Mental health professionals often work with people who have been traumatised in some way, either through being direct victims of abuse, violence, serious injury and threats of death, or by witnessing these events. Listening to patients sharing these stories can put the professional at risk of themselves experiencing what is known as ‘secondary traumatic stress’. Is this more likely to happen if the professional also has a history of trauma?
Terms used in this field can be confusing:
- Secondary traumatic stress is an acute reaction with symptoms rather like post-traumatic stress disorder (PTSD) and experienced when professionals get psychologically overwhelmed in their desire to support others (Orru et al, 2021)
- Vicarious trauma refers to the way our view of the world is altered when working with traumatised people over time. We struggle to continue to care, show empathy and understanding (Pearlman and Mac Ian, 1995)
- Compassion fatigue is a combination of secondary traumatic stress and burnout, leaving the professional mentally and physically exhausted (Figley, 1999)
- Burnout is the result of chronic stress in the workplace rather than working with traumatised patients (Edu-Valsania et al, 2022).
This review sets out both to identify the prevalence of a personal trauma history and secondary traumatic stress in mental health professionals and to examine whether there is an association between them.
Mental health professionals are at risk of secondary traumatic stress. Is this more likely if they also have a personal history of trauma?
Methods
The databases Medline, Embase, Web of Science and CINHAL were searched up to 17th August 2023.
Inclusion Criteria:
- Articles that assessed personal trauma OR secondary trauma (which included secondary traumatic stress, vicarious trauma or compassion fatigue)
AND one or both of the following:
- The correlation between trauma history and secondary trauma (any of 3 as above).
- The prevalence of either personal trauma history and/or secondary trauma (any of 3 as above).
Plus
- The sample consisted of mental health professionals including those who had experienced their own trauma (and students on placement).
- Utilised valid measures to assess prevalence.
Studies reporting on burnout only were excluded. Data on the prevalence and association between personal trauma history and secondary trauma were extracted independently by two reviewers. Risk of Bias was assessed using an adapted version of the Newcastle-Ottawa Scale (Wells et al, 2013). Due to study heterogeneity a meta-analysis was not possible.
Results
Search results
Out of the 4,779 studies located in searches, 23 studies were finally included, all of which were cross-sectional, i.e. collecting data at one time point only.
Study quality
Overall, a majority of the studies were described as of ‘fair’ quality, with only 5/23 scoring more than 6 on the 8 point modified Newcastle-Ottawa Scale. The sample size was judged as satisfactory in only 4 studies.
Measuring personal trauma history
There was considerable variation in how the studies asked about life experience of trauma. Two extraordinarily only included a yes/no option. Some asked if the participant had ever had a diagnosis of PTSD, some used a simple rating of personal history of trauma (0-10 with ‘0’ for no trauma to ‘10’ for extreme personal trauma history). Others asked much more detailed questions or utilised tools that authors had either developed themselves or adapted from others.
Measuring secondary trauma
The term ‘secondary traumatic stress’ was used in 11 studies, ‘compassion fatigue’ in 5 and ‘vicarious trauma’ in 3 studies. One used PTSD and 2 separated secondary traumatic stress and vicarious trauma. A variety of different measures were used, but different versions or subscales of the Professional-Quality of Life Scale (Pro-QOL) (original: Linley and Joseph, 2007) were typically employed.
Prevalence of personal trauma history
For the 19 studies that reported on personal trauma history, 13 used percentages to present their findings – ranging from 21.2% to 83.3%. So, between a fifth and over four-fifths of mental health professionals had experienced a history of personal trauma. The authors note this is significantly higher than the reported findings for the general population in the 3 main study locations (United States of America, Australia and United Kingdom).
Prevalence of secondary traumatic stress
17 studies reported significant levels of secondary traumatic stress. For the 6 that reported this in percentages, this ranged from 19-70%, between a fifth and over two thirds of mental health professionals reported experiencing secondary traumatic stress.
Association between secondary traumatic stress and trauma history
Fourteen of the studies found a positive association between secondary traumatic stress and a mental health professional’s experience of their own trauma history, 4 found no association and 5 did not report on this.
The majority of studies in this review found a positive association between secondary traumatic stress and a mental health professional’s experience of their own trauma history.
Conclusions
The authors concluded that:
both personal trauma history and secondary traumatic stress are common in mental health professionals,
and
personal trauma history is associated with post-traumatic stress.
They believe this finding is important for those involved in training, supervision and management of mental health professionals, as presence of a trauma history can put workers at higher risk of developing traumatic stress.
This review suggests that the presence of a trauma history can put workers at a higher risk of developing secondary traumatic stress.
Strengths and limitations
There has been only one previous systematic review of this topic. Leung and colleagues (2022) used different inclusion criteria, (including burnout) and a very broad definition of ‘mental health professionals’ including volunteers and even non-clinical workers. A single reviewer carried out assessments of suitability for inclusion and there was no quality assessment of included studies.
The present authors have vastly improved on this by defining the terms to describe ‘post-traumatic stress’, excluding burnout, and including studies focussed on clinical mental health professionals. Instead of a single reviewer, two reviewers assessed studies independently and a third was involved when they were unable to reach an agreement. Study quality was also assessed.
However, the authors themselves comment they only included studies written in English, and participant ethnicity was not recorded in many of the studies, limiting the generalisability of the findings. Reported correlations were small and many studies were likely underpowered. Those experiencing a personal trauma history and/or secondary traumatic stress were perhaps more likely to participate in such research, and all of the papers were of cross-sectional design, meaning this would have excluded those who left the workplace after developing secondary traumatic stress.
Given the considerable variation between the studies included in terms of sample size, typology of professionals included, setting in which they worked, and measures employed for assessing trauma history and secondary traumatic stress (asking a yes/no question about having either of these experiences is really insufficient). The decision to publish as a narrative review is quite understandable. However, I do wonder if the authors might have considered, after their initial scoping review, to narrow their inclusion criteria further to include only higher quality studies? The wide variation in the reported percentages of personal trauma history (in those 13 papers that included percentages) also makes the reported comparison with national data highly unreliable.
There was considerable variation between the studies included in terms of sample size, professionals included, work settings and measures employed for assessing trauma history and secondary traumatic stress.
Implications for practice
I agree with the authors that “there is a common acknowledgement in the workplace that those attracted to a career in this field of mental health are often those of some knowledge and experience of difficult life events.” This is true not only for me, but for many others I have known, yet it is rarely, if ever, acknowledged in our training. Quite the opposite, we have until recently been discouraged from and stigmatised for admitting we might need support or are actually seeking it.
As this review does demonstrate clearly through the breadth of its scope, the overall quality of research carried out in this area has been limited. We need prospective studies, not only to discern the strength of the association between personal trauma history and secondary traumatic stress, but also to explore when those with such a history are most at risk of developing it in their careers, and how to distinguish this from burnout, although this may co-exist. What makes us vulnerable and what can we do to prevent it? What part do gender and ethnicity play?
To be able to carry out such research requires much more widespread acknowledgement of the issue by those who train, supervise and manage mental health professionals. We need to teach about it and provide specialist supervision for those at risk of it. This is important for understanding not only how to retain our professional staff in mental health services, but improving the experience and outcomes of patients and service users. We continue to struggle in mental health services with not only unkind and unprofessional behaviour from mental health professionals, but sometimes frankly abusive actions. I can fully understand how service users and patients might believe that a focus on secondary traumatic stress experienced by professionals might be misplaced, when set against the potentially retraumatising impact of some mental health care (Hennessy et al, 2022), but a greater understanding could benefit not only professional wellbeing, but ultimately patients and service users too.
A better understanding of the extent and causes of secondary traumatic stress in mental health professionals could benefit not only professional wellbeing, but ultimately patients and service users too.
Statement of interests
I have no competing interests.
Links
Primary paper
Anita Henderson, Tom Jewell, Xia Huang, Alan Simpson. (2024) Personal trauma history and secondary traumatic stress in mental health professionals: A systematic review. (PDF) Journal of Psychiatric and Mental Health Nursing. 2024 Jun 30.
Other references
Edú-Valsania S, Laguía A, Moriano JA. (2022) Burnout: A review of theory and measurement. (PDF) International Journal of Environmental Research and Public Health. 2022 Feb 4;19(3):1780.
Figley, C. R. (1999) Compassion fatigue: Towards a new understanding of the costs of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, & educators (2nd ed., pp. 3–28). Lutherville, MD: Sidran Press.
Hennessy B, Hunter A, Grealish A. (2022) A qualitative synthesis of patients’ experiences of re‐traumatization in acute mental health inpatient settings. (PDF) Journal of Psychiatric and Mental Health Nursing. 2023 Jun;30(3):398-434.
Leung T, Schmidt F, Mushquash C. A personal history of trauma and experience of secondary traumatic stress, vicarious trauma, and burnout in mental health workers: A systematic literature review. [PubMed Abstract] Psychological trauma: theory, research, practice, and policy 2022 15, 213-221
Linley PA, Joseph S. (2007) Therapy work and therapists’ positive and negative well–being. Journal of Social and Clinical Psychology. 2007 Mar;26(3):385-403.
Orrù G, Marzetti F, Conversano C. et al (2021) Secondary traumatic stress and burnout in healthcare workers during COVID-19 outbreak. International Journal of Environmental research and public health. (PDF) 2021 Jan18(1) 337
Pearlman LA, Mac Ian PS. (1995) Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. (PDF) Professional Psychology: Research and practice. 1995 Dec;26(6):558.
Wells G, Shea B, O’Connell S. et al (2013) The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Cochrane. http://www.ohri.ca/programs/clinical_epidemiology/oxford.as
