Introduction
After ten years of work with victims of child abuse, I found myself in a deep clinical depression. I lost interest in food, found no pleasure in gardening, dreaded going to work, and was irritable with family and friends. I thought about quitting the work I had once loved. I realized that if I (considered one of the strongest people in our program, a person whose natural state is joy, curiosity and anticipation) left the work without discovering what was wrong and how to treat it, I would be leaving my best friends and coworkers to face the same problem, but without my support and without a remedy. As a doctor, I needed to know if this disease had a name, a cause and a cure. I began to read.
Professionals who work with child maltreatment encounter aspects of human suffering that most people never experience and do not wish to acknowledge. Daily encounters with new and horrifying ways people can be cruel to children can take its mental, physical, and spiritual toll. Every job has its occupational hazards; child abuse work is no exception. Four syndromes affecting those who work closely with human suffering have been described. There is a growing body of literature and research detailing their incidence, etiology, signs, symptoms and treatment. These four are burnout, posttraumatic stress disorder (PTSD), secondary trauma, and compassion fatigue.
Occupational Hazards of Child Protection Work
Burnout
When I first began this work, there were only a few physicians in the state who would evaluate abused children. Calls began pouring in. I answered these calls myself, made appointments, interviewed the families, examined and interviewed children, typed my own reports and did my own billing. Parents and caseworkers pled that every case was urgent. “You’re the only one.”
Burnout is “… a process in which a previously committed professional disengages from his or her work in response to stress on the job.” Symptoms include physical, mental, and emotional exhaustion, depersonalization, and a loss of enthusiasm and sense of mission with decreased motivation and effectiveness on the job. Signs of burnout include fatigue, irritability, anger over small issues, indifference, a decline in efficiency or overall work performance, rigidity, paranoia, and depression. , Burnout is common and, untreated, its cost can be high. In one survey of Canadian hospital-based child protection professionals, over one third exhibited burnout on a standard burnout inventory, and two thirds had seriously considered changing their work situation.
Burnout is attributed to progressive and prolonged job stress related to a person’s attempts to meet unrealistically high expectations. The origin of these expectations can be internal or external. Burnout occurs when we set our goals too high and cannot change them when people try to give us feedback. We begin the transformation from saints into martyrs.
Azar points out that unconscious assumptions held by professionals may serve as the source of unrealistic internal expectations. Here are examples:
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Family problems can always be solved and we have the tools to be helpful.
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Parents and children want my help and will be grateful for my efforts.
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Because of my role as a helper, I will be safe (e.g., I should be able to tolerate client verbal abuse and visiting unsafe neighborhoods).
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I will do no harm.
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I will approach my clients with a clear idea of my biases and have ways to keep them out of my work.
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I will always be available when someone needs my help.
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I will always be empathic, with my child and adolescent patients, their families, and even the perpetrator.
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I am on the side of truth and justice and thus the court will always agree with my point of view.
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I will be treated fairly by clients, lawyers, judges, all members of multi-disciplinary teams, and by the news media.
In describing strategies in supervision to prevent burnout in child abuse workers, Azar writes that uncovering these hidden assumptions, beliefs, and expectations is key. She also warns that they may be deeply held and that changing them requires skill and patience, since it is akin to changing a person’s religion.
Unrealistic external expectations often come from the public, the media, or government officials with superficial knowledge of the difficulties inherent in attempting to intervene in the dynamics of abuse. A state legislator who angrily criticizes state agencies for failing to protect a child from abuse may also vote to cut funding for hiring and training new child protection workers or law enforcement officers.
Posttraumatic Stress Disorder
After attending an autopsy on a child who was raped and tortured I find myself sitting and staring out the window, emotionally and mentally numb. This is a blessed protection against letting the feelings of horror come up, against my mind’s attempts to imagine the child’s last hours. This protective effect becomes disabling when “going unconscious” renders me unable to respond to my own child’s distress over a skinned knee or indifferent to a coworker complaining about a difficult client.
PTSD can occur in first responders who witness traumatic events as they unfold. Emergency response personnel rate certain events as the most stressful aspects of their occupation: death of a child, injury to a child, a personally life-threatening event, and grotesque sights and sounds, outside the usual range of human experience. Any professional evaluating and treating child victims is also likely to encounter these types of events and thus be susceptible to PTSD. Even reviewing graphic material such as autopsy pictures or videotapes of child pornography can elicit symptoms of PTSD.
Although state laws provide a measure of legal protection for mandated reporters, they do not provide protection from stressful consequences of their work. Flaherty et al surveyed 56 physicians who specialize in child abuse and found that 77% had experienced at least one negative consequence of their practice. Half had been verbally or physically threatened, an average of 2.7 times, and in 5% of cases a weapon had been displayed. Half had a formal complaint filed with their employer by parents or families. One quarter had been subjected to adverse local or national media attention as a result of their work. One in six had been sued for malpractice (one to three times), and one in eight had been reported to their professional licensing agency.
Johnson found that pediatricians and emergency room physicians rated court appearances as the most stressful aspect of child abuse work. Law and medicine have different rules and assumptions; law is inherently adversarial, and medicine inherently cooperative. It is acutely uncomfortable to feel pulled by both sides in what we consider an impersonal finding of facts, to be forced to reduce the complexities of human interactions and biology to yes-or-no answers, to be attacked for doing humanitarian work, or to feel that one word misspoken could set a dangerous criminal free.
Secondary Trauma
Secondary trauma (also called secondary victimization, vicarious trauma, and secondary trauma syndrome) is a group of signs and symptoms that develop through close contact with victims of “actual or threatened death, serious injury or threats to the physical integrity of self or others” and “hearing shocking material from clients.” , Interviewers often describe visualizing traumatic events as they are recounted, witnessing them through the eyes of their patients and clients.
Burnout is described as a process, whereas secondary trauma can emerge after a single exposure or incident such as working with victims of a mass disaster or terrorist bombing. Burnout can occur in any occupation, but secondary trauma is specific to those who work with victims of trauma and violence. Several authors describe symptoms attributed to secondary trauma in child abuse work. Many of these symptoms are identical to those of PTSD. The compiled list is long, but the most distinctive features are reexperiencing the traumatic event described by the patient through intrusive thoughts, dreams or visual imagery, emotional numbing, and persistent arousal, which leads to difficulty concentrating and hypervigilance.
Pearlman and Saakvitne discuss six basic human psychological needs that are sensitive to disruption by actual or vicarious trauma:
Safety: Working with victims heightens the sense of personal vulnerability and the fragility of life. Symptoms include preoccupation with safety, not letting anyone babysit one’s children, and hypervigilance.
Trust: Through exposure to the many cruel ways people deceive, betray, or violate the trust of others, we become overly suspicious. Symptoms include cynicism, isolation, and not trusting co-workers or one’s own instincts.
Esteem: Esteem is defined as the need to perceive others as benevolent and worthy of respect. Encountering so much human cruelty can shatter our world view. Symptoms occur such as pessimism and anger at individuals or the fate of mankind in general.
Intimacy: A sense of alienation emerges from exposure to horrific imagery that cannot be shared with others, because of their distress or confidentiality requirements. This is particularly painful if your spouse cannot bear to hear what you are doing in life or what is worrying you. Symptoms are emotional numbing and withdrawal from social life and personal intimacy.
Power or control: Realizing the fragility of life and encountering clients’ powerlessness, we may try to increase our sense of power in the world, by taking self-defense classes or becoming domineering. Symptoms include restricted personal freedom through fears of safety and despair about the uncontrollable forces of nature and the human world.
Frame of reference: We try to figure out the motive of the perpetrator or what the victim did wrong. How did this happen? Symptoms can be pervasive unease or loss of religious faith.
Compassion Fatigue
I believe that the most profound effect of this work is on our spiritual well being. When we remove children from abusive families and they are subjected to worse cruelty in foster homes, what have we accomplished? When people we know, ministers, police officers, protective service workers and even pediatricians abuse children, who is the enemy? It breaks through our denial. It becomes harder to hold the larger framework, the higher purpose that gives our life a sense of direction and meaning.
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