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Abstract
Purpose:
While there are established instruments offering psychometrically sound measurement of primary or secondary trauma, none capture the essence of dual exposure for mental health professionals living and working in traumatological environments.
Methods:
This study examined the experience of 244 mental health workers who lived and worked in New Orleans during Hurricane Katrina. An instrument, the Shared Trauma and Professional Posttraumatic Growth Inventory (STPPG), a 14-item, Likert-type scale composed of three subscales (Technique-Specific Shared Trauma, Personal Trauma, and Professional Posttraumatic Growth), was developed to understand the nature of dual trauma exposure.
Introduction
In the last century, there has been an increased awareness of natural and man-made disasters worldwide. Studies have noted a rise in natural disasters (Centre for Research on the Epidemiology of Disasters [CRED], 2009), while other reports have underscored a substantial number of victims from incidents of mass violence in the United States (Kepple, Loehrke, Hoeyer, & Overberg, 2013). America is not alone in the struggle to maintain safety in our communities. In fact, the international community has been plagued by a preponderance of terrorist attacks. In one year (2011), over 12,000 people were killed and more than 45,000 injured in 70 countries from acts of religious and political terrorism (U.S. Department of State, 2011). These figures do not take into account the number of people who were survivors or who were impacted secondarily through their work with disaster survivors, such as first responders and mental health practitioners.
Several decades ago, the need for discourse on disaster mental health was not readily acknowledged, nor the need heavily emphasized in academic and clinical circles. Following September 11, 2001, there was call for a cadre of prepared professionals who were able to respond to a disaster (Rogers, 2007). This call was further demonstrated when clinicians living and working near the attacks spontaneously published their personal and professional hardships and rewards after living and working in a disaster zone (e.g., Tosone, et al., 2003; Tosone & Bialkin, 2004; Eidelson, D’Alessio, & Eidelson, 2003; Saakvitne, 2002). These reports underscored the dual nature of trauma exposure for mental health responders who were impacted primarily as citizens of the region and secondarily through their work with disaster survivors.
The awareness of dual trauma exposure brought about by the September 11th attacks, coupled with increasing worldwide terrorist attacks and natural disasters, suggests the importance for mental health responders to attend to their own trauma reactions while also providing effective services to survivors and their families. The purpose of this study is to evaluate preliminary evidence of the construct validity of the Shared Trauma and Professional Posttraumatic Growth Inventory (STPPG), a measure to identify the core aspect of mental health responders’ dual exposure to trauma.
Review of the Literature
September 11, 2001, seemed to be the impetus for greater exploration into mental health workers’ reactions to acts of mass violence, both as citizens of the impacted region and as helpers attending to the behavioral health needs of others. In addition to the numerous investigations assessing posttraumatic stress disorder (PTSD) in the general public post-9/11 (e.g., Boscarino & Adams, 2009; Neria et al., 2008; Schuster et al., 2001), academics, researchers, and disaster-affected individuals came together to form a consensus on early response intervention strategies (e.g., National Center for PTSD, 2012; Young, 2006). Rigorous research efforts were made to understand secondary traumatic reactions among first responders and clinicians (e.g., Tosone, Bettmann, Minami, & Jasperson, 2010; Boscarino, Figley, & Adams, 2004; Creamer & Liddle, 2005; Racanelli, 2005).
At the same time, for many professionals, it became clear that the constructs used to investigate and measure the professional’s responses to engaging in trauma work, such as vicarious traumatization (McCann & Pearlmann, 1990), secondary trauma (Figley, 1995), and compassion fatigue (Figley, 1995) were insufficient. These constructs referred to the professional’s reactions to trauma work over time (i.e., vicarious trauma and compassion fatigue) or mirrored traumatic stress symptoms following exposure to a client’s trauma narrative (i.e., secondary trauma). In particular, these constructs define the affects of exposure to traumatic material that occur in a discretely professional capacity. By contrast, PTSD (e.g., Weathers, Litz, Huska, & Keane, 1994) refers primarily to a person’s personal reactions upon exposure to a traumatic event. None of these aforementioned constructs and measurements account for clinicians’ exposure to traumatic events that are both personal (i.e., living near the World Trade Center) and professional (i.e., listening to client’s experiences of the same threatening event). See Tosone, 2012 for a detailed discussion of the theoretical differences between dual exposure or “shared trauma” and existing secondary trauma constructs.
Initial reports from clinicians who were dually exposed described their experiences as shared trauma (Altman & Davies, 2002; Tosone, et al., 2003; Saakvitne, 2002), “shared traumatic reality” (Baum, 2010; Nuttman-Shwartz & Dekel, 2008), “intense shared experience” (Krug, Nixon, & Vincent, 1996), or “shared reality” (Kretsch, Benyakar, Baruch, & Roth, 1997). These terms brought an important distinction in relation to the aforementioned constructs, because some of the initial articles suggested that shared trauma places the professional at an increased risk for future traumatic reactions (e.g., Bride, 2007; Boscarino et al., 2004; Eidelson et al., 2003; Somer, Buchbinder, Peled-Avram, & Ben-Yizhack, 2004).
On the other hand, a number of studies following disaster found that traumatic responses were both positive, indicating the presence of posttraumatic growth, and negative, indicating the presence of traumatic stress symptoms (Linley, Joseph, Cooper, Harris, & Meyer, 2003; McMillen, Smith, & Fisher, 1997). Posttraumatic growth is the idea that when a person struggles with information about the traumatic event, their process may lead to positive change (Tedeschi & Calhoun, 1995). It is thought that over time, it is possible not only to recover but also to grow from a traumatic event (e.g., Cryder, Kilmer, Tedeschi, & Calhoun, 2006; Davis, Wohl, & Verberg, 2007; Linley et al., 2003).
While studies investigating growth following a traumatic event have primarily focused on the general population (e.g., Helgeson, Reynolds, & Tomich, 2006; Linley & Joseph, 2004), later studies found that mental health professionals may also experience growth from their clinical work (Arnold, Calhoun, Tedeschi, & Cann, 2005; Linley & Joseph, 2007; Linley, Joseph, & Loumidis, 2005; Putterman, 2005; Tehrani, 2007). A few studies investigated clinicians who experienced professional growth following a collective disaster or a shared trauma. Using qualitative methods or instruments used to assess primary and secondary traumas, these studies found that mental health professionals reported both positive and negative sequelae after September 11, 2001 (Bauwens & Tosone, 2010; Eidelson et al., 2003), Hurricane Katrina (Bauwens, 2012), and terrorist attacks in Israel (Lev-Wiesel, Goldblatt, Eisikovits, Admi, 2009).
In a first attempt to specifically measure shared trauma as a construct, Tosone, McTighe, Bauwens, & Naturale (2011) created a product term out of an instrument used to rate PTSD (Weathers et al., 1994) and compassion fatigue (Stamm, 2005). This investigation was an exploratory study, however, and the intent was merely to quantify the level of dual distress associated with a shared traumatic event, the nature of which was man made. In an effort to further validate the shared trauma construct with other types of collective disasters, the same composite measure was used in a follow-up study of clinicians exposed to a natural disaster (Tosone, McTighe, & Bauwens, 2014). Importantly, the items in this measure did not account for the unique experiences qualitatively reported by clinicians in the face of a disaster (e.g., Bauwens & Tosone, 2010; Baum, 2010; Somer et al., 2004), nor did the measure assess the possibility of positive change in response to shared event.
More recently, another effort to measure shared trauma was introduced (Baum, 2013). This study proposed a new 51-item scale to measure professionals who were dually exposed in the Gaza War. This study, however, did not include a metric to assess the unique features of growth in the professional community, nor has it been validated with professionals after a natural disaster. Further, this initial study was conducted with a relatively small sample (n = 63), although the preliminary findings demonstrate robust psychometric properties.
This current study is an attempt to evaluate preliminary evidence of the construct validity of shared trauma and professional posttraumatic growth in a relatively large sample of mental health professionals who lived and worked in New Orleans during Hurricane Katrina. The items included in this measure were created primarily to reflect clinicians’ open-ended responses to the Post-9/11 Quality of Professional Practice Survey that inquired about personal and professional experiences related to the man-made disaster of September 11, 2001, and have been adapted to Hurricane Katrina, a natural disaster. It is important to note that traumatogenic environments can be man made or natural in nature, and social workers are increasingly practicing in such environments due to climate change and increased violence. If the construct validity for the STPPG instrument is established, it would suggest that these items pertain to man-made and natural traumatogenic environments. Additionally, this current instrument has been informed by four constructs, including primary (e.g., Weathers et al., 1994) and secondary traumas (Stamm, 2005), posttraumatic growth (Tedeschi & Calhoun, 1995), and shared trauma (e.g., Tosone, et al., 2003; Baum, 2010; Saakvitne, 2002).
Method
Participants and Procedures
Following approval of the University Committee on Activities Involving Human Subjects of New York University, participants for this study were recruited from several sources. The Deans of the Schools of Social Work at Tulane University, Louisiana State University, and the University of Southern Mississippi provided lists of their alumni living in the impacted area of the Gulf Coast. These alumni were contacted via e-mail and invited to participate in the study by following a link to the Post Katrina Quality of Professional Practice Survey (PKQPPS) delivered via Zoomerang. An announcement regarding this research was posted on a Listserv serving mental health disaster responders with a link to the survey instrument. Two follow-up reminders were sent from the schools of social work as well as the Listserv. The researchers remained blind to the identity of potential participants. Because of this, calculation of an exact response rate was not possible.
The participants’ choice to complete the survey constituted informed consent. Inclusion criteria for participation in the study included (1) possession of at least a master’s degree in social work or a related mental health profession, (2) current employment in the mental health field (nonretired), and (3) the completion of at least some of the demographic questions.
A total of 513 people visited the website for the PKQPPS. Of these, 511 entered the survey and responded to at least 1 item, though a sizable number only answered a few questions (n = 116) or were retired (n = 153). Participants were included in the study only if they answered most of the demographic questions and if they were currently working in the mental health profession. In the end, 244 surveys remained that were usable and completed by participants who met the criteria for inclusion. This represents 48% of the total of those who visited the PKQPPS site.
Measures
The PKQPPS consisted of several measures in addition to demographic, practice, supervisory, training, and Katrina-related professional and personal experience questions (e.g., disaster-specific training prior to Katrina and major loss as a result of Katrina). A description of the standardized instruments that comprised the survey follows.
The Compassion Fatigue/Secondary Traumatic Stress subscale of Professional Quality of Life scale–Revised (PQLS-R) served to operationalize compassion fatigue. This 30-item, 6-point Likert-type self-report measure is comprised of three 10-item subscales that are designed to be used independently: Compassion Satisfaction, Compassion Fatigue/Secondary Traumatic Stress, and Burnout. The scale is widely used and has demonstrated good construct, convergent, and discriminant validity. PTSD was operationalized by the PTSD Checklist–Civilian Version (PCL-C). This is a very commonly used 17-item, 5-point Likert-type self-report scale that asks respondents to rate the extent to which they were “bothered” in a series of specific ways by a particular stressful event over the course of the past month. Its three subscales correspond to the reexperiencing, avoidant, and arousal symptom categories of PTSD. Posttraumatic Growth was measured by Posttraumatic Growth Inventory (α = .96 in this study; Tedeschi & Calhoun, 1996), which has 21 items with six response categories ranging from (0) I did not experience this change as a result of my crisis to (5) I experienced this change to a very great degree as a result of my crisis. The inventory consists of five subscales, including New Possibilities (five questions), Relationship With Others (seven questions), Personal Strength (four questions), Spiritual Change (two questions), and Appreciation for Life (three questions).
In previous studies (Tosone, McTighe, Bauwens, & Naturale, 2011; Tosone, McTighe, & Bauwens, 2014), we used the mean of scores on the PCL-C and the Compassion Fatigue subscale of the PQLS-R to measure Shared Traumatic Stress (ShTS). Responses on the 17 items of the PCL-C were rescaled using a 0–5 format to conform to the 0–5 format of the PQLS-R. Participants’ mean scores on the PCL-C were then averaged with the mean scores of the 10 items of the compassion fatigue subscale of the PQLS-R. This method allows for a balanced distribution of the weight accorded to both the PCL-C and PQLS-R and reflects the equal relationship and importance of the PTSD and compassion fatigue components of ShTS. Each of the components demonstrated very good reliability in the present and related (Tosone, McTighe, & Bauwens, 2014) study (compassion fatigue: α = .83; PCL-C: α = .92). Furthermore, the two measures were strongly, positively correlated (r = .67, p < .001), providing additional evidence of the validity of the shared trauma measure and lending further support to ShTS as a superordinate construct.
The measure under investigation in this article is The Shared Trauma/Professional Posttraumatic Growth Inventory (STPPG). It consists of 14, Likert-type items with a 5-point response scale indicating the extent to which the item is “true” of the respondent.
Results
Analysis of the demographic data revealed that respondents were predominantly female (82%), White (86%), married (48%), and possessed a master’s-level credential (83%). The mean age of respondents was 48 (SD = 13). The modal income category of the respondents was US$40–$60K (38%). Though 58% provided disaster-related services following Katrina such as counseling and referral services, only 37% reported having had specific disaster training. Sixty-one percent witnessed Hurricane Katrina personally, while 53% experienced a major loss due to Katrina. Examples of such losses included the death of a family member or loved one as well as loss of one’s home or job. Forty-one percent endorsed having discussed their personal reactions to Katrina with their clients. Participants gave a mean response of 3.57 (1 = not at all and 7 = very much) when asked to what extent they still felt affected by the events surrounding Hurricane Katrina.
Univariate descriptive statistics, that is, mean, median, minimum, maximum, standard deviation, skewness, and kurtosis were generated and examined for each of the 14 items comprising the measure. These items were reasonably normally distributed with only 3 of the 14 items having skewness statistics exceeding ±1.0 and only 2 of these 14 items having kurtosis statistics exceeding ±1.0. The linearity of the relationships between items was examined by comparing Pearson correlations, which presume linearity, with their corresponding nonparametric counterparts, that is, Spearman’s ρ correlations, which do not. Of the 91 pairwise correlations among the 14 items, only 5 of these correlations exhibited discrepancies that exceeded ±.05. Taken together, the univariate descriptive statistics and the bivariate correlations indicate that the 14 items, by and large, meet the normality and linearity assumptions underlying the common factor model to which the 14 items were submitted.
The purpose of this investigation to evaluate the construct validity—“internal” (factorial) and “external” (convergent)—of the STPPG. The internal construct validity is the focus of an exploratory factor analysis which is intended to evaluate whether the 14 items of this measure do, in fact, measure what they were designed to measure and can therefore be used to operationalize meaningful, coherent dimensions of shared trauma. External (convergent) validity is evaluated by examining correlations between the factors derived in the exploratory factor analysis and various validation criteria with which they would be expected to correlate if they are, in fact, valid measures of shared trauma.
Preliminary factor analyses were conducted in SPSS in order to gauge the “factorability” of the 14 STPPG items. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy for this item set is (KMO) = .86 which substantially exceeds the commonly recommended minimum value of .60 and indicates that there is a substantial degree of shared variance among these items. Bartlett’s test of sphericity which evaluates the null hypothesis that the correlation matrix of the 14 items is an identity matrix, that is, a matrix in which the off-diagonal elements are zero, is also rejected, χ2 = 1,153.71(91) p < .001. Taken together, the results of these two analyses indicate that the 14 STPPG items are indeed factorable.
An exploratory rather than a confirmatory factor analytic perspective was adopted because the relationships among the 14 items and the factors presumed to underlie them were considered uncertain. Moreover, since this is the first empirical analysis of the factor structure of the STPPG, an exploratory factor analytic perspective seemed like an appropriate place to begin an investigation of the psychometric properties of the measure.
This exploratory factor analysis was conducted using the Mplus computer program. Mplus was used because it provides various “goodness-of-fit” indices that can be helpful in selecting the “best fitting” exploratory factor model. The first of these measures is the model goodness-of-fit χ2 statistic which provides a formal statistical test of whether the model-implied correlations among the STPPG items differ significantly from the actual or observed correlations among these same items. In a good-fitting model, the discrepancies between the model-implied correlations and the observed correlations should be statistically insignificant, that is, p > .05.
Mplus provides three other goodness-of-fit indices such as (1) the comparative fit index (CFI), (2) the root mean square error of approximation (RMSEA), and (3) the standardized root mean square residual (SRMR), all of which are often used in selecting a good-fitting model. CFI values > .90 or .95 and RMSEA values between .05 and .08 suggest a “reasonable” fit of the (here, exploratory factor) model to the data. For the SRMR, a value <.05 is indicative of a good-fitting model.
Using listwise deletion, one-, two-, three- and four-factor solutions were examined using an oblique method of rotation (promax) in order to examine the correlations among the factors in those solutions that extracted more than one factor. In order to deal with minor violations of normality, the “robust” maximum likelihood (MLR) estimator was used. Table 1 presents the model χ2 statistic and its p value as well as the associated RMSEA and SRMR goodness-of-fit indices for each of these models.1
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Table 1. Exploratory Factor Analysis Solutions.
As displayed in the Table 1, the statistically significant model χ2 tests indicate that none of the four exploratory factor models provides an acceptable fit to the data. Although a statistically significant model χ2 statistic indicates a lack of fit between the model-implied correlations and the observed correlations for each of the four models, it is well known that this fit statistic is sensitive to sample size. With even moderately sized samples, like we have in this study, relatively small differences between the model-implied correlations and the observed correlations will often be found to be statistically significant. Inspecting the other goodness-of-fit measures, both the three-factor and four-factor models provide relatively good-fitting models. Since the difference in fit between the three- and four-factor models does not seem particularly noteworthy, the three-factor model would seem to be preferable simply on the grounds of parsimony. The “loadings” of the three-factor model are presented in Table 2.
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Table 2. Shared Traumatic and Professional Posttraumatic Growth Inventory–Exploratory Factor Structure (Promax Rotation).
The first factor extracted has been labeled “Technique-Specific Shared Trauma.” Visual inspection of the content of the 4 items that define this first factor reference how “sharing” the trauma inflicted by the Katrina event has precipitated changes in the way these social workers conduct the treatments of their clients. Specifically, the endorsement of these items suggests that sharing the Katrina event with their clients has “loosened” the traditional treatment boundaries between these clinicians and their clients. This interpretation also finds support in the 3 items that operationally define the third factor that has been labeled Personal Trauma. Again, these items attest to the personal impact of sharing the traumatic event, Katrina, on this group of therapists. While the third factor underlines the perhaps negative impact of sharing the Katrina event on these clinicians, the second factor points to some of the positive impacts of sharing the Katrina event. More specifically, the items which define the second factor speak to the “growth” aspects derived from sharing the Katrina event with their clients, that is, greater empathy, a search for more knowledge and professional development, and an appreciation of both the possibilities and the limitations of the helping professions. As such, the second factor has been labeled, Professional Posttraumatic Growth.
The correlations among the three factors are presented in the Table 3. As seen there, the three factors are, as expected, positively correlated and these correlations range in magnitude from moderate (r = .33) to strong (r = .62).
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Table 3. Promax Factor Correlations.
Composite scores for the “overall” or total scale score as well as for each of the three factors were generated using factor-based scales. The descriptive statistics and internal consistency reliabilities (Cronbach’s α) of these factor-based scales are presented in Table 4.
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Table 4. Descriptive Statistics and Internal Consistency Reliabilities.
With respect to the descriptive statistics, the Professional Posttraumatic Growth subscale is the most heavily endorsed of the four measures (mean = 2.99) followed by the overall scale score (mean = 2.49), the Technique-Specific Shared Trauma subscale (mean = 2.29) and the Personal Trauma subscale (mean = 1.57). It should be noted, however, that in no case does the mean of any of these measures transcend the midpoint of the response scale of the STPPG items (i.e., 3 = sometimes true). Stated somewhat differently, the two conceptual components of this measure—professional posttraumatic growth and shared trauma—are not “dominant” features of the study participants’ experiences with Hurricane Katrina.
Internal consistency reliability coefficients (Cronbach’s α coefficient) equal to (α =) .70 are generally considered to be “acceptable”; values equal to .80 are considered to be “good”; and values equal to .90 are considered to be “excellent.” Note, however, that reliability (α) coefficients are a function not only of the degree of correlation among the items in a scale but also of the number of items in the scale. Given that the first and third factors have a rather modest number of items (4 and 3 items, respectively), the reliability estimates are reasonably good.
Four factor-based scales were generated and then correlated with other variables available in the Katrina data set which, on apriori, logical grounds, should serve as external validation criteria for the overall scale as well as for the subscales of the Shared Trauma/Professional Posttraumatic Growth measure. The overall or total STPPG inventory score would be expected to correlate with the overall Tedeschi and Calhoun Posttraumatic Growth measure (Tedeschi & Calhoun, 1996) and the integrated Shared Trauma measure derived from the Posttraumatic Checklist and the Compassion Fatigue/Secondary Traumatic Stress measures (Tosone, McTighe, & Bauwens, 2014).
At the subscale level, the Professional Posttraumatic Growth subscale would be expected to correlate with the five subscales of the Tedeschi and Calhoun Posttraumatic Growth measure (Tedeschi & Calhoun, 1996). Similarly, the two remaining STPPG subscales, Personal Trauma and Technique-Specific Shared Trauma, should correlate with the components of the Shared Trauma measure, that is, the Posttraumatic Checklist and the Compassion Fatigue subscales. These correlations are presented in Table 5.
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Table 5. Correlations Among STPPG Factors and Criterion Variables.
As seen in this table, these expectations are confirmed. The overall STPPG measure is significantly and positively correlated with the overall Tedeschi and Calhoun Posttraumatic Growth measure as well as the Shared Trauma measure. However, the magnitude of these correlations varies considerably. Specifically, the overall STPPG measure is “strongly” correlated with the overall Tedeschi and Calhoun Posttraumatic Growth measure (r = .64, p < .001) but is more modestly correlated with the Shared Trauma measure (r = .29, p < .001). Taken together, these findings suggest that the STPPG measure does a better job of measuring Professional Posttraumatic Growth than it does of measuring Shared Trauma, at least as this construct is defined by the Shared Trauma validation measure.
With respect to the STPPG subscales, the Professional Posttraumatic Growth subscale exhibits generally strong, statistically significant and, as expected, positive correlations with the subscales of the Tedeschi and Calhoun Posttraumatic Growth measure ranging from (r = ) .45 to .62 (all, p < .05). Similarly, the Personal Trauma subscale of the STPPG exhibits moderately strong, statistically significant, positive correlations with the two components of the shared trauma measure (r > .35, p < .05). Finally, the third subscale, the Technique-Specific Shared Trauma subscale, is significantly related to these same measures but these correlations are somewhat weaker (r ~ .20, p < .01).
In summary, the Shared Trauma/Professional Posttraumatic Growth measure does reflect the substantive dimensions that motivated its construction. For this reason, it may be said that the exploratory factor analysis presented herein provides evidence of its internal (construct) validity. Also, each of the three factors that comprise the measure has reasonably good internal reliability. With respect to external validity, the overall STPPG measure is, as expected, correlated with both the Tedeschi and Calhoun Posttraumatic Growth measure and the Shared Trauma measure. Each of the three subscales of the STPPG also correlates, as anticipated, with the external validation measures in the Katrina data set with which they should correlate. Specifically, the Professional Posttraumatic Growth subscale of the STPPG exhibits the strongest set of validity correlations followed by those involving the Personal Trauma subscale and the Technique-Specific Shared Trauma factor.
Discussion and Applications to Social Work
The purpose of this study was to investigate a more precise understanding of shared trauma and its measurement. As a preliminary measure of the unique circumstances mental health responders encounter when living and working in regions impacted by disasters, the Shared Trauma/Professional Posttraumatic Growth Inventory demonstrates promise. Consistent with the literature on the theoretical construct (Altman & Davies, 2002; Tosone, et al., 2003; Saakvitne, 2002), the results suggest the reciprocal nature of shared trauma such that mental health responders’ personal disaster–related experiences can impact the nature of their practice, as can their interactions with trauma survivors influence their personal responses to the same precipitating traumatic event. The personal and professional aspects of the traumatic experience are interconnected and not readily separated except for descriptive and measurement purposes.
As the initial results suggest, the overall inventory corresponds positively to the Shared Trauma scale (Tosone, McTighe, Bauwens, & Naturale, 2011; Tosone, McTighe, & Bauwens, 2014) comprising standardized measures with strong psychometric properties for PTSD and secondary trauma, respectively, both of which are equally weighted to emphasize their mutual importance (Stamm, 2005; Weathers et al., 1994). This study suggests that the shared trauma construct can be further delineated into three interrelated domains, corresponding to technique-specific shared trauma (F1), professional posttraumatic growth (F2), and personal trauma (F3). In comparison to Baum’s (2013) instrument developed specifically to measure social workers’ dual trauma exposure to the Gaza War, the STPPG measure contains two subscale items that are analogous, namely statements regarding empathy in relation to patient care and appreciation for one’s professional role following disaster. Importantly, Baum’s (2013) instrument focuses on five key features characteristic of shared traumatic reality such as intrusive anxiety, lapses of empathy, immersion in one’s professional role, expansion of one’s professional role, and changes in place and time of work. As a related construct to shared trauma, shared traumatic reality refers specifically to ongoing exposure to war or terrorist threat. Shared trauma, by contrast, describes acute exposure to a collective disaster, whether man made or natural (Tosone, 2012; Tosone, Nuttman-Shwartz, & Stephens, 2012)
In discussing the subscales of the STPPG, it is important to reiterate that none of the three subscales’ means exceed the midway point (“sometimes true”), suggesting that Professional Posttraumatic Growth, Personal Trauma, and Technique-Specific Shared Trauma are significant but not dominant long-term features of the study participants’ experiences with Hurricane Katrina. The first factor, Technique-Specific Shared Trauma, is consistent with the anecdotal professional literature, suggesting that mental health professionals in general (Boulanger, Floyd, Nathan, Poitevant, & Pool, 2013), and psychologists (Faust, Black, Abrahams, Warner, & Bellando, 2008) and social workers (Naturale, 2007) in particular report that their personal exposure to Hurricane Katrina impacted the nature of their practices, such that the boundaries between the personal and professional realms were more blurred and they were more likely to self-disclose their Hurricane-related experiences with their clients. The findings of this study also suggest that the blurring of boundaries and increased self-disclosure can extend beyond the specific traumatic event and can be generalized to other client situations.
The second factor, Professional Posttraumatic Growth (Bauwens & Tosone, 2010), is discussed sparsely in the mental health literature as compared to posttraumatic growth proper among mental health practitioners and in the general population. The findings of this study are consistent with the few studies examining posttraumatic growth in the context of clinical practice (Arnold et al., 2005; Linley et al., 2005; Linley & Joseph, 2007; Tehrani, 2007). Participants in these studies reported personal and professional growth from engaging in their work as trauma clinicians (Arnold et al., 2005; Linley et al., 2005; Linley & Joseph, 2007). In this study, subjects endorsed items indicating greater client empathy in general and in work with trauma clients specifically as a result of their personal disaster-related experiences. Subjects also reported taking active steps to enhance their professional practice experience by seeking additional knowledge, changing their practice orientation, making their practice more manageable, and by developing an appreciation for the strengths and limitations of what the mental health profession can offer to clients. The fact that the professional posttraumatic growth items were the most heavily endorsed and constituted the largest subscale speaks to the salience of positive work-related experiences in response to collective traumatic events. Furthermore, these findings provide additional clarity in understanding the professional aspects of growth than accompany trauma exposure and endorse Janoff-Bulman’s (1992) assertion that trauma exposure can permanently alter one’s worldview, both positively and negatively.
The mutual influence of personal experiences and professional responsibilities in concert with the intermingling of positive and negative responses to trauma exposure speaks to the multidimensional nature of shared trauma as a construct. The third factor, personal trauma, underscores the reciprocal nature of the therapeutic exchange such that one’s personal traumatic experiences can be triggered by clients’ discussions of the same or other traumatic events. Relatedly, subjects reported wanting to avoid hearing clients’ trauma narratives, suggesting that the self-other boundaries are permeable when the topic is of a traumatic nature. This finding is consistent with those of Seeley (2008) and Saakvitne (2002) who report increased therapist vulnerability upon hearing client narratives of the same traumatic event. This is the distinct feature of shared trauma: Client narratives of a specific traumatic event trigger one’s own memories of the same event. In this specific study, clinical work with disaster survivors kindled their own Katrina-related memories. The attribution of the therapist’s traumatic reaction is related to primary as well as secondary trauma exposure. In comparison to secondary trauma phenomena, including compassion fatigue and vicarious trauma, one’s traumatic reaction is attributed to an empathic immersion into the client’s subjective traumatic experience. Clinicians primarily impacted are at greater risk of secondary trauma and vicarious traumatization, and they are at greater risk of future traumatic reactions.
With regard to the limitations of this measure, it would be important to note that, the exploratory factor analysis is “context bound,” that is, it is a study of the “structure” of the STPPG measure in the context of a natural disaster. Whether, and to what extent, the same or a similar factor structure would emerge in a different context is unknown. In a similar vein, the majority of the subjects were female, and it is not known if a similar factor structure would emerge if there were equal numbers of males in the study. Since there weren’t enough male respondents in the Katrina sample, there is no way to know about this aspect of the generalizability of the STPPG factor structure. Additionally, if the conceptualization of shared trauma and professional posttraumatic growth were to change in the coming years, it would be prudent to re-factor the augmented item pools designed to incorporate those changes. If the 14 items of the STPPG were to be retained “as is,” it would be useful to build on the present exploratory factor analysis by trying to replicate the factor structure found in this investigation using confirmatory factor analytic techniques in other samples as they become available.
Despite these limitations, the preliminary STPPG measure offers a positive step forward in capturing the nuanced experiences of mental health professionals dually exposed to man-made and natural disasters. Together with the shared trauma scale studied previously and established measures for PTSD, secondary trauma, and posttraumatic growth, these instruments can further our understanding of the unique experiences and challenges facing mental health professionals living and working in disaster-prone environments. These mental health providers can potentially serve as models for addressing traumatic and negative life experiences and, in this way, can guide their colleagues and inform the training and supervision of students. In addition to replicating the factor structure found in this study, future research should identify other aspects of shared trauma not captured in the existing STPPG instrument through qualitative research with other types of dual trauma exposure.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Notes
1.
The Comparative Fit Index (CFI) is not available wit a Promax rotation, the type of rotation used in these analyses.
References
|
Altman, N., Davies, J. M. (2002). Out of the blue: Reflections on a shared trauma. Psychoanalytic Dialogues, 12, 359–360. Google Scholar | Crossref | |
|
Arnold, D., Calhoun, L. G., Tedeschi, R. G., Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of Humanistic Psychology, 45, 239–263. Google Scholar | SAGE Journals | ISI | |
|
Baum, N. (2010). Shared traumatic reality in communal disasters: Toward a conceptualization. Psychotherapy Theory, Research, Practice, Training, 47, 249–259. Google Scholar | Crossref | |
|
Baum, N. (2013). Professionals’ double exposure in the shared traumatic reality of wartime: Contributions to professional growth and stress. British Journal of Social Work, 24, 1–22. Google Scholar | |
|
Bauwens, J. (2012). Clinicians' posttraumatic growth following Hurricane Katrina: The influence of life events, professional quality of life, and primary and secondary traumatic stress. (Order No. 3488432, New York University). ProQuestDissertations and Theses, 193. Retrieved from https://ezproxy.library.nyu.edu/login?url=http://search.proquest.com/docview/914373177?accountid=12768. (914373177). Google Scholar | |
|
Bauwens, J., Tosone, C. (2010). Professional posttraumatic growth after a shared traumatic experience: Manhattan clinicians' perspectives on post 9/11 practice. Journal of Loss and Trauma, 15, 498–517. Google Scholar | Crossref | |
|
Boscarino, J., Adams, R. (2009). PTSD onset and course following the world trade center disaster: Findings and implications for future research. Social Psychiatry Epidemiology, 44, 887–898. Google Scholar | Crossref | Medline | |
|
Boscarino, J. A., Figley, C. R., Adams, R. E. (2004). Compassion fatigue following the September 11 terrorist attacks: A study of secondary trauma among New York City social workers. International Journal of Emergency Mental Health, 6, 57–66. Google Scholar | Medline | |
|
Boulanger, G., Floyd, L., Nathan, K., Poitevant, D., Pool, E. (2013). Reports from the front: The effects of Hurricane Katrina on mental health professionals in New Orleans. Psychoanalytic Dialogues, 23, 15–30. Google Scholar | Crossref | |
|
Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52, 63–70. Google Scholar | Crossref | Medline | ISI | |
|
Centre for Research on the Epidemiology of Disasters . (2009). Natural disasters trends. Retrieved February 10, 2011, from http://www.emdat.be/natural-disasters-trends Google Scholar | |
|
Creamer, T. L., Liddle, B. J. (2005). Secondary traumatic stress among disaster mental health workers responding to the September 11 attacks. Journal of Traumatic Stress, 18, 89–96. Google Scholar | Crossref | Medline | ISI | |
|
Cryder, C. H., Kilmer, R. P, Tedeschi, R. G., Calhoun, L. G. (2006). An exploratory study of posttraumatic growth in children following a natural disaster. American Journal of Orthopsychiatry, 76, 65–69. Google Scholar | Crossref | Medline | ISI | |
|
Davis, C. G., Wohl, M. J. A., Verberg, N. (2007). Profiles of posttraumatic growth following an unjust loss. Death Studies, 31, 693–712. Google Scholar | Crossref | Medline | ISI | |
|
Eidelson, R. J., D’Alessio, G. R., Eidelson, J. I. (2003). The impact of September 11 on psychologists. Professional Psychology: Research & Practice, 34, 144–150. doi:10.1037/0735-7028.34.2.144 Google Scholar | Crossref | |
|
Faust, D. S., Black, F. W., Abrahams, J. P., Warner, M. S., Bellando, B. J. (2008). ‘After the storm: Katrina's impact on psychological practice in New Orleans' Professional Psychology: Research and Practice, 39, 1–6. Google Scholar | Crossref | |
|
Figley, C. R. (1995). Compassion fatigue: Toward a new understanding of the costs of caring. In Stamm, B. H. (Ed.), Secondary traumatic stress: Self-care issues for clinicians researchers, and educators (pp. 3–28). Lutherville, MD: Sidran. Google Scholar | |
|
Helgeson, V. S., Reynolds, K. A., Tomich, P. L. (2006). A meta-analytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74, 797–816. Google Scholar | Crossref | Medline | ISI | |
|
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY: Free Press. Google Scholar | |
|
Kepple, K. A., Loehrke, J., Hoyer, M., Overberg, P. (2013, 2 22). Mass shootings toll exceeds 900 in past seven years. USA Today. Retrieved from http://www.usatoday.com/story/news/nation/2013/02/21/mass-shootings-domestic-violence-nra/1937041 Google Scholar | |
|
Kretsch, R., Benyakar, M., Baruch, E., Roth, M. (1997). A shared reality of therapists and survivors in a national crisis as illustrated by the Gulf War. Psychotherapy: Theory, Research, Practice, Training, 34, 28–33. Google Scholar | Crossref | ISI | |
|
Krug, R. S., Nixon, S. J., Vincent, R. (1996). Psychological response to the Oklahoma City bombing. Journal of Clinical Psychology, 52, 103–105. Google Scholar | Crossref | Medline | |
|
Lev-Wiesel, R., Goldblatt, H., Eisikovits, Z., Admi, H. (2009). Growth in the shadow of war: The case of social workers and nurses working in a shared war reality. British Journal of Social Work, 39, 1154–1174. Google Scholar | Crossref | ISI | |
|
Linley, P. A., Joseph, S. (2004). Positive change following trauma and adversity: A review. Journal of Traumatic Stress, 17, 11–21. Google Scholar | Crossref | Medline | ISI | |
|
Linley, P. A., Joseph, S. (2007). Therapy work and therapists’ positive and negative well-being. Journal of Social and Clinical Psychology, 26, 385–403. Google Scholar | Crossref | |
|
Linley, P. A., Joseph, S., Cooper, R., Harris, S., Meyer, C. (2003). Positive and negative changes following vicarious exposure to the September 11 terrorist attacks. Journal of Traumatic Stress, 16, 481–485. Google Scholar | Crossref | Medline | |
|
Linley, P. A., Joseph, S., Loumidis, K. (2005). Trauma work, sense of coherence, and positive and negative changes in therapists. Psychotherapy & Psychosomatics, 74, 185–188. Google Scholar | Crossref | Medline | |
|
McCann, L., Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131–147. Google Scholar | Crossref | |
|
McMillen, C. J., Smith, E. M., Fisher, R. H. (1997). Perceived benefit and mental health after three types of disaster. Journal of Consulting and Clinical Psychology, 65, 733–739. Google Scholar | Crossref | Medline | ISI | |
|
National Center for PTSD . (2012). Psychological first aid: Field operations guide. Retrieved on September 25, 2012 from http:www.ptsd.va.gov/professional/manuals/manualpdf/pfa/PFA_2ndEditionwithappendices.pdf Google Scholar | |
|
Naturale, A. (2007). Secondary traumatic stress in social workers responding to disasters: Reports from the field. Clinical Social Work Journal, 35, 173–181. Google Scholar | Crossref | ISI | |
|
Neria, Y., Olfson, M., Gameroff, M. J., Wickramaratne, P., Gross, R., Pilowsky, D. J., Weissman, M. M. (2008). The mental health consequences of disaster-related loss: Findings from primary care one year after 9/11 terrorist attacks. Psychiatry, 71, 339–348. Google Scholar | Crossref | Medline | |
|
Nuttman-Shwartz, O., Dekel, R. (2008). Training students for a shared traumatic reality. Social Work, 53, 279–281. Google Scholar | Crossref | Medline | ISI | |
|
Putterman, I . (2005). The relationship between posttraumatic growth and professional quality of Life (Compassion fatigue/secondary trauma, compassion satisfaction, and burnout) among social workers in Texas. (Doctoral dissertation, University of Houston, 2005). Dissertation Abstracts International, 66, 11. Google Scholar | |
|
Racanelli, C. (2005). Attachment and compassion fatigue among American and Israeli mental health clinicians working with traumatized victims of terrorism. International Journal of Emergency Mental Health, 7, 115–124. Google Scholar | Medline | |
|
Rogers, J. (2007). Disaster response and the mental health counselor. Journal of Mental Health Counseling, 29, 1–3. Google Scholar | Crossref | |
|
Saakvitne, K. (2002). Shared trauma. The therapist’s increased vulnerability. Psychoanalytic Dialogues, 12, 443–450. Google Scholar | Crossref | |
|
Schuster, M. A., Stein, B. D., Jaycox, L., Collins, R. L., Marshall, G. N., Elliott, M. N., Berry, S. H. (2001). A national survey of stress reactions after the September 11, 2001, terrorist attacks. The New England Journal of Medicine, 345, 1507–1512. Google Scholar | Crossref | Medline | ISI | |
|
Seeley, K. M. (2008). Therapy after terror: 9/11, psychotherapists, and mental health. New York, NY: Cambridge University Press. Google Scholar | Crossref | |
|
Somer, E., Buchbinder, E., Peled-Avram, M., Ben-Yizhack, Y. (2004). The stress and coping of Israeli emergency workers following terrorist attacks. Qualitative Health Research, 14, 1077–1093. Google Scholar | SAGE Journals | |
|
Stamm, B. H. (2005). The Proqol manual: The professional quality of life scale: Compassion satisfaction, burnout & compassion fatigue/secondary trauma scales. Lutherville, MD: Sidran Press. Google Scholar | |
|
Tedeschi, R. G., Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 451–471. Google Scholar | Crossref | |
|
Tehrani, N. (2007). The cost of caring-the impact of secondary trauma on assumptions, values and beliefs. Counseling Psychology Quarterly, 20, 325–339. Google Scholar | Crossref | |
|
Tosone, C., Lee, M., Bialkin, L., Martinez, A., Campbell, M., Martinez, M. M.…Stefan, A. (2003). Shared trauma: Group reflections on the September 11th disaster. Psychoanalytic Social Work, 10, 57–77. Google Scholar | Crossref | |
|
Tosone, C., Bialkin, L. (2004). Mass violence and secondary trauma in clinical practice. In A. Straussner, S. L., Phillips, N. K. (Eds.), Social work with victims of mass violence (pp. 157–167). New York, NY: Pearson Allyn & Bacon. Google Scholar | |
|
Tosone, C., Bettmann, J., Minami, T., Jasperson, R. (2010). New York city social workers after 9/11: Their attachment, resiliency, and compassion fatigue. International Journal of Emergency Mental Health, 12, 103–116. Google Scholar | Medline | |
|
Tosone, C., McTighe, J., Bauwens, J., Naturale, A. (2011). Shared traumatic stress and the long-term impact of 9/11 on Manhattan clinicians. Journal of Traumatic Stress, 24, 546–552. Google Scholar | Crossref | Medline | |
|
Tosone, C. (2012). Shared trauma. In Figley, C. R. (Ed.), Encyclopedia of trauma: An interdisciplinary guide (pp. 624–627). London, England: Sage. Google Scholar | |
|
Tosone, C., Nuttmann-Shwartz, O., Stephens, S. (2012). Shared trauma: When the professional is personal. Clinical Social Work Journal, 40, 231–239. Google Scholar | Crossref | |
|
Tosone, C., McTighe, J., Bauwens, J. (2014). Shared traumatic stress among social workers in the aftermath of Hurricane Katrina. British Journal of Social Work. doi:10.1093/bjsw/bct194 Google Scholar | ISI | |
|
U.S. Department of State . (2011). Country reports on terrorism 2011 national counterterrorism center: Annex of statistical information. Retrieved from http://www.state.gov/j/ct/rls/crt/2011/195555.htm Google Scholar | |
|
Weathers, F. W., Litz, B. T., Huska, J. A., Keane, T. M. (1994). PTSD checklist—civilian version. Boston, MA: National Center for PTSD, Behavioral Science Division. Google Scholar | |
|
Young, B. H. (2006). The immediate response to disaster: Guidelines for adult psychological first aid. In Friedman, M. J., Watson, P. J., Ritchie, E. C. (Eds.), Interventions following mass violence and disasters: Strategies for mental health practice (pp. 134–154). New York, NY: Guilford Press. Google Scholar |