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Secondary Trauma and Burnout in Attorneys - Effects of Work with Clients Who are Victims of Domestic Violence and Abuse, Levin, 2007

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Secondary Trauma and Burnout in Attorneys:
Effects of Work with Clients Who are Victims of Domestic Violence and Abuse
Andrew P. Levin, MD
Dr. Levin is Assistant Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons,
Medical Director of Westchester Jewish Community Services, and site supervisor for the Forensic Fellowship at the
Albert Einstein College of Medicine. Dr. Levin practices and teaches in the area of psychological trauma and
provides consultation in civil and criminal matters. Please direct inquiries to Andrew P. Levin, MD, Medical Director,
Westchester Jewish Community Services, 141 North Central Avenue, Hartsdale, NY 10530 or by email at

Over the last generation and particularly following the inclusion of Posttraumatic Stress
Disorder (“PTSD”) in the 1980 Diagnostic and Statistical Manual of Mental Disorders,
Third Edition (“DSM-III”), 1 the mental health field has witnessed an explosion of interest
in trauma and its effects. A decade after the publication of DSM-III, the mental health
community began to recognize the effects of working with trauma victims on helping
professionals themselves. 2 The phenomenon of “Secondary Traumatic Stress” (“STS”),
also labeled “Compassion Fatigue,” has been defined as the “natural consequent
behaviors and emotions resulting from knowing about a traumatizing event experienced
by a significant other—the stress resulting from helping or wanting to help a traumatized
or suffering person.” 3 STS, as defined by Figley, involves symptoms analogous to those
seen in PTSD, i.e., re-experiencing images of the traumas of the person receiving aid,
avoidance of reminders of this material, numbing in affect and function, and persistent
arousal. 4
“Vicarious Traumatization” (“VT”), a related concept developed to describe the
reactions of therapists working in long-term psychotherapy with victims of domestic
violence and child abuse, involves the disruption of deeply held “schema.” 5 Therapists
working with these individuals come to doubt deeply held beliefs about safety, the
inherent kindness of others, and intimacy. Available research on therapists and
counselors working with victims of trauma has consistently established the presence of
STS and VT responses. 6 Research in this area has also revealed a correlation between
STS and VT and general psychological distress, 7 and there is a consensus that STS
and VT degrade the professional’s ability to perform his or her task and function in daily
life beyond the job. 8
In addition to STS and VT, the psychological literature has recognized the syndrome of
“burnout.” Burnout develops gradually due to the accumulation of stress and the
erosion of idealism resulting from intensive contact with clients. 9 It is characterized by
fatigue, poor sleep, headaches, anxiety, irritability, depression, hopelessness,
aggression, cynicism, and substance abuse. Although this mixture of symptoms has led
some to criticize burnout as an imprecise construct, Jenkins and Baird observe that
burnout is supported by multiple statistical analyses and, in fact, has been more
rigorously studied than secondary trauma. 10 Risk factors for burnout include female
gender, overwork, the slow and erratic pace of the work, lack of success, and the
tendency of the work to raise personal issues. 11

Secondary Trauma Among Legal Professionals
The major thrust in quantitative research on secondary trauma exposure has focused
on those who have brief but direct contact with the victim (and may themselves be
exposed to danger) such as disaster workers, 12 firefighters, 13 and relief workers. 14 The
intensity of exposure in these groups would suggest that it is difficult to analogize their
responses to those of therapists and other helpers significantly removed from the
trauma itself. However, in spite of the apparent differences between emergency
workers and therapists or other helpers, risk factors for the development of STS in
therapists parallel those for the development of PTSD in emergency workers, including
a prior history of trauma, 15 prior treatment for a psychological disorder, 16 and
percentage of trauma survivors in therapists’ caseloads 17 (analogous to the degree of
exposure in firefighters 18 and relief personnel 19 ). A further risk factor for therapists is
lack of experience and supervision. 20
A small number of studies have focused on psychological responses in legal and law
enforcement professionals who work with trauma victims. Follette et al. found that
police officers experience significantly greater symptoms of psychological distress
(anxiety, depression, dissociation, sleep problems) and PTSD than mental health
professionals. 21 A study of 23 Canadian prosecutors working with “sensitive cases”
involving domestic violence and incest revealed symptoms of demoralization, anxiety,
helplessness, exhaustion, social withdrawal. 22 A major factor was the high caseloads—
the 23 prosecutors worked in 51 different courts and regularly put in as many as 10-40
hours per week overtime.
Jaffe, et al. surveyed 105 judges in criminal, family and juvenile courts. 23 They reported
that 63% experienced symptoms of vicarious trauma. Female judges and those who
had been on the bench more than six years were at greatest risk. Additional symptoms
included sleep disturbances, intolerance of others, physical complaints, and depression.
Judges identified the increased number of specialty courts with a “steady diet of highly
emotional cases” as particularly stressful aspects of the work. Further, their efforts to
be impartial coupled with a sense of isolation from other judges and an inability to
discuss cases with others created additional stress.
With an eye to secondary trauma, the clinical law literature has raised issues regarding
the lawyer-client relationship and resultant identification and counter-transference in
attorneys representing domestic violence victims. 24 Separate and apart from the issues
of vicarious trauma, an earlier literature has described substance abuse and mental
illness among attorneys, conceptualizing these disorders as sequela of legal work, but
not specifically as the effects of work with traumatized clients. 25 The possible
connection between secondary trauma and these problems deserves further
Allegretti calls for increased training of attorneys in managing the “face-to-face, longterm, and intensely personal relationship” that develops between client and attorney. 26
In a joint presentation by the Center for Constitutional Rights and the Bellevue/NYU

Program for Survivors of Torture at the 2007 conference of the International Society for
Traumatic Stress Studies, professionals described the development of vicarious trauma
in attorneys representing prisoners at Guantanomo. 27 To support the attorneys, the
psychologists of the NYU program educated the attorneys about PTSD, techniques for
interviewing clients who have suffered torture, and methods of self-care to combat
secondary trauma.
In recognition of the complexities of representing individuals with a variety of
psychological symptoms and patterns, law school curricula have integrated materials
such as Groves’ article “Taking Care of the Hateful Patient,” 28 and “The Difficult Legal
Client,” co-authored by a psychiatrist. 29 At the Santa Clara University School of Law,
students working at the Katharine and George Alexander Community Law Center
representing victims of torture seeking asylum participated in course work to learn about
the impact of trauma on their clients. 30 In addition, the faculty, in collaboration with
psychologists, imparted techniques to facilitate interviewing of these complex clients
and to address the impact of work with this difficult material on the students themselves.
The Pace Study of DV Attorneys
In collaborating with domestic violence and criminal attorneys over a several year
period, I found varying degrees of psychological distress congruent with the syndromes
of STS, VT, and burnout. Supervisors at the Pace Women’s Justice Center, a service
for indigent women seeking legal remedies to domestic violence, identified a pattern of
fear and revulsion in attorneys developing after initial contact with traumatic material,
followed by over-involvement with clients, diminished performance, and high rates of
turnover. Attorneys working in the homicide arena complained of frustration, fatigue,
and demoralization that interfered with performance and family life.
In order to characterize the effects of work with trauma victims on attorneys, we
undertook a preliminary questionnaire survey to determine the presence of these
symptoms among attorneys working with traumatized clients and to compare them with
mental health professionals and social services workers serving similar populations.
Full details of the study have been described by Levin and Greisberg. 31 The study
recruited 55 attorneys from agencies specializing in domestic violence and family law as
well as public defender criminal services. The 87 mental health professionals who
participated included therapists such as social workers and psychologists, psychiatrists,
and social service workers at a county agency investigating child abuse. Participants
completed a two page questionnaire assessing secondary trauma and burnout as well
as demographics, professional discipline, years on the job, work hours per week,
number of clients in the last year who had traumatic material, personal trauma history,
and a history of treatment for “emotional problems” and “substance use.”
Compared with mental health professionals and social service workers, attorneys were
consistently higher on both secondary trauma and burnout scales. Across both
attorneys and mental health professionals, women had significantly higher scores than
men. Mental health treatment history also predicted a higher score on the questionnaire

for both attorneys and mental health professionals. Prior childhood and adult trauma
history were not predictive of higher scores on any of the measures, although they have
been in other studies of secondary trauma. 32
Correlation analysis for all subjects revealed a significant positive relationship between
number of clients and total score. Hours per week were weakly correlated with burnout
score. Caseloads of traumatized clients during the prior year were significantly greater
for the attorneys compared to both mental health professionals and social services
workers. Fifty-two percent of attorneys saw more than 21 cases in the prior 12 months
compared with only 25% and 28% of the mental health and social services
professionals, respectively. The small sample size precluded a definitive demonstration
that the higher caseloads of attorneys were responsible for their higher questionnaire
scores, but the data trended in that direction.
During the course of the study, I had occasion to hear informally from attorneys
regarding their experiences. One attorney at a legal aid office representing victims of
domestic violence wrote:
It actually feels good to hear that I am not the only one who feels depressed and
helpless and that these issues are worth studying. Fortunately, the stress has
decreased with experience and time for me, but I still have vivid memories of
quite traumatic experiences representing victims of domestic violence who were
so betrayed that it was difficult to continue to have faith in humankind.
The themes identified by this attorney include both the direct symptomatic presentation
of secondary trauma as well as the long-term effects on worldview identified by McCann
and Pearlman. 33 For this attorney it also appears that effects of the work have
persisted, albeit at a lower intensity, over an extended time frame. Another common
theme was the frustration in representing women who appeared passive and unable to
utilize the resources provided. Attorneys drew on the paradigms of “Battered Women
Syndrome” 34 and “learned helplessness” 35 to assist in understanding these behavioral
Study of Law Students
As a follow-up to the study of practicing attorneys we turned to law students working
with victims of trauma. 36 The participants were 43 second and third year law students
enrolled in a semester long practicum at the Pace Women’s Justice Center working
under the direct supervision of faculty interviewing women seeking orders of protection
and court intervention, preparing motions, and arguing before the court. The students
completed questionnaires at the start and end of the semester measuring secondary
trauma, burnout, professional satisfaction, and responses to traumatic material. The
students registered only a mild increase in symptoms of burnout and scored significantly
lower on secondary trauma and burnout than the practicing attorneys studied earlier.
Measures of satisfaction fell in the normal range indicating that the students enjoyed
their work and felt they had a positive impact on the lives of their clients. On the

measure of response to “the most upsetting client trauma,” scores measuring intrusive
memories and avoidance of the material were comparable to the responses of medical
students encountering cadavers and were approximately half of those seen in a clinical
population with PTSD. 37 Three students registered responses in the clinical range,
indicating a significant impact caused by learning about a client’s trauma. Overall, the
study demonstrated that the majority of students working in a family court setting with
traumatized clients will not be seriously affected but a small minority may have
significant responses. Law school faculty need to be alert to these individuals to
provide support and even possible referral to counseling if needed.
Future Directions
In light of the studies described, the observations in the clinical law literature, and the
two small studies done by our group, it is clear that work with traumatized clients,
especially when attorneys grapple with high caseloads and a frustrating system, creates
a significant risk of secondary trauma and burnout. Attorneys discussing their
experience of secondary trauma at a “Think Tank” on domestic violence felt that in
addition to their high case loads, the lack of systematic education regarding the effects
of trauma on their clients and themselves—as well as the paucity of forums for regular
discussion of these issues—were significant contributors to development of STS and
burnout. 38 Even among mental health professionals with advantages of education and
supervision, secondary trauma responses are common. 39 Further risk factors for
attorneys in the family court include work with cases involving children, a risk factor
previously established for secondary trauma, 40 and identification with battered women, 41
as demonstrated by the higher scores among female attorneys and therapists in our
In response to the risks of STS, Silver has advocated for educational programming for
law students and attorneys regarding the effects of trauma on their clients and
themselves. 42 These recommendations build on the strategies advocated by Pearlman
and Saakvitne, including education, support, supervision, maintenance of proper
boundaries, and self care. 43 They also emphasize the importance of the institutional
environment, often described by attorneys in our study as either “hostile” or, at best,
“indifferent” to their personal needs. Similarly, in a recent review, Salston and Figley
noted, “We must do all that we can to insure that those who work with traumatized
people—including but not limited to those exposed to crime victimization—are prepared.
[…] A place to start is to incorporate stress, burnout, and compassion fatigue into our
curriculum, and especially our supervision.” 44
Consulting mental health professionals can assist legal professionals in high risk areas
(family court or criminal settings) in identifying STS, burnout, and vicarious trauma, as
well as collaborating in the development of consistent approaches to monitoring and
managing its effects. In addition to consultation, mental health professionals, as utilized
at Santa Clara University School of Law, can play an important role in the development
of law school curricula and continuing legal education programs. 45 Future research
should focus on clarifying the nature and extent of secondary traumatic responses,

understanding their relationship to PTSD, and delineating the risk factors for their
development in attorneys, judges, and allied professions. This work would then form
the basis for identifying the most effective interventions for reducing secondary trauma
among legal professionals in order to enhance the delivery of legal services to victims of

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