A deep-seeded military value is to never leave a comrade behind nor forget the sacrifices of a soldier. It is just as important, though, to not forget those who care for soldiers; caregivers help “bring home” soldiers who have suffered in battle, while experiencing risks of their own. The focus of this book is to provide critical information related to the literature on secondary trauma and burnout in combination with specific findings from our military mental health provider project called SupportNet. It was designed to identify and address these risks directly related to military-based caregivers.
Collectively, this monograph reports on the important findings of SupportNet, including (a) the prevalence of secondary trauma and burnout among military mental health providers, (b) the development of a web-based support system, (c) details related to a life-balance-based coaching program, (d) challenges and findings related to the first randomized controlled trial of an intervention for secondary trauma and burnout in military mental health providers, and (e) critical lessons learned along with recommendations for future directions. In addition, to the specific findings related to the project, each chapter will contextualize the findings relative to the broader literature.
What’s the Problem? Secondary Trauma and Burnout in Military Mental Health Providers
The Caregiver Demand.
Over 1.6 million troops have been deployed in Iraq and Afghanistan since the start of the Iraq War in 2003. As of October 4, 2010, the Department of Defense (DOD) estimated 4408 soldiers died in Iraq and 1304 in Afghanistan (Fischer, 2010). At the same time, approximately 31,934 and 8530 were wounded in action in Operation Iraqi Freedom and Operation Enduring Freedom, respectively. Over 90 percent of soldiers wounded in action to date survived their injuries, a rate higher than in any previous war (Gawande, 2004). Tempering this more positive news for combat soldiers, however, is the consequence to caregivers. Support systems for these soldiers have seen a dramatic increase in demand, in the form not only of the number of active duty soldiers and veterans coping with physical challenges, but those suffering psychological difficulties as well.
For example, many of the returning soldiers will have suffered traumatic brain injuries (TBI) combined with psychological issues complicating the increased caregiver demand. The Armed Forces Health Surveillance Center (AFHSC, 2015) reported that as of 2014, over 300,000 combat soldiers had been diagnosed with some form of TBI. Although the majority of these injuries are “mild” (approximately 247,000), mild TBI is nevertheless associated with a range of psychological difficulties. Further, it is difficult to determine whether soldiers’ symptoms (such as cognitive difficulties, mood changes, and impulsivity) stem from TBI, post-traumatic stress disorder (PTSD), or both.
Estimates of PTSD prevalence among troops deployed to Iraq and Afghanistan vary considerably, likely due to methodological and measurement differences (Ramchand et al., 2010). Sundin, Fear, Iversen, Rona, and Wessely (2010) conducted a comprehensive review of prevalence studies published from 2004 to 2008, each of which used large (N > 300), nontreatment-seeking samples. These authors found, among these methodologically sound studies, rates of PTSD ranging from 10 to 17 percent in studies with samples of line infantry units and 2.1 to 11.6 percent in random-population-based studies. PTSD prevalence among treatment-seeking samples appears to be considerably higher (Erbes, Westermeyer, Engdahl, & Johnsen, 2007; Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008; Seal et al., 2009). Indeed, Seal et al. (2009) reported 21.8 percent of Iraq and Afghanistan Veterans who were first-time users of VA health care between 2002 and 2008 had received a diagnosis of PTSD. Clearly, PTSD, along with other primary mental health challenges such as major depressive disorder, bipolar disorder, general anxiety disorder, and so on, characterizes a demand for mental health treatment through the DOD, the Veterans Administration, and local communities across the nation that is unprecedented. In sum, both the numerical demands on the mental health system to care for these soldiers and the complexity of these demands are beyond anything previously seen.
The Caregiver Consequence.
A major risk to behavioral health providers working with combat veterans is the development of secondary traumatic stress (STS). Secondary exposure to trauma is a widespread phenomenon referring to the different types of indirect exposure to traumatic material, such as contacts with people who have experienced traumatic events, exposure to graphic trauma content (e.g., reported by the survivor), exposure to people’s cruelty to one another, and observation of and participation in traumatic reenactments (Pearlman & Saakvitne, 1995). Indirect exposure may be an inherent hazard for mental health providers, health-care personnel, and social workers who provide clinical services to military combat veterans (Elwood, Mott, Lohr, & Galovsky, 2011). Research suggests indirect exposure is predictive of higher levels of distress (Pearlman & Mac Ian, 1995), job burnout (Ballenger-Browning et al., 2011), compassion fatigue (Figley, 2002), and secondary traumatic stress (Elwood et al., 2011).
We define secondary traumatic stress (STS) as reactions resembling post-traumatic stress, such as intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased arousal, all resulting from indirect exposure to trauma. The recent introduction of the DSM-5 provides the opportunity for diagnosing PTSD through indirect exposure (e.g., through client contact) demonstrating the crossover between STS and PTSD (American Psychiatric Association, 2013). STS prevalence rates differ across occupation groups; for example, criteria for a PTSD-like diagnosis of secondary traumatic stress were met by a significant percentage of providers working with trauma survivors including 15.2 percent of social workers (Bride, 2007), 16.3 percent of cancer providers (Quinal, Harford, & Rutledge, 2009), 19 percent of substance abuse therapists (Bride, Hatcher, & Humble, 2009), 20.8 percent of family or sexual violence counselors (Choi, 2011), 32.8 percent of emergency room nurses (Dominguez-Gomez & Rutledge, 2009), 34 percent of child protective service providers (Bride, Jones, & Macmaster, 2007), and 39 percent of juvenile justice education employees (Hatcher, Bride, Oh, King, & Catrett, 2011). Craig and Sprang (2010) found 6 percent of a national representative sample of clinical psychologists, and clinical social workers reported high levels of compassion fatigue (a construct very similar to STS) and 12 percent reported elevated levels of job burnout (Leiter, Harvie, & Frizzell, 1998).
Burnout has been found to substantially contribute to decreased effectiveness and poorer treatment outcomes (Lasalvia et al., 2009). Moreover, it is associated with more frequent voluntary and involuntary hospital admissions among patients of mental health providers and contributes to a more negative attitude toward patients (Holmqvist & Jeanneau, 2006; Priebe, 2004). Burnout also is related to important organizational outcomes including a decreased commitment to the organization, higher levels of absenteeism, greater presenteeism (present, but inefficacious), and greater turnover rates. Clearly, STS and job burnout can substantia...