Addressing Vicarious Trauma in the Legal Profession through a Webinar-Based Format

Addressing Vicarious Trauma in Legal Professions through a Webinar-Based Format

In 2013, the American Psychiatric Association (APA) published updated criteria for defining a traumatic event within the diagnosis of post-traumatic stress disorder (PTSD). In the Diagnostic and Statistical Manual (DSM-5), the APA outlines the impact of exposure to trauma during the course of one’s work. Specifically, it states that: “Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders)” may create trauma symptoms. Since that time the issue of vicarious trauma has been increasingly focused on both in epidemiologic research as well as exploring interventions for those in high exposure professions [1, 2, 3].

The professions that have been described in the literature include social workers [4, 5, 6, 7], mental health workers [3, 8], domestic violence and sexual assault advocates [9], first responders such as firefighters, police, and paramedics [10, 11]. One group that has received minimal attention is attorneys. Yet, attorneys and other professionals who work in areas such as legal aid, family law and child/elder abuse are faced with traumatic stories repeatedly. Advocating on behalf of highly emotional clients in the field of family law regularly exposes professionals to traumatic information, including domestic and child abuse victims, families undergoing divorce, and the children and parents enduring custody disputes [12]. Additionally, there are relatively few studies exploring the effectiveness of interventions for vicarious trauma.

Trauma stewardship is an approach developed by Lipsky LV, et al. [13] in a book of the same name. Lipsky LV, et al. [13] define trauma stewardship as: “A daily practice through which individuals, organizations and societies tend to the hardship, pain, or trauma experienced by humans, other living beings, or our planet itself” (p. 11). In addition, the authors describe what they call trauma exposure response which details the many manifestations of vicarious trauma. The purpose of this article is to:

• Describe a multiple session training on vicarious trauma and trauma stewardship which was delivered to groups of professionals (N=2 to 24) working as advocates, most of them attorneys, for domestic violence and elder abuse victims,
• Briefly describe the development of a new measurement instrument for trauma exposure response,
• Present data about the effectiveness of the approach, and
• Provide suggestions for ongoing research and intervention.

Literature Review

Vicarious traumatization (VT) and trauma exposure response (TER) are inextricably linked to the experience of those whose profession involves helping, tending to or assisting others who have experienced trauma [14, 15, 16, 17]. Vicarious trauma (VT) refers to a more global phenomenon that occurs because of accumulated exposure to the traumatic material of others [13, 16]. Lipsky LV, et al. [13] defines trauma exposure response (TER) as: “the transformation that occurs in individuals as a result of exposure to the suffering of other living beings or the planet” (p. 41). This definition is somewhat comparable to the definition of vicarious trauma, although one can delineate the difference between the two by positioning TER as describing the various ways that one reacts to vicarious traumatization. These include specific strategies to cope with the harsh reality of VT which also carry the potential to become maladaptive [13]. The transformative nature of TER is thought to impact any individual, regardless of discipline, who works in a helping profession and is exposed to the traumatic suffering of another. At present, there is a great deal more research on vicarious traumatization as opposed to trauma exposure response [13, 18, 19].

Much of the past research has focused on mental health professionals while the effects of VT and TER in attorneys is much less understood, despite findings that suggest exposure and response to traumatic material occurs among legal practitioners [20]. Lawyers and legal practitioners are taught the importance of establishing empathy with their clients who have experienced trauma, yet there is limited attention relegated to teaching these practitioners the deleterious effects of being exposed to trauma in the course of professional duties and experiencing vicarious trauma over time when working with these clients [21].

Vicarious Trauma in Attorneys

While there may be professional differences between the roles of the more well-studied professions and legal professionals, working with trauma survivors in any capacity has the potential to evoke VT and TER, thereby increasing the likelihood of experiencing a negative impact in cognitive, affective, and interpersonal domains [13, 22]. Maguire G, et al. [23] noted that while psychotherapists are often trained in concepts such as countertransference (or the affective response that is evoked in the therapist by the client), attorneys are typically taught to exclusively prioritize their attention toward the facts of the case and knowledge of the law. Maguire G, et al. [23] examined the effect that exposure to traumatic information has on both mental health professionals as well as legal practitioners and compared whether individuals in either of these professions are affected by vicarious trauma. Lawyers were found to score higher in symptoms of post-traumatic stress, depression, anxiety, and stress compared to mental health professionals. These findings support Levin AP, et al. [24] research, which found that attorneys experienced rates of secondary traumatic stress and burnout at a significantly higher rate than mental health providers and social services workers.

This disparity was in part the result of attorneys’ lack of supervision regarding trauma and its impact. Norton L, et al. [25] reported that lawyers are more susceptible to compassion fatigue and burnout than mental health professionals or those who work in social welfare. The discrepancy between these professions was understood as the product of the values and environment that lawyers are frequently exposed to in training and professional life, namely an emphasis on competition, self-sufficiency, repudiation of emotional needs, and the adversarial and isolated atmosphere present in many law practices. Maguire G, et al. [23] concluded that professionals in the mental health field are better equipped to handle exposure to others’ trauma due to the affordance of trauma-specific training as well as accessibility to informed support from peers.

In their study aimed at exploring vicarious trauma in professionals who work in the legal profession, Vrklevski LP, et al. [20] compared symptomatic distress and changes in cognitive schemata in lawyers who worked with traumatized clients with lawyers who did not. The results of this study support the notion that lawyers who represent traumatized clients experience significant levels of vicarious trauma. This group reported higher levels of subjective distress, depression, stress and disruptive alterations in cognitive beliefs about intimacy and safety compared to lawyers who did not come into contact with traumatized individuals. Vrklevski LP, et al. [20] writes of the high likelihood that lawyers in other areas of legal practice will inevitably come across clients who are experiencing domestic/intimate partner violence. This inevitability further underscores the value of implementing trauma-informed training to lawyers, regardless of legal specialty, and education to raise awareness of the benefits of trauma stewardship.

Trauma Informed Practice

Trauma-informed practice is a burgeoning approach for mental health care workers, social workers, counselors, and now for lawyers [21, 27]. Trauma-informed practice is when the practitioner places “the realities of the clients’ trauma experiences at the forefront in engaging with clients and adjusts the practice approach informed by the individual client’s trauma experience” [21]. The steps outlined by Katz S, et al. [21] to adopting a trauma informed practice include:

• Learning to identify trauma,
• Adjusting the lawyer-client relationship,
• Adapt litigation strategy, and finally,
• Preventing vicarious trauma.

In addition to improving an attorney’s service to their clients, this approach also includes the practitioner completing modes of self-care in an act to counterbalance the impact of the client’s trauma experience. Due to the experiences of lawyers working directly with clients who have severe trauma, it is a necessary prerequisite for lawyers to take care of themselves and their clients. Therefore, teaching “trauma-informed practice” is imperative to graduate students and practicing lawyers alike to know and understand.

Katz S, et al. [21] outline the importance of utilizing psychoeducation to teach lawyers who work directly with traumatized clients how to manage vicarious trauma. This would lead to better experiences from both the practitioner and the client. It is a crucial factor of a law students’ education to gain self-awareness and become knowledgeable of potential symptoms and mental health risks when working with clients who have trauma. “A little knowledge about trauma goes a long way in helping students adjust their practice skills to competently and zealously represent clients who have experienced trauma” [21]. Through the implementation of the four ideal pedagogical goals of trauma-informed lawyering, clinical law professors will not only be enhancing the advocacy of their students but also teaching the imperative lasting skills which will allow their students to remain in the field and walk the road to being great lawyers throughout the fruition of their professional careers.

Methods

The training participants were employed with legal aid and state entities and were regularly exposed to details of traumatic experiences of their clients. The majority of them were trained as attorneys, though some may have come to their advocate roles through other professions. They also experienced frequent frustrations and challenges in dealing with systems that may not be responding to their client’s needs or acting in their client’s best interests. Many of the participants were working with less than adequate resources. For the training, participants were grouped by issues they were working with including domestic violence, elder abuse, and advocacy for the institutionalized.

A post-test survey was conducted via Survey Monkey (N = 16) after the conclusion of the training series that assessed level of TER before and after the training. Because people are often unaware of their level of trauma exposure response until after they have been educated about the effects of VT, a retrospective pretest-posttest design was used [26]. Also included in the survey were questions designed to measure the following: likelihood of engaging in self-care strategies, and relevance of various training topics. Descriptive statistics and a paired t-test analysis were run to explore these data.

The participants were also given some opportunities to answer open-ended questions related to the reasons for change, the best and worst parts of training and give suggestions for change within their organizations to better support trauma stewardship. These qualitative data were analyzed by the four authors reviewing the responses and developing themes individually, these themes were then discussed within a research team meeting and collated into agreed upon themes.

Measures

For the sake of measuring a person’s trauma exposure response, as described by Lipsky LV, et al. [13], a 17-item TER Scale was developed asking “Please indicate the extent to which you were experiencing each of these states BEFORE/AFTER the training:” A 5-point Likert scale was utilized including: Always, Frequently, Sometimes, Rarely, Never. Each item was based on one of the 16 Warning Signs of TER described by Lipsky LV, et al. [13] and gave a short description of the sign. An example item for the warning sign of “persecution” is: “Having a sense of others trying to make my life harder.” A final category of “other” was offered, with an opportunity to elaborate. The items were recoded so that higher scores indicated higher trauma exposure response. Internal consistency analysis for this sample showed both scales to have high reliability with the Cronbach’s alpha for the BEFORE scale .89 and for the AFTER scale .88. To investigate the construct validity of the TER Scale, the authors explored the relationship between the single question: “Before/After the training I would say my level of Trauma Exposure Response/Vicarious Trauma/Compassion Fatigue was:” with the options of: Very High, Somewhat High, Average, Somewhat Low, Very Low. For the before question and before TER Scale, the Pearson’s r = .74 and for the after question and after TER Scale the Pearson’s r = .75, suggesting the newly created TER scale appears to be measuring the intended construct.

Intervention

The training sessions, focused on the broad topic of vicarious trauma and trauma stewardship, took place mainly over video conference, although one in-person session was planned for each group. Each group received 4 to 6, one-hour video conference sessions which included slides, instructional video, and discussion. Each week focused on a different topic and addressed issues such as: understanding neurobiology of trauma, providing trauma-informed services, assessing professional quality of life, exploring one’s trauma exposure response, and developing adequate self-care strategies.

Results

The sample (N =16) was 83% female, and 44% had been working in the field for less than 2 years, 27.8% between 2-9 years, and 27.8% over 9 years. Sixty-seven percent of the sample had never had training in vicarious trauma or compassion fatigue. A paired t-test was run on the mean scores on the TER before the training and after the training to determine the impact of the training on the participants’ vicarious trauma reactions [29]. The results showed a statistically significant reduction in the mean score of the severity of trauma exposure response endorsed (x =2.32 v. 1.98, t = 3.502, df =15, p = .003), suggesting that the participants experienced a decrease in their overall reactions to trauma exposure, and perhaps had begun to find new ways to manage their exposure. Along those lines, of the 10 strategies discussed in the training, the top three that participants indicated they were more likely to engage in due to the training were:

• Spending time in nature,
• Meditation/breathing, and
• Paying attention to sleep.

Participants were also asked to respond to an open- ended question about what they felt contributed to the change in their trauma exposure response. These responses revealed a few themes including:

• Opportunities to build self-awareness,
• Recognizing the universality of these trauma exposure responses, and
• Learning proactive practices to manage responses.

Additionally, the research team analyzed the best/ worst of the training as well as organizational change that the participants recommended. They recommended what the researchers termed “building a community of support” including:

• Feeling supported and heard by their organization,
• Support for and flexibility in taking time off, and
• More resources and support for mental health.

Finally, in responding to questions about the effectiveness of the training, participants enjoyed the approachable and relatable style of the training, the normalizing of the experience of trauma exposure response, and the concrete actions discussed. The most referenced drawback was the video conference format for most of the training was not seen as ideal.

Discussion

This study sought to describe and assess the effectiveness of training for legal professionals addressing experiences of vicarious trauma and trauma exposure response. Given the increasing evidence of trauma exposure responses resulting from working directly with those who have been traumatized, this study provides a timely description of an effective method for delivering education to ameliorate vicarious trauma, supporting the work of Katz S, et al. [21] calling for psychoeducation for attorneys. The training described here combined didactic education with discussion and experiential learning such as demonstrating breathing techniques, giving attorneys not only the knowledge to understand vicarious trauma but the tools to address the impact.

Given previous findings that demonstrate the negative impact of exposure to traumatic material in attorneys [20, 23], the results of the current research lend support to the notion that additional training in trauma exposure response and vicarious trauma in legal agencies may be effective in reducing the severity of its deleterious effects. Norton L, et al. [25] suggested that many law practices may contain an atmosphere of isolation and a lack of attention to emotional needs. Participants’ responses that were in favor of organizational changes with respect to providing a supportive environment, especially in the areas of mental health and social support, indicate that further attention to the needs of legal practitioners related to vicarious trauma is warranted. This perspective aligns with the notion that professionals in the mental health field may be better suited to handle exposure to traumatic material due to trauma- informed training and a greater degree of accessibility to support from peers [23].

There are limitations to the current study. This study was evaluation of an innovative training program, it was not designed to be a controlled study with inclusion/exclusion criteria. The sample was small and there may have been selection bias in which participants chose to complete the post training assessment. However, it is hoped that giving detailed information about the curriculum and method of presentation will allow for others looking to develop educational programming to be able to engage in further study of the best ways to deliver this important content. Additionally, although some participants stated they would have preferred more in-person training, the webinar format provided an opportunity for accessible and ongoing training that proved effective. Especially during this time, when a global pandemic has forced more people to grow accustomed to this format, future efforts may be even more effective and successful.