By Maria Masotta, PsyD
Posted on June 15, 2011 – Providing healthcare in criminal justice environments such as jails, prisons and community corrections is challenging. At the beginning of each work day, most employees must leave their personal cell phones in the car or a locker; each person is searched as is property brought in to the facility. In some facilities, employees are not allowed to bring in food or water. Astute staff leave their personal identities at the door. They refrain from displaying pictures on desks or in their offices. They do not discuss hobbies, weekend activities, friends, families, likes or dislikes in public areas. They keep the personal private, to avoid having an inmate learn something revealing and use it.
Working in correctional environments comes with risks such as the threat of physical harm from workplace assaults or exposure to infectious disease. For some, there’s the frequent physical and emotional discomfort of working in such an environment. And then, there’s the less obvious, insidious risk that the clinical work will negatively impact who one is. This destructive force can erode one’s view of the world, of other people, and of oneself. It can infiltrate one’s identity, personal relationships, core values and sense of efficacy. These challenges are unavoidable and therefore critical to understand. Despite and in some cases because of them, doctors and nurses continue to provide healthcare in correctional environments. For many, the decision to pursue correctional healthcare was a calling. For others, it was an interesting opportunity worth exploring. But for all, it can be challenging, interesting, rewarding work – work that can only be sustained by a professional passion and dedication in the face of adversity and competing demands.
What Is Trauma?
To fully grasp the concept of vicarious traumatization, we must briefly review the concept of trauma. Trauma can occur when an individual has either experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and the person’s response involved intense fear, helplessness, or horror (APA, 2000, p. 467). Events such as experiencing or witnessing emotional, physical or sexual abuse or assault, an extremely painful or frightening medical procedure, catastrophic injuries or illnesses, having been mugged, domestic violence, burglary and combat can be traumatic.
Examples in the correctional environment include: an unexpected inmate or peer death at work via suicide or following an assault; an inmate or colleague being seriously harmed in the institution; threats to family members or colleagues by an inmate; an inmate disclosing traumatic experiences or reporting details of a traumatic crime.
Trauma History Among Inmates
A history of trauma, often multiple traumas, is pervasive among inmate populations. Based on a sample of over 7500 male and female inmates, Wolf and Shi (2009) found that inmates have experienced high prevalence of trauma. With reports of physical abuse in male inmates ranging between 43% and 66%; sexual abuse between 7% and 26%; and emotional abuse between 35% and 53%. Similarly female inmates reported a history physical abuse ranging between 38% and 77%; of sexual abuse between 31% and 65%; and emotional abuse between 36% and 59%.
Traumatization and Vicarious Traumatization
Healthcare clinicians working in the criminal justice system can be exposed to trauma either directly or vicariously. Direct exposure includes witnessing a use of force, witnessing or responding to self-injurious or suicidal behaviors, and being threatened or assaulted. Vicarious exposure can occur when hearing details of violent crimes, learning of inmates’ trauma in the community or prison and witnessing an inmate re-live or re-enact a trauma. Clinicians may experience horror, terror or revulsion in reaction to these adverse experiences and these emotions can lead to intense and potentially chronic stress reactions, including chronic anger. Similarly, facing antisocial behavior on a daily basis can lead to distrust and hardened anger which may then grow into contempt or disengagement. Vicarious Traumatization (VT) was first identified by McCann and Pearlman (1990) and expanded on by Pearlman and Mac Ian (1995) as the transformation that occurs within the therapist (or other trauma worker) as a result of empathic engagement with the clients’ trauma experiences and their sequelae (p. 558). Conditions that can give rise to VT include, listening to graphic descriptions of horrific events, bearing witness to people’s cruelty to one another, and witnessing and participating in traumatic reenactments, (id., at p. 558). In correctional healthcare clinicians, VT can result in the alteration of one’s views of themselves, the world and others (Pearlman & Mac Ian, 1995). This can occur after hearing an inmate’s disclosure of traumatic events, regardless of whether these events occurred prior to incarceration or during their current incarceration. This can also occur after the clinician witnesses an inmate assault or a forced move.
Healthcare personnel including doctors, midlevel practitioners and nurses, are all likely to experience vicarious trauma exposure at some point during their career. Some may be exposed to one of these experiences or a variety of them several times a day. VT can also result in disruptions in spirituality and one’s ability to tolerate strong emotions (Neumann & Gamble, 1995) as well as disruptions to our schemas (cognitive frameworks or mental representations) about safety, trust, intimacy, and control (McCann & Pearlman, 1990). Pearlman and Mac Ian (1995) suggest that VT can occur after years of chronic exposure. The cumulative nature of the work can lead to PTSD-like symptoms that persist for months or years after providing trauma treatment (McCann & Pearlman, 1990). Given the intensity of correctional environments, the authors also suggest that VT can develop after one incident. Not surprisingly, Secure and prison settings were consistently related to higher level of distress (Moulden & Fireston, 2007, p. 78).
These experiences exemplify the impact that working in the criminal justice system has on the clinician’s view of self, others and the world. Just as PTSD can be explained as the body’s normal reaction to an abnormal, terrible experience, VT is a normal reaction to the stressful and sometimes traumatizing work of treating trauma survivors (McCann & Pearlman, 1990). Thus, VT is not a reflection of pathology in the therapist, nor intentionally inflicted on the part of the survivor client, (Pearlman & Mac Ian, 1995, p. 558). It can best be conceptualized as an occupational hazard for those who work with trauma survivors, (Pearlman & Mac Ian, 1995, p. 558). The authors opine that, given the high incidences of trauma in the inmate population, VT is without a doubt an occupational hazard of providing healthcare in the criminal justice system.
Moulden and Firestone (2007) summarize the literature and find that that there are higher incidents of VT in clinical staff employed in secure settings, such as a prison or secure hospital unit, when compared to clinical staff working in outpatient or community units. Clinicians in secure settings experienced increased emotional exhaustion and increased depersonalization. Staff in secure settings also experienced decreased feelings of accomplishment. It was believed that elevated levels of VT could be the result of the dangerousness of the environment and clientele, as well was the isolated work environment (Moulden & Firestone, 2007). While this article focused on mental health clinicians, it is this writer’s opinion that these findings would generalize to all healthcare providers.
Protecting Clinicians
Sommer (2008) indicated that as protective factors increase, trauma symptoms decrease. Protective factors include professional experience, income and post-graduate training and supervision (Baird & Kracen, 2006). Correctional healthcare clinicians can and must protect themselves from the occupational hazards of providing treatment in criminal justice settings. There are a variety of strategies one can utilize.
Recognizing VT
Correctional healthcare clinicians with several protective factors and few risk factors may still experience VT. Some signs and symptoms that are indicative of VT are behavioral changes in relation to interactions with an inmate or work responsibilities, intrusion of inmates’ stories or imagery into the provider’s life, burn-out, feeling overwhelmed, withdrawal from inmates or colleagues, impaired self-care, numbing, flooding, denial, PTSD symptoms, nausea, headaches, sleep disturbances, difficulty trusting others, feelings of horror, hypervigilance related to keeping self and loved ones safe, exhaustion, and sexual difficulties (McCann & Pearlman, 1990; Moulden & Firestone, 2007; Neuman & Gamble, 1995; Sommer, 2008;).
If a clinician experiences VT, revisiting the use of preventative strategies above can help. Additionally, increased supervision and/or personal therapy depending on the nature of the distress can be useful. In supervision, the use of healthy coping strategies can be discussed:
As providers tell their clients, healthy coping strategies take time and are not a quick fix. Many times, when stressed individuals are drawn to unhealthy coping strategies, such as drugs, alcohol, denial and disengaging from friends, family, colleagues or enjoyable hobbies and activities. While these strategies provide immediate relief or numb the symptomatology, they can be associated with higher symptoms of VT (Schauben & Frazier, 1995) and have long term consequences. Conversely, those who used active coping, planning, sought emotional or instrumental support (talking with family friends or consulting with colleagues) and used humor experienced less VT (Schauben & Frazier, 1995).
This article began with a reference to the challenges of working in the criminal justice system with which clinicians are faced on a daily basis because they are passionate about the work. To maintain this passion it is essential to maintain optimism and hopefulness about the clientele, colleagues and the system itself often in the face of conflicting or contradictory information and experiences. Providers should identify and talk about the positive aspects of the work they do with colleagues, families and friends. One of the most impressive things about working in corrections is the strength of the inmate population, despite, for many of them, a life of hardship, poverty and abuse. Recognizing and cherishing human resilience is powerful. McCann and Pearlman’s (1990) believe that maintaining optimism and hopefulness in the face of tragedy is an essential component to making our work with victims possible, (pp. 146-147). They further recommend that practitioners acknowledge and confirm the many positive experiences in our work as well as the positive impacts this has had on ourselves and our lives. It is important to remind ourselves and others that this work has enriched our lives in countless ways, (p. 147).
This article has covered a fair amount of what clinicians as individuals can do to either minimize the likelihood of VT occurring or if experienced, ways to manage it. There are also systemic response strategies that can be implemented, when feasible.
When reviewing emergency procedures in the event of a crash landing, the flight attendant explains that passengers are not able to assist others if they do not put on their own oxygen mask first. Similarly, before treating our clients, supporting our colleagues, and supervising supervises, we must take care of ourselves. Self-awareness and self-care are as important as theoretical orientation and clinical techniques. So before running off to the next task on your list, take a minute and write down how you plan to sustain yourself and what you will do for self-care this week.
Dr. Masotta is Mental Health Director with MHM Correctional Services. Readers may contact her at mmasotta@mhm-services.com.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Edition, Text Revision). Washington, DC: Author, pp. 467-468. Baird, K. & Kracen, A.C. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counseling Psychology Quarterly, (19)2, 181-188.
McCann, IL & Pearlman LA (1990). Vicarious traumitization: A framework understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.
Harrison, R.L. & Westwood, M.J. (2009). Preventing vicarious traumatization of mental health therapists: Identifying protective factors. Psychotherapy Theory, Research, Practice, Training, 4 (2), 203-219.
Moulden, H.M. & Firestone, P. (2007). Vicarious traumatization: The impact on therapists who work with sexual offenders. Trauma, Violence, and Abuse, 8, 67-83.
Neumann, D.A. & Gamble, S.J. (2009). Issues in the professional development of psychotherapists: Countertransference, and vicarious traumatization in the new trauma therapist. Pyschotherapy, 32 (2), 341-347.
Pearlman LA & Mac Ian PS (1995) Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists: Professional Psychology: Research and Practice, 26, 558-565 Pearlman, L (1999). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B.H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators. (2nd ed., pp. 51-64). Lutherville, MD: Sidran Press.
Schauben LJ & Frazier PA (1995). Vicarious trauma: the effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly, 19, 49-64
Sommer, C.A. (2008). Vicarious traumatization, trauma-sensitive supervision and counselor preparation. Counselor Education and Supervision, 48, 61-71.
Wolff, N. & Shi, J. (2009). Victimisation and feelings of safety among male and female inmates with behavioural health problems. The Journal of Forensic Psychiatry and Psychology, 20, S56-S77.
