Victims' Response to Trauma and Implications for Interventions: A Selected Review and Synthesis of the Literature

4. IMPLICATIONS FOR PROFESSIONALS

4. IMPLICATIONS FOR PROFESSIONALS

The implications of the preceding review are quite broad-based and not at all consistent. That cognitive changes occur is a reasonable conclusion, but how this affects what professional do is another matter altogether. Clinically, victims represent a diverse group that has been lumped together through an external, non- controllable process. Thus, service-deliverers need to approach this group quite differently. They must take measures not to assume any specific commonality, including trauma. Instead service-deliverers need to accurately assess victims and recommend appropriate interventions. Furthermore, this challenging work means that service-deliverers must attend closely to self-care and the risk of vicarious traumatization and burnout.

4.1 Assessment and Screening

One of the more important functions of a service delivery model is the identification of client need and linking clients to services. The following issues need to be a part of client assessment and used to direct clients to appropriate services. It is important to note that these areas of investigation need to be linked to clinical judgement and not seen as a simple screening checklist.

Victim Characteristics: History

Victim Characteristics: Current

Crime-related Characteristics

As a victim shows increased distress and symptoms, they need to access either more, or more intensive, services. Thus, a victim who is not having a severe reaction may not nee to join a support group or receive individual therapy. However, they might benefit from information sessions or written literature. It is this matching of clients to a service within a continuum that will benefit the most clients, while remaining cost-effective.

4.2 Client Matching and Continuum of Services

In discussing the matching of clients to service and continuum of services needed, recall the discussion of heterogeneity of victims. Given the wide variation of clients and client reactions, service-deliverers need to focus on delivering focused interventions to particular client. Basically, services need to range from information sharing to intensive individual therapy. This could include public education, pamphlets, information sessions, support groups, peer counselling, paraprofessional support, clinical support and psychological interventions. Furthermore, these interventions need not only target the primary victim, but also the victim's support network and society as a whole. This is especially true of education efforts, as it is reasonable to assume that initiatives such as public education and information sharing will help new victims assess the system faster and, perhaps, avoid the distress associated with searching for resources.

Education of Victim

At minimum, victims need access to education around the process of coping with trauma. Pamphlets recommending easy, positive coping strategies need to be widely available, including how to seek more help. Victims may also benefit from a primer on the criminal justice process, possible outcomes and the professionals involved with their case and their respective roles. This may help alleviate some to the secondary victimization some victims report in dealing with the "system". Further, victims need to clearly understand the goals and processes of therapy to make an informed choice on what treatment option is best for them. These issues should be covered in pamphlet, booklet and information seminars for victims and support people. These initiatives may also help precontemplators to understand their reactions and encourage them to seek help.

Education of Support System

Natural supports need to be educated on how to provide emotional, informational and appraisal support. These support people need to better understand the traumatization process and likely reactions. They also act as the first line of monitoring the victim's distress and need to understand the warning signs to get the victim help if he/she deteriorates. They also need to understand how they might react to their friend or partner's victimization and how to seek help for their reaction (e.g., a husband having difficulty with his wife's sexual assault). A basic pamphlet that introduces these concepts for loved-ones should be made available to all victims and supports. Some supports may also be able to attend information sessions.

Despite efforts in the area of criminal justice personnel, more work can be done to educate this group on effectively handling victims. Research has indicated that these groups can be important sources of information and also offer tangible support (Norris et al., 1997). Education and training around avoiding secondary traumatization and burnout may also be beneficial to this group. Similarly, medical personnel and mental health workers education efforts is warranted. This might not only be for clients dealing with victimization, but also for those clients coping with other problems or who have a history of victimization and trauma.

Education in this area should not only focus on helping identified victims, but also on developing appropriate screening questions to uncover hidden victims. The research is clear that minimal group intervention (e.g., four group sessions) can alleviate much distress.

Peer Support groups

Research indicates that victims pay more attention to co-victims than innocent bystanders (Greenberg & Ruback, 1992). Similarly, we know that not all victims require professional intervention, especially if their reaction is minor. Thus, support of peer programs makes sense as a cost-effective way for these victims to work towards recovery. It is recommended that such programs be linked, in some way, to professional supports. The goal is not supervision, but to allow quick access for victims who need more intensive services or interventions. These programs can also work as a final step out of the victims system, helping victims to consolidate gains already made.

Professional Support groups

Professionally led support groups may be important for more severely traumatized clients. This could include those clients that would have difficulty in more active treatment programs but, instead, need some time to build the strength to enter these programs. Such clients would be inappropriate for peer support program alone, as the problems would likely be beyond the skills of group leaders. However, professionally lead support programs could help the victim move forward to make positive change.

Therapy

Finally, both individual and group therapy lead by accredited professionals should be supported for those victims experiencing severe trauma reactions. Importantly, relatively brief intervention may be beneficial to clients, so this option need not be expensive. Professionals offer specific skills in identifying and intervening in trauma-related symptoms. They should be better able to allow the victim to tell his or her story and help make sense of that story. Further, they can individually tailor interventions in group and individual treatment to help the victim move more quickly through the recovery process. This should help alleviate both the personal suffering and help the person regain normal functioning.

Use of Paraprofessionals

One issue of importance in examining victims, and the interventions that might be helpful, is the use of paraprofessionals in victims' service. Paraprofessionals are an important part of the continuum of services needed for victims. Recall that perceived and actual social support have a major beneficial impact on victims. Paraprofessionals, with reasonable training, are able to fill this gap and help victims with problematic reactions and to understand their reactions. Professionals, on the other hand, can be useful for those clients who require more intensive help. Although not all victims need professional services, there can be a great benefit in providing this service.

In order to develop a competent and responsive continuum of services, there is a need for clear screening and training regarding when it is necessary to bring professionals into service delivery. However, if such a system were put in place, victims would be able to access a more efficient system and quickly be matched with the appropriate level of service. This would be cost-effective for the system and more beneficial to the client who should be able to access services faster, rather than deal with long waitlist or overworked professionals. On the theme of overworked professionals, the issue of vicarious traumatization and burnout is also important when attempting to deliver effective victim services.

4.3 Vicarious Traumatization and Burnout

A major consideration in providing services to crime victims is how to maintain the health of service providers. Gorman (2001) pointed out that service providers and supervisors must monitor secondary or vicarious traumatization, compassion fatigue, countertransference, and the risk of burnout. Brown and O'Brien (1998) examined job stress in battered women's shelters and how shelter workers coped with these stressors. They found that 65% of workers find the following as moderately to highly stressful: frustration when a battered woman returns to a dangerous home, anger at perpetrators and coping with the "pain and horror" of domestic violence. Emotional exhaustion/depersonalization was most related to time pressures. Other stressors linked with burnout were: red tape, physical demands, lack of participation, and lack of achievement (Brown & O'Brien, 1998). It is interesting to note that some of the stressors are related not to the victims but to politics within the system.

In their book on professional burnout, Grosch and Olsen (1994) made several recommendations to professionals to avoid burnout. These are discussed below.

Self-assessment

Professional, paraprofessionals and volunteers need to continually engage in a process of self-assessment. A major element of this involves distinguishing between normal fatigue and the exhaustion that is related to burnout. This also relates to supervision and consultation regarding how one is coping and engaging in self-care behaviours.

Interventions for Service-deliverers

Professionals and paraprofessionals also need to learn when to seek out help. Possible treatment options include self-help, support groups, psychotherapy, and outpatient/inpatient treatment (Grosch & Olsen, 1994).

Use of effective supervision/consultation/peer support

As noted above, service-deliverers need to rely on others as a barometer of their own stress level (Gorman, 2001; Grosch & Olsen, 1994). Perceived social support from supervisors and perceived social support from friends and family were both negatively correlated with emotional exhaustion and depersonalization (Brown & O'Brien, 1998). Thus, service-deliverers need to know they are supported and that others will provide them with clear feedback. It would be useful to include "burnout checks" as part of normal supervision or team discussions.

Building a balanced life

People in the helping professions need to learn to set boundaries and build a balanced life (Grosch & Olsen, 1994). This recommendation to avoid burnout is so pervasive, it could be defined as cliché. However, it is common because it is possibly one of the most important elements in training, development and maintenance of effective therapist/counsellors. Simply put, providers who become overly focused on work run the risk of meeting their own personal needs through providing help. These needs may be to feel useful, social contact, being valued, to address unresolved childhood or relationship issues. If, on the other hand, the provider is meeting these needs in other areas (e.g., home life, friendships, spirituality, etc.) they may be at less risk of burnout. The unfortunate element for those in the helping profession is the reinforcement peers, supervisors, and clients give to "dedication" or those on a "mission" to change things. The line between being the "hero" of the clinic and stress leave may be very fine.

Thus, professionals, paraprofessionals and volunteers working with victims need to remain ever vigilant that they, themselves, are not running the risk of becoming casualties of victimization. The above noted strategies are important when dealing with any client population, as it is easy to feel as though one needs to "give a little more". However, if service-delivers work consistently to this level, one day they will be unable to provide any support or intervention.