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WORK-RELATED SECONDARY
TRAUMATIC STRESS
B. Hudnall Stamm, PhD
National Center for PTSD and
White River Junction VAM&ROC
Dartmouth Medical School
The great controversy about helping-induced trauma is not ³Can it happen?² but
³What shall we call it?² After reviewing nearly 200 references from PILOTS,
Psychlit, Medline, and Social Sciences In-dex, it is apparent that there is
no routinely used term to designate exposure to anotherıs traumatic material
by virtue of oneıs role as a helper. Four terms are most common: ³compassion
fatigue² (CF); ³countertransference² (CT); ³secondary traumatic stress² (STS);
and ³vicarious traumatization² (VT). Field-specific literature emerged as early
as 1980 in relation to emergency services workers (Dunning & Silva, 1980). In
1985, Hartsough and Myers wrote the now classic Disaster Work and Mental Health.
One of the early, well-cited empirical studies is Durham et al. (1985). None
of these papers attempts to create a specific diagnostic or nomological term
for worker-related stress.
Among therapists, the reaction was originally subsumed under the moniker of
³countertrans-ference.² The importance of Haleyıs 1974 paper about therapistsı
reactions to war atrocities cannot be underestimated. Wilson and Lindyıs (1994)
book continues to use the countertransference construct to discuss a vast array
of specific interventions and therapistsı reactions. McCann and Pearlmanıs (1990)
pivotal paper recognizes the life-pervasive effects of working with trauma victims.
While they discuss countertransference, they raise questions about the constructıs
adequacy, suggesting it is too narrow because it does not address the lasting
and perva-sive schema alterations (McCann & Pearlman, 1990; Neumann & Gamble,
1995; Pearlman & Saakvitne, 1995). ³Vicarious traumatization,² the term they
propose, describes the negative cognitive schema and behavioral changes in therapists.
In 1991, Figley first used the term ³compassion fatigue² in relation to PTSD
in his book, Helping Traumatized Families. In 1992, he proposed re-defin-ing
PTSD in his paper, ³Traumatic Stress Reactions and Disorders: Re-configuring
PTSD,² at the First World Conference of the International Society for Traumatic
Stress in Amsterdam, The Netherlands (June 21-26, 1992). He argued that ³primary
trau-matic stress disorder² should refer to those who were directly in harmıs
way. For Figley, ³secondary traumatic stress disorder² represents disorders
dis-played by supporters/helpers of those experiencing PTSD, and ³tertiary traumatic
stress disorder² applies to the supporters of supporters of those experiencing
PTSD. At that same conference, Varra and I presented the paper, ³Vicarious Traumatiza-tion
in Emotional Support Providers for Victims of Sexual and Physical Assault,²
and used the term ³confiding² to describe the primary emotional sup-port providers
and ³secondary confiding² to de-scribe the support providersı conversations
with others. Time has shown these proposals are too cumbersome to be appealing
to a broad audience.
Recent Major Works. Wilson and Lindyıs counter-transference text was published
in 1994. In 1995, three major texts were published, including edited volumes
by Figley and by me and one written by Pearlman and Saakvitne. These three books
show triadic cross-fertilization; each personıs work ap-pears in the other two
books. Yet, each book chooses a different word to describe the effects of working
with traumatized individuals. Figley uses CF in the title; CF and STS both appear
in the text. Pearlman and Saakvitne use VT. I use STS in the title and all terms
in the chapters. Paton and Violantiıs 1996 book circumnavigates the label issue
by choosing a descriptive title. Other terms are also used. Perhaps the most
common is ³burnout,² but examination of the etiology generally shows increased
work load and institutional stress are the precipitating factors, not trauma.
Another term is ³indirect-trauma²: it is the name of an Internet list led by
Pearlman and me (). Thus, even with the sudden increase
in the literature, there is no uni-form designator, nor is there a meaningful
tax-onomy for the multiple words.
I believe countertransference is a broader concept that refers to our reactions
to our clients and their material. It may direct our therapeutic choices and
is a state condition tied directly to the patient. By contrast, CF/STS/VT, which
results from working with trauma victims, induces more trait-like changes to
our values, beliefs, and behaviors. The differen-tiation, while possibly academic,
certainly is elu-sive. Countertransference can occur outside of the context
of exposure to traumatic material. CF/STS/ VT always arises as a result of exposure
to a clientıs traumatic material. I believe countertransference applies more
to how our patients affect our work with them, and CF/STS/VT is about how our
pa-tients affect our lives, our relationships with our-selves, and our social
networks, as well as our work.
I suggest ³secondary traumatic stress² (STS) as
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the broadest term, with other terms, such as "compassion
fatigue" and "vicarious traumatization," and even some
forms of "countertransference," serving as specific types of
STS. At this point, none of the words is truly satisfying for
describing helper-encounters with another's traumatic
material. In fact, even the descriptive definition becomes
an issue. Does this apply only to those who are profession-
als, or also to volunteers? To all health care professionals?
To researchers? What about teachers teaching about
trauma? Are emergency service workers exposed second-
arily because of another's trauma, or is rescue in perilous
situations, or body handling, direct trauma? These are
difficult questions. In reality, the taxonomy will emerge as
consensus arises from use.
For the purposes of this review, I first mention the new
comprehensive texts. Next, I sort the literature into two
broad groups: theory and populations. Each of these is
further categorized by types of theory or populations.
Comprehensive Texts. These books have been mentioned
above and will only be briefly discussed here. Wilson and
Lindy (1994) cover a wide range of topics and the effect of
client material on providing interventions. It is somewhat
different from the texts below in that it is focused toward
the provision of services more than the effect of providing
services. Figley's (1995) book examines the extant litera-
ture to lay the groundwork for legitimizing CF. Pearlman
and Saakvitne (1995) provide us with a comprehensive
theory for understanding VT. My (1995) book entered into
development after Figley's and Pearlman and Saakvitne's
books were nearly finished, and, as such, builds on the two
books above. The book makes the assumption that healthy
caregivers are better caregivers; chapters are focused to-
ward protection of the professional's overall well-being.
Paton and Violanti (1996) focus on risks for emergency
service personnel developing traumatic stress reactions.
The authored chapters cover a variety of professions dis-
cussing assessment and interventions.
General Theory Papers. There are a number of papers on
ethics, including four in my book (1995). In a paper mixing
ethics and legal issues, Simon (1993) discusses the ob-
stacles faced by mental health professionals who are trying
to become involved in cases of human rights violations. He
also discusses the increasing number of cases in which
mental health professionals have been successful in sur-
mounting these obstacles. Recognizing STS is an organiza-
tional legal dilemma, because this may lead to STS-based
lawsuits. Howard (1995) notes that there have been fewer
claims in jurisdictions where claims require the injury to be
the fault of the defendant, than in other jurisdictions where
fault is not required to be established. Many organizations
choose to be proactive in attempting to prevent STS rather
than defend against litigation. Richards (1994) discusses
how this model fits with the conceptualization of the "new
public health movement," in which causality and preven-
tion are merged into a comprehensive view of health.
Emergency Service Provision. There are many good theo-
retical and empirical papers in this area. It is undoubtedly
the best documented segment of the professional STS
literature. I will not reiterate the chapters from the books
above, although the reader should not overlook them.
Drawing on theoretical and clinical experience, Foreman
(1994) discusses primary and secondary prevention and
the characteristics of the traumatic event which contributes
to the greater likelihood of the development of PTSD
among responders. In two new empirical papers, Marmar,
Weiss and colleagues focus on EMS workers responding to
the Nimitz Freeway collapse during the 1989 Loma Prieta
earthquake in the San Francisco Bay Area (Marmar et al.,
1996; Weiss et al., 1995). Summing across the papers, 9% of
EMS workers exhibited symptoms similar to psychiatric
outpatients; shy, inhibited individuals were more likely to
have dissociative responses; and dissociative responses at
the time of the event were predictive of poorer outcomes.
Health Care Providers. These papers include mental health
and general health care providers. There are few empirical
papers at this point, perhaps because of the newness of the
area of study. Although somewhat dated, Riordan and
Saltzer's (1992) offers a good literature review of the effects
of patient trauma on general medical providers. As a
group, Pearlman and colleagues are the most frequent
contributors to this area of the literature. In addition to the
previously mentioned theoretical works, Pearlman and
Mac Ian's (1995) empirical study found that therapists with
personal trauma histories reported more difficulties with
client material than those without.
Exposure Due to Research and Teaching About Trauma.
Direct service providers, while confronted with difficult
material, can ameliorate feelings of helplessness by inter-
vening to change the patient's life. Teachers and research-
ers may not be able to seek this redemptive alternative. In
fact, researchers can be exposed to traumatic material,
including risks such as suicidality, without ever being able
to identify the person at risk. Pickett et al. (1994) discuss the
use of debriefing to reduce researchers' traumatic reac-
tions to the research material. McCammon (1995) discusses
teaching techniques, both preventative and remedial, for
addressing the effects of (a) exposing students to traumatic
material during teaching, or (b) triggering students who
have a personal trauma history with traumatic material.
Exposure Due to Other Occupations. There are other occu-
pations that place the worker in the path of traumatic
material, but few papers discuss them. Here is a sample of
the ones that do. McCarroll et al. (1995) discuss museum
workers' responses to preparing the Holocaust Memorial
Museum exhibit. Hafemeister (1993) alerts us to the diffi-
culties of jury work. Freinkel et al. (1994) studied media
eyewitnesses of an execution and found higher levels of
dissociative symptoms than should be expected. Clergy
receive little attention but may be exposed to a great deal
of traumatic material as a result of their work. Bricker and
Fleischer (1993) discuss the social support systems of Ro-
man Catholic priests.
Summary. There is a rapidly growing literature on the
risks, reactions, and prevention of harm from exposure to
another's traumatic material by virtue of a professional
relationship with the primary victim. There is a small but
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cohesive body of ethics literature. The empirical literature
regarding emergency service personnel is quite well devel-
oped, and the empirical literature about health care pro-
viders is growing. Other professions are lagging behind,
but show promise of developing an expanded awareness
of the problem. One continuing difficulty is the dilemma of
nomenclature. At this point, there is no consistent or truly
satisfying language to describe the phenomenon. Perhaps
one area of research could be developing operational defi-
nitions of the terms used to describe the costs of caring.
REFERENCE
FIGLEY, C.R. (1989). Helping traumatized families. San Fran-
cisco: Jossey-Bass.
SELECTED ABSTRACTS
BRICKER, P.L. & FLEISCHER, C.G. (1993). Social support as
experienced by Roman Catholic priests: The influence of occa-
sionally imposed network restrictions. Issues in Mental Health
Nursing, 14, 219-234. This qualitative descriptive study explored
the experience of social support as perceived by four Roman
Catholic priests who are community caregivers subject to role-
related stressors, and who have vocational limitations placed on
their social support networks. The data collection process con-
sisted of two semistructured interviews employing open-ended
questions. Content and concept analysis techniques yielded
seven core themes (person-role disharmony, intimate connec-
tions, network leveling, moving networks, caregiver survival,
vocation-person esteem, caring relationships); three prevailing
themes (subsistent relationships, person-priest being, reciprocal
fulfillment); and one contextual theme (presence). The priests
actively sought support as a means of coping with the daily stress
associated with their caregiving roles. Large and diffuse net-
works were unable to compensate for restrictions resulting from
vows of celibacy, discord accompanying midlife transition, or
conflicts associated with socially prescribed role expectations of
the priesthood. The instability of their support networks result-
ing from mandatory transfers may have been a contributing
factor. Existential presence, an enduring theme, was identified as
an inherent quality of caregiving and social support.
FIGLEY, C.R. (1995). Compassion fatigue: Toward a new
understanding of the costs of caring. In B.H. Stamm (Ed.),
Secondary traumatic stress: Self-care issues for clinicians, researchers,
and educators. (pp. 3-28). Lutherville, MD: Sidran Press. Discusses
the emergence of information that forms the basis of our under-
standing of compassion fatigue and compassion stress and the
recognition that something specific must be done to counteract
these challenges. We now know that we can help caring health
professionals to recognize their shortcomings-their special
vulnerability to compassion stress and fatigue-and help them to
cope more effectively with the cost of caring. There is no doubt
that traumatic events will continue to occur and affect hundreds
of thousands of people each year. These traumatized people
require the services of professionals who are well prepared to
help, and, in turn, to help themselves; therefore, we need to keep
these caring professionals at work and satisfied. The chapter also
addresses the following topics: the question of why there are so
few reports of secondary trauma; why STSD (secondary trau-
matic stress disorder); definition of secondary traumatic stress
(STS) and stress disorder; contrasts between STS and other con-
cepts; countertransference and secondary stress; burnout and
secondary stress; why compassion stress and compassion fa-
tigue; and implications for training and educating the next gen-
eration of professionals. [Adapted from Text]
FOREMAN, C. (1994). Immediate post-disaster treatment of
trauma. In M.B. Williams & J.F. Sommer (Eds.), Handbook of post-
traumatic therapy (pp. 267-282). Westport, CT: Greenwood Press.
Certain features of traumatic events contribute to the greater
likelihood of the development of PTSD among survivors and
rescue workers. In this chapter, the author draws upon current
research and his own professional experience relating to three
traumatic incidents from northern California. Aspects of trauma,
features of survivors, and subsequent provision of services are
presented and discussed. [Adapted from Text]
FREINKEL, A., KOOPMAN, C., & SPIEGEL, D. (1994). Disso-
ciative symptoms in media eyewitnesses of an execution. Ameri-
can Journal of Psychiatry, 151, 1335-1339. The first execution in
California since 1976 took place recently in the San Quentin
Prison gas chamber. 18 journalists were invited as media eyewit-
nesses. The authors postulated that witnessing this execution
was psychologically traumatic, and that dissociative and anxiety
symptoms would be experienced by the journalists. To investi-
gate the prevalence and specific nature of these symptoms,
questionnaires were sent to all the journalists about a month after
the execution. The questionnaire contained 17 items assessing
dissociative symptoms from the authors' questionnaire of 35
highly intercorrelated acute stress items. 15 of 18 of the witnesses
returned the questionnaire. Items were endorsed on a scale of 0
("have not experienced") to 5 ("very often experienced") and
analyzed as being dichotomously present or absent. The mean
age of the respondents was 37.6 (SD = 8.6), and mean years as a
journalist were 15.2 (SD = 9.0). 9 subjects were men and 6 were
women. Journalists witnessing the execution endorsed an aver-
age of 5.0 dissociative items, ranging from "I saw, heard, or felt
things that were not really there" (endorsed by no one) to "I felt
estranged or detached from other people" (endorsed by 60 per-
cent). This prevalence of reported dissociative symptoms is com-
parable to that seen among persons who endured the recent
Oakland/Berkeley, California, firestorm. The experience of be-
ing an eyewitness to an execution was associated with the devel-
opment of dissociative symptoms in several journalists.
HAFEMEISTER, T.L. (1993). Juror stress. Violence and Victims,
8, 177-186. Media reports have focused on the impact of the trial
process on jurors, exploring the intense pressures and stress they
may be required to undergo. This article explores this subject and
reports on the findings of a pilot study of a survey instrument
used in Howard County and Baltimore County, Maryland, in
conjunction with the Psychology Department at the College of
William and Mary, to find elevated stress levels in jurors serving
on trials where the evidence was particularly graphic and grue-
some. [Adapted from Text]
HOWARD, G. (1995). Occupational stress and the law: Some
current issues for employers. Journal of Psychosomatic Research,
39, 707-719. The principles and illustrations from the case law in
England and Wales relate to the common law which forms the
basis of the English legal system. Any claim, therefore, requires
fault to be shown on the part of the defendant and also that the
injury was caused by the fault of the defendant -at least `on the
balance of probabilities.' So far as this system is unique to En-
gland and Wales (albeit inherited by a number of Common-
wealth jurisdictions), the principles illustrated and discussed will
relate only to the English legal system. However, in other juris-
dictions, fault is not required to be established, and in countries
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such as the USA, the case law has developed in the area of stress-
related claims far more quickly in recent years than in the UK. The
English Courts may, and often do, refer to authorities in other
Commonwealth jurisdictions for guidance on liability and the
extent of the duty of care. Australian cases, for example, have
proved very helpful in stress-related cases and cases on the harm
caused by passive smoking. The first successful claim for stress
against an employer in the UK occurred at the end of last year,
involving a social worker, John Walker, working for Northum-
berland County Council. This important decision is discussed.
[Adapted from Text]
MARMAR, C.R., WEISS, D.S., METZLER, T.J., & DELUCCI,
K.L. (1996). Characteristics of emergency services personnel
related to peritraumatic dissociation during critical incident
exposure. American Journal of Psychiatry, 153, 7 Festschrift Supple-
ment, 94-102. The aim of this study was to identify characteristics
of emergency services personnel related to acute dissociative
responses at the time of critical incident exposure, a phenomenon
designated "peritraumatic dissociation." The authors studied
157 rescue workers who responded to the Nimitz Freeway col-
lapse during the 1989 Loma Prieta earthquake in the San Fran-
cisco Bay Area, as well as 201 rescue workers who were not
involved in that disaster. Demographics, level of critical incident
exposure, perceived threat at the time of exposure, personality
attributes (assessed by the Hogan Personality Inventory), coping
strategies (assessed by the Ways of Coping Questionnaire), and
locus of control were related to subjects' scores on the Peritraumatic
Dissociative Experiences Questionnaire. According to univariate
tests, the subjects with clinically meaningful levels of peritraumatic
dissociation were younger; reported greater exposure to critical
incident stress; felt greater perceived threat; had lower scores on
the adjustment, identity, ambition, and prudence scales of the
Hogan Personality Inventory; had higher scores on measures of
coping by means of escape-avoidance, self-control, and active
problem solving; and had greater externality in locus of control.
Linear modeling with multiple logistic regression analyses indi-
cated that greater feelings of perceived threat, coping by means of
escape-avoidance, and coping by means of self-control were
associated with a greater likelihood of being in the peritraumatic
dissociation group, above and beyond age and exposure to stress.
Rescue workers who are shy, inhibited, uncertain about their
identity, or reluctant to take leadership roles, who have global
cognitive styles, who believe their fate is determined by factors
beyond their control, and who cope with critical incident trauma
by emotional suppression and wishful thinking, are at high risk
for acute dissociative responses to trauma and subsequent PTSD.
MCCAMMON, S.L. (1995). Painful pedagogy: Teaching about
trauma in academic and training settings. In B.H. Stamm (Ed.),
Secondary traumatic stress: Self-care issues for clinicians, researchers,
and educators. (pp. 105-120). Lutherville, MD: Sidran Press. The
melodic title of "Painful Pedagogy" belies the potential struggle
that lurks beneath the convoluted issues of teaching about trauma.
Many of the people drawn to trauma training carry with them
trauma histories. While supervision in psychotherapy training
can be difficult, at least the supervisor is expected to work with
the student. Imagine seeing a student flee the room in tears when
you deliver a lecture to a large undergraduate class. Experiences
like these can leave the professor with a sense of helplessness and
without institutional guidelines. McCammon's chapter offers
succor to the teacher preparing difficult course material and
suggests pedagogical strategies to lessen the negative impact of
trauma material while preserving its integrity and the heart of the
professor.
MCCARROLL, J.E., BLANK, A.S., & HILL, K. (1995).Working
with traumatic material: Effects on Holocaust Memorial Mu-
seum staff. American Journal of Orthopsychiatry, 65, 66-75. Prepa-
ration for the opening of the United States Holocaust Memorial
Museum in Washington, D.C., in April 1993, exposed workers to
potentially disturbing personal artifacts of Holocaust victims and
other reminders of the horrors of the Holocaust. The process of
psychological consultation is described, and the resultant ap-
proaches to interventions designed to lower distress among
museum workers and volunteers are discussed.
NEUMANN, D.A. & GAMBLE, S.J. (1995). Issues in the pro-
fessional development of psychotherapists: Countertrans-
ference and vicarious traumatization in the new trauma thera-
pist. Psychotherapy, 32, 341-347. Psychotherapy with survivors of
chronic childhood trauma poses unique challenges to therapists.
In this article, we describe countertransference responses that are
common to work with survivors. We also examine the phenom-
enon of vicarious traumatization (i.e., the impact upon the
therapist's psyche of empathic engagement with trauma survi-
vors). Both aspects of trauma therapy are framed in light of their
particular impact on new trauma therapists. Last, we address
organizational and personal factors that can ameliorate these
negative correlates of trauma work. By proactively addressing
these issues, organizations, training programs, supervisors, and
therapists can promote the personal and professional develop-
ment of new clinicians.
PATON, D. & VIOLANTI, J. (Eds.) (1996). Traumatic stress in
critical occupations: Recognition, consequences and treatment. Spring-
field, IL: Charles C. Thomas. Describes traumatic stress phenom-
ena in terms of the complex interactions between the person, the
traumatic event, and the social and organizational background
against which performance takes place. Focuses primarily on
police officers, fire fighters, and emergency medical service pro-
fessionals. The narrative provides a comprehensive overview of
current theory in this area and draws upon this to demonstrate its
use in developing and implementing practical solutions to the
individual and organizational issues that emerge in disaster and
other traumatic contexts. Strategies designed to promote the
recognition and identification of the diverse personal,
organisational and event-related factors that contribute to trau-
matic reactivity are discussed. [Adapted from Text]
PEARLMAN, L.A. & SAAKVITNE, K.W. (1995). Trauma and the
therapist: Countertransference and vicarious traumatization in psycho-
therapy with incest survivors. New York: Norton. Our goal has been
to cover the breadth of issues for the therapist working with
survivors of childhood sexual abuse in enough depth to be useful
clinically and theoretically. We strive to address the issues with
enough clarity to be useful to therapists new to psychotherapy
with trauma survivors, and with enough complexity to be thought-
provoking for experienced therapists and experienced trauma
therapists. The book is divided into five parts: Theoretical under-
pinnings; Countertransference in psychotherapy with incest sur-
vivors; Vicarious traumatization in psychotherapy with incest
survivors; The interaction between countertransference and vi-
carious traumatization; and Therapist self-care. [Adapted from
Text]
PEARLMAN, L.A. & MAC IAN, P.S. (1995). Vicarious trauma-
tization: An empirical study of the effects of trauma work on
trauma therapists. Professional Psychology: Research and Practice,
26, 558-565. This study examined vicarious traumatization (i.e.,
the deleterious effects of trauma therapy on the therapist) in 188
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self-identified trauma therapists. Participants completed ques-
tionnaires about their exposure to survivor clients' trauma mate-
rial as well as their own psychological well-being. Those newest
to the work were experiencing the most psychological difficulties
and Symptom Checklist-90-Revised symptoms. Trauma thera-
pists with a personal trauma history showed more negative
effects from the work than those without a personal history.
Trauma work appeared to affect those without a personal trauma
history in the area of other-esteem. The study indicates the need
for more training in trauma therapy and more supervision and
support for both newer and survivor trauma therapists.
PICKETT, M., BRENNAN, A.M.W., GREENBERG, H.S., LICHT,
L., & WORRELL, J.D. (1994). Use of debriefing techniques to
prevent compassion fatigue in research teams. Nursing Research,
43, 250-252. Nurses often study subjects who have experienced
traumatic events involving intense and emotionally charged
consequences. This paper describes how the process of crisis
debriefing can be used to mitigate the concerns of interviewers
who collect data from such subjects. Some clinical practice set-
tings, such as emergency, trauma, intensive care, and home
hospice settings, provide debriefing sessions that incorporate
some of the elements directed toward the prevention of second-
ary PTSD. However, debriefing sessions designed specifically for
research team members who interview traumatized persons
have not been reported in the literature. [Adapted from Text]
RIORDAN, R.J. & SALTZER, S.K. (1992). Burnout prevention
among health care providers working with the terminally ill: A
literature review. Omega, 25, 17-24. A review of the literature on
burnout and its prevention among caregivers to the dying is
presented in this article. The literature shows that health care
providers who work with the dying do experience many stres-
sors unique to the specialty, but also many which are common to
other health care workers. External and internal stressors com-
mon to this specialty field are summarized, and suggestions for
reduction or elimination of these stressors are generated from the
literature. A self-care wellness program is extracted from the
various literature sources and provides what is thought to be an
essential foundation to burnout prevention.
SIMON, B. (1993). Obstacles in the path of mental health
professionals who deal with traumatic violations of human
rights. International Journal of Law and Psychiatry, 16, 427-440. This
paper is divided into two parts. The first part, the longer, deals
with obstacles in the path of mental health professionals becom-
ing more involved in issues of human rights violations. The
second part deals with a few of the increasing number of instances
in which mental health professionals have become more in-
volved. These discussions center around issues involving chil-
dren, although most of what is said applies to both children and
adults. In referring to "human rights" violations, the boundaries
between the devastation of large scale wars between nations and
within nations (such as the Holocaust and the Cambodian geno-
cide) and the harm done in more narrowly defined "human
rights" violations (such as the arrest, torture, and often "disap-
pearance" of thousands in Argentina and Chile) are not exactly
clear. For our purposes, the rough working definition of human
rights violations includes the devastation wrought by plans to
persecute and destroy individuals, classes, ethnic groups, or
religious sects, independent of the absolute numbers involved.
[Adapted from Text]
STAMM, B.H. (Ed.) (1995). Secondary traumatic stress: Self-care
issues for clinicians, researchers, and educators. Lutherville, MD:
Sidran Press. The authors of this book begin with the premise that
engaging empathically with another's traumatic material carries
risks. The book begins with a summary paper by Figley, in which
he raises the issues of compassion fatigue-or, as he puts it, the
costs of caring. The next three chapters (Pearlman; Rosenbloom
et al.; and Catherall) offer suggestions for ways in which trauma
therapists can create safe environments in which to work.
McCammon's paper introduces ideas that are beginning to take
hold in clinical training and university settings. Harris and Linder
raise a beguilingly simple issue: How do we communicate when
we are under stress? Bills, who is trained both as an internist and
a psychiatrist, offers a systematic approach with which the pri-
mary care provider can diagnose trauma. One of the more sweep-
ing approaches to addressing secondary traumatic stress is pre-
sented by Terry in "Kelengakutelleghpat." This paper outlines a
region-wide, community-based intervention program that in-
cludes everyone in the community as part of the healing commu-
nity. Recognizing that not all people will be able to create elabo-
rate treatment communities in which to practice, Pearce and
Stamm offer an alternative strategy for developing professional
community. The last four chapters directly address ethical issues
related to self care and STS. [Adapted from Text]
WEISS, D.S., MARMAR, C.R., METZLER, T.J., & RONFELDT,
H.M. (1995). Predicting symptomatic distress in emergency
services personnel. Journal of Consulting and Clinical Psychology,
63, 361-368. This study identified predictors of symptomatic
distress in emergency services (EMS) personnel exposed to trau-
matic critical incidents. A replication was performed in two
groups: 154 EMS workers involved in the 1989 Interstate 880
freeway collapse during the San Francisco Bay area earthquake,
and 213 counterparts from the Bay area and from San Diego.
Evaluated predictors included exposure, social support, and
psychological traits. Replicated analyses showed that levels of
symptomatic distress were positively related to the degree of
exposure to the critical incident. Level of adjustment was also
related to symptomatic distress. After exposure, adjustment,
social support, years of experience on the job, and locus of control
were controlled, two dissociative variables remained strongly
predictive of symptomatic response. The study strengthens the
literature linking dissociative tendencies and experiences to dis-
tress from exposure to traumatic stressors.
WILSON, J.P. & LINDY, J.D. (Eds.) (1994). Countertransference
in the treatment of PTSD. New York: Guilford Press. This is a book
about what we go through as we listen to and work with our
trauma patients, and how our own experiences may help or
hinder the recovery process. It is also about how awareness of our
human reactions to patients' trauma is indispensable in keeping
these powerful treatments on track. It is a book about how we
must apply this awareness judiciously, functioning not outside
but within the boundaries of our professional relationships with
survivors. In this way, we strive to help our clients regain a sense
of continuity and meaning in life, and to enhance our own
function as clinicians. Part I is a theoretical and practical intro-
duction to the book, outlining the general issues raised histori-
cally and currently in the areas of countertransference and trauma.
In Part II, we examine the special forces at work in counter-
transference when helping women and children who have wit-
nessed, or been the victims of, violent and/or sexual assault. In
Part III, we examine countertransference arising in those who
treat the survivors of political violence and war. In Part IV, we
expand our discussion of trauma to indirect trauma survivors, as
well as direct ones. [Adapted from Text]
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ADDITIONAL CITATIONS
Annotated by the Editors
DANIELI, Y. (1994). Countertransference, trauma, and train-
ing. In J.P. Wilson & J.D. Lindy (Eds.), Countertransference in the
treatment of PTSD (pp. 368-388). New York: Guilford Press.
Addresses the problem of countertransference in training profes-
sionals who work with trauma survivors, particularly in light of
the professionals' trauma histories. The author presents a train-
ing program that can be used to help professionals identify and
process trauma-related countertransference reactions. Case ma-
terial is included to illustrate various aspects of these reactions.
DERRY, P. & BAUM, A. (1994). The role of the experimenter
in field studies of distressed populations. Journal of Traumatic
Stress, 7, 625-635.
Describes problems that researchers may confront when study-
ing traumatized populations and suggests strategies for manag-
ing these problems. The authors propose that trauma researchers
adopt a flexible behavioral style, explicate their values with co-
investigators (especially values regarding how much support to
provide to research participants), develop relational and commu-
nication skills, and learn about posttraumatic stress.
DUNNING, C.M. & SILVA, M.N. (1980). Disaster-induced
trauma in rescue workers. Victimology, 5, 287-297.
Studied rescue workers who responded to either a plane crash or
a mass suicide. The authors encourage rescue agencies to be
aware of and respond to the traumatic stress reactions of rescue
personnel.
DURHAM, T.W., MCCAMMON, S.L., & ALLISON, E.J. (1985).
The psychological impact of disaster on rescue personnel.
Annals of Emergency Medicine, 14, 664-668.
Assessed PTSD and coping in 79 police, fire, emergency medical,
and hospital personnel following a disaster. Ten percent had 8 or
more of 21 PTSD symptoms. Workers who had been at the
disaster had more symptoms than did hospital staff.
FOLLETTE, V.M., POLUSNY, M.M., & MILBECK, K. (1994).
Mental health and law enforcement professionals: Trauma
history, psychological symptoms, and impact of providing
services to child sexual abuse survivors. Professional Psychol-
ogy: Research and Practice, 25, 275-282.
Examined predictors of posttraumatic symptoms in profession-
als exposed to traumatic stress through their jobs. Multiple re-
gression analysis showed that among 225 mental health profes-
sionals, posttraumatic symptoms were associated with negative
coping, stress, and negative clinical response to sexual abuse
cases, but not with trauma history or sexual abuse caseload.
Among 46 law enforcement professionals, symptoms were asso-
ciated with negative response to investigating sexual abuse cases,
stress, and trauma history.
HALEY, S.A. (1974). When the patient reports atrocities: Spe-
cific treatment considerations of the Vietnam veteran. Ar-
chives of General Psychiatry, 30, 191-196.
Presents several cases that illustrate the special problems encoun-
tered by the therapist whose war-veteran patient reports witness-
ing or participating in atrocities. The first step in treating such
cases is for the therapist to come to terms with feelings that
reinforce seeing the patient as "bad" and the therapist as "good."
HARTSOUGH, D.M. & MYERS, D.G. (1985). Disaster work and
mental health: Prevention and control of stress among workers.
Rockville, MD: National Institute of Mental Health (DHHS
publication, (ADM) 87-1422).
Provides practical information for dealing with stress in disaster
response work. The practical information is presented in terms of
a solid theoretical discussion. This manual, now over 10 years old,
is still used today for training trauma workers.
MCCAMMON, S.L., DURHAM, T.W., ALLISON, E.J., &
WILLIAMSON, J.E. (1988). Emergency workers' cognitive
appraisal and coping with traumatic events. Journal of Trau-
matic Stress, 1, 353-372.
Continued the analysis by Durham et al. (1985) of PTSD and
coping in 79 police, fire, emergency medical, and hospital person-
nel following two disasters. The most frequent coping strategies
reported were attempts to reach cognitive mastery over the
events and to ascertain meaning.
MCCANN, I.L. & PEARLMAN, L.A. (1990). Vicarious trauma-
tization: A framework for understanding the psychological
effects of working with victims. Journal of Traumatic Stress, 3,
131-149.
Uses constructivist self-development theory to discuss
therapists'reactions to clients' traumatic material. Such vicarious
traumatization may disrupt the therapist's mental images and
schemas for trust, safety, power, independence, esteem, inti-
macy, and frame of reference. Strategies for dealing with these
disruptions are presented.
RICHARDS, D. (1994). Traumatic stress at work: A public
health model. British Journal of Guidance and Counselling, 22, 51-
64.
Presents a model for handling traumatic stress in the workplace.
The model, which includes primary, secondary, and tertiary
prevention, is illustrated by an organizational case example. The
strategies employed include inter-departmental working, appro-
priate use of management and social support, pretrauma train-
ing, and cognitive-behavioral therapy.
SUTKER, P.B., UDDO, M., BRAILEY, K., VASTERLING, J.J., &
ERRERA, P. (1994). Psychopathology in war-zone deployed
and nondeployed Operation Desert Storm troops assigned
graves registration duties. Journal of Abnormal Psychology , 103,
383-390. Abstracted in PTSD Research Quarterly, 7(1), 1996.
THEORELL, T., LEYMANN, H., JODKO, M., KONARSKI, K.,
& NORBECK, H. E. (1994). `Person under train' incidents
from the subway driver's point of view-a prospective 1-
year follow-up study: The design, and medical and psychi-
atric data. Social Science and Medicine, 38, 471-475.
Longitudinally studied 40 subway drivers who had experienced
a "person under train" (PUT) accident. Compared with matched
control drivers who had not experienced an accident, PUT driv-
ers had more sick days at 3 weeks and 12 months. At 3 weeks, the
PUT drivers had mild prolactin elevation and increased sleep
disturbance, relative to controls. PUT drivers also reported a
deterioration of their psychosocial work environment at 12
months, relative to no change in controls.
Prev Page 7 Next
PILOTS UPDATE
We receive many requests for information on PTSD, from all
segments of the public. We hear from veterans and others who
have been diagnosed with PTSD, and from members of their
families; from therapists treating their first traumatic stress cases
and from lawyers representing trauma survivors; from middle
school students doing class reports, and from university profes-
sors compiling definitive textbook chapters and literature re-
views. We receive their requests by letter and telephone and,
increasingly, by electronic mail.
To meet their needs, we have begun to produce a range of fact
sheets and reading lists, and we are looking at new ways to make
available the technical reports, assessment instruments, and other
specialized materials emerging from National Center research
and educational activities. These documents are expensive and
cumbersome to print and store, and it is impossible to ensure that
we will always have sufficient supplies on hand to respond
immediately to urgent requests. So we are increasingly relying
upon our World Wide Web site to make this material available to
the many publics we serve.
We have redesigned our Web site to make it easier for visitors
to find what they need, and to ensure that anything copied or
printed from our site contains an indication of its origin. When
you log on to our site, the first thing you see is our home page,
with its directory of our Web site's contents:
PILOTS Thesaurus Revision
One of our projects for this summer is the triennial revision of the PILOTS
Thesaurus. This is the list of terms ("descriptors") that we use to indicate
the subject content of papers indexed in the PILOTS database. We shall be evaluating
potential new descriptors, and examining existing descriptors to determine whether
making changes might make searching the database easier for its users. As part
of this process, we would welcome any suggestions for new descriptors or for
modification of existing ones. Please address these to Fred Lerner at our headquarters
in White River Junction, Vermont.
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If you are a frequent visitor, you can use our "What's New" list
to see material added since your last visit. If you wish to find out
more about the National Center or use its services, the second part
of the directory will take you to the right place on our home page
from which to begin. And if you are a veteran, student, therapist,
researcher, or trauma survivor looking for authoritative informa-
tion, you will find a contents page describing-and linking you
to-material produced with your particular needs in mind.
Many PILOTS users are accustomed to the robust search ca-
pabilities of the older command-based textual interface. This
version of the database remains available, and may be accessed
either through our Web site (if your browser software is equipped
to use the telnet protocol) or by direct telnet connection to
Our Home Page describes the National Center's most impor-
tant activities and services. One of these is the PILOTS database,
and our Web site offers PILOTS users a new graphical interface.
This makes it easier than ever to find things in PILOTS: just use the
pull-down menus to select the type of search you wish to perform.
For more complex searches, click on "expert search" to bring up
a box into which you may type multiple search terms.
Our Web site does not attempt to include everything that the
Internet has to offer on PTSD. By restricting its content to material
produced by the National Center, we are able to ensure its validity
and timeliness. Our goal is to make
the World Wide Web's most authoritative source for information
on PTSD.
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