EXAMEN DEL FUNCIONAMIENTO Y APLICACIÓN DEL ACUERDO MSF

Prevention and treatment for secondary traumatic stress should be anticipated in the workplace as STS is a common reaction to an abnormal level of trauma or violence or unusual situations such as natural disasters, experienced personally or from working with survivors and traumatized individuals. While secondary traumatic stress is not a predictable outcome for all workers who deal with traumatized people, preparing for the impact of distress and preventing normal stress reactions from developing into secondary traumatic stress should be part of prevention processes. Prevention of STS involves developing the idea of preparation, which starts with recognition of the effects of working with traumatized individuals.

2.14.1 Building Resilience and Coping Skills

Collins (2008) has suggested that resilience is a vital characteristic that provides professionals with the ability to work with human suffering on a daily basis without succumbing to psychological pain and despair. Resilience is a source of personal ability and characteristics that help the person to rebound and cope successfully despite significant hardship or adversity and an understanding of what protective measures are vital for developing healthy functions among professionals working with victims of trauma (Collins 2008).

Jacobsen et al. (2004) observed mental health social workers and their reactions to fatal and non-fatal client suicidal behaviours. They reported that female and male therapists responded differently to the stress, with female therapists experiencing more shame and guilt following fatal patient suicidal behaviours. Males and females might utilize different ways of coping with severe stress events such as avoidance, compartmentalization and internalization which might provide resilient outcomes, as opposed to other ways of coping (e.g. shame, guilt, self-doubt and preoccupation) which may result in negative outcomes. Few researchers (Lazaruz and Folkman

1984; Ting, Jacobson and Sanders 2008) have recognized the resilient clinician as an individual who uses protective coping successfully to become accustomed to and protected against trauma. Such research work has noted adaptive methods utilized constantly in changing cognitive and behavioural efforts to manage the specific external and/or internal demands that are recognized as taxing or exceeding the resources of the person involved (Lazaruz and Folkman 1984).

In contrast, maladaptive behaviours and conditions that damage adaptive methods have been recognized as developing clinician vulnerability. Lawson and Venart (2005) argued that therapeutic harm occurs when a therapist’s professional functioning is impaired by stress, trauma or difficult life events. These researchers also noted various threats to a therapist’s ability to maintain a healthy functionality with problems that include substance abuse, mental illness, personal crisis, physical illness or debilitation. Lawson and Venart (2005) also noted traumatic situations as being a contributor to vicarious trauma or burnout. They confirmed that protecting against vulnerability to harm entailed effectively utilizing adaptive coping methods and different self-care activities such as discussing cases with work colleagues, spending time with family or friends, attending workshops, travel, hobbies, talking with work colleagues between sessions, socializing, exercise, limiting case loads, developing a spiritual life and receiving supervision.

Ablett and Jones (2007) highlighted precursor factors that played a role in endorsing resilience and sustaining well-being in palliative care nurses. Their study suggested constructs connected to hardiness and consistency that assisted both meaning and purpose in stressful cancer care workers dealing with repeated exposure to the pain, suffering and death of patients. Personal attitudes, job satisfaction and methods of coping also contributed to the nurses’ resilience. Ablett and Jones concluded that the nurses’ adaptive attitude towards change was the main factor for hardiness and resilience. Further research recognizing features that endorse

resilience in clinicians is needed in order to create methods for protecting the health and well- being of workers and trauma victims. Eventually it might be possible to recognize predictors of resilience in association with the personal traits of mental health workers. Researching how these predictors manipulate positive results that protect mental health professionals from compassion fatigue might lead to methods of constructing them in preventive approaches that can be adapted among general population of clinicians (Ablett and Jones 2007).

Cognitive restructuring and skills training are developed to promote mastery, collaboration and optimism. Cognitive restructuring is designed to help manage work-associated stress. Psycho-education helps participants to comprehend isolating behaviours that can be an outcome of work-related stress (SAHMSA 2008). The intervention had promising outcomes and is part of a growing understanding that resiliency is a moderating factor in secondary traumatic stress.

The Accelerated Recovery Program (ARP) for compassion fatigue is a treatment strategy generated by Gentry et al. (2002). This particular comprehensive treatment programme includes a five-session treatment protocol and is the first of its kind. The programme goals include symptom identification, recognition of secondary traumatic stress triggers, identification and utilization of resources, learning grounding and containment skills, initiating conflict resolution, and implementing a supportive aftercare plan. This aftercare plan is called the Pathways self-care programme (Gentry et al 2002). The ARP follows a standardized component treatment model that addresses therapeutic alliance, qualitative assessment of secondary traumatic stress, anxiety management, narrative, exposure/resolution of secondary traumatic stress, cognitive restructuring, and the Pathways self-care and aftercare plan (Gentry et al 2002).

2.14.2 Improving Training

Several professions such as law enforcement, disaster relief workers and therapists come into contact with trauma. With regard to therapists, there is a lot of training in diagnosis, reporting requirements and establishing therapeutic alliance to combat trauma-related reactions. However, little has been put in place about working and dealing with patient’s traumatic material. Cornille and Meyers (1999) recommend educating those working with traumatized people to identify secondary traumatic stress and further teach them to recognize, predict and prepare them with secondary traumatic stress reactions. Secondary traumatic stress reactions need to be normalized and professionals need to be aware of personal factors affecting secondary traumatic stress such as personal history of trauma, coping techniques and work environment.

Chrestman (1999) reported empirical evidence that supports the utilization of additional training to reduce the reactions of PTSD among counsellors working with traumatized victims. Follette et al (1994) indicated that 96% of mental health workers who were educated about sexual abuse reported the experience was essential in making them effective during difficult patient cases. Alpert and Paulson (1990) developed graduate training courses to assist students to have strong emotional reactions in dealing with traumatic material. Setting the stage for secondary traumatic stress and its impact at this point in a mental health workers training can help in later practice. O’Halloran and O’Halloran (2001) also provided students with additional self-care methods that could guide them in later professional life. These self-care methods involve behavioural strategies such as eating balanced meals, proper sleep and exercise and the importance of relaxation, recreation and play. The authors also prepared students for the impact trauma work might have on them by encouraging the students to develop self-care plans. They recommended coping methods like journalizing, physical release such as crying, or talking to

someone the students felt comfortable with. O’Halloran and O’Halloran (2001) also addressed developing and utilizing support systems and exploring spirituality as additional prevention methods.

2.14.3 Agency Policies

Trippany et al. (2004) have highlighted the responsibility of agencies that treat trauma to avoid secondary traumatic stress in their service providers. They recommend formal measures of informed consent regarding risk of trauma counselling to new counsellors. Furthermore they recommend professional development resources like opportunities for supervision, continuing professional development education and availability for consultation. Pearlman and Saakvitne (1995) recommend that giving employees benefits to cover personal counselling and paid holiday, and limiting the number of trauma cases on a counsellor’s caseload can help prevent secondary traumatic stress. Cornille and Meyers (1999) recommend that agencies with high levels of trauma cases reduce the amount of hours employees are required to work to no more than 40 per week. They also highlight the necessity for agencies to make sure a safe and supportive work environment is in place. Agencies should develop safety procedures for counsellors who go into dangerous areas and situations. Providing a safe place for counsellors to release feelings and discuss their specific fears around trauma cases can help reduce severe secondary traumatic stress reactions (Cornille and Meyers 1999).

2.14.4 Professional Peer Group

Flannery (1990) investigated the importance of social support within the professional peer group as a prevention method for secondary traumatic stress. Examples of helpful social support include emotional support, information, social companionship and instrumental support. These are most useful in the context of a professional group with unambiguous formal organization

such as a consultation group, treatment team, case conference or clinical seminar (Flannery 1990). Professional peers can be supportive by providing resources such as how to deal with paperwork, or giving support during non-working hours (Catherall 1995). Moreover, peer support can help workers clarify insights and emotions and it can help correct distortions the counsellor may hold in regard to traumatic cases. It can also provide perspectives, reframing and empathy, all of which can be vital factors in the prevention of secondary traumatic stress (Catherall 1995). This kind of group support should be considered an addition to and not a substitute for clinical supervision. Figley (2000) suggested a 5:1 ratio rule – for every five hours of discussing a traumatic case there should be one hour of personal processing time. This can take the form of non-work conversation or a formal post-incident debriefing.

2.14.5 Effective Coping and Self-care

Effective coping activities prevent secondary traumatic stress reactions (McSwain et al. 1998; Pearlman and Saakvitne 1995a, b; Schauben and Frazier 1995). Among these are clear boundaries between home and work and taking part in regular physical activity that helps one to relax and promotes physical health. Additionally, taking time off work, journalizing, listening to music, pursuing hobbies and meditation are recommended coping methods. Techniques such as limiting exposure to traumatic material are also recommended (e.g. books, movies). Norcross (2000) wrote that important self-care strategies for therapists are diversifying and balancing their patient caseloads. Secondary traumatic stress might be prevented if the therapist’s caseload has an appropriate balance of patient issues (trauma and non-trauma), types of therapy (group, families, individual and couple) and other professional practices including supervision, teaching, research and writing (Pearlman and Saakvitne 1995a,b ). It is also vital to foster relationships with other workers in the field for support. Staying connected with traumatized patients, utilizing

support groups, attending workshops and sharing coping methods with other therapists are also useful means of handling secondary traumatic stress.

Additionally, Moran (2002) recommends the use of humour as a useful coping method, one that will enhance physical well-being. Self-care is a crucial part of prevention of secondary traumatic stress. A study of 117 trauma therapists carried out by Pearlman (1995) found that at least one-third of the participants regarded socializing, exercising and spending time with family and friends as helpful in coping with traumatic material. Wee and Myers (2002) list personal stress management activities in their research of mental health professionals after a disaster event. These include leisure and diversion activities such as dinner, social activities, reading and spending time outdoors. Other self-care strategies include family time, exercise, relaxation, and meditation, informal group therapy with co-workers and personal counselling and prayer (Wee and Myers 2002).