactivity 13.1 Sense of reliving clients trauma 9.4 Disturbing dreams about clients 9.5 Symptom cluster Intrusion Avoidance Arousal

21 Aim 2: Factors associated with STS 21

22 Demographics STS + (n = 82) STS (n = 330) % Female Mean age (SD) 45.4 (10.0) 44.0 (10.9) % Indigenous Australian % Completed tertiary education * * p <.05

23 Training, supervision & work experience STS + (n = 82) STS (n = 330) % AOD training % Mental health training % Mental health training last 12 months % Psychological trauma training % Psychological trauma training last 12 months Median years working in AOD (range) 10.0 ( ) 10.0 ( ) Median years working in mental health (range) Median hours of clinical supervision per month (range) * * p < ( ) 9.0 ( ) 1.0 ( ) 2.0 ( )

24 Trauma & mental health STS + (n = 82) STS (n = 330) % Current PTSD Diagnosis ** % Experienced any type of trauma * Trauma types experienced (range) ** 3 (0-10) 2 (0-10) % Severe Anxiety ** % Severe Stress ** % Severe Depression** ** p <.01 * p <.05 Workers with STS were more likely to have been: exposed to combat in a war (OR 3.64); in a lifethreatening accident (OR 2.17); seriously physical attacked or assaulted (OR 2.09); threatened with a weapon, held captive or kidnapped (OR 1.86); and sexually assaulted (OR 1.68), childhood trauma (69% vs. 49%; OR 2.32) and childhood sexual assault (40% vs. 27%; OR 1.76)

25 Factors related to STS Completed tertiary education Experienced at least one trauma Number of trauma types experienced Experienced childhood sexual abuse Experienced childhood physical abuse Experienced combat exposure in a war Experienced a life threatening accident Experienced rape as an adult Experienced physical attack as an adult Experienced threat with a weapon Current PTSD diagnosis DASS - depression DASS anxiety DASS stress # of hours per month of clinical supervision % of clients have experienced trauma % of clients have experienced childhood physical abuse % of clients have experienced childhood sexual abuse % of clients have experienced rape as an adult % of clients have experienced physical abuse as an adult % of clients who witnessed a bad injury or someone being killed Cu

26 Factors related to STS Variable Odds ratio 95% CI s DASS - Stress DASS - Anxiety % of clients have experienced trauma # of hours per month of clinical supervision The odds of experiencing STS are increased by 30% for every 10% increase in the proportion of traumatised clients treated The odds of experiencing STS are decreased by 25% for every 1hr of supervision provided per month

27 Discussion 20% prevalence of STS among AOD workers Independently associated with: - high stress and anxiety - clinical supervision, - traumatised client workload

28 Stress & anxiety Cross-sectional study, causal attributions cannot be made. STS may lead to higher levels of stress and anxiety OR higher levels of stress and anxiety may predispose workers to developing STS. BUT previous research has shown that pre-trauma anxiety increases an individual s risk of experiencing post-traumatic stress reactions following trauma exposure (Koenen et al., 2002). Workers with high levels of anxiety may be more vulnerable to STS when working with traumatised clients.

29 Stress & anxiety Regardless of the nature of the relationship between these variables, research has demonstrated an association between STS and lower job satisfaction and occupational commitment (Bride et al., 2011). It is possible that STS and other associated sources of distress may contribute significantly to the high levels of staff turnover seen within the AOD sector (Duraisingam et al., 2009). Addressing STS among AOD workers may improve worker retention as well as improving client treatment and outcomes.

30 Supervision & workload Consistent with research among health-care providers more broadly (Galek et al. 2011, Knudsen et al., 2008) STS was associated with receiving fewer hours of clinical supervision each month. Highlights the importance of clinical supervision for AOD workers who are treating complex clients, even if trauma is not the primary reason for treatment (Knight, 2004). In addition to reducing the likelihood of experiencing STS, clinical supervision is associated with greater job satisfaction, reduced staff turnover, and improved client outcomes (Hyrkäs et al., 2006; Callahan et al., 2009; Roche et al., 2007; Knudsen et al., 2008).

31 Supervision & workload Both workers with and without STS reported working with high proportions of traumatised clients (median of 90% vs. 80% of clients). As found by Brady et al. (1999) in their examination of STS among female psychotherapists, workers experiencing STS reported a significantly greater traumatised client workload compared with those without STS. Underscores the importance of monitoring the number and distribution of traumatised clients allocated to individual workers.

32 Trauma training Despite the high volume of traumatised clients accessing AOD services, less than two-thirds of workers surveyed reported having received trauma training Specific details regarding the nature of training received were not obtained. May have been substantial variation in the type (e.g. attendance at professional seminars/workshops, training provided as part of obtaining professional qualifications, certification) and content of training received (e.g. training on assessment and delivering trauma-informed care versus training regarding the delivery of trauma-focused treatments).

33 Trauma training Although an association between trauma training and the presence of STS was not found, the effect may have been diluted because of the heterogeneity of training received. Nonetheless, this finding highlights a significant gap in AOD worker training and the need for further research, and consideration at a policy level, regarding the level and type of trauma training that is appropriate for this workforce.

34 Trauma and PTSD High rates of trauma exposure and PTSD identified among the AOD workers themselves, particularly those with STS. Findings regarding the relationship between an individual s own trauma and PTSD history and the development of STS have been mixed (Ortlepp and Friedman s, 2002; Bride et al. 2007) In the present study, the prevalence of trauma exposure and PTSD was found to be significantly higher in the bivariate analyses but were not shown to be independent predictors in the final multivariate model, Indicates that the relationship between trauma, PTSD and STS may be confounded by other personal and professional characteristics.

35 Limitations Web-based questionnaire - only those who had access to the Internet were able to complete it. Eligibility criteria study limited to participants currently working in the AOD sector. Does not capture people who have left the workforce potentially due to STS Response bias - possible response bias whereby individuals who had a particular interest in trauma research, either due to their own personal experiences or those of their clients, may havebeen more likely to respond. Generalisability - information regarding the response rate was unable to be collected, along with the characteristics of non-respondents who may have been too distressed to participate in the study.

36 Conclusion Findings underscore the crucial importance of adequate and appropriate training and support for AOD workers, in general, and specifically in relation to treating clients with trauma experiences Provision of adequate clinical supervision Increasing the awareness of the impact learning about someone else s psychological trauma can have and STS, Standardised psychological trauma training, Access to employee assistance program

37 Conclusion Largely overlooked area and one in which relatively little was known about the potential impact on workers. What was once referred to as compassion fatigue might be more accurately referred as secondary traumatic stress or vicarious traumatisation. Improved knowledge and understanding of this issue can facilitate the provision of appropriate support and protective mechanisms be put in place to safeguard the well-being of the AOD workforce.

38 Thank you Mental Health and Substance 38