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Interventions for Secondary Traumatic Stress With Mental Health Workers: A Systematic Review
Melissa L. Bercier and Brandy R. Maynard
Research on Social Work Practice published online 20 April 2014
DOI: 10.1177/1049731513517142
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Research Article

Interventions for Secondary Traumatic

Stress With Mental Health Workers:
A Systematic Review

Research on Social Work Practice

1-9
The Author(s) 2013
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DOI: 10.1177/1049731513517142
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Melissa L. Bercier1 and Brandy R. Maynard2

Abstract
Objective: A systematic review was conducted to examine effects of indicated interventions to reduce symptoms of secondary
traumatic stress (STS) experienced by mental health workers. Method: Systematic review methods were employed to search,
retrieve, select, and analyze studies that met study inclusion criteria. Results: Over 4,000 citations were reviewed, 159 full-text
reports were screened, and two studies were fully coded and determined to be ineligible. No studies met criteria for inclusion in
this review. Discussion: There is compelling evidence of psychological effects of working with trauma victims; however, no
rigorous evidence meeting eligibility criteria was found to inform how to intervene most effectively with mental health workers
who experience symptoms of STS. While it is important to provide effective interventions to helpers who may be experiencing
symptoms related to secondary trauma, it seems apparent that there is yet more we need to do in order to advance efforts in
evaluating the outcomes of practices currently being used and under development.
Keywords
systematic review, secondary traumatic stress, vicarious trauma, compassion fatigue

Social workers are the nations largest group of mental health

services providers and comprise over 40% of all disaster mental health volunteers trained by the American Red Cross
(National Association of Social Workers, 2012). Social workers who provide mental health services are often in positions
within hospitals, community mental health centers, social service organizations, or criminal justice settings working with
individuals who have experienced trauma. Caring for and
intervening in the lives of those who have experienced trauma
have been associated with negative psychological, emotional,
and cognitive effects from the exposure to the traumatic stories of clients (Bride, 2007; Conrad & Kellar-Guenther, 2006;
Figley, 1995). This phenomenon has been labeled secondary
traumatic stress (STS) and two similar, often interchangeably
discussed constructs, compassion fatigue (CF) and vicarious
trauma (VT). CF, STS, and VT affect approximately 515%
of therapists in the clinical range of severity (Adams & Riggs,
2008; Bride, 2007; Choi, 2011; Kadambi & Truscott, 2004)
and are increasingly being recognized in the mental health
field as a considerable risk for mental health workers who
work with trauma survivors (Dunkley & Whelan, 2006).
CF, STS, and VT are terms coined to describe the phenomenon
of helpers experiencing posttraumatic stress-like symptoms in
response to being exposed to trauma material they hear from their
clients. STS, a term coined by Figley and later renamed to CF
(Figley, 1995), is defined as the natural, consequent behaviors
and emotions resulting from knowledge about a traumatizing

event experienced by a significant other (Figley, 1995, p. 10).

VT has been defined as the cumulative transformation in the
inner experience of the therapist that comes about as a result of
empathic engagement with the clients traumatic material
(Pearlman & Saakvitne, 1995a, p. 31). While nuances differentiating the constructs have been asserted (Beck, 2011; Devilly,
Wright, & Varker, 2009; Figley, 1995; Jenkins & Baird, 2002;
Sabin-Farrell & Turpin, 2003; Sexton, 1999), there is no clear evidence that the concepts are conceptually distinct (Craig & Sprang,
2010). Indeed, the terms are often used interchangeably, misused,
or used ambiguously in the literature (Boscarino, Adams, & Figley, 2010; Jenkins & Baird, 2002), creating confusion about the
definition and measurement of the constructs and perpetuating
a lack of consensus and inconsistencies in the field (Najjar, Davis,
Beck-Coon, & Doebbeling, 2009).
While the specific definitions or conceptualizations of CF,
STS, and VT remain ambiguous, there seems to be some consensus in the field that those who work with trauma victims
may be negatively affected, as they experience emotions and

1
2

Walk and Talk Therapy & Life Consulting, P.C, Elmhurst, IL, USA
School of Social Work, Saint Louis University, St. Louis, MO, USA

Corresponding Author:
Brandy R. Maynard, School of Social Work, Saint Louis University, Tegeler Hall,
3550 Lindell Boulevard, St. Louis, MO 63103, USA.
Email: bmaynar1@slu.edu

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Research on Social Work Practice

symptoms similar to, or evoked from, their clients traumatic

experiences. Negative impacts of working with trauma survivors
can include a broad range of emotional and behavioral consequences, including nightmares, intrusive thoughts, disturbing
imagery along with affective states such as anger, sadness, and
anxiety that correspond to their clients traumatic material
(McCann & Pearlman, 1990). Figley (1995) categorized effects
of working with trauma survivors into three categories: (a) indicators of psychological distress or dysfunction; (b) cognitive shifts;
and (c) relational disturbances. Indicators of psychological distress include distressing emotions (Clark & Gioro, 1998; Harbert
& Hunsinger, 1991; McCann & Pearlman, 1990), intensive imagery by the trauma worker of the clients traumatic material
(Figley, 1995; Herman, 1992; McCann & Pearlman, 1990;
Stamm, 1995), numbing or avoidance of working with traumatic
material from the client (Bober & Regehr, 2006; Figley, 1995),
somatic complaints and sleep disturbances (Bride, 2007; Figley,
1995), addiction or compulsive behavior (Dutton & Rubinstein,
1995), physiological arousal (Clark & Gioro, 1998; Davis,
1996), and/or impairment of day-to-day functioning in social and
personal roles (Dutton & Rubinstein, 1995). Changes in cognitive
shifts include changes in dependence and trust, a heightened sense
of vulnerability, extreme sense of helplessness, and loss of personal control and freedom (Iliffe & Steed, 2000; Jackson, Holzman, & Barnard, 1997; Ortlepp & Friedman, 2002; Pearlman &
Mac Ian, 1995; Regehr & Cadell, 1999; Rich, 1997; Schauben
& Frazier, 1995). Relational disturbances found to be associated
with VT, CF, and/or STS include increased stress or difficulties
related to trust and intimacy (Clark & Gioro, 1998; White, 1998).
Impacts of CF, STS, and VT can also extend beyond the
mental health worker and can negatively affect the services
provided by the healthcare professional (Najjar et al., 2009,
p. 271). Indeed, mental health workers become more vulnerable to significant stress when they work with trauma victims,
which can lead to negative consequences that can affect their
clients. Professionals who are affected by VT are at a higher
risk of making poor professional judgments than those who are
not affected (Bride, Radey, & Figley, 2007; Munroe et al.,
1995; Pearlman & Saakvitne, 1995b; Stamm, 1997). Dutton
and Rubinstein (1995) and Neumann and Gamble (1995) assert
that defense mechanisms, such as detachment and nonempathic
distancing used by mental health workers to deal with clients
traumatic experiences, can lead to clients feeling emotionally
isolated and detached from those workers who are trying to
help them. Victim blaming (Astin, 1997) and the disruption
of empathic abilities that result in therapeutic impasses or
incomplete therapies (Pearlman & Saakvitne, 1995b) have also
been found in the work of therapists who experienced CF, STS,
and VT. This ineffective or compromised care can be detrimental to the client who is seeking competent treatment.

Interventions Targeted at Decreasing Negative Effects of

CF, STS, and VT
The number of interventions designed to decrease symptoms of
CF, STS, and VT has been growing in the past decade as

researchers in the trauma field are recognizing that traumatized

clients are not the only individuals in need of interventions.
Because CF, STS, and VT are recognized problems among various professions, including social work, psychology, criminal
justice, emergency response teams, lawyers, doctors, nurses,
and others, the conceptualizations of the problem as well as the
approaches used to intervene with CF, STS, and VT are
diverse, and a number of different modalities of interventions
have been used, modified, or developed to treat CF, STS, and
VT. Intervention strategies targeting CF, STS, and VT range
from individual-level interventions to various organizational
level modalities.
Individual interventions include traditional individual or
group therapy using a variety of theoretical models, including
interpersonal psychotherapy, cognitive behavioral therapy, and
psychoeducation among others. Interventions developed in the
crisis and trauma fields have also been used with those experiencing symptoms of CF, STS, and VT, including crisis debriefing, psychological debriefing, and crisis intervention stress
debriefing. Some interventions have been developed specifically to treat CF, STS, and VT, such as the Accelerated Recovery Program (ARP; Gentry, Baranowsky, & Dunning, 2002).
The ARP is a five-session program that offers helpers the
opportunities to learn by experiential participation and brief
treatment procedures for negative arousal reduction resulting
from VT. Although the primary focus of interventions used
to prevent and decrease symptoms of CF, STS, and VT has traditionally been on the individual level, organizational level
interventions have also been used to prevent or reduce symptoms. Some organizational interventions include the provision
of supervision, workshops, and a supportive organizational culture (Inbar & Ganor, 2003).
A search for prior reviews and meta-analyses of interventions related to the problems of CF, STS, and VT was undertaken through a search in nine databases (Academic Search
Premier, Dissertation & Theses @ Loyola, PILOTS, ProQuest,
ProQuest Dissertations & Theses, PsycINFO, Social Service
Abstracts, Sociological Abstracts, and TRIP Database). One
meta-analysis exploring the effects of group psychological
debriefing on VT with emergency care providers was found
(Everly, Boyle, & Lating, 1999). The meta-analysis included
10 peer-reviewed articles found through an unspecified search
in medical and psychological databases that met adequate
group or statistical control mechanisms (p. 231) and included
studies with emergency workers, police personnel, British soldiers, adolescents post ship sinking, adults victims post hurricane, helpers and victims post earthquake, and firefighters;
studies involving mental health workers were not in the review.
Trauma symptoms, anxiety, depression, stress symptoms, and
the impact of events were measured through various instruments (e.g., Impact of Event scale, SCL-90, Becks Depression
Inventory, STAI, General Health Quest). The authors concluded that the results support the effectiveness of group psychological debriefings in alleviating the effects of vicarious
psychological distress in emergency care providers (Everly
et al., 1999, p. 229); however, primary victims were the

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Bercier and Maynard

subjects in at least 4 of the 10 included studies, thus it is unclear

why those studies were included if the authors were assessing
effects on VT. Also, this now dated meta-analysis is limited
by bias associated with limiting the review to published studies
as well as due to its unclear inclusion criteria, search strategy,
and coding process.
While a number of interventions have been modified and
developed to decrease symptoms of CF, STS, and VT in mental
health workers based on the known factors that have been
implicated in contributing to CF, STS, and VT, little is known
about their effects in treating CF, STS, and VT among mental
health workers. In theory, if the interventions are targeting
known causes or factors, then the intervention techniques
should be effective in reducing the problem of CF, STS, and
VT. Unfortunately, there seems to be very minimal outcome
research to support the effectiveness of the interventions being
developed or adapted for treating CF, STS, or VT with mental
health workers. The outcome research that has been published
is scattered and seems to focus primarily on primary victims of
trauma and other professionals. This makes it difficult for policy makers and practitioners to use research to guide their decision making specifically for mental health workers
experiencing symptoms related to their work with trauma survivors. A systematic review and meta-analysis to synthesize the
intervention research in this area is greatly needed and warranted. To date, no systematic review or meta-analysis has been
conducted to synthesize the evidence of effects of interventions
with mental health workers who are experiencing symptoms
related to their work with traumatized individuals.

Purpose of the Study

While there is much we are learning about the causes and outcomes of mental health workers exposure to their clients
trauma, there has been less focus on effectiveness of interventions. It is imperative for both the mental health worker and the
clients with whom they work that we examine what does and
doesnt work to ameliorate negative effects experienced by
mental health workers from exposure to clients traumatic
material. The purpose of this study was to examine and synthesize the effects of interventions on symptoms of CF, STS, and
VT with mental health workers; provide evidence-informed
recommendations to inform social work practice; and recommend priorities for future research. Specifically, the research
questions guiding this study were as follows: (1) Are interventions targeting CF, STS, and VT effective in reducing symptoms of psychological distress, cognitive shifts, and relational
disturbances? and (2) Are different modalities of interventions
more effective than others in decreasing symptoms of CF, STS,
and VT?

Method
Systematic review procedures, following the Campbell Collaboration guidelines (see www.campbellcollaboration.org),
were used for all aspects of the search, retrieval, selection, and

coding of published and unpublished studies meeting study

inclusion criteria. The protocol, screening, and coding instruments guiding the conduct of this study are available from the
first author upon request.

Study Eligibility Criteria

Studies were eligible for inclusion if they examined interventions with a stated primary goal of decreasing symptoms of
CF, STS, and/or VT among mental health workers who were
experiencing symptoms of CF, STS, and/or VT. Mental health
workers were defined as social workers, psychologists, counselors, or therapists and must have accounted for at least 50% of
the sample. Studies must have employed a randomized experimental or quasi-experimental design comparing effects of the
intervention to a comparison condition (i.e., no treatment, business as usual, or another treatment), and measured outcomes
broadly related to symptoms associated with CF, STS, or VT
(e.g., stress, anxiety, STS, VT, burnout, and CF). We excluded
no studies based on geographical context or setting, but studies
must have been written in English and been conducted between
1983 and 2012.

Search Strategy
A comprehensive and systematic search strategy was conducted in an attempt to identify and retrieve all relevant published and unpublished studies meeting inclusion criteria.
The search, completed in September 2012, involved several
sources including electronic databases; search of websites of
relevant research institutes, academies, and professional associations; personal contacts with researchers working in the
field; and reference lists of studies and prior reviews. Eleven
databases (i.e., Academic Search Premier, Database of
Abstracts of Reviews of Effectiveness, Loyolas library catalog, Published International Literature on Traumatic Stress,
ProQuest Dissertations and Theses, PsychInfo, Social Services
Abstracts, Social Work Abstracts, Sociological Abstracts,
TRIP Database, and WorldCat) were searched using the following key words: (compassion fatigue OR secondary
traumatic stress OR vicarious trauma*) AND (evaluation
OR intervention OR treatment OR outcome) AND (social
worker OR mental health OR therapist OR counselor OR
psychologist). All fields were searched in each database using
the key words listed above. Variations and plurals of key words
were searched using the wildcard character when allowed by
the database (e.g., outcome*).

Retrieval, Selection, and Coding of Studies

Titles and abstracts of the studies found through the search procedures were screened for relevance by the first author and
those that were obviously ineligible or irrelevant were screened
out. For example, studies that were deemed inappropriate at the
title/abstract review stage were those that did not involve the
target population (e.g., nurses and emergency technicians), did

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Research on Social Work Practice

not involve an intervention, or were theoretical or descriptive in

nature. If there was any question as to the appropriateness of
the report at this stage, the full-text document was retrieved and
screened for eligibility using a screening instrument developed
by the authors. The first and second authors then independently
coded all studies that passed the screening stage using a coding
instrument developed by the authors to guide systematic examination and extraction of data. The coding instrument included
categories concerning all relevant bibliographic information,
study context, intervention and sample descriptors, research
methods and quality descriptors, outcome measures, and effect
size data (Lipsey & Wilson, 2001). Any discrepancies in the
coding between the authors were discussed and resolved.

Results
The search procedures yielded 4,134 titles. After review of
titles and abstracts, 191 were identified for full-text retrieval;
however, 32 were duplicate reports that had been listed in more
than one source. The full text of 159 reports was then retrieved
and screened for basic eligibility criteria. Of those 159 reports,
8 appeared to be reporting effects of interventions with CF,
STS, and/or VT. Of those eight reports, six were excluded at
the screening stage because they did not meet eligibility criteria
related to study design or participant characteristics and two
were excluded at the full coding stage (see Table 1 for a summary of excluded intervention studies). One of the two studies
that went to full coding was excluded because the study
(Cohen, Gagin, & Peled-Avram, 2006) was not a true experimental intervention study, but rather a retrospective survey
examining the relationship between level of secondary traumatization and reported participation in supervision and debriefing and is therefore not included in Table 1. No studies met
inclusion criteria for this review. See Figure 1 for the flowchart
detailing the search and selection process.

Discussion and Application to Social Work Practice

The purpose of this study was to examine effects of indicated
interventions intended to affect symptoms of CF, STS, and/or
VT with mental health workers to inform practice in this area.
A systematic review methodology was employed to search,
retrieve, and extract data from studies that met explicit, a priori
inclusion criteria found through a transparent and comprehensive search procedure to limit bias. While prior narrative
reviews have been published, the present study is, to our
knowledge, the first systematic review aimed to examine
effects of interventions for CF, STS, and VT with mental health
workers. Despite our comprehensive and systematic search, no
studies met inclusion criteria for this review. In other words,
this systematic review is what is commonly referred to as an
empty review (Lang, Edwards, & Fleiszer, 2007). As such,
we are unfortunately not able to synthesize or summarize evidence to inform practice in this area. While no specific guidelines have been established for reporting an empty review, our
discussion of the present study results will be guided by

suggestions offered by Lang, Edwards, and Fleiszer (2007),

Schlosser and Sigafoos (2009), and Yaffe (personal communication, June 1, 2013).
While we were not altogether surprised to find no studies
meeting eligibility criteria for this review, we were indeed disappointed. However, empty reviews are not necessarily uncommon; nearly 9% of the systematic reviews published by the
Cochrane Collaboration were empty reviews (i.e., finding no
studies that met the review inclusion criteria; Yaffe, Montgomery, Hopewell, & Shepard, 2012). Moreover, empty reviews
may not provide evidence to inform practice directly, but they
do offer value in that they can draw attention to the state of the
evidence, illuminate gaps in the research base, stimulate appropriate research, and provide practitioners with the knowledge
that rigorous evidence is lacking in favor of, or against, specific
interventions (Green, Higgins, Schunemann, & Becker, 2007;
Yaffe et al., 2012). Empty reviews can also provide an impetus
to promote awareness and discussion, which we believe would
be a beneficial outcome of this review to the mental health
field, as STS is often surrounded in silence and shame as professionals avoid speaking up due to fears of being pathologized
or labeled (Jorgensen, 2012).
CF, STS, and VT have received a great deal of attention over
the past decade, so where are the studies assessing effects of
interventions and what could account for the lack of studies
meeting criteria for this review? First, although much has been
published in this area, this field of research is, on the whole, relatively nascent and contested. Researchers first drew attention
to the issue of STS and related constructs in the early 1980s and
1990s (Figley,1995; Joinson, 1992); however, while there
seems to be a large body of literature that has accumulated over
the past two decades in this area, much of it is theoretical, anecdotal, or descriptive in nature (Jorgensen, 2012). The empirical
research related to CF, STS, and VT seems to be indicative of
an emerging field as the research tends to focus on the nature,
prevalence, measurement, and etiology of CF, STS, and VT
rather than effects of interventions. An examination of the literature on CF, STS, and VT also reveals that the constructs are
not well developed, the terms are not well specified and often
used interchangeably, and although much work has been done
on the assessment and measurement of CF, STS, and VT, many
weaknesses remain in how it (and what) is measured.
A recent review of secondary trauma and related constructs
conducted by Elwood, Mott, Lohr, and Galovski (2011), building from a prior review by Sabin-Farrell and Turpin (2003),
examining the prevalence, severity, and impairment as well
as correlates and measurement of STS and related constructs,
revealed that some advances have been made in the field over
the past decade. While Elwood and colleagues recognized the
advances and additional research since the Sabin-Farrell and
Turpin review, their conclusions largely reflect those from the
review conducted almost a decade earlier. Elwood and colleagues argue that the findings from current evidence are neither clear nor consistent and warrant additional research (p.
34). Moreover, they argue that the evidence regarding the prevalence and severity of STS symptoms are equivocal, and there

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Single-session music ther- RCT

apy group intervention;
one-hour duration

Wlodarczyk (2010)
Dissertation

Cluster RCT

Results

Reason for Exclusion

Did not meet participant

Author reported that providing
criteria
feedback did not lead to
reduced levels of PTSD
symptoms or distorted beliefs 2
months later

Did not meet participant

criteria

IES; PSS; TSIB;

CSI; ACTS

NSQ

N 25; variety of
professionals (e.g.,
police, court,
hospital,
psychotherapy)
N 68; hospice
workers (e.g.,
doctors, nurses,
social workers,
home health aides,
and chaplains)
N 72; domestic
violence shelter
workers

Author reported no significant

differences between the
experimental and control
groups on risk of burnout or
compassion fatigue

ProQOL R-V;
SQ; SHS

N 67; mental health

workers (39%) and
students (61%)

Significant effect on compassion Did not meet study design

criteria
fatigue and burnout;
nonsignificant effect on
compassion satisfaction
Did not meet participant
No significant differences were
criteria
found on any measured
outcomes between Reiki,
placebo and control groups
Author reported that 71% of the Did not meet study design
and participant criteria
participants reported a positive
change in their vicarious trauma
symptoms
CSF; HCGI;
WES

CSFST, TRS,
SRS, GCS

N 5; licensed
marriage and family
therapists

TSI (at pretest, Author concluded that the model Did not meet study design
or participant criteria
of art therapy is effective in
no posttest);
reducing secondary trauma and
NSQs
burnout for mental health
workers who work with
domestic violence and sexual
assault survivors
Did not meet study design
N 83; licensed mental CFSFT
Participants reported significant
criteria
health counselors
reduction in compassion fatigue
and burnout and elevation of
compassion satisfaction at
posttest

Measures

Note. SGPP single group pre-post test; QED quasi-experimental design; RCT randomized controlled trial; ITS interrupted time-series design; CSFST Compassion Satisfaction Self-Test; TSI Trauma
Symptom Inventory; NSQ nonstandardized questionnaire(s); HCGI Hospice Clinician Grief Inventory; CSF compassion satisfaction and fatigue test; WES Work Environment Scale; IES Impact of
Events Scale; PSS Modified PTSD Symptom Scale; TSIB Traumatic Stress Institute Belief Scale; CSI Coping Strategies Inventory; ACTS assessment of coping with traumatic stress; ProQOL R-V
Professional Quality of Life: Compassion Satisfaction and Fatigue Subscale; SQ Symptom Questionnaire; SHS State Hope Scale; PTSD posttraumatic stress disorder.

Jeffrey (1999)
Dissertation

Feedback based on
assessment battery
scores and suggestions
to ameliorate
secondary traumatic
stress

Vicarious resiliency
training; 3-day training

Shew (2010)
Dissertation

Novoa (2011)
Dissertation

ITS

SGPP
Certified Compassion
Fatigue Specialist
Training (training-astreatment); 1720 hr
over a 2- to 3-day
period
Sharevision 6 expressive SGPP
arts-integrated workshops; 18.75 hr over 12
weeks
RCT
50-min Reiki treatment
once weekly for 4
weeks

Gentry, Baggerly, and

Baranowsky (2004)
Peer reviewed

Landis (2010)
Dissertation

Sample

Single-subject N 12; Only 5/12

A-B design
participants were
experiencing STS
symptoms prior to
intervention

Study Design

Art therapy8-week
program

Intervention

Van der Vennet (2002)

Dissertation

Study/Publication Type

Table 1. Summary of Excluded Intervention Studies.

Research on Social Work Practice

Identification

Reviewed 4,134 citations

Screening

Screened 159 full-text

reports for eligibility

Excluded 3,943 studies

deemed inappropriate
upon review of the title

Excluded 157 reports that

did not meet eligibility
criteria
Eligibility

Coded 2 studies
Excluded 2 studies upon
further inspection
0 studies included

Included

Figure 1. Study search and selection process flowchart.

is a paucity of research examining impairment related to STS

symptoms. Elwood and colleagues concluded the extant
research does not warrant systematic implementation of prevention and treatment recommendations (p. 34). They also
cautioned that a broad and concerted effort to implement secondary trauma education and prevention programs before even
knowing whether this is really a significant problem could
result in unnecessary costs to agencies and practitioners and
could potentially cause or increase levels of distress in clinicians. Given the nascent and contested nature of the literature
in this area and the lack of intervention studies meeting criteria
for this review, we agree with Elwood and colleagues (2011)
that universally recommending the implementation of prevention or intervention efforts on a large-scale seems premature at
this point. Additional and more rigorous research, as recommended by Elwood and colleagues, on the criterion, course,
and associated impairment seems warranted, along with
improvements in assessment and measurement.
While large-scale intervention research may be premature at
this point, it seems apparent that more rigorous research is
needed on the effects of intervention programs aimed at preventing or decreasing symptoms associated with CF, STS, and
VT. As can be seen by the excluded intervention studies, there
are several dissertation studies and one study published in a
peer-reviewed journal that attempted to assess the effects of
various interventions with mental health professionals; however, the study designs used were weak and limited by biases
inherent in study designs that do not use comparison groups
or were not conducted with mental health professionals exhibiting symptoms of CF, STS, or VT. Arguably, given the issues
described above related to the definition, criterion, and measurement of CF, STS, and VT, conducting rigorous outcome

research on prevention and intervention programs for STS and

related constructs could be challenging.
Even if the field was in agreement about the definitions, criterion, and measurement of CF, STS, and VT, challenges to
conducting rigorous and valid outcome research remain, particularly in terms of achieving sample sizes large enough to obtain
the statistical power to detect effects of interventions. Recruiting and retaining participants can be a barrier, in part due to a
lack of availability and willingness of mental health professionals to commit to participate because of busy schedules. Indeed,
most of the excluded intervention studies were plagued by
small sample sizes. Authors of the two excluded studies
described specific challenges associated with the availability
of mental health workers and the willingness of organizations
to be flexible in providing the opportunity for their staff to
participate in the intervention and study (Landis, 2010;
Wlodarczyk, 2010). Additionally, Figley (personal communication, October 20, 2009) and Landis (personal communication,
November 14, 2012) reported that the lack of rigorous intervention research is due, at least in part, to a lack of funding.
While large-scale randomized controlled trials (RCTs) of
CF, STS, and VT interventions may be premature or challenging to implement at this point, researchers and practitioners
could advance the field by conducting smaller scale betweengroup studies in a more rigorous manner or test intervention
effects using rigorously conducted single subject design (SSD)
studies. Emerging standards for rigorous SSD studies and
advances made in estimating effect sizes for SSD studies
(Hedges, Pustejovsky, & Shadish, 2012; Shadish, Hedges,
et al., 2013; Shadish, Rindskopf, Hedges, & Sullivan, 2013)
would allow multiple SSD studies to be synthesized using
meta-analytic techniques that could contribute to the evidence

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Bercier and Maynard

base to inform decision making and clinical practice with mental health workers experiencing symptoms of CF, STS, and VT.

Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.

Limitations
While this study sheds light onto the present status of CF, STS,
and VT intervention research with mental health professionals,
the present study is not without limitations. Despite our
attempts at a comprehensive and exhaustive search process,
we may not have discovered potentially eligible studies.
Although we intended this review to focus on a specific problem and population to provide more specific evidenceinformed guidance, this review was limited to those studies that
were examining effects of indicated interventions with mental
health workers with a stated goal of affecting symptoms of CF,
STS, and/or VT. Also, our review was limited to English language articles and thus we may have missed relevant studies
written in other languages. Despite these limitations, the present review provides an important contribution for both
researchers and practitioners in shedding light onto the state
of knowledge of interventions intended to treat mental health
workers experiencing symptoms of CF, STS, and VT.

Conclusion
Mental health workers who treat clients who have experienced
trauma may experience symptoms of CF, STS, and VT that can
have debilitating effects on the mental health worker as well as
compromise the care they provide to clients. Although there
has been a priority on developing and rigorously assessing
trauma interventions for those who directly experience various
types of trauma, it appears that little effort is being made to rigorously test interventions to help the helpers. While there may
be some aspects or techniques of primary trauma treatment that
can inform and be adapted to treat CF, STS, and VT, we should
be careful to not assume that trauma interventions intended to
treat primary trauma will be effective in treating CF, STS, and
VT. Like all other interventions, interventions intended to treat
mental health workers also need to undergo rigorous evaluationwe need rigorous evidence to inform effective care to the
helpers so they can continue to provide effective care to those
they are intending to help. While it is important to provide
effective interventions to mental health workers who may be
experiencing symptoms related to the trauma material to which
they are exposed when working with trauma clients, it seems
apparent that there is yet more we need to learn about the phenomenon and steps we need to take to advance efforts in intervening with mental health workers experiencing symptoms of
CF, STS, and VT. There is yet much to be gained from further
research in this area for mental health workers, organizations as
a whole, and their clients.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

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