Secondary Trauma and Burnout in Attorneys - Effects of Work with Clients Who are Victims of Domestic Violence and Abuse, Levin, 2007
Download original document:
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
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 firstname.lastname@example.org. 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 exploration. 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 patterns. 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 study. 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 trauma. 1 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition (1980). 2 Lisa McCann & Laurie Anne Pearlman, Vicarious Traumatization: A Framework for Understanding the Psychological Effects of Working with Victims. 3 J. Traumatic Stress 131-149 (1990); Charles R. Figley, Compassion Fatigue As Secondary Traumatic Stress Disorder: An Overview, in Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized 1-20 (Charles R. Figley, ed., 1995). 3 Figley, supra, at 7. 4 Id. 5 McCann & Pearlman, supra note 2. 6 J.L. Brady, J.D. Guy, P.L. Poelstra & B.F. Brokaw, Vicarious Traumatization, Spirituality, and the Treatment of Sexual Abuse Survivors: A National Survey of Women Therapists, 30 Prof. Psychol.: Res. & Prac. 586-393 (1999); Laurie Anne Pearlman & P.S. MacIan, Vicarious Traumatization: An Empirical Study of the Effects of Trauma Work on Trauma Therapists, 26 Prof. Psychol.: Res. & Prac. 558-565 (1995); L.J. Schauben & P.A. Frazier, Vicarious Trauma: The Effects on Female Counselors of Working with Sexual Violence Survivors, 19 Psychol. of Women Q. 49-64 (1995); T.W. Meyers & T.A. Cornille, The Trauma of Working With Traumatized Children, in Treating Compassion Fatigue 39-55 (Charles R. Figley, ed. 2002); D.F. Wee & D. Myers, Stress Response of Mental Health Workers Following Disaster: The Oklahoma City Bombing, in Treating Compassion Fatigue 57-83 (Charles R. Figley, ed. 2002). 7 S.H. Jenkins & S. Baird, Secondary Traumatic Stress and Vicarious Trauma: A Validation Study, 15 J. Traumatic Stress 423-432 (2002). 8 McCann & Pearlman, supra note 2; Figley, supra note 2; Pearlman & MacIan, supra note 10; Schauben & Frazier, supra note 10. 9 Jenkins & Baird, supra note 10; B.A. Farber & L.J. Heifetz, The Process and Dimensions of Burnout in Psychotherapists, 13 Prof. Psychol. 293-301 (1982). 10 Id. 11 Farber & Heifetz, supra note 31; C. Maslach, W.B. Schaufeli & M.P. Leiter, Job Burnout, 52 Ann. Rev. Psychol. 397-422 (2001). 12 Robert Ursano, Carol Fullerton, Kelly Vance & Tzu-Cheg Kao, Posttraumatic Stress Disorder and Identification in Disaster Workers, 156 Am. J. Psychiatry 353-359 (1999). 13 Dieter Wagner, Markus Heinrichs, & Ulrike Ehlert, Prevalence of Symptoms of Posttraumatic Stress Disorder in German Professional Firefighters, 155 Am. J. Psychiatry 1727-1732 (1998). 14 C.B. Erikson, et al, Trauma Exposure and PTSD Symptoms in International Relief and Development Personnel, 14 J. Traumatic Stress 205-212 (2001). 15 Brady, Guy, Poelstra & Brokaw, supra note 10. 16 Figley, supra note 2. 17 Brady, Guy, Poelstra & Brokaw, supra note 10; Schauben & Frazier, supra note 10. 18 Wagner, Heinrichs, & Ehlert, supra note 6. 19 Erikson, et al, supra note 7. 20 Pearlman & MacIan, supra note 10. 21 V.M. Follette, M.M. Polusny & Milbeck, Mental Health and Law Enforcement Professionals: Trauma History, Psychological Symptoms, and Impact of Providing Services to Child Sexual Abuse Survivors, 25 Prof. Psychol.: Res. & Prac. 275-282 (1994). 22 I.M. Gomme & M.P. Hall, Prosecutors at Work: Role Overload and Strain, 15 J. Crim. Just. 191-200 (1995). 23 Peter Jaffe, Claire Crooks, Billie Lee Dunford-Jackson, & M. Town, Vicarious Trauma in Judges: The Personal Challenge of Dispensing Justice. 54 Juv. & Fam. Ct. J. 1-9 (2003). 24 Joan Meier, Notes from the Underground: Integrating Psychological and Legal Perspectives on Domestic Violence in Theory and Practice, 21 Hofstra L. Rev. 1295-1366 (1993); M.A. Silver, Love, Hate, and Other Emotional Interference in the Lawyer/Client Relationship, 6 Clinical L. Rev. 259-313 (1999). 25 See, e.g., D. Brooke, Impairment in Medical and Legal Professionals, 43 J. Psychosom. Res. 27-34 (1997) and L. Klingen, Note and comment, The Mentally Ill Attorney, 27 Nova L. Rev. 157-190 (2002). 26 J. Allegretti, Shooting Elephants, Serving Clients: An Essay on George Orwell and the Lawyer-Client Relationship, 27 Creighton L. Rev. 1-24 (1993). 27 G. Gitanjali, K. Portefield & L. Nguyen, Psychology, Law, and Culture: Re-Traumatization and ReEnactment with Torture Victims, Panel presented at the 23rd International Society for Traumatic Stress Studies Annual Meeting (Baltimore, November 15-17, 2007). 28 J.E. Groves, Taking Care of the Hateful Patient, 298 New Eng. J. Med. 883-7 (1978). 29 J.A. Barrette & N.S. Kaye, The Difficult Legal Client, 94 Case & Comment 1-33 (1989). 30 L. Parker, Increasing Law Students’ Effectiveness When Representing Traumatized Clients: A Case Study of the Katherine & George Alexander Community Law Center, 21 Geo. Immigr. L.J. 163-199 (2007). 31 Arthur Levin & S. Greisberg, Vicarious Trauma in Attorneys, 24 Pace L. Rev. 245-257 (2003). 32 Pearlman & MacIan, supra note 10; Jenkins & Baird, supra note 10. 33 See Figley, supra note 2; McCann & Pearlman, supra note 2. 34 Lenore Walker, The Battered Woman Syndrome (1984). 35 S.F. Maier & M.E.P. Seligman, Learned Helplessness: Theory and Evidence, 105 J. Exper. Psychol.: Gen’l 3-46 (1976). 36 Arthur Levin, A. Moot-Levin & S. Rosencranz, Evaluating Secondary Trauma in Law Students, Poster presented at the 23rd International Society for Traumatic Stress Studies Annual Meeting (Baltimore, November 15-17, 2007). 37 M. Horowitz, N. Wilner & W. Alvarez, Impact of Event Scale: A Measure of Subjective Stress, 41 Psychosom. Med. 209-218 (1979). 38 Pace Women’s Justice Center, The Second Annual Domestic Violence Think Tank, 24 Pace L. Rev. 187-298 (2003). 39 McCann & Pearlman, supra note 2; Figley, supra note 2; Brady, Guy, Poelstra & Brokaw, supra note 10; Pearlman & MacIan, supra note 10; Schauben & Frazier, supra note 10. 40 Meyers & Cornille, supra note 10. 41 Figley, supra note 2. 42 Silver, supra note 23. 43 Laurie Anne Pearlman & K.W. Saakvitne, Trauma and the Therapist (1995). 44 M. Salston & Charles R. Figley, Secondary Traumatic Stress Effects Of Working With Survivors Of Criminal Victimization, 16 J. Traumatic Stress 173 (2003). 45 Parker, supra note 28.