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Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Factors associated with Type II trauma inoccupational groups working with traumatisedchildren: a systematic review

Clara A. M. Sage, Samantha K. Brooks & Neil Greenberg

To cite this article: Clara A. M. Sage, Samantha K. Brooks & Neil Greenberg (2017): Factorsassociated with Type II trauma in occupational groups working with traumatised children: asystematic review, Journal of Mental Health, DOI: 10.1080/09638237.2017.1370630

To link to this article: http://dx.doi.org/10.1080/09638237.2017.1370630

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http://tandfonline.com/ijmhISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 1–11� 2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2017.1370630

REVIEW ARTICLE

Factors associated with Type II trauma in occupational groups workingwith traumatised children: a systematic review

Clara A. M. Sage, Samantha K. Brooks, and Neil Greenberg

Department of Psychological Medicine, King’s College London, London, United Kingdom

Abstract

Background: There is evidence that ‘‘Type II trauma’’ (TTT) - repeated exposure to traumaticevents - can lead to the development of post-traumatic stress disorder (PTSD). TTT frequentlyoccurs in occupational groups working with children who are themselves victims of trauma.Aim: To conduct a systematic review identifying risk factors for/protective factors againstTTT-associated mental ill-health in employees working with traumatised children and explorehow this type of work impacts upon social functioning.Method: Databases were searched for relevant studies and supplemented by hand searches.Results: 836 papers were found and 13 were included in the review. The key themes identifiedwere coping mechanisms; social support; personality; demographics; occupational support;work-related stressors; traumatic exposure; organisational satisfaction; training/experience andimpact on life.Conclusion: Unhelpful coping strategies (e.g. denial) appeared to increase the risk of TTT.Training and strong support may be protective and work-related stressors (e.g. excessiveworkload) appeared detrimental. Despite some positive impacts of the work (e.g. becomingmore appreciative of life) many negative impacts were identified, demonstrating theimportance of minimising risk factors and maximising protective factors for staff at risk of TTT.

Keywords

Child welfare workers, complex trauma,secondary trauma, trauma, type II trauma

History

Received 26 October 2016Revised 14 June 2017Accepted 20 July 2017Published online 7 September 2017

Introduction

Experiencing a traumatic event can lead to the development

of post-traumatic stress disorder (PTSD), characterised by the

symptoms of re-experiencing, avoidance, negative thoughts/

feelings or hyperarousal. The Diagnostic and Statistical

Manual of Mental Disorders 5 (DSM 5; American

Psychiatric Association, 2013) states that PTSD is triggered

by exposure to actual or threatened death, injury or sexual

violation. This exposure can result not only from direct

experience but from witnessing the traumatic event happen to

someone else or learning that the traumatic event happened to

a close other. Importantly, it is also suggested that PTSD can

develop in individuals who experience repeated or extreme

exposure to aversive details of the traumatic event. This

suggests that those occupational groups who work with

traumatised individuals daily therefore experience second-

hand trauma exposure - such as social workers or therapists -

may be at risk.

‘‘Type I Trauma’’ refers to the development of PTSD-type

symptoms following a single, discrete traumatic incident,

while ‘‘Type II Trauma’’ (TTT) results from exposure to

repeated ordeals (Terr, 1991) – i.e. TTT involves symptoms of

PTSD arising following repeated exposure to traumatic

material over a period of time, rather than after one traumatic

event. Different constructs have been used to describe the

psychological effects that can be experienced by those close

to victims of trauma. Secondary traumatic stress (STS; Figley,

1983) refers to the development of PTSD symptoms in a

person close to the victim caused by indirect exposure to

traumatic material and subsequent identifying and empathis-

ing with the victim. This compassion felt towards the victim

can lead to compassion satisfaction (Stamm, 2005), referring

to the positive growth that can occur from helping traumatised

individuals. However, this compassion can also eventually

lead to the development of exhaustion or energy depletion,

referred to as compassion fatigue (Figley, 1995). If this

develops further then Burnout can occur; this is a syndrome

characterised by emotional exhaustion, depersonalisation and

reduced feelings of personal accomplishment (Maslach, 1982)

which can occur as a result of any occupational stress and is

therefore not limited to occupations affected by indirect

trauma. The final concept relevant to TTT is vicarious

traumatisation (McCann & Pearlman, 1990), which refers to

the psychological changes – such as changes in cognitions,

beliefs and assumptions about the self and others – that occur

as a result of empathising with a traumatised victim.

Exposure to TTT can lead to the development of PTSD or

other trauma-related reactions as described above and may

negatively affect the lives of those suffering from it by

altering their psychological balance and mental health

Correspondence: Neil Greenberg, King’s College London, Departmentof Psychological Medicine, Cutcombe Road, London, SE5 9RJ, UnitedKingdom. Tel: 020 7848 5351. E-mail: neil.greenberg@kcl.ac.uk

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(Cook et al., 2005) and reducing their ability to function

normally in society and in their workplaces (Breen et al.,

2014; Salston & Figley, 2003). Trauma-related reactions as a

result of TTT exposure are believed to be more prevalent than

they are currently recognised to be (Ford, 2009). For these

reasons it is important that these reactions are studied further

in order to gain a greater understanding of them, to identify

those who may be at greater risk and to ensure these people

are well-supported.

Research has identified the presence of PTSD and other

trauma-related reactions in occupational groups who work

with victims of trauma – for example, a systematic review has

shown that nurses are at risk of STS with papers in the review

reporting rates from 25 to 78% (Beck, 2011). In one study,

70% of therapists working with adult trauma clients were

found to be at high risk of STS (Sodeke-Gregson et al., 2013).

Evidence suggests that the development of STS is affected by

a number of factors including time spent engaging in

development activities, perceived supportiveness from man-

agers, personal trauma history and engagement in individual

supervision and self-care activities.

Less attention has been paid specifically to those employ-

ees who work with child victims of trauma. As yet, no review

has synthesised the results of studies in this area and therefore

there is no comprehensive overview of the risks and

implications associated with TTT which have been identified

to date. The aim of this paper was therefore to review the

literature exploring TTT in this group of workers in order to

identify any risk or protective factors that may influence the

development of a PTSD-type disorder or depression. The

review also aimed to identify possible mechanisms for ‘‘at-

risk’’ organisations to minimise the risks associated with TTT

exposure on their employees. In this paper PTSD is used as an

umbrella term to cover all PTSD and the associated trauma-

related reactions that can develop as a result of exposure to

TTT; however different terms (such as STS or compassion

fatigue) are used where those are the terms used in specific

papers.

Method

Inclusion criteria

To be considered relevant for inclusion in the review, studies

were required to:

� Be published in a peer-reviewed journal;

� Be published in the english language;

� Include participants over the age of 18 who were

employed in occupations involving working with trau-

matised children on a regular basis;

� Explore exposure to TTT;

� Consider either the risk/protective factors for developing

PTSD following TTT exposure in the workplace or the

impact of TTT on the physical, mental or social

wellbeing of employees.

Literature search

It should be noted that this paper, focusing on TTT in

individuals working with children, forms part of a wider

review on TTT in occupational groups in general; thus the

search terms are broad. The search was divided into two parts:

Search 1 used TTT/PTSD-related terms (e.g. ‘‘Type II

Trauma’’,’’ Vicarious Trauma’’’) and Search 2 used occupa-

tional terms (e.g. ‘‘emergency response’’, ’’social work*’’).

All Search 1 terms were combined with ’’OR’’, as were all

Search 2 terms, and then the results of the two searches were

combined using ’’AND’’. (Full search strategy available on

request.)

Online databases - EMBASE Classic 1947–1973,

EMBASE 1974–2015 Week 40, Ovid MEDLINE� 1946 –

October Week 1 2015, PsycINFO� 1806 – October Week 1

2015 and Web of Science - were searched and reference lists

of the papers considered eligible for inclusion were searched

for any relevant studies that were not identified during the

initial search.

All citations found as a result of the searches were

exported into RefWorks. One author (CAMS) removed

duplicate papers and evaluated titles for relevance, removing

clearly irrelevant papers to the study. Using the inclusion

criteria, the same author then screened abstracts of remaining

citations, again removing any clearly not relevant articles to

the review. The full-text articles of remaining citations were

retrieved and read and those that satisfied the study criteria

were included in this review. Any uncertainties about

inclusion were discussed with a second author (SKB) until a

decision could be made. Reference lists of full-texts meeting

the inclusion criteria were also hand-searched.

Data extraction and synthesis

Data extraction was standardised by the use of a pre-designed

Microsoft Excel spreadsheet. The spreadsheet headings

included first author; year of publication; country of study;

design; number of participants; occupation of participants;

primary aim of paper; psychological measures used; key

results and conclusions. Descriptive analysis was carried out

of the factors that emerged from the studies as either being

protective against or increasing the risk of developing PTSD

following TTT exposure and of the impact of this on the

occupational groups studied. Thematic analysis was used to

synthesise the data (Braun & Clarke, 2006). Common factors

were grouped together; for example, all data relating to

workload and management were grouped together under the

broad theme ‘‘occupational factors’’. A theme had to be

identified by at least two papers in order to be considered

relevant for discussion in this review. Further thematic

analysis focused on identifying actions which may be

protective for occupational groups exposed to TTT. The

final list of themes was reached when no new themes were

found in the data.

Study appraisal

Quality appraisal was performed in order to assess the quality

of the included studies. The quality of qualitative studies was

appraised using the qualitative research checklist (Critical

Appraisal Skills Programme, 2013) while quantitative studies

were appraised using a quality appraisal tool previously used

for similar reviews (Brooks et al., 2015, 2016). The quality of

quantitative studies was assessed in three areas: study design;

2 C. A. M. Sage et al. J Ment Health, Early Online: 1–11

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data collection and methodology; and analysis and interpret-

ation of results. Each study was given a percentage score for

each area and then these were combined to give an overall

score for each study (full quality appraisal tools available on

request).

Results

A total of 836 citations were found with the initial database

search, with an additional four from hand-searching. Of these,

13 papers were deemed relevant for this review. A flow

diagram of the screening process can be seen in Figure 1.

All papers were of cross-sectional design with seven being

quantitative, four being qualitative and two being mixed

methods. Seven of the papers were from the US, two from

Canada and Israel respectively and one each from Turkey and

Australia. Subjects worked in varied roles including child

welfare/protection officers (four papers), working with vic-

tims of child abuse (three papers) and investigating/working

against Internet child exploitation (three papers) and as

therapists, helpline counsellors and mental health workers

(one paper each). A more extensive overview of the studies

included in the review can be seen in Table 1.

A number of themes emerged from these studies and these

were divided into risk/protective factors which were inherent

to the individual or the individual’s social surroundings;

factors which were related to the individual’’s occupational or

work environment and finally the impact that TTT had on

employees lives. A summary of the evidence for each theme

can be seen in Table 2.

On average the quality of the studies was very high. Both

qualitative and quantitative studies had a mean total quality

percentage score of 94.44%. Quantitative studies tended to

have scored highest on aspects of data collection and lowest

on aspects of analysis and interpretation.

Individual/social factors

The most prevalent theme to arise from the individual or

social factors was the role of an individual’s coping mech-

anisms in the development of a PTSD-type disorder following

exposure to TTT. Poor coping mechanisms such as tobacco

and alcohol consumption and the use of denial as a coping

strategy was associated with an increased risk of developing

STS amongst Internet Crimes Against Children (ICAC)

personnel, of whom 43.7% were identified as having moder-

ate to severe levels of STS (Bourke & Craun, 2014). Exercise

was hypothesised to be a positive coping strategy in this

paper, however no significant association between exercise

and STS was found. However, other studies suggested that

positive coping strategies may be protective against PTSD-

type disorders. One study (Furlonger & Taylor, 2013) found

Figure 1. Flow chart of screening process. Identification

Screening

Eligibility

Included

836 papers found through database searching

420 papers after duplicates removed

224 papers remained after titlescreening

196 papers removed through titlescreening

99 papers remained after abstract screening

125 papers removed through abstract screening

19 full-text articles assessed for eligibility

6 papers excluded as not eligible for inclusion

19 papers deemed appropriate for current review

80 papers deemed potentially relevant for the wider TTT review

4 papers found through hand searching

13 studies included in review

DOI: 10.1080/09638237.2017.1370630 Type II trauma in child welfare workers 3

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Table 2. Summary of evidence.

Theme Evidence

Coping mechanismsSocial coping strategies/Occupational coping

strategies

Increased tobacco/alcohol consumption in past year and trying to cope withdenial were both related to higher Secondary Traumatic Stress (STS)levels¼ poor coping mechanisms (Bourke & Craun, 2014)

Counsellors who had experienced regular supervised practice had aboveaverage positive coping strategies with higher use of problem-solving andseeking social support and below average use of avoidance (Furlonger &Taylor, 2013)

Coping strategies included walking and exercising, taking a break fromoffice/leaving early, spending time with families and engaging in hobbies(Van Hook & Rothenberg, 2009)

Occupational coping strategies included gradual introduction to images, timeto prepare mentally, monitoring self and taking breaks, remaininganalytical and determining when and where to view images was best forthem. Social coping strategies included exercise, grounding exercises(yoga), music, knowing when to switch off from work and leave work atwork (Burns et al, 2008)

Occupational coping strategies included therapy and consultation. Socialcoping strategies included self-care, family, religion and spirituality(Cohen et al., 2015)

36% found social support to be the most effective coping strategy, otherstrategies included out of work hobbies, religion and focusing on positiveimpact of their work (Perez et al., 2010)

Social support Social support outside of work was the third strongest predictor of lower STSscores (Bourke & Craun, 2014)

Increased supportive relationships led to decrease ST and exhaustion andgreater levels of professional efficacy. 36% reported social support to bethe most effective coping strategy (Perez et al., 2010)

Social support and spending time with family was identified as a protectivefactor against ST and VT (Burns et al., 2008; Cohen et al., 2015 ; VanHook & Rothenberg, 2009)

Individual factorsPersonality factors/Self- efficacy

Self-efficacy was significantly related to disengagement and secondarytrauma but not to burnout (Perron & Hiltz, 2006)

As disturbances of relational capacity and sense of being out of controlincreased – as did distress levels (Regehr et al., 2004)

Demographic factorsAge/Gender

Younger age was associated with higher risk of ST (Bonach & Heckert, 2012)Males had lower STS scores (Bourke & Craun, 2014)CS lower and burnout and ST higher in younger individuals. ST and burnout

higher in females (Van Hook & Rothenberg, 2009)Occupational supportUnion support/Managerial support/Peer support/

Supervised practice

Internal and external job support were significantly related to ST. A salientwork related concern was over poor support from leadership (Bonach &Heckert, 2012)

Positive supervisory support was the strongest predictor of lower STS scores.Having co-workers who could be relied on was also a predictor of lowerscores (Bourke & Craun, 2014)

Counsellors who had experience in regular supervised practice exhibitednormal levels of VT but not a significant relationship (Furlonger & Taylor,2013)

Increased reliance on coworkers positively correlated to STS, exhaustion andcynicism. 18% wanted increased management concern (Perez et al., 2010)

As union support increased, as did distress. Managerial support played nosignificant role (Regehr et al., 2004)

Understanding supervision and organisational support (training opportu-nities, right equipment and access to psychological support) wereprotective factors (Burns et al., 2008)

Supervision, peer support and team work were major sources of support(Cohen et al., 2015)

Work related stressorsLevel of employment/Work load/Type of work/

Leadership

As workload stressors increased, as did distress. Difficult clients, organisa-tional change and public scrutiny also increased distress (Regehr et al.,2004)

CS was lower in dependency case managers (directly responsible for the childtherefore high stress role), they also were at highest risk of burnout. Peoplewith supervisory roles had higher levels of ST than lower level employees.Employees reported case load, staff shortages and lack of admin support asadditional stressors (Van Hook & Rothenberg, 2009)

Work related concerns included poor teamwork and no room for debriefing(Bonach & Heckert, 2012)

Balanced work load, team work and internal resources were all importantfactors influencing VT (Cohen et al., 2015)

For 32% workload and management issues were important difficulties. 25%wanted reduced workload and 21% wanted job rotation (Perez et al., 2010)

(continued )

DOI: 10.1080/09638237.2017.1370630 Type II trauma in child welfare workers 5

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that counsellors working for a children’s counselling helpline

exhibited normal levels of vicarious traumatisation, as they

fell within the normalised range of 45–55 on the Trauma

Attachment and Belief Scale (Pearlman, 2003) and also had

low scores on the Impact of Events Scale, which is a measure

of PTSD symptoms. These counsellors were also found to

Table 2. Continued

Theme Evidence

Traumatic exposureDuration of exposure/Time since exposure/Amount

of exposure

Time working in law enforcement and time in the field of child exploitationwere related to STS but did not reach significance (Bourke & Craun,2014)

Time working with disturbing media was significantly correlated with STSbut not with burnout. Time since first exposure was significantlycorrelated with STS and cynicism. Number of disturbing media cases notrelated to burnout or STS. Overall exposure to disturbing media wasrelated to increased ST (Perez et al., 2010)

Number of years of employment was not related to secondary trauma orexhaustion but was related to the disengagement burnout subscale (Perron& Hiltz, 2006)

As length of time since the traumatic incident decreases and as number ofevents in the past year increases – distress also increases (Regehr et al.,2004)

CS, ST and burnout were not related to time at agency (Van Hook &Rothenberg, 2009)

Organisational Satisfaction STS was not related to organisational satisfaction (Bonach & Heckert, 2012)High organisational satisfaction associated with lower disengagement and

exhaustion but not secondary trauma (Perron & Hiltz, 2006)Training & experience The need for information about secondary trauma prevention and interven-

tion was highlighted. Suggestions included ongoing training and stressmanagement and nationally mandated training funded by regulatoryagency (Bonach & Heckert, 2012)

Training and experience were important factors in relation to the develop-ment of STS (Burns et al., 2008)

Training and prior professional experience were important protective factors(Cohen et al., 2015)

Positive impact on lifePersonality improvement/Appreciation of life/

Impact on relationships/Compassion satisfaction/Pride in work

Pride in ones work was high (Bourke & Craun, 2014)50.7% had good potential for CS, 22.6% had high potential and 1.7% had

extremely high potential. Those with higher CS had lower levels of CF(Conrad & Kellar-Guenther, 2006)

Could relate to children and feel sympathy which led to a strong sense ofcommitment to the children. Very high satisfaction from their work.Positive feedback from children and the school helped (Cohen et al., 2015)

More open minded, tolerant and flexible (at work and at home). Moreappreciative of their own lives and not as bothered by the small negativethings, realised that they could have it a lot worse by comparing their liveswith the children’s lives. By seeing children focusing on developingrelationships made them appreciate their interpersonal relationships more(Hyatt-Burkhart, 2014)

Negative impact on lifeIntent to leave job/Distrust of public/Increased

protectiveness/Impact on parenthood/Intrusion

High STS scores were associated with higher general distrust of the world,overprotectiveness, turnover intentions and lower job satisfaction (Bourke& Craun, 2014)

Law enforcement workers (LEWs) had more democratic and authoritarianparenting styles than control group – strict, overprotective and authori-tarian parenting increased with number of abuse cases seen per year.LEWs also had more overprotective and authoritarian parenting attitudescompared to health workers (Dursun et al., 2014)

STSD, exhaustion and cynicism positively correlated to turnover intentionsand thinking about leaving agency. Increased sense of general distrustpositively correlated to ST (Perez et al., 2010)

Work with the children brought back negative memories from their ownchildhood, including flashbacks and caused them to identify with thechildren. Children’s stories traumatised them ‘‘it was so extreme that I gotscared. the drawing haunted me’’. Intrusion into private lives (50%), threetherapists found preoccupation persisted after therapy stopped and dreamtabout them (Cohen et al., 2015)

Identification of two interrelationships between officers professional identityand maternal identity. ‘‘Anxious motherhood’’ - anxiety from experiencesand seeing negativity of the world causes stress in the form of increasedmaternal anxiety, leading to trying to increase protection. Secondly‘‘reflective motherhood’’ - where exposure to abusive/neglectful parentsincreases own stresses associated with motherhood and causes them toreassess own mothering (Menashe et al., 2014)

CS: compassion satisfaction; CF: compassion fatigue; ST: secondary traumatisation; VT: vicarious trauma.

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have above average positive coping strategies, including

problem-solving and seeking social support, according to the

Coping Strategy Indicator (CSI) (Amirkhan, 1990).

Furthermore, avoidance, a negative coping strategy, was

used at below average levels. These findings indicate that the

positive coping mechanisms utilised by these counsellors may

have protected them from developing vicarious traumatisa-

tion, unlike in ICAC personnel where their negative coping

mechanisms (such as denial) were associated with higher STS

levels. Another study found that using psychological

approaches to work was an effective coping mechanism for

internet child exploitation personnel (Burns et al., 2008);

examples included gradual introduction to images, allowing

time to prepare mentally, remaining analytical, taking breaks

and determining the best time and location to view the

images. Participants in this study also reported that they found

exercise, yoga and listening to music to be effective in helping

them cope with their work. Other studies identified similar

positive coping strategies: 25% of child pornography law

enforcement officers found off-work hobbies to be important

(Perez et al., 2010); 27.5% of child welfare staff believed they

benefitted from walking and exercise (Van Hook &

Rothenberg, 2009); 18.2% of child welfare staff found

engaging in hobbies to be beneficial (Van Hook &

Rothenberg, 2009) and self-care including hobbies such as

writing and art, as well as relaxation, was found to be

protective against secondary traumatic stress in child therap-

ists (Cohen et al., 2015).

Seeking and receiving social support was also found to be a

key coping strategy as well as a protective factor against

developing a PTSD-type disorder in the presence of TTT. In

child pornography law enforcement officers obtaining social

support from family, friends and co-workers was found to be the

most effective coping strategy, identified by 36% of officers

during their qualitative interviews (Perez et al., 2010). Social

support was also protective in child therapists (Van Hook &

Rothenberg, 2009), Internet child exploitation personnel (Burns

et al., 2008), ICAC personnel (Bourke & Craun, 2014) and child

welfare staff, where spending time with families was seen as

helpful by 25.7% of the employees (Cohen et al., 2015).

The other main themes identified which related to

individual factors were the demographic and personality

factors of the personnel. It was found that younger employees

and women were at increased risk of developing STS in

comparison with older employees and men (Bonach &

Heckert, 2012; Bourke & Craun, 2014; Van Hook &

Rothenberg, 2009). The personality factors which were

associated with a higher risk of developing STSwere disturb-

ances of relational capacity and sense of being out of control,

with self-efficacy being found to be a protective personality

factor (Perron & Hiltz, 2006; Regehr et al., 2004).

Occupational factors

A salient theme for which there was concordance amongst the

papers was the importance of support from co-workers and

management. For forensic interviewers of abused children, both

internal job support (support from colleagues and supervisors)

and external job support (support from clients and the public)

were significantly related to STS according to the Secondary

Traumatic Stress Scale (STSS) (Bonach & Heckert, 2012). In

the same study, responses to an open-ended qualitative question

suggested poor support from leadership was an important work-

related concern for these employees. Good managerial support

was also highlighted as being important in helping Internet child

exploitation workers cope with their work (Burns et al., 2008),

child therapists (Cohen et al., 2015) and ICAC task force

personnel, where positive supervisory support was one of the

strongest predictors of lower STSS scores (Bourke & Craun,

2014). Supportive relationships were associated with lower

secondary traumatic stress in child pornography law enforce-

ment officers, along with a decrease in exhaustion and an

increase in professional efficacy (Perez et al., 2010); however, a

substantial number of participants did not report supportive

relationships, with 18% expressing management concern and

32% reporting management issues to be important difficulties

they faced. Helpline counsellors who reported regular super-

vised practice were especially likely to have ‘‘normal’’

vicarious traumatisation scores according to the Impact of

Event Scale-Revised (IES-R) although vicarious traumatisation

was not completely eliminated (Furlonger & Taylor, 2013).

Other forms of occupational support such as peer support and

teamwork were key positive factors for approximately 33% of

child therapists (Cohen et al., 2015); however, in child welfare

staff, an increase in union support was unexpectedly associated

with an increase in distress (Regehr et al., 2004). In the latter

study managerial support was not found to play a significant

role.

Workload was highlighted as being an important stressor to

many occupational groups, including 36% of child therapists

(Cohen et al., 2015), 25% of child pornography law enforce-

ment officers (Perez et al., 2010) and 22% of child welfare

staff members (Van Hook & Rothenberg, 2009). Furthermore,

for child welfare staff working for Children’s Aid Society the

relationship between distress and workload stressors was the

strongest relationship observed (Regehr et al., 2004). Forensic

interviewers of abused children expressed poor support from

leadership, poor teamwork and lack of feeling supported or

validated by colleagues following emotionally draining work

as work-related concerns and suggested implementing

ongoing training and stress management might improve

coping (Bonach & Heckert, 2012). Work-related stress was

not only caused by workload but also by work role, as child

welfare staff members who had supervisory roles had higher

levels of STS according to the Professional Quality of Life

Survey(ProQOL) than lower-level employees and burnout was

higher in dependency case managers, who dealt directly with

the affected cases (Van Hook & Rothenberg, 2009). 11.1% of

these child welfare staff indicated the need to increase staff

and 20.9% indicated the need to increase admin support.

A theme for which there was mixed findings was the

importance of traumatic exposure, including the duration of

the exposure, time since the exposure and number of

traumatic cases exposed to. Some studies found that increased

traumatic exposure incurred an increased risk for the devel-

opment of PTSD-type disorders in the presence of TTT; in

child welfare staff, as the number of traumatic events exposed

to in the last year increased, so did distress as measured by the

IES and post traumatic growth measured by the stress related

growth scale (Regehr et al., 2004). Child pornography law

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enforcement officers who had worked with traumatic material

for a longer period of time scored higher on the STSS and the

cynicism subsection of the Maslach Burnout Inventory (Perez

et al., 2010). The qualitative section of this study also found

traumatic exposure to be important with 46% of officers

stating that the viewing of images was the most disturbing

thing about their work. However, even this study did not

unanimously find traumatic exposure to be a risk factor for

the development of STS, as the number of disturbing cases

seen was not related to burnout or STS. Two other studies also

found traumatic exposure not to be a risk factor, firstly in

forensic interviewers of abused children, where there was also

no correlation between STSS scores and years of employment

or number of interviews conducted each month (Perron &

Hiltz, 2006) and secondly in ICAC task force personnel where

the relationship between time working in the field and STS

did not reach significance (Bourke & Craun, 2014). Another

study showed that not only was burnout not related to

exposure but also that compassion satisfaction was not related

to time spent working for the child welfare agency (Van Hook

& Rothenberg, 2009).

Other occupational factors impacting on TTT included

training , experience and organisational satisfaction. During

their interviews 50% of child therapists expressed training as

being important and 43% considered prior professional

experience to be protective (Cohen et al., 2015); these were

also important factors for Internet child exploitation personnel

(Burns et al., 2008). Organisational satisfaction was not

significantly related to STS (Bonach & Heckert, 2012) but

was related to exhaustion and lower disengagement in

forensic interviewers of abused children (Perron & Hiltz,

2006).

Impact on life

The third aspect of TTT that this review revealed was the

impact that this type of work could have on participant’s lives;

this fell into two categories, positive and negative effects.

ICAC task force personnel who had high levels of STS

suffered negatively as a result but nevertheless pride in one’s

work was high (Bourke & Craun, 2014). There was a similar

finding in child protection staff where 64.2% were at

moderate to high risk of compassion fatigue but 75% had

’’good to high’’ potential for compassion satisfaction; also

those with higher compassion satisfaction had lower levels of

compassion fatigue (Conrad & Kellar-Guenther, 2006). Some

studies also identified more specific positive effects of

working with affected children. For example, child therapists

felt able to relate to the children and as a result felt sympathy

and a stronger sense of commitment to the children, which

subsequently led to very high satisfaction from their work

(Cohen et al., 2015). Mental health workers suggested that as

a result of their work they were more open-minded, tolerant

and flexible (Hyatt-Burkhart, 2014). They were also more

appreciative of their own lives and less occupied by ‘‘small’’

things deemed insignificant by the lives of the children and

seeing the children focussing on developing relationships

made them appreciate their own relationships.

The negative effects of TTT exposure were often due to the

avoidance, hyper-arousal and intrusion of PTSD; 50% of child

therapists suffered from high levels of intrusion into their

private lives, with this preoccupation persisting in three

therapists after the therapy stopped (Cohen et al., 2015).

ICAC task force personnel who suffered from high levels of

STS also had higher general distrust of the world, greater

overprotectiveness, more turnover intentions and lower job

satisfaction (Bourke & Craun, 2014). Higher turnover inten-

tions and general sense of distrust were also present in child

pornography law enforcement officers where they correlated

with STS levels and with exhaustion and cynicism on the

burnout scale (Perez et al., 2010). Furthermore, TTT affected

employees relationships with their own children. Healthcare

and law enforcement workers who work with abused children

were found to have more democratic and authoritarian

parenting styles than a comparison group of employees in

the same occupation who were not working with abused

children; these parenting styles increased with number of

cases seen per year (Dursun et al., 2014). In Israeli child

welfare officers ‘‘anxious motherhood’’ and ‘‘reflective

motherhood’’ were identified, the first causing increased

maternal anxiety and increased protection and the latter

causing them to reassess their own mothering styles, showing

how the stress of TTT influenced their everyday lives

(Menashe et al., 2014).

Discussion

This study aimed to identify: the presence of TTT in

occupational groups working with traumatised children; the

impact that exposure to TTT can have on employees work and

personal life and ways to reduce PTSD levels following TTT

exposure. A number of key findings emerged which will now

be discussed, along with suggestions for future occupational

management which could protect employees in at-risk

occupations.

Many studies highlighted the importance of effective

coping mechanisms in reducing the risks associated with

TTT. The effect of coping strategies on developing PTSD-

type disorders following TTT exposure has been identified

elsewhere; for example, in a study looking at vicarious

traumatisation in clinicians working with survivors of trauma

and torture, appropriate coping strategies were found to

minimise distress and maximise wellbeing (Moulden &

Firestone, 2007). The identification of positive and negative

coping mechanisms might aid employers of TTT-exposed

staff in explaining to their employees which coping mechan-

isms would be more beneficial to adopt and which would be

better to avoid. For example, it was suggested that tobacco

and alcohol consumption were detrimental to psychological

wellbeing whereas spending time on hobbies such as exercise

were protective. Although it should be noted that a causal

relationship cannot be inferred and it may be that those who

feel more distressed are more likely to smoke or drink,

identification of positive coping strategies may still be helpful

and identification of aberrant coping styles by managers or

colleagues might also act as early indicators of a current or

impending poor state of mental health. Previous research has

shown that educating people, such as patients waiting for

worrying genetic diagnoses, about effective coping strategies

can help minimise psychological distress (Phelps et al., 2013).

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Education on coping strategies in the workplace has also been

found to be effective; for example, Shimazu et al. (2006)

found that a stress management course including coping skills

reduced employees psychological distress. Therefore, it may

be useful for employers to encompass education about

successful coping into their workplace, including encourage-

ment of engaging in off-work hobbies, taking time to relax

and seeking social support. There were other coping strategies

deemed to be ineffective which employers could potentially

modify in the workplace. For example, denial and avoidance

were shown to be deleterious, supporting previous research on

social workers treating trauma clients (Gil & Weinberg,

2015), whereas acknowledging the risks associated with

trauma work and planning one’s work in light of this helped

some occupational groups. So, good supervision and planning

to help overcome the tendency to ‘‘avoid’’ or ‘‘deny’’ could

help protect employees: employers could highlight the

importance of taking time to prepare mentally with gradual

introduction to traumatic material and taking necessary

breaks. Additionally, periodic manager-led discussions of

risks might help overcome denial.

The demographic risk factors identified included being

younger and being female, the former of which has also been

identified as being a risk factor for trauma treatment

therapists (Craig & Sprang, 2010) and sexual assault nurse

examiners (SANE; Townsend & Campbell, 2009). The

identification of these as risk factors means employers

could be more vigilant with these employees, immersing

them more slowly into the job with more thorough training,

including better preparation for the role and information

regarding the stressors associated with it.

Many studies showed that strong social support was

effective in reducing the risks associated with TTT.

Although confiding in family members or friends could be

beneficial, further research is required to identify whether this

could lead to an increased risk of experiencing trauma-related

reactions in these confidants. Studies have shown that spouses

of military personnel suffering from PTSD are at increased

risk of suffering from secondary traumatisation; one study

found that spouse secondary traumatisation levels positively

correlated with PTSD levels in their husbands who are former

prisoners of war (Greene et al., 2014). Social support could be

balanced out with the provision of support in the workplace,

as many studies in this review identified the importance of

professional and managerial support; this would lessen the

pressure on family members and friends. Social events could

be beneficial in organisations where there is a high level of

work-related stress, as these could be a useful release of

tension for all employees. Although one study on child

welfare staff (Regehr et al., 2004) showed contradictory

results, with union support associated with increased distress,

it is possible that the relationship is the reverse of what it

seems and that rather than union support causing distress, it is

the distressed staff members that seek out greater union

support. It must also be noted that this particular study had a

low response rate (30%) therefore it is possible this skewed

the results as it may have been the less busy and therefore less

prone to secondary traumatisation staff who responded. It is

also possible that distressed staff could view their leaders less

positively and therefore, as causation cannot be certain, this

could negatively skew some of the results regarding man-

agerial support. Nevertheless, occupational support was

identified as a protective factor in many studies and has

also been identified in other occupational groups including

SANE (Townsend & Campbell, 2009). Therefore, this review

suggests that supportive, understanding and easily available

managerial support should be a key aspect of any occupa-

tional group dealing with traumatised children.

Findings regarding the importance of traumatic exposure

were surprisingly mixed. We certainly did not find that

greater exposure to TTT was inevitably associated with

greater risk of PTSD. However, it is possible that there were

other factors influencing the results of studies where a

significant relationship was not found such as selection,

training and management style. As traumatic exposure cannot

be avoided due to the nature of their work, it is important that

employees in at-risk occupations are prepared to the greatest

possible extent for the trauma exposure. This could include

teaching sessions to explain the nature of TTT so that

employees are aware of the risks they are facing and

continuous training in how to cope with the problems

associated with it. The finding that training and experience

were important protective factors in both studies where they

were investigated supports this suggestion. As peer support

was also an important factor, Trauma risk management

(TRiM; Greenberg et al., 2008), which aims to educate

employees in how to recognise problems in their colleagues

and how to best support them, could be utilised in these at-

risk occupational groups. TRiM has been shown to improve

attitudes towards mental health in employees of at-risk

occupations, including significantly improving attitudes

about help-seeking, PTSD and stress in military personnel

(Gould et al., 2007) and showing possible long-term benefits

in railway workers (Sage et al., 2016). TRiM training and

proper education could prepare employees in at-risk occupa-

tions for the consequences of exposure to TTT in themselves

and their peers and could therefore have an effect in reducing

the prevalence and risk of PTSD-type disorders when this

exposure occurs.

Teaching sessions could also provide information regard-

ing the effects that TTT exposure can have on employees

lives. This review identified many implications of exposure to

TTT, perhaps most importantly the impact that it can have on

employees relationships with their own children. Therefore,

sessions that increase awareness about the potential risks

could allow for employees to psychologically prepare for and

possibly prevent a change in their parenting. These sessions

could make employees aware of ways in which they can be

helped if these changes arise, including which support and

counselling sessions are available to those who require it.

Employers might also consider providing educational sessions

for the families of TTT-exposed staff in order to help them

detect adverse psychological impacts at an early and more

treatable, stage.

Limitations

There were a number of limitations to this review. Firstly, a

number of the studies had a small sample size and the total

number of studies was also small, therefore the amount of

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data collected was limited and this could explain why some of

the results did not reach significance, as a larger sample size

may have been needed for significant results to be obtained.

Secondly, all of the studies were cross-sectional, therefore it

was not possible to observe how TTT exposure might

progress with time spent working in this field. It is also

possible that as the studies were cross-sectional there may

have been bias in the identification of TTT, as people who

were severely affected by exposure to TTT may have stopped

working and therefore been unable to participate in the

studies. Thirdly, as results were often obtained from ques-

tionnaires sent out to many employees, a selection of whom

then chose to respond, people who were more affected by

TTT might have been more likely to respond to the

questionnaire, as it was relevant to them, leading to a positive

selection bias. This was also present in some papers that

specifically chose affected personnel to be included in their

study. Also, although many of the studies did look at STS

using the STSS, which focuses specifically on symptoms

suffered as a result of one’s occupation, it is possible that

some of the stress recorded by these studies could actually be

reflecting the stress caused by other non-occupational stres-

sors. This bias is more likely in studies that were not directly

measuring STS, e.g. qualitative studies, but could potentially

be present in all the studies as a result of unrelated stressors

subconsciously affecting participants responses. Finally, there

are limitations with our own review methodology – for

example, our searches were limited to the Embase,

MEDLINE�, PsycINFO� and Web of Science databases

and we did not search more specialised databases. This may

mean that relevant papers were missed, although our hand-

searching of key reference lists may have mitigated this. Our

decision to limit the review to English-language papers only

may also have led to us excluding relevant papers; future

reviews may consider translating foreign-language papers.

Conclusion

This review highlights a number of factors which may affect

trauma-related reactions in occupations at risk of exposure to

TTT events, specifically those who work with traumatised

children. Our results suggest that many of the risk factors for

the development of disorders such as PTSD identified in this

study can be controlled and modified through good supervi-

sion by trained, and aware managers. Additionally, educating

employees about coping styles and the potential impact of

TTT and considering providing information to families too,

may well be beneficial. If effective coping mechanisms are

utilised along with strong support both at home and in the

workplace, then the risk of developing PTSD-type disorders

could be reduced. Strong, well-organised management that

avoids its employees having too great a workload should

accompany effective workplace support. Given the likely

negative impact of TTT on employees this paper provides

strong evidence that employers should pay attention to its

effects and seek to mitigate its impact where possible.

Acknowledgements

The research was funded by the National Institute for Health

Research Health Protection Research Unit (NIHR HPRU) in

Emergency Preparedness and Response at King’s College

London in partnership with Public Health England (PHE).

The views expressed are those of the author(s) and not

necessarily those of the NHS, the NIHR, the Department of

Health or Public Health England. The funding body did not

play a role in the design, collection, analysis or interpretation

of data; the writing of the manuscript; or the decision to

submit the manuscript for publication.

Declaration of interest

NG runs a psychological health consultancy which provides

among other services TRiM training.

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DOI: 10.1080/09638237.2017.1370630 Type II trauma in child welfare workers 11

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