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Drug and Alcohol Review (May 2015), 34, 252–258 DOI: 10.1111/dar.12204
The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia PHILIPPA L. EWER1,2, MAREE TEESSON1,2, CLAUDIA SANNIBALE1,3, ANN ROCHE4 & KATHERINE L. MILLS1,2 1
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia, 2NHMRC Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia, 3Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia, and 4National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
Abstract Introduction and Aims. The high prevalence of trauma exposure and post-traumatic stress disorder (PTSD) among clients of alcohol and other drug (AOD) services is well documented. Less is known, however, about the impact this has on workers who assess and treat such clients. The aim of this study was to examine the prevalence and correlates of secondary traumatic stress (STS) among AOD workers in Australia. Design and Methods. An anonymous web-based survey was undertaken and completed by 412 Australian AOD workers.The questionnaire assessed current levels of trauma training, extent of exposure to clients with a history of trauma history, AOD workers’ own history of trauma exposure and PTSD, and current STS. Analyses compared individuals who currently met criteria for experiencing STS with those who did not. Results. Despite the high volume of traumatised clients accessing AOD services, less than two-thirds of AOD workers reported having ever received trauma training. The prevalence rate of STS was 19.9% and was independently predicted by a higher traumatised client workload, fewer hours of clinical supervision, and stress and anxiety levels of the worker. Discussion and Conclusions. The findings highlight the importance of providing adequate trauma training and clinical supervision to AOD workers in order to maintain their health and welfare and ensure optimal treatment to clients with PTSD. [Ewer PL, Teesson M, Sannibale C, Roche A, Mills KL. The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug Alcohol Rev 2015;34:252–58] Key words: secondary traumatic stress, substance abuse, PTSD, clinical supervision, workforce.
Introduction Over recent years, there has been growing recognition of the high prevalence of trauma exposure and posttraumatic stress disorder (PTSD) among clients of alcohol and other drug (AOD) services. Trauma exposure is almost universal in this population and up to two-thirds of clients have current PTSD [1–4]. Compared with individuals with a substance use disorder alone, individuals with comorbid PTSD report more extensive polydrug use histories, suffer poorer social and occupational functioning, poorer physical and mental health, and higher rates of attempted suicide [3–8]. Furthermore, a history of trauma and PTSD has
consistently been associated with poorer treatment outcomes and a more chronic course of illness [9–11]. It is therefore unsurprising that treatment providers consider clients with this comorbidity to present a significant clinical challenge [12,13]. Little is known, however, about how working with traumatised clients impacts upon the AOD workers who treat them. Research has shown that exposure to an individual’s trauma history through assessment and treatment results in an increased risk of the clinician becoming traumatised themselves. This is often referred to as ‘vicarious traumatisation’ or ‘secondary traumatic stress’ (STS; [14–16]). STS has been defined as ‘the natural, consequent behaviours and emotions resulting
Philippa L. Ewer BPsych(Hons), MPsych(Clin), Research Psychologist, Maree Teesson BSc(Hons), PhD, Professor, Claudia Sannibale BA(Hons) (Psych), MPsych(Clin), PhD, Clinical Psychologist, Ann Roche BA, MEd, PhD, Professor, Katherine L. Mills BHlthSc(Hons), PhD, Associate Professor. Correspondence to Dr Katherine L. Mills, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia. Tel: +612 9385 0331; Fax: +612 9385 0222; E-mail: [email protected] Received 11 May 2014; accepted for publication 6 August 2014. © 2014 Australasian Professional Society on Alcohol and other Drugs
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from knowledge about a traumatising event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatised or suffering person’ (p. 10) [14]. An individual who meets criteria for experiencing STS develops symptoms of PTSD, including intrusion, avoidance and hyperarousal [15]. Until recently, however, STS was considered distinct from PTSD because of the nature of the traumatic event (i.e. exposure to a traumatised individual’s retelling of a traumatic event, as opposed to experiencing the event oneself) [14]. In recognition of the legitimacy of STS, the most recent revision to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) has included repeated or extreme indirect exposure to aversive details of the event(s) in the course of professional duties as a qualifying event [16]. STS has been referred to as an occupational hazard for those working with trauma survivors [17,18]; however, there is a dearth of research examining STS among the AOD workforce.To our knowledge, only one study has been conducted in the USA. Of the 225 AOD counsellors surveyed, 19% met criteria for current STS [19]. This figure is of concern as STS has been associated with a number of adverse consequences relating to a person’s cognitions (e.g. diminished concentration, decreased self-esteem), emotions (e.g. hypersensitivity) and interpersonal functioning (e.g. social isolation) [20]. Furthermore, associations have been made between STS and lower job satisfaction and occupational commitment [21]. The latter are known to contribute to burnout, job turnover and loss to the AOD workforce. Given the high prevalence of trauma and PTSD among clients of AOD services in Australia [1,3], it is likely that similarly high rates of STS may be present among Australian AOD workers; however, the degree to which it is suffered by AOD workers in Australia is unknown. The present study aimed to address this gap in the literature by examining the prevalence and correlates of STS among AOD workers in Australia.
Method Procedure Participants were recruited via an email that was distributed Australia wide to members of the main AOD professional bodies (i.e. the Alcohol and Drugs Council of Australia, Australasian Professional Society on Alcohol and Other Drugs, and Drug and Alcohol Nurses Australasia). The email invited individuals working in the AOD sector to participate in an anonymous web-based questionnaire examining the issue of working with traumatised clients. Email recipients were also encouraged to forward the email to colleagues who
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did not belong to these professional bodies that may be interested. Ethical approval was granted by the University of New South Wales Human Ethics Review Committee. Web-based questionnaire The web-based questionnaire took approximately 15 min to complete. Information was collected on participants’ demographic characteristics, level of education and training, and number of clinical supervision hours each month (i.e. guidance and feedback on matters of personal, professional and educational development in the context of their work with clients). Exposure risk to STS was measured by asking participants to provide an estimate of the percentage of clients they had worked with in their current workplace who had a trauma history and specific trauma types experienced by clients. Past-week symptoms of STS were assessed using the Secondary Traumatic Stress Scale (STSS; [17]). Specifically, participants were asked to indicate how frequently they had experienced a list of 17 re-experiencing, avoidance, numbing and hyperarousal symptoms after working with psychologically traumatised clients in the past week. Individuals were classified as meeting criteria for STS if they endorsed experiencing at least one re-experiencing, three avoidance or numbing and two hyperarousal symptoms [15]. The STSS has demonstrated good psychometric properties, with construct validity established through convergent, discriminant, and factorial analyses [17,22]. Past trauma exposure and PTSD among participants were also assessed. Trauma history was measured using the Composite International Diagnostic Instrument version 2.1 [23], which assesses lifetime exposure to combat, life-threatening accidents, natural disasters, witnessing serious injury or death, rape, sexual molestation, serious physical assault, being threatened with a weapon, held captive or kidnapped, being tortured or being the victim of terrorists, any other extremely stressful or upsetting event, or a great shock because one of the aforementioned events has happened to someone else. Participants were also asked to indicate if any of the traumas they had experienced occurred before the age of 16 years. Participants reporting exposure to one or more traumatic events were asked to complete the PTSD Checklist—Civilian Version (PCL-C; [24]), which assesses past-week frequency and severity of PTSD symptoms. The PCL-C has been shown to have good internal consistency, test–retest reliability, convergent validity and discriminant validity [25]. Past-week symptoms of depression, anxiety and stress were measured using the short form Depression Anxiety Stress Scale (DASS-21; [26]). The DASS-21 © 2014 Australasian Professional Society on Alcohol and other Drugs
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has demonstrated good internal consistency for all three subscales that comprise the measure as well as good convergent and discriminant validity compared with other validated measures of depression and anxiety [27].
Prevalence of STS One in five participants (19.9%) met criteria for STS. There were no differences between workers with and without STS in relation to any of the sample characteristics reported above (Table 1).
Analyses Analyses were conducted with ibm spss Statistics Version 20.0 (Armonk, NY: IBM Corp.). Means with standard deviations (SDs) were reported for normally distributed data, and differences between groups examined using t-tests. Where continuous data were highly skewed, Mann–Whitney U-tests were conducted, and the median and range reported. Percentages are provided for categorical variables and between-group differences examined using χ2 tests [results reported as odds ratios (ORs) and 95% confidence intervals (95% CIs)] or Fischer’s exact tests for variables with expected cell counts of less than five. All variables found to be significantly associated with STS in the bivariate analyses were entered into a multivariate backward stepwise logistic regression. Results
Correlates of STS Education, training, workload and supervision. There were no significant differences between workers with and without STS in the proportion who had received training in AOD (92.7% vs. 96.7%; OR 0.44, 95% CI 0.16–1.22), mental health (85.4% vs. 89.1%; OR 0.71, 95% CI 0.35–1.44) and trauma (57.3% vs. 64.5%; OR 0.74, 95% CI 0.45–1.21). However, workers with STS were less likely to have completed tertiary education (95.1% vs. 99.4%; P = 0.016, Fischer’s exact test) and received less clinical supervision each month compared with workers without STS (median 1 h vs. 2 h; Z = −2.69, P = 0.007). Workers with STS also reported having a larger proportion of clients with a trauma
Table 1. Characteristics of AOD workers with and without STSa
Sample characteristics and the prevalence of STS Four-hundred and eighteen participants responded to the survey. Data from six participants were excluded from the analysis because of a large amount of missing data, including the data required to determine whether they met the criteria for STS. Thus, the final sample consisted of 412 AOD workers (70.5% female). The mean age of the sample was 44.3 years (SD 10.7) and a minority identified as being of Aboriginal or Torres Strait Islander background (3.7%). The median number of years working in the AOD sector was 10 (range 0–47). The sample comprised a range of professionals including nurses (21.7%), counsellors (20.5%), psychologists (12.4%), case workers (11.5%), social workers (7.1%) and other AOD professionals including doctors, intake officers, managers, psychiatrists and youth workers (26.8%). Participants worked in services located across Australia, most commonly New South Wales (36.6%), Queensland (21.8%) and Victoria (20.6%), followed by the Australian Capital Territory (6.6%), Western Australia (4.7%), South Australia (4.2%), Northern Territory (3.9%) and Tasmania (3.7%). The majority worked in urban areas with populations of over 100 000 (57.9%) or between 1000 and 99 000 (36.4%). A small proportion worked in localities with populations between 200 and 999 (2.9%) or less than 200 (2.9%). © 2014 Australasian Professional Society on Alcohol and other Drugs
Characteristic Mean age (SD) % Female % Indigenous descent State/territory % New South Wales % Queensland % Victoria % Australian Capital Territory % Western Australia % South Australia % Northern Territory % Tasmania Population size % >100 000 % 1000–99 000 % 200–999 % 0.05. AOD, alcohol and other drug; SD, standard deviation; STS, secondary traumatic stress.
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Table 2. Comparison of trauma types experienced by AOD workers with and without STS
Trauma type
+ STS % (n) (n = 82)
− STS % (n) (n = 330)
Total % (n) (n = 412)
OR
95% CI
Threatened, held captive or kidnapped* Life-threatening accident* Witnessed serious injury or death Serious physical attack or assault* Sexual assault* Natural disaster Tortured or victim of terrorists Combat in a war*
45.7 (37) 56.1 (46) 47.6 (39) 56.1 (46) 51.2 (42) 39.0 (32) 3.7 (3) 7.3 (6)
31.1 (102) 37.1 (122) 42.7 (141) 38.0 (125) 38.5 (127) 27.9 (92) 1.2 (4) 2.1 (7)
34 (139) 40.9 (168) 43.7 (180) 41.6 (171) 41.0 (169) 30.1 (124) 1.7 (7) 3.2 (13)
1.86 2.17 1.22 2.09 1.68 1.66 3.10 3.64
1.14–3.05 1.33–3.53 0.75–1.98 1.28–3.40 1.03–2.73 0.99–2.74 0.68–14.09 1.19–11.11
*P < 0.05. AOD, alcohol and other drug; CI, confidence interval; OR, odds ratio; STS, secondary traumatic stress.
history in their current service compared with workers without STS (median 90.0% vs. 80.0%; Z = 4.18; P < 0.0001). Personal exposure to trauma and mental health. Workers with STS were more likely to have experienced a traumatic event (88.9% vs. 79.0%; OR 2.12, 95% CI 1.01– 4.46) and experienced more trauma types (median 3 vs. 2; Z = 3.52, P < 0.01) compared with workers without STS. As shown in Table 2, there were between-group differences in the types of traumas experienced. Compared with workers without STS, those with STS were more likely to have been: exposed to combat in a war (OR 3.64); in a life-threatening accident (OR 2.17); seriously physical attacked or assaulted (OR 2.09); threatened with a weapon, held captive or kidnapped (OR 1.86); and sexually assaulted (OR 1.68). Workers with STS were also more likely to have experienced childhood trauma (69.2% vs. 49.2%; OR 2.32, 95% CI 1.37–3.94) and childhood sexual assault (39.5% vs. 27.1%; OR 1.76, 95% CI 1.06–2.92) compared with workers without STS. In regard to mental health, workers with STS were more likely to meet criteria for current PTSD (22.2% vs. 2.7%; OR 10.16, 95% CI 4.37–23.64) and had higher scores on the depression (median 24 vs. 16; Z = 8.87, P < 0.01), anxiety (median 22 vs. 14; Z = 9.25, P < 0.01) and stress (median 30 vs. 20; Z = 9.40, P < 0.01) subscales of the DASS-21. Independent predictors of STS All factors found to be significant at the bivariate level were entered into a backward stepwise logistic regression to determine independent predictors of STS. Four variables remained in the final model. STS was found to be independently associated with higher levels of stress (OR 1.18, 95% CI 1.11–1.26), higher levels of
anxiety (OR 1.13, 95% CI 1.04–1.22), a higher traumatised client workload (OR 1.03, 95% CI 1.01–1.06) and receiving fewer hours of clinical supervision (OR 0.75, 95% CI 0.63–0.90).
Discussion This is one of few investigations undertaken to examine the prevalence of STS among AOD workers, and it is the first study to examine this issue in Australia. Consistent with the findings of Bride et al.’s [19] US study of AOD counsellors, one in five (19.9%) AOD workers in the present study met criteria for STS. This rate is concerning given the potential impact of STS for workers both personally and professionally [20,21]. The present study found an independent association between STS and higher levels of stress and anxiety. Because of the cross-sectional nature of this study, however, causal attributions cannot be made. Although STS may lead to higher levels of stress and anxiety, it may also be that higher levels of stress and anxiety predispose workers to developing STS. Research has shown that pre-trauma anxiety increases an individual’s risk of experiencing post-traumatic stress reactions following trauma exposure [26]. Thus, workers with high levels of anxiety may be more vulnerable to STS when working with traumatised clients. Regardless of the nature of the relationship between these variables, research has demonstrated an association between STS and lower job satisfaction and occupational commitment [21]. It is possible that STS and other associated sources of distress may contribute significantly to the high levels of staff turnover seen within the AOD sector [28]. Hence, addressing STS among AOD workers may improve worker retention as well as improving client treatment and outcomes. Consistent with the high prevalence of self-reported trauma and PTSD among clients of AOD services [1], © 2014 Australasian Professional Society on Alcohol and other Drugs
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both workers with and without STS reported working with high proportions of traumatised clients (median of 90% of clients vs. 80% of clients). As found by Brady et al. [29] in their examination of STS among female psychotherapists, workers experiencing STS reported a significantly greater traumatised client workload compared with those without STS. Furthermore, this caseload was identified as an independent predictor in the final multivariate model.These results of this model suggest that the odds of experiencing STS are increased by 30% for every 10% increase in the proportion of traumatised clients treated. This finding underscores the importance of monitoring the number and distribution of traumatised clients allocated to individual workers. High rates of trauma exposure and PTSD were also identified among the AOD workers themselves, particularly among those with STS. Findings regarding the relationship between an individual’s own trauma and PTSD history and the development of STS have been mixed. Ortlepp and Friedman’s [30] study of trauma counsellors found no relationship, whereas Bride et al. [31] found that child protective service workers with a personal history of trauma were at increased risk of STS. In the present study, the prevalence of trauma exposure and PTSD was found to be significantly higher in the bivariate analyses; however, these factors were not shown to be independent predictors in the final multivariate model, indicating that the relationship between trauma, PTSD and STS is confounded by other personal and professional characteristics. Consistent with research among health-care providers more broadly [32,33], STS was associated with receiving fewer hours of clinical supervision each month.The findings emphasise the importance of clinical supervision for AOD workers who are treating complex clients, even if trauma is not the primary reason for treatment [34]. In addition to reducing the likelihood of experiencing STS, clinical supervision is associated with greater job satisfaction [35], reduced staff turnover [33] and improved client outcomes [36]. It is therefore not surprising that clinical supervision has been suggested as a promising workforce development strategy within the AOD workforce [37]. Despite the high volume of traumatised clients accessing AOD services, less than two-thirds of workers surveyed reported having received trauma training; however, specific details regarding the nature of training received were not obtained. There may have been substantial variation in the type (e.g. attendance at professional seminars/workshops, training provided as part of obtaining professional qualifications, certification) and content of training received (e.g. training on assessment and delivering trauma-informed care versus training regarding the delivery of trauma© 2014 Australasian Professional Society on Alcohol and other Drugs
focused treatments). Therefore, although an association between trauma training and the presence of STS was not found, the effect may have been diluted because of the heterogeneity of training received. Nonetheless, this finding highlights a significant gap in AOD worker training and the need for further research, and consideration at a policy level, regarding the level and type of trauma training that is appropriate for this workforce. The results of the current study need to be considered in light of a number of limitations. Firstly, while there are a number of benefits to utilising a web-based questionnaire such as low cost [38], automatic data entry [24] and reduced propensity for socially desirable responses [39], employing a web-based questionnaire meant only those who had access to the Internet were able to complete it. Secondly, in order to take part in the study, participants had to be currently working in the AOD sector. As STS has been associated with job satisfaction and occupational commitment [21], it is possible that an unknown proportion of individuals may not have been captured by the study as they were no longer working in the AOD sector as a result of experiencing STS. Thirdly, although the demographic characteristics of the sample were similar to those reported in previous studies of the Australian AOD workforce [28,40,41] it is possible that there was a response bias whereby individuals who had a particular interest in trauma research, either due to their own personal experiences or those of their clients, may have been more likely to respond. Lastly, because of the anonymous nature of the study, information regarding the response rate was unable to be collected (i.e. those who received the email inviting them to respond to the survey compared with those who actually responded), along with the characteristics of non-respondents who may have been too distressed to participate in the study. In spite of these limitations, the present study highlights the impact of working with traumatised clients on the psychological well-being of the worker. It provides valuable information regarding the prevalence of STS among individuals working in the Australian AOD sector, along with the factors associated with an individual experiencing STS. These findings underscore the crucial importance of adequate and appropriate training and support for AOD workers, in general, and specifically in relation to treating clients with trauma experiences. To date, this has been a largely overlooked area and one in which relatively little was known about the potential impact on workers. What was once referred to as ‘compassion fatigue’ might be more accurately referred as ‘secondary traumatic stress’ or ‘vicarious traumatisation’, and with our improved knowledge and understanding of this issue, we can now provide
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appropriate support and ensure protective mechanisms are in place to safeguard the well-being of the AOD workforce. Acknowledgements The authors wish to thank all study participants and the professional organisations who advertised this study. Maree Teesson was supported by a National Health and Medical Research Council Senior Research Fellowship and Katherine L. Mills was supported by a National Health and Medical Research Council Career Development Award and the National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use. References [1] Dore G, Mills KL, Murray R, Teesson M, Farrugia P. Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev 2012;31:294–302. [2] Driessen M, Schulte S, Luedecke C, et al. Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study. Alcohol Clin Exp Res 2008;32:481–8. [3] Mills KL, Lynskey M, Teesson M, Ross J, Darke S. Posttraumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates. Drug Alcohol Depend 2005;77:243–9. [4] Reynolds M, Mezey G, Chapman M, Wheeler M, Drummond C, Baldacchino A. Co-morbid post-traumatic stress disorder in a substance misusing clinical population. Drug Alcohol Depend 2005;77:251–8. [5] Najavits LM, Gastfriend DR, Barber JP, et al. Cocaine dependence with and without PTSD among subjects in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Am J Psychiatry 1998;155:214–19. [6] Najavits LM, Weiss RD, Shaw SR. A clinical profile of women with PTSD and substance dependence. Psychol Addict Behav 1999;13:98–104. [7] Ouimette P, Goodwin E, Brown PJ. Health and well being of substance use disorder patients with and without posttraumatic stress disorder. Addict Behav 2006;31:1415– 23. [8] Najavits LM, Runkel R, Neuner C, et al. Rates and symptoms of PTSD among cocaine-dependent patients. J Stud Alcohol 2003;64:601–6. [9] Mills KL, Teesson M, Ross J, Darke S. The impact of post-traumatic stress disorder on treatment outcomes for heroin dependence. Addiction 2007;102:447–54. [10] Ouimette PC, Finney JW, Moos RH. Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychol Addict Behav 1999;13:105–14. [11] Hien DA, Nunes E, Levin FR, Fraser D. Posttraumatic stress disorder and short-term outcome in early methadone treatment. J Subst Abuse Treat 2000;19:31–7. [12] Back S, Waldrop A, Brady K. Treatment challenges associated with comorbid substance use and posttraumatic stress disorder: clinicians’ perspectives. Am J Addict 2009;18:15– 20.
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[13] Najavits LM. Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. J Subst Abuse Treat 2002;22:79–85. [14] Weible R, Wallace J. The impact of the Internet on data collection. Mark Res 1998;10:19–23. [15] Bride BE. Prevalence of secondary traumatic stress among social workers. Soc Work 2007;52:63–70. [16] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edn. Arlington, VA: American Psychiatric Publishing, 2013. [17] Bride BE, Robinson MM, Yegidis B, Figley CR. Development and validation of the secondary traumatic stress scale. Res Soc Work Pract 2004;14:27–35. [18] Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. In: Stamm BH, ed. Secondary traumatic stress: self-care issues for clinicians, researchers, and educators. Baltimore, MD: The Sidran Press, 1995:3– 28. [19] Bride BE, Hatcher SS, Humble MN. Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology 2009;15:96– 105. [20] Yassen J. Preventing secondary traumatic stress disorder. In: Figley CR, ed. Compassion fatigue: coping with secondary traumatic stress in those who treat the traumatized. New York: Brunner Mazel, 1995:178–208. [21] Bride BE, Kintzle S. Secondary traumatic stress, job satisfaction, and occupational commitment in substance abuse counselors. Traumatology 2011;17:22–8. [22] Ting L, Jacobson JM, Sanders S, Bride BE, Harrington D. The Secondary Traumatic Stress Scale (STSS): confirmatory factor analyses with a national sample of mental health social workers. J Hum Behav Soc Environ 2005;11:177–94. [23] World Health Organization. Composite International Diagnostic Interview (CIDI) core version 2.1, 12 month version. Geneva: World Health Organization, 1997. [24] Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003;20:545–51. [25] Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. Psychometric properties of the PTSD checklist—civilian version. J Trauma Stress 2003;16:495–502. [26] Koenen KC, Harley R, Lyons MJ, et al. A twin registry study of familial and individual risk factors for trauma exposure and post- traumatic stress disorder. J Nerv Ment Dis 2002;190:209–18. [27] Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005;44:227–39. [28] Duraisingam V, Pidd K, Roche AM. The impact of work stress and job satisfaction on turnover intentions: a study of Australian specialist alcohol and other drug workers. Drugs Educ Prev Pol. 2009;16:217–31. [29] Brady JL, Guy JD, Poelstra PL, Brokaw BF. Vicarious traumatisation, spirituality, and the treatment of sexual abuse survivors: a national survey of women psychotherapists. Prof Psychol Res Pr 1999;30:386–93. [30] Ortlepp K, Friedman M. Prevalence and correlates of secondary traumatic stress in workplace lay trauma counselors. J Trauma Stress 2002;15:213–22. [31] Bride BE, Jones JL, Macmaster SA. Correlates of secondary traumatic stress in child protective services workers. J Evid Based Soc Work 2007;4:69–80. © 2014 Australasian Professional Society on Alcohol and other Drugs
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[32] Galek KKPT. Burnout, secondary traumatic stress, and social support. Pastoral Psychol 2011;60:633–49. [33] Knudsen HK, Ducharme LJ, Roman PM. Clinical supervision, emotional exhaustion, and turnover intention: a study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse. J Subst Abuse Treat 2008;35:387–95. [34] Knight C. Working with survivors of childhood trauma. Clin Superv 2004;23:81–105. [35] Hyrkäs K, Appelqvist-Schmidlechner K, Haataja R. Efficacy of clinical supervision: influence on job satisfaction, burnout and quality of care. J Adv Nurs 2006;55:521–35. [36] Callahan JL, Almstrom CM, Swift JK, Borja SE, Heath CJ. Exploring the contribution of supervisors to intervention outcomes. Train Educ Prof Psychol 2009;3:72–7. [37] Roche AM, Todd CL, O’Connor J. Clinical supervision in the alcohol and other drugs field: an imperative or an option? Drug Alcohol Rev 2007;26:241–9.
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[38] Kypri K, Gallagher SJ, Cashell-Smith ML. An Internetbased survey method for college student drinking research. Drug Alcohol Depend 2004;76:45–53. [39] Booth-Kewley S, Larson GE, Miyoshi DK. Social desirability effects on computerized and paper-and-pencil questionnaires. Comput Human Behav 2007;23:463–77. [40] Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia 2007-08: Findings from the National Minimum Data Set. Bulletin no. 74 Cat no. AUS 118. Canberra: AIHW, 2009. [41] Roche A, O’Neil M, Wolinski K. Alcohol and other drug specialist treatment services and their managers: findings from a national survey. Aust N Z J Public Health 2004;28:252–8.
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Drug and Alcohol Review (May 2015), 34, 252–258 DOI: 10.1111/dar.12204
The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia PHILIPPA L. EWER1,2, MAREE TEESSON1,2, CLAUDIA SANNIBALE1,3, ANN ROCHE4 & KATHERINE L. MILLS1,2 1
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia, 2NHMRC Centre of Research Excellence in Mental Health and Substance Use, University of New South Wales, Sydney, Australia, 3Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia, and 4National Centre for Education and Training on Addiction, Flinders University, Adelaide, Australia
Abstract Introduction and Aims. The high prevalence of trauma exposure and post-traumatic stress disorder (PTSD) among clients of alcohol and other drug (AOD) services is well documented. Less is known, however, about the impact this has on workers who assess and treat such clients. The aim of this study was to examine the prevalence and correlates of secondary traumatic stress (STS) among AOD workers in Australia. Design and Methods. An anonymous web-based survey was undertaken and completed by 412 Australian AOD workers.The questionnaire assessed current levels of trauma training, extent of exposure to clients with a history of trauma history, AOD workers’ own history of trauma exposure and PTSD, and current STS. Analyses compared individuals who currently met criteria for experiencing STS with those who did not. Results. Despite the high volume of traumatised clients accessing AOD services, less than two-thirds of AOD workers reported having ever received trauma training. The prevalence rate of STS was 19.9% and was independently predicted by a higher traumatised client workload, fewer hours of clinical supervision, and stress and anxiety levels of the worker. Discussion and Conclusions. The findings highlight the importance of providing adequate trauma training and clinical supervision to AOD workers in order to maintain their health and welfare and ensure optimal treatment to clients with PTSD. [Ewer PL, Teesson M, Sannibale C, Roche A, Mills KL. The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug Alcohol Rev 2015;34:252–58] Key words: secondary traumatic stress, substance abuse, PTSD, clinical supervision, workforce.
Introduction Over recent years, there has been growing recognition of the high prevalence of trauma exposure and posttraumatic stress disorder (PTSD) among clients of alcohol and other drug (AOD) services. Trauma exposure is almost universal in this population and up to two-thirds of clients have current PTSD [1–4]. Compared with individuals with a substance use disorder alone, individuals with comorbid PTSD report more extensive polydrug use histories, suffer poorer social and occupational functioning, poorer physical and mental health, and higher rates of attempted suicide [3–8]. Furthermore, a history of trauma and PTSD has
consistently been associated with poorer treatment outcomes and a more chronic course of illness [9–11]. It is therefore unsurprising that treatment providers consider clients with this comorbidity to present a significant clinical challenge [12,13]. Little is known, however, about how working with traumatised clients impacts upon the AOD workers who treat them. Research has shown that exposure to an individual’s trauma history through assessment and treatment results in an increased risk of the clinician becoming traumatised themselves. This is often referred to as ‘vicarious traumatisation’ or ‘secondary traumatic stress’ (STS; [14–16]). STS has been defined as ‘the natural, consequent behaviours and emotions resulting
Philippa L. Ewer BPsych(Hons), MPsych(Clin), Research Psychologist, Maree Teesson BSc(Hons), PhD, Professor, Claudia Sannibale BA(Hons) (Psych), MPsych(Clin), PhD, Clinical Psychologist, Ann Roche BA, MEd, PhD, Professor, Katherine L. Mills BHlthSc(Hons), PhD, Associate Professor. Correspondence to Dr Katherine L. Mills, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia. Tel: +612 9385 0331; Fax: +612 9385 0222; E-mail: [email protected] Received 11 May 2014; accepted for publication 6 August 2014. © 2014 Australasian Professional Society on Alcohol and other Drugs
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from knowledge about a traumatising event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatised or suffering person’ (p. 10) [14]. An individual who meets criteria for experiencing STS develops symptoms of PTSD, including intrusion, avoidance and hyperarousal [15]. Until recently, however, STS was considered distinct from PTSD because of the nature of the traumatic event (i.e. exposure to a traumatised individual’s retelling of a traumatic event, as opposed to experiencing the event oneself) [14]. In recognition of the legitimacy of STS, the most recent revision to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) has included repeated or extreme indirect exposure to aversive details of the event(s) in the course of professional duties as a qualifying event [16]. STS has been referred to as an occupational hazard for those working with trauma survivors [17,18]; however, there is a dearth of research examining STS among the AOD workforce.To our knowledge, only one study has been conducted in the USA. Of the 225 AOD counsellors surveyed, 19% met criteria for current STS [19]. This figure is of concern as STS has been associated with a number of adverse consequences relating to a person’s cognitions (e.g. diminished concentration, decreased self-esteem), emotions (e.g. hypersensitivity) and interpersonal functioning (e.g. social isolation) [20]. Furthermore, associations have been made between STS and lower job satisfaction and occupational commitment [21]. The latter are known to contribute to burnout, job turnover and loss to the AOD workforce. Given the high prevalence of trauma and PTSD among clients of AOD services in Australia [1,3], it is likely that similarly high rates of STS may be present among Australian AOD workers; however, the degree to which it is suffered by AOD workers in Australia is unknown. The present study aimed to address this gap in the literature by examining the prevalence and correlates of STS among AOD workers in Australia.
Method Procedure Participants were recruited via an email that was distributed Australia wide to members of the main AOD professional bodies (i.e. the Alcohol and Drugs Council of Australia, Australasian Professional Society on Alcohol and Other Drugs, and Drug and Alcohol Nurses Australasia). The email invited individuals working in the AOD sector to participate in an anonymous web-based questionnaire examining the issue of working with traumatised clients. Email recipients were also encouraged to forward the email to colleagues who
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did not belong to these professional bodies that may be interested. Ethical approval was granted by the University of New South Wales Human Ethics Review Committee. Web-based questionnaire The web-based questionnaire took approximately 15 min to complete. Information was collected on participants’ demographic characteristics, level of education and training, and number of clinical supervision hours each month (i.e. guidance and feedback on matters of personal, professional and educational development in the context of their work with clients). Exposure risk to STS was measured by asking participants to provide an estimate of the percentage of clients they had worked with in their current workplace who had a trauma history and specific trauma types experienced by clients. Past-week symptoms of STS were assessed using the Secondary Traumatic Stress Scale (STSS; [17]). Specifically, participants were asked to indicate how frequently they had experienced a list of 17 re-experiencing, avoidance, numbing and hyperarousal symptoms after working with psychologically traumatised clients in the past week. Individuals were classified as meeting criteria for STS if they endorsed experiencing at least one re-experiencing, three avoidance or numbing and two hyperarousal symptoms [15]. The STSS has demonstrated good psychometric properties, with construct validity established through convergent, discriminant, and factorial analyses [17,22]. Past trauma exposure and PTSD among participants were also assessed. Trauma history was measured using the Composite International Diagnostic Instrument version 2.1 [23], which assesses lifetime exposure to combat, life-threatening accidents, natural disasters, witnessing serious injury or death, rape, sexual molestation, serious physical assault, being threatened with a weapon, held captive or kidnapped, being tortured or being the victim of terrorists, any other extremely stressful or upsetting event, or a great shock because one of the aforementioned events has happened to someone else. Participants were also asked to indicate if any of the traumas they had experienced occurred before the age of 16 years. Participants reporting exposure to one or more traumatic events were asked to complete the PTSD Checklist—Civilian Version (PCL-C; [24]), which assesses past-week frequency and severity of PTSD symptoms. The PCL-C has been shown to have good internal consistency, test–retest reliability, convergent validity and discriminant validity [25]. Past-week symptoms of depression, anxiety and stress were measured using the short form Depression Anxiety Stress Scale (DASS-21; [26]). The DASS-21 © 2014 Australasian Professional Society on Alcohol and other Drugs
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has demonstrated good internal consistency for all three subscales that comprise the measure as well as good convergent and discriminant validity compared with other validated measures of depression and anxiety [27].
Prevalence of STS One in five participants (19.9%) met criteria for STS. There were no differences between workers with and without STS in relation to any of the sample characteristics reported above (Table 1).
Analyses Analyses were conducted with ibm spss Statistics Version 20.0 (Armonk, NY: IBM Corp.). Means with standard deviations (SDs) were reported for normally distributed data, and differences between groups examined using t-tests. Where continuous data were highly skewed, Mann–Whitney U-tests were conducted, and the median and range reported. Percentages are provided for categorical variables and between-group differences examined using χ2 tests [results reported as odds ratios (ORs) and 95% confidence intervals (95% CIs)] or Fischer’s exact tests for variables with expected cell counts of less than five. All variables found to be significantly associated with STS in the bivariate analyses were entered into a multivariate backward stepwise logistic regression. Results
Correlates of STS Education, training, workload and supervision. There were no significant differences between workers with and without STS in the proportion who had received training in AOD (92.7% vs. 96.7%; OR 0.44, 95% CI 0.16–1.22), mental health (85.4% vs. 89.1%; OR 0.71, 95% CI 0.35–1.44) and trauma (57.3% vs. 64.5%; OR 0.74, 95% CI 0.45–1.21). However, workers with STS were less likely to have completed tertiary education (95.1% vs. 99.4%; P = 0.016, Fischer’s exact test) and received less clinical supervision each month compared with workers without STS (median 1 h vs. 2 h; Z = −2.69, P = 0.007). Workers with STS also reported having a larger proportion of clients with a trauma
Table 1. Characteristics of AOD workers with and without STSa
Sample characteristics and the prevalence of STS Four-hundred and eighteen participants responded to the survey. Data from six participants were excluded from the analysis because of a large amount of missing data, including the data required to determine whether they met the criteria for STS. Thus, the final sample consisted of 412 AOD workers (70.5% female). The mean age of the sample was 44.3 years (SD 10.7) and a minority identified as being of Aboriginal or Torres Strait Islander background (3.7%). The median number of years working in the AOD sector was 10 (range 0–47). The sample comprised a range of professionals including nurses (21.7%), counsellors (20.5%), psychologists (12.4%), case workers (11.5%), social workers (7.1%) and other AOD professionals including doctors, intake officers, managers, psychiatrists and youth workers (26.8%). Participants worked in services located across Australia, most commonly New South Wales (36.6%), Queensland (21.8%) and Victoria (20.6%), followed by the Australian Capital Territory (6.6%), Western Australia (4.7%), South Australia (4.2%), Northern Territory (3.9%) and Tasmania (3.7%). The majority worked in urban areas with populations of over 100 000 (57.9%) or between 1000 and 99 000 (36.4%). A small proportion worked in localities with populations between 200 and 999 (2.9%) or less than 200 (2.9%). © 2014 Australasian Professional Society on Alcohol and other Drugs
Characteristic Mean age (SD) % Female % Indigenous descent State/territory % New South Wales % Queensland % Victoria % Australian Capital Territory % Western Australia % South Australia % Northern Territory % Tasmania Population size % >100 000 % 1000–99 000 % 200–999 % 0.05. AOD, alcohol and other drug; SD, standard deviation; STS, secondary traumatic stress.
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Table 2. Comparison of trauma types experienced by AOD workers with and without STS
Trauma type
+ STS % (n) (n = 82)
− STS % (n) (n = 330)
Total % (n) (n = 412)
OR
95% CI
Threatened, held captive or kidnapped* Life-threatening accident* Witnessed serious injury or death Serious physical attack or assault* Sexual assault* Natural disaster Tortured or victim of terrorists Combat in a war*
45.7 (37) 56.1 (46) 47.6 (39) 56.1 (46) 51.2 (42) 39.0 (32) 3.7 (3) 7.3 (6)
31.1 (102) 37.1 (122) 42.7 (141) 38.0 (125) 38.5 (127) 27.9 (92) 1.2 (4) 2.1 (7)
34 (139) 40.9 (168) 43.7 (180) 41.6 (171) 41.0 (169) 30.1 (124) 1.7 (7) 3.2 (13)
1.86 2.17 1.22 2.09 1.68 1.66 3.10 3.64
1.14–3.05 1.33–3.53 0.75–1.98 1.28–3.40 1.03–2.73 0.99–2.74 0.68–14.09 1.19–11.11
*P < 0.05. AOD, alcohol and other drug; CI, confidence interval; OR, odds ratio; STS, secondary traumatic stress.
history in their current service compared with workers without STS (median 90.0% vs. 80.0%; Z = 4.18; P < 0.0001). Personal exposure to trauma and mental health. Workers with STS were more likely to have experienced a traumatic event (88.9% vs. 79.0%; OR 2.12, 95% CI 1.01– 4.46) and experienced more trauma types (median 3 vs. 2; Z = 3.52, P < 0.01) compared with workers without STS. As shown in Table 2, there were between-group differences in the types of traumas experienced. Compared with workers without STS, those with STS were more likely to have been: exposed to combat in a war (OR 3.64); in a life-threatening accident (OR 2.17); seriously physical attacked or assaulted (OR 2.09); threatened with a weapon, held captive or kidnapped (OR 1.86); and sexually assaulted (OR 1.68). Workers with STS were also more likely to have experienced childhood trauma (69.2% vs. 49.2%; OR 2.32, 95% CI 1.37–3.94) and childhood sexual assault (39.5% vs. 27.1%; OR 1.76, 95% CI 1.06–2.92) compared with workers without STS. In regard to mental health, workers with STS were more likely to meet criteria for current PTSD (22.2% vs. 2.7%; OR 10.16, 95% CI 4.37–23.64) and had higher scores on the depression (median 24 vs. 16; Z = 8.87, P < 0.01), anxiety (median 22 vs. 14; Z = 9.25, P < 0.01) and stress (median 30 vs. 20; Z = 9.40, P < 0.01) subscales of the DASS-21. Independent predictors of STS All factors found to be significant at the bivariate level were entered into a backward stepwise logistic regression to determine independent predictors of STS. Four variables remained in the final model. STS was found to be independently associated with higher levels of stress (OR 1.18, 95% CI 1.11–1.26), higher levels of
anxiety (OR 1.13, 95% CI 1.04–1.22), a higher traumatised client workload (OR 1.03, 95% CI 1.01–1.06) and receiving fewer hours of clinical supervision (OR 0.75, 95% CI 0.63–0.90).
Discussion This is one of few investigations undertaken to examine the prevalence of STS among AOD workers, and it is the first study to examine this issue in Australia. Consistent with the findings of Bride et al.’s [19] US study of AOD counsellors, one in five (19.9%) AOD workers in the present study met criteria for STS. This rate is concerning given the potential impact of STS for workers both personally and professionally [20,21]. The present study found an independent association between STS and higher levels of stress and anxiety. Because of the cross-sectional nature of this study, however, causal attributions cannot be made. Although STS may lead to higher levels of stress and anxiety, it may also be that higher levels of stress and anxiety predispose workers to developing STS. Research has shown that pre-trauma anxiety increases an individual’s risk of experiencing post-traumatic stress reactions following trauma exposure [26]. Thus, workers with high levels of anxiety may be more vulnerable to STS when working with traumatised clients. Regardless of the nature of the relationship between these variables, research has demonstrated an association between STS and lower job satisfaction and occupational commitment [21]. It is possible that STS and other associated sources of distress may contribute significantly to the high levels of staff turnover seen within the AOD sector [28]. Hence, addressing STS among AOD workers may improve worker retention as well as improving client treatment and outcomes. Consistent with the high prevalence of self-reported trauma and PTSD among clients of AOD services [1], © 2014 Australasian Professional Society on Alcohol and other Drugs
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both workers with and without STS reported working with high proportions of traumatised clients (median of 90% of clients vs. 80% of clients). As found by Brady et al. [29] in their examination of STS among female psychotherapists, workers experiencing STS reported a significantly greater traumatised client workload compared with those without STS. Furthermore, this caseload was identified as an independent predictor in the final multivariate model.These results of this model suggest that the odds of experiencing STS are increased by 30% for every 10% increase in the proportion of traumatised clients treated. This finding underscores the importance of monitoring the number and distribution of traumatised clients allocated to individual workers. High rates of trauma exposure and PTSD were also identified among the AOD workers themselves, particularly among those with STS. Findings regarding the relationship between an individual’s own trauma and PTSD history and the development of STS have been mixed. Ortlepp and Friedman’s [30] study of trauma counsellors found no relationship, whereas Bride et al. [31] found that child protective service workers with a personal history of trauma were at increased risk of STS. In the present study, the prevalence of trauma exposure and PTSD was found to be significantly higher in the bivariate analyses; however, these factors were not shown to be independent predictors in the final multivariate model, indicating that the relationship between trauma, PTSD and STS is confounded by other personal and professional characteristics. Consistent with research among health-care providers more broadly [32,33], STS was associated with receiving fewer hours of clinical supervision each month.The findings emphasise the importance of clinical supervision for AOD workers who are treating complex clients, even if trauma is not the primary reason for treatment [34]. In addition to reducing the likelihood of experiencing STS, clinical supervision is associated with greater job satisfaction [35], reduced staff turnover [33] and improved client outcomes [36]. It is therefore not surprising that clinical supervision has been suggested as a promising workforce development strategy within the AOD workforce [37]. Despite the high volume of traumatised clients accessing AOD services, less than two-thirds of workers surveyed reported having received trauma training; however, specific details regarding the nature of training received were not obtained. There may have been substantial variation in the type (e.g. attendance at professional seminars/workshops, training provided as part of obtaining professional qualifications, certification) and content of training received (e.g. training on assessment and delivering trauma-informed care versus training regarding the delivery of trauma© 2014 Australasian Professional Society on Alcohol and other Drugs
focused treatments). Therefore, although an association between trauma training and the presence of STS was not found, the effect may have been diluted because of the heterogeneity of training received. Nonetheless, this finding highlights a significant gap in AOD worker training and the need for further research, and consideration at a policy level, regarding the level and type of trauma training that is appropriate for this workforce. The results of the current study need to be considered in light of a number of limitations. Firstly, while there are a number of benefits to utilising a web-based questionnaire such as low cost [38], automatic data entry [24] and reduced propensity for socially desirable responses [39], employing a web-based questionnaire meant only those who had access to the Internet were able to complete it. Secondly, in order to take part in the study, participants had to be currently working in the AOD sector. As STS has been associated with job satisfaction and occupational commitment [21], it is possible that an unknown proportion of individuals may not have been captured by the study as they were no longer working in the AOD sector as a result of experiencing STS. Thirdly, although the demographic characteristics of the sample were similar to those reported in previous studies of the Australian AOD workforce [28,40,41] it is possible that there was a response bias whereby individuals who had a particular interest in trauma research, either due to their own personal experiences or those of their clients, may have been more likely to respond. Lastly, because of the anonymous nature of the study, information regarding the response rate was unable to be collected (i.e. those who received the email inviting them to respond to the survey compared with those who actually responded), along with the characteristics of non-respondents who may have been too distressed to participate in the study. In spite of these limitations, the present study highlights the impact of working with traumatised clients on the psychological well-being of the worker. It provides valuable information regarding the prevalence of STS among individuals working in the Australian AOD sector, along with the factors associated with an individual experiencing STS. These findings underscore the crucial importance of adequate and appropriate training and support for AOD workers, in general, and specifically in relation to treating clients with trauma experiences. To date, this has been a largely overlooked area and one in which relatively little was known about the potential impact on workers. What was once referred to as ‘compassion fatigue’ might be more accurately referred as ‘secondary traumatic stress’ or ‘vicarious traumatisation’, and with our improved knowledge and understanding of this issue, we can now provide
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appropriate support and ensure protective mechanisms are in place to safeguard the well-being of the AOD workforce. Acknowledgements The authors wish to thank all study participants and the professional organisations who advertised this study. Maree Teesson was supported by a National Health and Medical Research Council Senior Research Fellowship and Katherine L. Mills was supported by a National Health and Medical Research Council Career Development Award and the National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use. References [1] Dore G, Mills KL, Murray R, Teesson M, Farrugia P. Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders. Drug Alcohol Rev 2012;31:294–302. [2] Driessen M, Schulte S, Luedecke C, et al. Trauma and PTSD in patients with alcohol, drug, or dual dependence: a multi-center study. Alcohol Clin Exp Res 2008;32:481–8. [3] Mills KL, Lynskey M, Teesson M, Ross J, Darke S. Posttraumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates. Drug Alcohol Depend 2005;77:243–9. [4] Reynolds M, Mezey G, Chapman M, Wheeler M, Drummond C, Baldacchino A. Co-morbid post-traumatic stress disorder in a substance misusing clinical population. Drug Alcohol Depend 2005;77:251–8. [5] Najavits LM, Gastfriend DR, Barber JP, et al. Cocaine dependence with and without PTSD among subjects in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Am J Psychiatry 1998;155:214–19. [6] Najavits LM, Weiss RD, Shaw SR. A clinical profile of women with PTSD and substance dependence. Psychol Addict Behav 1999;13:98–104. [7] Ouimette P, Goodwin E, Brown PJ. Health and well being of substance use disorder patients with and without posttraumatic stress disorder. Addict Behav 2006;31:1415– 23. [8] Najavits LM, Runkel R, Neuner C, et al. Rates and symptoms of PTSD among cocaine-dependent patients. J Stud Alcohol 2003;64:601–6. [9] Mills KL, Teesson M, Ross J, Darke S. The impact of post-traumatic stress disorder on treatment outcomes for heroin dependence. Addiction 2007;102:447–54. [10] Ouimette PC, Finney JW, Moos RH. Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder. Psychol Addict Behav 1999;13:105–14. [11] Hien DA, Nunes E, Levin FR, Fraser D. Posttraumatic stress disorder and short-term outcome in early methadone treatment. J Subst Abuse Treat 2000;19:31–7. [12] Back S, Waldrop A, Brady K. Treatment challenges associated with comorbid substance use and posttraumatic stress disorder: clinicians’ perspectives. Am J Addict 2009;18:15– 20.
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[13] Najavits LM. Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. J Subst Abuse Treat 2002;22:79–85. [14] Weible R, Wallace J. The impact of the Internet on data collection. Mark Res 1998;10:19–23. [15] Bride BE. Prevalence of secondary traumatic stress among social workers. Soc Work 2007;52:63–70. [16] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edn. Arlington, VA: American Psychiatric Publishing, 2013. [17] Bride BE, Robinson MM, Yegidis B, Figley CR. Development and validation of the secondary traumatic stress scale. Res Soc Work Pract 2004;14:27–35. [18] Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. In: Stamm BH, ed. Secondary traumatic stress: self-care issues for clinicians, researchers, and educators. Baltimore, MD: The Sidran Press, 1995:3– 28. [19] Bride BE, Hatcher SS, Humble MN. Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology 2009;15:96– 105. [20] Yassen J. Preventing secondary traumatic stress disorder. In: Figley CR, ed. Compassion fatigue: coping with secondary traumatic stress in those who treat the traumatized. New York: Brunner Mazel, 1995:178–208. [21] Bride BE, Kintzle S. Secondary traumatic stress, job satisfaction, and occupational commitment in substance abuse counselors. Traumatology 2011;17:22–8. [22] Ting L, Jacobson JM, Sanders S, Bride BE, Harrington D. The Secondary Traumatic Stress Scale (STSS): confirmatory factor analyses with a national sample of mental health social workers. J Hum Behav Soc Environ 2005;11:177–94. [23] World Health Organization. Composite International Diagnostic Interview (CIDI) core version 2.1, 12 month version. Geneva: World Health Organization, 1997. [24] Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003;20:545–51. [25] Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. Psychometric properties of the PTSD checklist—civilian version. J Trauma Stress 2003;16:495–502. [26] Koenen KC, Harley R, Lyons MJ, et al. A twin registry study of familial and individual risk factors for trauma exposure and post- traumatic stress disorder. J Nerv Ment Dis 2002;190:209–18. [27] Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005;44:227–39. [28] Duraisingam V, Pidd K, Roche AM. The impact of work stress and job satisfaction on turnover intentions: a study of Australian specialist alcohol and other drug workers. Drugs Educ Prev Pol. 2009;16:217–31. [29] Brady JL, Guy JD, Poelstra PL, Brokaw BF. Vicarious traumatisation, spirituality, and the treatment of sexual abuse survivors: a national survey of women psychotherapists. Prof Psychol Res Pr 1999;30:386–93. [30] Ortlepp K, Friedman M. Prevalence and correlates of secondary traumatic stress in workplace lay trauma counselors. J Trauma Stress 2002;15:213–22. [31] Bride BE, Jones JL, Macmaster SA. Correlates of secondary traumatic stress in child protective services workers. J Evid Based Soc Work 2007;4:69–80. © 2014 Australasian Professional Society on Alcohol and other Drugs
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[32] Galek KKPT. Burnout, secondary traumatic stress, and social support. Pastoral Psychol 2011;60:633–49. [33] Knudsen HK, Ducharme LJ, Roman PM. Clinical supervision, emotional exhaustion, and turnover intention: a study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse. J Subst Abuse Treat 2008;35:387–95. [34] Knight C. Working with survivors of childhood trauma. Clin Superv 2004;23:81–105. [35] Hyrkäs K, Appelqvist-Schmidlechner K, Haataja R. Efficacy of clinical supervision: influence on job satisfaction, burnout and quality of care. J Adv Nurs 2006;55:521–35. [36] Callahan JL, Almstrom CM, Swift JK, Borja SE, Heath CJ. Exploring the contribution of supervisors to intervention outcomes. Train Educ Prof Psychol 2009;3:72–7. [37] Roche AM, Todd CL, O’Connor J. Clinical supervision in the alcohol and other drugs field: an imperative or an option? Drug Alcohol Rev 2007;26:241–9.
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[38] Kypri K, Gallagher SJ, Cashell-Smith ML. An Internetbased survey method for college student drinking research. Drug Alcohol Depend 2004;76:45–53. [39] Booth-Kewley S, Larson GE, Miyoshi DK. Social desirability effects on computerized and paper-and-pencil questionnaires. Comput Human Behav 2007;23:463–77. [40] Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia 2007-08: Findings from the National Minimum Data Set. Bulletin no. 74 Cat no. AUS 118. Canberra: AIHW, 2009. [41] Roche A, O’Neil M, Wolinski K. Alcohol and other drug specialist treatment services and their managers: findings from a national survey. Aust N Z J Public Health 2004;28:252–8.
