An episode of “Changing the Conversation” podcast
Kristin Dempsey and Ali Hall discuss the impact of secondary trauma on people working in health and human services and Motivational Interviewing strategies to address it and promote post-traumatic growth with host Jeff Olivet.
May 10, 2021
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Jeff Olivet, Host: [00:05] This is Jeff Olivet with Changing the Conversation. Our topic today is secondary trauma and its impact on behavioral health staff. This is part of our ongoing series of conversations on Motivational Interviewing or MI, and I am pleased to be joined today by Dr. Kristin Dempsey and by an old friend of the podcast, Ali Hall. Dr. Dempsey is a therapist who specializes in working with individuals struggling with co-occurring mental health conditions, addiction, trauma, anxiety, and depression. She’s on the faculty at the Wright Institute Masters in Counseling program, and also on the lecturing faculty of San Francisco State University. Kristin provides consultation to behavioral health systems seeking to improve their recovery-oriented, culturally-responsive, and trauma-informed practices. Kristin, it’s so good to have you on the podcast.
Kristin Dempsey, Guest: [00:55] Thank you so much, Jeff.
Jeff: [00:57] And Ali Hall is an independent trainer, consultant, and coach in Motivational Interviewing, and a member and board member of the Motivational Interviewing Network of Trainers. Ali, it’s great to have you back.
Ali Hall, Guest: [1:08] Thanks, Jeff. It’s great to be here today with you and Kristin.
Jeff: [1:12] Kristin, let’s start with just defining the terms for people. We’ve talked a lot on this podcast about trauma and about its impact on individuals. We’ve talked about trauma-informed care and how clinicians and organizations’ non-clinicians can provide trauma-informed support. Today we’re talking about secondary trauma, what is that?
Kristin: [1:34] It’s just confusing actually thinking about the different types of traumas and a number of the definitions, because sometimes they’re easy to confuse. I’m using some terminology developed by Dr. Charles Figley, who’s done tremendous amount of research in this area and really defining some of the terms. Secondary trauma or secondary traumatic stress is a term that we use to describe a phenomenon whereby we, providers, are traumatized not directly by experiencing a traumatic event, but rather by hearing about a traumatic event experienced by someone else. This is distinct maybe from what we might also know as vicarious traumatization, where our empathic engagement with folks over time can actually result in some trauma just through the hearing, kind of reprocessing of other trauma.
Kristin: [2:21] So sometimes people will say STS, or that secondary traumatic stress, can happen with even one incident, whereas vicarious traumatization is often a process that can occur over time. I also want to add this other term that we’re using sometimes now about shared trauma. And this is a term that became more common after 2001, after the World Trade Center tragedy, where we’re becoming more aware of that providers are having a shared traumatic reality, in that we’re often sharing some of the same kind of emotional and behavioral, and cognitive, maybe spiritual responses that people we’re working with are. And that in fact, we’re exposed to the same collective trauma with the people that we’ve work with. And I think right now during our current pandemic this is clearly a common potential occurrence.
Jeff: [3:14] I’d love to talk about that. So, as you were talking, I was thinking about an experience I had working with a team after Hurricane Katrina, training behavioral health providers, first responders, public health people, shelter workers, who were responding to the needs of people who had been displaced by Hurricane Katrina and Hurricanes Rita and Wilma in the following weeks. And not only were the providers reaching out to, connecting with, and providing support for people who had lost their homes, lost loved ones, lost livelihoods, they were also experiencing those losses themselves. So, it wasn’t just that they were hearing about it and taking on this as secondary trauma, they were also survivors of the primary trauma as well, and they’re taking on the pain and sadness and loss and trauma of the people that they were serving. As you said, that is replicating itself right now with the COVID pandemic. Can you talk about what you’re seeing around the intersection of secondary trauma and this shared or collective shock, collective trauma that we’re all going through right now in a lot of ways?
Kristin: [4:26] Yes, absolutely. And just your example also made me think about COVID, and the impact that’s happening on both providers as well as their clients. I was thinking also out here in California about forest fires, and that we have entire communities, including entire communities of practitioners, who are losing their homes and actually also out in the shelters taking care of folks in the community. And we know this has been just an incredibly difficult to maintain the quality of care and the resilience and what needs to happen in order for some good care to occur. And some of the things we’re starting to notice early now with the COVID is we’re looking at things around post-traumatic stress and secondary traumatic stress, rather, and burnout during COVID-19.
Kristin: [5:08] And a recent article published by the Journal of Environmental Research and Public Health, they started to notice among healthcare workers on 45 different countries, and it had 184 folks, they started to look at the different levels of secondary traumatic stress, and they’re noticing high levels of emotional exhaustion, prevalence of depersonalization, also issues around emotional exhaustion, especially when we have folks who are being exposed to their patients’ deaths. And so these are really becoming very much predictive factors for secondary traumatic stress or individuals working on front lines. Other kind of meta analyses or studies have been able to notice early on that if you’re a female younger frontline worker, a nurse, maybe someone even with less work experience, exposure to infected people, maybe having poor social support or difficult access to psychological material, symptoms of insomnia, all these are potential risk factors for later traumatic symptoms in providers. So, these are things we’re learning, we’re learning early, are already becoming rather apparent among providers in the field.
Jeff: [6:18] As you know this is a conversation about Motivational Interviewing, so let’s bring Motivational Interviewing to the table here. As you’re thinking about your work with providers, with people who are experiencing all sorts of levels of trauma, primary, secondary, etc., vicarious, all of it. How do you see Motivational Interviewing playing into this? How do you see it as a protective factor for the providers potentially, but also the benefit for the people being served?
Kristin: [6:50] For me personally, Motivational Interviewing is such an important way to work in general, but it has been an absolute lifesaver for this last year. And the main reason for that is really the therapeutic stance, kind of the approach we take when we’re using Motivational Interviewing. And some of us really need to come at it from the place of spirit, right? This idea of how am I holding someone who’s really struggling with a lot of stress? And so the ability to use the spirit, which is, of course, the values and attitudes that we bring to the work, the ability to accept people for where they’re at, to seek collaboration, to support autonomy, to help try to reduce one’s suffering while giving them the time to really talk and take up the space, and to not have this compulsion to immediately try to take on or to problem-solve what’s going on with someone has been really important, because so much of this last year has been about grief, so much had been about just tremendous loss, despair.
Kristin: [7:52] And relationships heal. And I believe that Motivational Interviewing stance of putting relationship first, and creating this safe environment has been so critical for this healing to happen. And I know even for individuals that I supervise, this can be really challenging because so many individuals they work with have tried to do a lot of their own problem-solving. Some of it has been successful, but resources are at times running thin, and individuals are waiting for responses, and they’re stressed out, and honestly, there’s not a lot that can be done. And so, being in relationship is absolutely the medicine that’s needed because just the sharing, the hope that’s inspired by being in a relationship is what’s absolutely essential for both the people that we serve, but also for ourselves, because it takes the pressure off of, “I have to try to solve all this.”
Kristin: [8:46] Now that said, I think when there’s a place that we can think of being able to do some linkage, or there is an aspect accessing resource, the Motivational Interviewing approach of seeking collaboration is so important. Because people have been traumatized, and one of the most challenging parts of being traumatized is gaining access to our coping mechanisms. So, if someone comes in and tells us what to do, that can most certainly be rejected, but it can also be overwhelming or disempowering. So, to be able to share with someone this sense of, “You’re the expert, what have you already thought of? What will be helpful? What do you need?” Even when trying to find some aspect of solution can also just be very healing and respectful, which is also so needed in a time of really remarkable stress.
Jeff: [9:37] I think that impulse to fix, the impulse to problem-solve, the impulse to sort of kick into action mode is very strong among healthcare providers, among social service providers, among counselors, it’s sort of what you’re trained to do, is kind of help people figure out a situation and fix it. But what Motivational Interviewing does is sort of turn that on its ear a little bit, and the notion of being present with people and listening very deeply and reflecting back what you’re hearing all of the skills of MI as well as the spirit and the therapeutic stance are so critical in a time like this. And I think you’re getting at this. I was having a conversation with some friends last night about all of the deferred grief when people are losing loved ones that they don’t get to see in the last days and hours of their lives.
Jeff: [10:25] The notion of funerals and wakes and Shiva, and time together in the days and weeks and months after a loss or after all of the other traumatic stuff that’s going on with COVID, the economic fallout, loss of jobs, loss of homes, sometimes just being with people, and sometimes letting them have space to take the conversation where they want it to go at the pace they want it to go is the best thing a provider can do. Ali Hall, I’d like to draw you into this conversation. You’ve been listening for the last few minutes. You are an expert in MI, how are you seeing the connection between Motivational Interviewing and secondary trauma and the pandemic? It’s that sort of that complex intersection that we’re talking about right now? What are you hearing? What are you thinking about?
Ali: [11:20] Kristin has brought up a really important factor here, the blurring between work and life. And sometimes a little bit of barrier or buffer between work and life can be a protective factor sort of compensating for the secondary trauma and for caregivers really who are just answering the call of their profession to be able to heal and restore and recuperate. Because as we see increased content achieve presentations, uncertainty, not clear about any end in sight, increasing demand, all of the demands that are increasing now upon the caregiver. And we certainly know that a large part because of secondary trauma, caregivers are the ones most susceptible to burnout with life and death consequences. The incidents of suicide and other kinds of self-harm are far greater among the caregiver population simply as a result of secondary trauma.
Jeff: [12:17] And Ali, what is the relationship of Motivational Interviewing to all of this?
Ali: [12:21] Generally what we see is that MI is helpful on at least three levels. And we know that it helps those we’re serving. It helps us, the provider or facilitator of the motivational conversation. And one thing we know is that between compassion and empathy there’s an inverse relationship to burn out the protective factor against secondary trauma. And we can also think of MI on an organizational level. So, a lot of different ways that MI, the spirit, and the full processes can be incredibly powerful, especially at this time.
Jeff: [12:54] I’d like to explore more of that organizational dimension. One thing I’ve seen over the years is that when an organization really embraces Motivational Interviewing as a predominant way of training their staff and a functioning in the world that not only does that have benefits for the clients and the individual providers, but also for organizational culture as a whole. And Kristin, I’d love to hear your thoughts on this. What do you see around how organizations are transformed by Motivational Interviewing?
Kristin: [13:25] Yes, organizations really have an opportunity to be able to, I think, think creatively about — there’s a number of different parallel processes. And this is kind of where it’s come from me in terms of my training is, when we’re teaching staff to use Motivational Interviewing it changes their relationship to the people they serve. And then organizations, I think need to change relationship to their staff in terms of, “Are we really able to do kind of this parallel process of helping our staff also become more empowered and also being able to be in a way that we’re responding to things in terms of what needs to be done as opposed to what the rules are, as opposed to — and again, obviously every organization has a certain amount of rules that they have to go by in terms of compliance and quality improvement, etc.
Kristin: [14:13] However, there’s so many ways that a staff that’s really empowered and able to make their own choices, and to have ways of being able to be evocative and come up with their own change targets towards these organizational goals can actually achieve them in a way there are so much more, I should say, preserving of their own integrity, which also helps prevent burnout, which I think is another aspect we haven’t really talked about here in terms of some of the traumatic stress continuum, if you will, that organizations if they can just pull back, I think give more trust through their staff who are trained in Motivational Interviewing to be able to see the organizational goals as being not in conflict with, but also being connected to in relation to what’s actually being provided to the community. I think that can really go a long way in terms of preserving the overall integrity of an organization, and actually allowing the organization to be more flexible and more responsive to an ever-changing and really challenging world. Especially as we’re looking at all these environmental factors that are often really difficult to anticipate.
Jeff: [15:20] I’m here with Dr. Kristin Dempsey and Ali Hall talking about the connection between secondary trauma and its impacts on staff working in behavioral health programs and other settings, and how Motivational Interviewing can play a role in helping everybody all the way around. Ali, the stress and strain that organizations have been under for the last year in the face of this terrible global pandemic are overwhelming, and the stress and strain on individual staff is overwhelming, and the stress and strain on individual clients is overwhelming. What are some of the organizational level and individual level strategies for preventing and mitigating secondary trauma?
Ali: [16:05] One of the things we know from theory of work motivation is that the causes of satisfaction and dissatisfaction at work are actually independent of one another. Generally organizations provide more than their share of meaningful work for people to engage in. And that’s an enormous source of satisfaction on the job, providing time for relationships, providing a sense of importance and autonomy at work, these are really things that organizations can do not only to prevent, but to mitigate secondary trauma. The sources of dissatisfaction though come around conditions, quality of supervision and things like that. And here’s another place that MI can not only, is increasing satisfaction at work, but also reducing dissatisfaction at work, increasing individual say in the conditions of work, improving the supervisory relationship, these are really important things to create a better work environment, even in virtual or work at home types of situations.
Ali: [17:08] Some things that often the burden goes to the individual, and in fact, we know we need to take responsibility for ourselves, no question, we want to take responsibility as individuals for our own health and wellbeing, and yet organizations play a really big role in this. And there are many things that they can do. So, leaders, managers, supervisors can ask individuals what they want, what they need. Very often key leadership will come up with very elaborate or expensive solutions for helping their staff that may not be what staff want. So, providing voice, “What do you do? What would be helpful?” Or very often just having a buffer or some sort of a firebreak, some sort of space, even a breakout room or some way of honoring and respecting a couple of minutes of time that people have.
Ali: [17:57] Certainly something that we’ve seen in the virtual world is that even if there is a five-minute break, staff end up filling it with multitasking, checking emails, doing other things like that. A break really needs to be a break. There needs to be a buffer, and organizations can provide that. They can also do some very low cost things in order to allow their staff to withdraw and get some peace in order to even make a better jump, as they say in French, but honoring and respecting restorative breaks, things that don’t require a diagnosis for an employee to access, some really helpful things. These are all antidotes to isolation as well.
Jeff: [18:36] Yeah, thank you for all of those great organizational strategies that groups can employ to support their staff. Kristin, this is getting at the question of burnout, which you raised a few minutes ago. How do you think about supporting staff as they’re either on the edge of burnout or beyond the edge of burnout? And how do you both prevent that from happening in the first place, but deal with it once it’s already happened? I think sometimes we would talk when I was in Healthcare for the Homeless direct service world about getting crispy, I’m just feeling a little fried today. This is beyond burned out in a lot of ways. I’m just sort of, “Can I even come back from that?” How do you think about this? And what can individuals do? What can supervisors do? And what can organizations do?
Kristin: [19:26] In addition to some of the important strategies that Ali was talking about, coming to think about what I’ve learned in this last year as being a provider for myself. And for any of us, how did we get through this last year? And we’re going to be in this for a while, and how much I’ve learned from the individuals I’ve worked with? From my own clients so to speak. And what I’ve learned through listening and through adapting the spirit of MI and just hearing people talk and where we continue to go, I think has a key to some of this in terms of preventing burnout, and also in terms of maybe recovering from it. And I found that those who are really kind of recovering were able to identify meaning and values. In all of this and all this craziness, what was kind of driving us forward? Where do our values bring us? And how are we making meaning out of this really very tragic and difficult situation where we have no control.
Kristin: [20:21] A big part of what burnout is not having control. So, what can I control? I mean, how is that kind of consistent with my values? I think the important parts for preventing and recovering from burnout. Also just being able to practice acceptance and loneliness, just that there’s a lot of things that are very difficult. Boy, there’s a lot of things I wish weren’t happening and that shouldn’t be happening, and they are. And now that they are, where can I have a place being able to hopefully be willing to make some change? Given things aren’t the way I like it, but where can I get started? And also another important thing that I wanted to mention around this place of perseverance, if you will, and strength is really being able to identify and embrace gratitude wherever it shows up.
Kristin: [21:07] And I think that’s also another important part of helping us stay well at work is, as difficult as it is, why am I here? How’s this fitting into, again, back to my values, but what am I grateful for even with all the yuck that might have occurred today or the things that are so incredibly frustrating? It does give us a chance to build a certain aspect of resilience. So, wherever we can help employees find a place of having some sense of control of being able to identify and work on their strengths, we do have an opportunity here for another trauma issue, which is post-traumatic growth, which is out of all of this that we’re going through, where are the places where we’re developing stronger relationships? Where are we learning more about what we can and cannot control these acceptance aspects? What we’re learning about who we are in terms of meeting in our own spiritual discovery. I think these are places of both potential prevention and also for recovery.
Jeff: [22:04] I think that’s a wonderful place to land this conversation, in a place of hope and in a place of renewal. I love the way that you talked about recovering from burnout. I don’t know that people always think of it in those terms, that this is also a thing to recover from and not just recover to a pre-trauma baseline or a pre-burnout baseline, but to recover to a place of even greater strength through rebirth, regrowth, renewal, post-traumatic growth as you’re talking about. Kristin Dempsey, thank you so much for being here. Thank you for sharing your wisdom with us today.
Kristin: [22:41] Thank you, Jeff. And thank you, Ali.
Jeff: [22:42] Ali Hall, it’s always great to have you.
Ali: [22:44] Thank you, Jeff. And thank you, Kristin. And if I could just put in one last plea for organizations to look for a way to awaken compassion. Little things make a very big difference. We know that it makes a difference when we express compassion to others, when we experience it for ourselves, and organizations can play a very big part in this, and this is the time to bring it.
Jeff: [23:07] Good words to end on. Thank you, Ali. And to our listeners, we know that this is an immensely difficult time for you personally, for the people that you love and care about, for the people that you serve every day in your organizations, trauma abounds in early 2021 as we record this podcast. We have gone through and continue to move through a very, very difficult time as humans together on this planet, in our communities, in our neighborhoods, in our cities and states and nations. And it is so important to remember that we are in this together in a very deep way. Regardless of all of the divisions that separate us, there is so much that unites us and so much that we are moving through together and that we will recover from together. Join us next time on Changing the Conversation.
Erika Simon, Producer: [24:01] Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song is written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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