The Importance of Helping the Helper
By Roger Friedman, Ph.D., LCSW
A recently graduated social worker receives a phone call on a Sunday morning at home from her supervisor. She's told that a 16-year-old teenager she has worked with for six months in foster care has been shot and killed in a drug deal. Her supervisor asks her to visit the youngster's foster and biological families that day to give them the terrible news.
Drug dealers on the street intimidate two workers as they are making a home visit, and, when the dealers discover that they are from social services, they tell the workers if they see them on that block again they'll shoot them. One flashes a pistol he has tucked into his belt, and the workers run to their car fearing for their lives.
A worker and aide pull a six-year-old girl from the angry arms of her mother and transport the girl to a foster home across town. The workers know that she will be safer there, but the workers can't get the child's wailing cries of help and fear out of their heads. They had never heard a child cry the way this little one did in their car. The workers feel they've destroyed something valuable in order to save it. They worry alone, crying by themselves, all weekend.
Traumatic experience—terrible knowledge about life
On September 11, 9:00 a.m. unit meetings in a child welfare agency in a Washington, DC suburb were broken up with the news of the attack on the World Trade Center. A few minutes later as televisions were dragged into hallways, staff huddled together and watched as the Pentagon was attacked just a few miles away. Agency phone lines were jammed, cell phone connections went down—no one could contact loved ones or children in school—there was only their colleagues to hold onto, to cry together, to wonder when more bombs or planes would hit in the Washington area. Then, together they saw the unbelievable as the World Trade Towers crumbled. The workers went through this like a family. Although personal life called, staff hesitated to leave one another. They had been through so much together, they understood intuitively that this was another trauma they had to help each other with. Like so much of the "terrible knowledge about life" they encounter together, they knew they would never be the same after this.
Reflection on traumatic experience
In the past few years a new and deeper understanding of the prevalence and impact of traumatic stress on child welfare staff has developed. It has long been recognized that child welfare agencies are rewarding but very difficult places to work—agency resources are usually inadequate, client numbers and needs are great, demands for speed and productivity are high, and salary/benefits are usually very low. General work stresses such as these, which exist in many human service settings, can contribute to difficulties in recruitment and retention as well as low morale and burnout. But there is a new understanding of the challenges of child welfare work. We know that frequent and prolonged exposure to traumatized individuals, families, and communities inevitably creates secondary traumatic stress for the helper. Secondary traumatic stress, which can evolve into post-traumatic stress disorder, is caused by directly or indirectly helping severely traumatized children and adults.
This regular exposure to trauma and terrible knowledge about life can deeply affect staff's emotional, behavioral, and spiritual well-being in painful and unsettling ways. Although general work stress is frustrating, secondary traumatic stress can, over time, change people forever.
This article discusses the common sources and signs of secondary traumatic stress in child welfare and how individuals and agencies can more successfully cope with these challenges. Furthermore, the article explores how the society-wide trauma caused by the September 11 terrorist attacks is adding traumatic stress on child welfare staff and how agencies and individuals are coping.
Secondary traumatic stress: definitions, sources, and signs
Human disasters cause painful trauma for primary victims. Those who are helping become secondary victims of the disaster. Common sources of secondary trauma in social services include:
Though death of a child under protective care is relatively infrequent, it has tremendous impact on the staff involved, the agency, and family for months or years. The other events occur regularly in most child welfare settings, and if staff have 20 to 30 children on their caseload, these traumas may be present in most if not all of their families.
The signs of traumatic stress are similar to post-traumatic stress disorder. Workers speak of crying unexpectedly, being unable to focus, feeling victimized, guilty, alone, and angry.
They talk of not being able to leave work issues behind when they go home and being preoccupied with the thoughts, smells, and sounds of traumatic events they have just encountered. Cognitive symptoms like these include preoccupation with the images of the trauma, lack of concentration, despair, and recurring regrets or guilty worries about one's own competency and responsibility for the trauma, consideration of leaving the job, and being distracted by all of this away from work. Emotional symptoms include alternating anger and depression, loss of hope in society and in child welfare, anxiety for one's own children, and irritability toward colleagues and one's family. Physical signs can take the form of sleep disturbance, fatigue, psychosomatic illness such as migraine headaches, psoriasis, and muscular pain, and substance abuse/over-eating to manage anxiety.
Traumatic stress socially isolates staff who are often ashamed of their strong reactions and uncomfortable burdening colleagues or loved ones at home with their painful worries.
Finally, exposure to such terrible knowledge about life often forces staff to re-examine their assumptions about religion, God, families, and life itself. Most child welfare staff report that their exposure to trauma in their work has changed them, as people, forever. These changes have been painful, and many, without support at work, leave their job because of them. But if they stay, and co-workers are compassionate and supportive, in the long run many staff feel that these challenges have helped them mature. They report becoming more humble and wiser as social workers, more compassionate for others, more content or appreciative of the relationships and relative security they have in their own lives, and more spiritual. They often say that they come to see their work not only as a job but as a calling, i.e., an intrinsically valuable way to help rebuild a broken world. What better way to live out one's days on earth? What important lessons trauma has to teach us.
Terrorism and trauma
The terror of September 11, and the continuing drama of anthrax, war in Afghanistan, and security issues on the "homefront," have affected child welfare staff just as they have the larger society. In workshops on trauma and traumatic stress, staff talk freely about their new found anxieties. In many agencies staff have come together for public discussions. They speak of how suddenly they are aware of the dangers in the larger world; how they feel they are citizens of the world overnight. What a terrorist is doing thousands of miles away affects them in the streets of Baltimore or in a Maryland suburb. In the Washington, DC area many workers with small children wonder, "should I remain in the primary target zone during the coming months and years of battle with terrorists?" Older workers nearing retirement speak in anger and fear about their retirement funds having been cut in half since the stock market's precipitous drop and their need to work more years than they had anticipated. Air travel is a worry, and many staff won't fly.
Staff who are of Middle Eastern background or who are practicing Muslims worry aloud about being discriminated against or blamed for the recent events. One Muslim social worker talks through her tears about how important it is that her co-workers accept and trust her and understand her love for America and her fear for family still in Pakistan. Many talk of how their innocent faith in the world has been shattered, and how sad they are that their children must now grow up in fear of world violence and war.
The heightened anxiety following September 11 has made staff all the more vulnerable to traumatic stress from work. Now, not only as social workers, but as American citizens, parents, and human beings, they feel attacked and fearful. Their resilience, ability to concentrate, and hopefulness about life is challenged on a broader scale.
Client families are often so overwhelmed by their immediate daily crises that they seem oblivious to September 11. It reminds many workers of how isolated they are from their clients, of what a different world they live in from the families they serve who may be homeless or on the brink of collapse or disaster in the inner city. In child welfare agencies, the terrorism has made for an emotional environment that is even more intense, isolating, and in need of group cohesion.
Healing responses: Trauma support programs and activities
Many agencies and state systems are developing and implementing trauma support programs that will be responsive to the traumatic stress of work and added anxieties of a world filled with terrorism. There are several important dimensions to these efforts: education; trauma debriefing and group support; unit-level support for casework; and agency-wide commitment to human resources. First, education about traumatic stress and its sources and signs is needed for all direct service and administrative staff. This is not just "training," but rather an effort to bring staff together to talk about the personal impact of their work and gain some new language and understandings about how trauma affects them as people. This education involves a sea change in the culture of many social service agencies.
Historically, child welfare workers have survived traumatic stress through grit, stoicism, and humor. Those who couldn't "handle it" left or stayed on in demoralized careers. Truly heroic workers survived but more on their own fortitude than on any support they received from colleagues or the agency. A model of practice has been taught in child welfare that emphasized that mature and competent social workers should not react emotionally to client situations. If a worker was traumatized by a situation then this was a sign of counter-transference, lack of experience, or personal immaturity.
What is becoming clearer is that no matter how skilled or experienced, when helpers work in close proximity to major trauma they will be impacted by it. The goal is not to inoculate ourselves from traumatic stress, but rather to develop individual and group supports that help us live with this pain and find ways to learn from it and renew ourselves. This model of practice normalizes the emotional and personal intensity of child welfare work and challenges individuals, units, and agencies to organize themselves in ways that honor these new understandings.
A second area of trauma support is developing the capacity to provide debriefing services to workers within 24 hours of their traumatic experience. These debriefings are adapted from Critical Incident Debriefing protocols (see the International Critical Incident Stress Foundation at www.icisf.org) used in disaster relief and in medical emergency and police settings. The debriefing is a structured interview, where workers describe the trauma in detail and talk about the emotional and cognitive impact the incident is having on them. The worker is given information about the expected effects of trauma and suggestions for renewal. The worker is asked to identify immediate resources and activities that can help him or her cope more effectively.
Legal and casework reviews are important following traumatic incidents, but they cannot take the place of this personal worker-centered debriefing process. Research and clinical evidence point to the value of providing staff an opportunity to discuss the personal impact of their experience and to discuss how they can help themselves through it in a non-judgmental atmosphere.
These debriefings can be done by a trained peer support staff, by external crisis counselors, or by employee assistance program counselors. The challenge is to set up a system that is easily accessed, confidential, and has little or no stigma for workers attached to it. Peer support teams have been a good way to address these issues, but the agency needs to provide some training and organizational help to make this work.
In addition to debriefing services, many agencies are starting biweekly trauma support groups that are open for anyone to attend, occur at the same time twice a month, and focus on discussion of traumatic stress in the lives of workers. Some meetings may have only two or three participants while at other times, like after September 11, 40 staff attended.
At the unit level, trauma support is crucial. In most child welfare agencies, staff identity is based on the unit and service to which you belong, and the closest relationships you have are with co-workers in your unit. Units that are supportive in times of trauma spend time at meetings talking about the personal side of work; staff are comfortable disclosing how traumatized they might feel. Co-workers offer to help with paperwork or to join others on home visits during particularly traumatic periods. Work schedules need to be flexible including "mental health" leave or days spent in the office and not making field visits. Workers need not be best friends, but they need to know what is going on that is stressful in each other's lives and be expected to respond with support when traumatic work events occur. Though supervisors can facilitate this, it is really a matter of team education and team support. Trauma cannot be carried alone; it demands collective action.
Finally, an agency commitment from the top down is very important if this change in culture is to happen. In some programs, directors have led division-wide meetings to discuss the effects of September 11, or to grieve together the death of a child or a terminal illness of a fellow worker. These are painful moments, but when the administration of an agency supports these behaviors, it helps supervisors and direct service staff to follow. Senior management support helps everyone find the resilience and hope to continue. The agency as a community of helpers is an important concept to establish by senior leadership. As a community, staff support each other a great deal, not only in their technical work but also in those areas of personal pain that are related to the work with trauma. In meetings and trainings with senior administrators, it is important to emphasize their role as emotional leaders and champions of resilience and hope in the organization. It is important for them to think about how they can model these values for all staff.
One of the organizational problems in child welfare is that no department or administration is designated to manage trauma support efforts. In large and small child welfare agencies, seldom is there a human resources department. Whatever formal support is given to staff is often diffused or delegated to a county personnel officer or to an already over-worked administrative or supervisory staff. It may be crucial for some agencies to create a trauma support manager, explore grant funding, or make special requests for a staff position that can coordinate trauma education and debriefing services. In some agencies, these initiatives could be incorporated into worker task forces or Continuous Performance Improvement committees.
Building the capacity of agencies to better cope with the traumatic stress of their staff is an important part of the agenda for the future of child welfare. It is an essential and often missing element in strategies for organizational development, recruitment, and retention of staff in public social services. The cultural shift in understanding how client trauma inevitably affects the helper is an important next step in professional education and socialization of social workers in child welfare. The social trauma our society experienced on September 11, and the continuing struggle to battle with terrorism in an increasingly smaller world, makes these challenges in child welfare all the more urgent.
Figley, Charles (Editor). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner/Mazel, 1995.
Stamm, B. H. (Editor). Secondary Traumatic Stress: Self-care Issues for Clinicians, Researchers, and Educators. Lutherville, MD: Sidran Press, 1995.
Roger Friedman, Ph.D., LCSW, has been a consultant for state and county child welfare programs across the country for the past 20 years. He focuses on helping agencies enhance clinical services, become more family-centered and community-based, and build capacity to cope with secondary traumatic stress. Dr. Friedman serves on the Editorial Board of The Preservation Journal, is Adjunct Faculty for the University of Maryland School of Social Work, and maintains a clinical practice in Silver Spring, Maryland. He can be reached at RSF9826@aol.com or 301.588.4442.
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