Indirect exposure to client trauma and the impact on trainee clinical psychologists: Secondary traumatic stress or vicarious traumatization?

OBJECTIVES: The study investigated the relationship between exposure to trauma work and well-being (general psychological distress, trauma symptoms, and disrupted beliefs) in trainee clinical psychologists. It also assessed the contribution of individual and situational factors to well-being. DESIGN: A Web-based survey was employed. METHODS: The survey comprised the General Health Questionnaire, Secondary Traumatic Stress Scale, Trauma and Attachment Belief Scale, Trauma Screening Questionnaire, and specific questions about exposure to trauma work and other individual and situational factors. The link to the online survey was sent via email to trainee clinical psychologists attending courses throughout the UK RESULTS: Five hundred sixty-four trainee clinical psychologists participated. Most trainees had a caseload of one to two trauma cases in the previous 6 months; the most common trauma being sexual abuse. Exposure to trauma work was not related to general psychological distress or disrupted beliefs but was a significant predictor of trauma symptoms. Situational factors contributed to the variance in trauma symptoms; level of stress of clinical work and quality of trauma training were significant predictors of trauma symptoms. Individual and situational factors were also found to be significant predictors of general psychological distress and disrupted beliefs. CONCLUSIONS: This study provides support for secondary traumatic stress but lacks evidence to support belief changes in vicarious traumatization or a relationship between exposure to trauma work and general psychological distress. The measurement and validity of vicarious traumatization is discussed along with clinical, theoretical implications, and suggestions for future research. PRACTITIONER POINTS: Secondary traumatic stress is a potential risk for trainee clinical psychologists. Training courses should (a) focus on quality of trauma training as it may be protective; (b) advocate coping strategies to reduce stress of clinical work, as the level of stress of clinical work may contribute to trauma symptoms. LIMITATIONS INCLUDE: Exposure to trauma work only uniquely explained a small proportion of variance in trauma symptoms. The study was cross-sectional in nature therefore cannot imply causality.

Attitudes and Preferences towards Self-help Treatments for Depression in Comparison to Psychotherapy and Antidepressant Medication.

BACKGROUND: Self-help is an effective treatment for depression. Less is known, however, about how acceptable people find different self-help treatments for depression. AIMS: To investigate preferences and attitudes toward different self-help treatments for depression in comparison to psychotherapy and antidepressants. METHOD: N = 536 people who were not actively seeking treatment for depression were randomly assigned to read about one of five treatment options (bibliotherapy, Internet-based self-help, guided self-help, antidepressants, or psychotherapy) before rating how acceptable they found the treatment. Participants also ranked the treatments in order of preference. RESULTS: Psychotherapy and guided self-help were found to be the most acceptable and preferred treatment options. Antidepressants and bibliotherapy were found to be the least acceptable treatments, with antidepressants rated as the most likely to have side effects. Preference data reflected the above findings - psychotherapy and guided self-help were the most preferred treatment options. CONCLUSIONS: The findings highlight differences in attitudes and preferences between guided and unguided self-help interventions; and between self-help interventions and psychotherapy. Future research should focus on understanding why unguided self-help interventions are deemed to be less acceptable than guided self-help interventions for treating depression.

The journey through cannabis use: a qualitative study of the experiences of young adults with psychosis.

The present study explored the personal experiences of cannabis and psychosis among young adults, including the reasons and meanings of cannabis use and the perceived relationship between cannabis and mental health. Interviews with seven young adults with psychosis who described regular current or past cannabis use were conducted and analyzed using Interpretative Phenomenological Analysis. Four master themes emerged: The Journey Through Cannabis Use, The Social and Cultural World, The Struggle to Make Sense, and The Depths and Beyond. Respondent validation supported these themes, particularly the idea of cannabis use as a journey that changed in time. Social and cultural factors clearly influenced the initiation of and decision whether to continue using cannabis. Individuals could simultaneously hold positive and negative views on using cannabis. Implications for clinical interventions are explored, and the relevance of motivational interviewing and the stages of change models of behavior change are noted.

A qualitative exploration of communication within the community mental health team.

This qualitative study sought to explore conceptual models employed by community mental health team (CMHT) staff in the care of their clients and how CMHT clinicians communicated with one another, particularly in relation to complex clinical work. The qualitative method of interpretive phenomenological analysis was used, and semistructured in-depth interviews with seven UK CMHT clinicians were conducted and analyzed. Four themes were evident in the data and showed that clinicians face complex and competing demands and draw on a range of therapeutic models in their work. It was also clear that much discussion centred primarily on pragmatic issues and lacked conceptual depth. The results underline the complex and challenging nature of CMHT work and suggest that a more systematic approach to interdisciplinary training within teams could be beneficial in increasing clinicians' knowledge, skills, and their understanding of the conceptual models used across different disciplines.

Habituation and sensitization of protective reflexes: dissociation between cardiac defense and eye-blink startle.

We examined the habituation and recovery of two protective reflexes, cardiac defense and eye-blink startle, simultaneously elicited by a white noise of 500ms as a function of the time interval between stimulus presentations. Participants were 90 volunteers (54 women) randomly distributed into 6 inter-trial interval (ITI) conditions. They all received three presentations of the stimulus with a time interval of 30min between the first and third noise. The timing of the second noise was manipulated in six steps, using a between-group design, in order to increase the ITI between Trials 1 and 2 and symmetrically decrease the ITI between Trials 2 and 3. Cardiac defense showed fast habituation at the shortest ITI (2.5min), but reduced habituation and increased recovery at the longest ITI (27.5min). In contrast, eye-blink startle showed sensitization irrespective of the ITI. This pattern of findings highlights dissociations between protective reflexes when simultaneously examined. The results are discussed in the context of the cascade model of defense reactions.

Visuospatial working memory interference with recollections of trauma.

OBJECTIVES: Laboratory research using a working memory framework has shown modality-specific reductions in image vividness and emotionality when concurrent tasks are performed while maintaining the image in consciousness. We extended this research to trauma images in a clinical population awaiting treatment for post-traumatic stress symptoms. DESIGN: A within-subjects design was used, with each participant completing an imagery task under three concurrent task conditions: side-to-side eye-movements, counting, and exposure only (no concurrent task). METHODS: Eighteen participants selected three images each, the images being those that were the most distressing from participants' trauma memories and most likely to intrude involuntarily. Participants gave baseline ratings of the vividness and emotionality of each of their trauma images. Each image was assigned to a condition. Each condition comprised 8 trials in which participants recollected the appropriate image for 8 s while performing eye-movements, counting or no concurrent task, and then rated its vividness and emotionality. Follow-up ratings were obtained by telephone 1 week later. RESULTS: The eye-movement task reduced vividness and emotionality of the trauma images relative to the counting task and exposure only, but did so only during the imagery period and not at follow-up. The images were predominantly visual. CONCLUSIONS: Concurrent tasks matched to the modality of trauma images may provide a useful treatment aid for temporarily dampening emotional responses to recollections of trauma.

A randomised controlled trial of the effectiveness of writing as a self-help intervention for traumatic injury patients at risk of developing post-traumatic stress disorder.

The study investigated the effects of writing and self-help information on severity of psychological symptoms in traumatic injury patients at risk for developing post-traumatic stress disorder (PTSD). Patients attending Accident and Emergency (A & E), were screened for Acute Stress Disorder and randomised to an information control group (n=36) or a writing and information group (n=31). Participants in both groups received an information booklet one-month post-injury. Participants in the writing group also wrote about emotional aspects of their trauma during three 20-min sessions, five to six weeks post-injury. Psychological assessments were completed within one month and at three and six months post-injury. There were significant improvements on measures of anxiety, depression and PTSD over time. Differences between groups on these measures were not statistically significant. However, subjective ratings of the usefulness of writing were high. In conclusion, the results do not currently support the use of writing as a targeted early intervention technique for traumatic injury patients at risk of developing PTSD.

Mejorando el acceso a las terapias psicológicas: Una iniciativa nacional para asegurar la prestación de terapias de alta calidad basadas en la evidencia / No disponible

El acceso a las terapias psicológicas para las personas que presentan los problemas de salud mental comunes en el Reino Unido hatendido a ser pobre y limitado por la calidad de los servicios locales. En especial, este es el caso de las personas que acuden al mé-dico de familia en Atención Primaria, el cual históricamente ha tenido que hacer la inaceptable elección de hacer uso sólo de la me-dicación o bien de derivar el caso para una intervención psicológica; pero con la condición de largos plazos de espera que, confrecuencia, exceden a los 12 meses.Los recientes progresos en el desarrollo de directrices clínicas basadas en datos, en el Reino Unido, ha significado que las terapiaspsicológicas han sido recomendadas por ser a la vez altamente efectivas, relativamente seguras y económicamente viables, para unamplio rango de problemas comunes de salud mental; especialmente ansiedad y depresión. Al mismo tiempo, ha sido ampliamenteapreciado por los significativos costes para las personas y para la sociedad, en cuanto a las adversas circunstancias que tiene unapobre salud mental sobre el bienestar, la capacidad de trabajo y el impacto económico, tanto para el sistema de salud en generalcomo especialmente para el erario público, en forma de prestaciones y pagos por incapacidad.Este artículo describe el fundamento teórico subyacente y la puesta en práctica del programa nacional de inversión gubernamental,Mejorando el Acceso a Terapias Psicológicas (Improving Access to Psychological Therapies) en Inglaterra, para ofrecer la elecciónde terapias psicológicas basadas en datos, con buenos recursos, a aquellas personas que experimentan problemas de salud mentalcomunes en atención primaria, y generalmente para apoyar su recuperación y funcionamiento en el trabajo y en la sociedad

Access to psychological therapies for people presenting with common mental health problems within the United Kingdom has tendedto be poor and limited by the quality of local services. This is especially the case for people presenting to their general practitionerwithin primary care who historically have been faced with the unacceptable choice of either only medication or referral to psycholog-ical interventions but with the proviso of long waiting times, frequently in excess of 12 months.Recent progress around the development of evidence based clinical guidelines within the UK, has meant that psychological therapieshave been recommended as both highly effective, relatively safe and economically viable for a wide range of common mental healthproblems, particularly anxiety and depression. At the same time the significant costs to individuals and Society in terms of the adverseconsequences of poor mental health on well-being, capacity to work and the economic impacts on both the health system generallyand more specifically the exchequer, in the form of incapacity benefits and payments, has become more widely appreciated. This paper describes the rationale behind and the implementation of a national programme of government investment, Improving Ac-cess to Psychological Therapies, within England, to provide a choice of well-resourced, evidence based psychological therapies tothose individuals in primary care who experience common mental health problems, and to support generally their recovery and func-tioning within employment and Society

Multidisciplinary community mental health team staff's experience of a 'skills level' training course in cognitive analytic therapy.

This study sought to explore community mental health teams' (CMHTs) experiences of receiving an innovative introductory level training in cognitive analytic therapy (CAT). CMHTs are important providers of care for people with mental health problems. Although CMHTs have many strengths, they have been widely criticized for failing to have a shared model underlying practice. Inter-professional training which develops shared therapeutic models from which to plan care delivery is, therefore, essential. We have been developing such a training based on the psychotherapeutic principles of CAT. Twelve community mental health staff (six mental health social workers and six community psychiatric nurses) were interviewed by an independent interviewer following the completion of the training programme. The interviews were analysed using a qualitative thematic analysis. The analysis revealed that the programme increased the participants' self-assessed therapeutic confidence and skill and fostered the development of a shared model within the team, although the training was also perceived as adding to workload. The results of this study suggest that whole-team CAT training may facilitate cohesion and also suggest that having some shared common language is important in enabling and supporting work with 'difficult' and 'complex' clients, for example, those with personality disorders. Further development of such training accompanied by rigorous evaluation should be undertaken.

A randomised controlled trial to assess the effectiveness of providing self-help information to people with symptoms of acute stress disorder following a traumatic injury.

BACKGROUND: Patients attending accident and emergency (A&E) may develop long-term psychological difficulties. Psycho-education has been suggested to reduce the risk of post-injury disorders. AIMS: We tested the efficacy of providing self-help information to a high-risk sample. METHODS: A&E attenders were screened for acute stress disorder and randomised to two groups: patients (n=116) receiving a self-help booklet and those who did not (n=111). A sample of 'low' scorers was also included (n=120); they did not receive a booklet. Psychological assessments were completed at baseline (within 1 month post-injury) and 3 and 6 months post-injury. RESULTS: Post-traumatic stress disorder (PTSD), anxiety and depression decreased (p<0.001) across time but there were no group differences in these measures or quality of life. However, subjective ratings of the usefulness of the self-help booklet were very high. CONCLUSIONS: This trial failed to support the efficacy of providing self-help information, as a preventative strategy to ameliorate PTSD.

Self-reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy.

The aims of this study were to explore the relationship between therapists' self-reported attachment styles and therapeutic orientation with the self-reported general therapeutic alliance and therapist-reported problems in psychological therapy.A sample of 491 psychotherapists from differing therapeutic orientations responded to a postal questionnaire. The questionnaire contained standardized measures of therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy, and a brief personality inventory.Therapist-reported attachment styles generally explained a significant additional proportion of the variance in alliance and problems in therapy, over and above variance explained by general personality variables. Self-reported secure attachment style was significantly positively correlated with therapist-reported general good alliance. Self-reported anxious attachment styles were significantly negatively correlated with good alliance, and significantly positively correlated with the number of therapist-reported problems in therapy. Therapeutic orientation independently predicted a small but significant amount of the variance in reported general alliance quality in addition to that explained by attachment behaviours.

Investigation of social and emotion information processing in temporal lobe epilepsy with ictal fear.

This study examined whether patients with temporal lobe epilepsy (TLE) and ictal fear (IF) show emotion recognition deficits similar to those associated with amygdala damage. Three groups of patients (13 with TLE and IF, 14 with TLE and nonfear auras (non-IF), and 10 with idiopathic generalized epilepsy (IGE)) completed tests of visual and face processing, face emotion recognition and social judgment, together with measures of psychological adjustment (Hospital Anxiety and Depression Scale; SCL-90-R) and Quality of Life (QOLIE-31). All three epilepsy groups had fear recognition deficits, with relatively greater impairments in the IF group. Fear recognition deficits were associated with impaired social judgment of trustworthiness, duration of epilepsy, and a measure of quality of life. Social cognition impairments previously associated with amygdala dysfunction are also a feature of the neuropsychology of TLE, and extend the hypothesis in that they may additionally play a role in IGE.

An attitudinal study of responses to a range of dermatological conditions using the implicit association test.

The Implicit Association Test (IAT) was used to explore implicit attitudes to dermatological conditions. The stimuli employed were photographs representing skin conditions and clear skin. Explicit attitudes were measured using rating scales and questions concerning participants' experience of dermatitis. Participants (N=64) completed the IAT, explicit measures and demographics. The results showed a statistically significant implicit preference for people with clear skin and suggested that people who knew someone with a skin condition may exhibit stereotype inhibition. This concurs with earlier research into disfigurement, and in accord with previous IAT research, correlations between implicit and explicit measures were not significant.

Effectiveness of providing self-help information following acute traumatic injury: randomised controlled trial.

BACKGROUND: Patients attending an accident and emergency department may exhibit psychological disturbances post-injury. Early interventions have been suggested to reduce the risk of post-injury disorder, including psychoeducation. AIMS: We assessed the efficacy of providing such self-help information. METHOD: Patients who had experienced trauma were randomised to two groups: those given (n=75) and not given (n=67) a self-help booklet. Psychological assessments were completed within 2, 10-12 and 24-26 weeks. RESULTS: Post-traumatic stress disorder (PTSD), anxiety and depression decreased (P < 0.05) with time but there were no group differences in PTSD or anxiety. The controls were less depressed (P < 50.05) at follow-up. There was a reduction in PTSD caseness within the control (50%) compared with the intervention (20%) group which was almost significant (P < 0.06). CONCLUSIONS: This trial failed to support the efficacy of providing self-help information as a preventive strategy to ameliorate PTSD.

Covert and overt attention in trait anxiety: a cognitive psychophysiological analysis.

The effect of threatening cues and anxiety upon attention within a Posner paradigm was investigated in two experiments. It was predicted anxious individuals would show a bias to threat-related material. Heart rate and eye movements were obtained to assess the attentional processes associated with this cognitive bias. Sixty and 40 participants were allocated respectively to groups based on self-reported scores of anxiety and repressive coping style. All participants were exposed to threat and non-threat cue words within a word based Posner cueing task. In the second study, spatial position of the target was manipulated, together with instructional set. Differential patterns of attentional disengagement to threat were found that were modulated by trait anxiety in study 2. A bias towards threat involving uninstructed eye movements was observed amongst anxious participants. Repressors made few such eye movements. Findings are discussed in relation to models of attentional deployment to threat.

Intrusive and non-intrusive memories in a non-clinical sample: the effects of mood and affect on imagery vividness.

We studied the number, valence, and vividness of intrusive and non-intrusive memories in two groups (N = 20) of pre-screened non-depressed mood and depressed mood undergraduate participants. They were asked to generate as many intrusive memories (IMs) as possible from the prior 2 weeks, together with pleasant and unpleasant non-intrusive memories from the same period. They subsequently formed images of these memories and rated them on measures of vividness, valence, arousal, and overall affect, while having their heart rate, skin conductance, and electromyogram monitored. IMs were common, with participants generating a mean of 1.15 pleasant IMs and 1.60 unpleasant IMs, and there was some evidence that they were mood-congruent. IMs were more vivid than non-intrusive memories, a difference not due to either valence or arousal. We conclude that IMs are a general feature of human memory rather than just a symptom of certain clinical disorders.

Determinants of the vividness of visual imagery: the effects of delayed recall, stimulus affect and individual differences.

This study investigated the influence of emotion on vividness of imagery. A total of 80 undergraduate participants saw 25 pictures from the International Affective Picture System, representing different dimensions of valence and arousal. They rated each stimulus for valence, arousal, and emotionality. Each stimulus was then presented again, and participants formed an image of it, rating the image for vividness, valence, arousal, and emotionality. During a 15-minute retention interval, participants completed several individual differences questionnaires. They then recalled each image from a verbal prompt and re-rated its quality. Slides rated as extremely valenced and highly arousing were more vividly imaged than neutral slides. Low mood was also associated with more vivid imagery. The influence of stimulus variables was greater in the immediate imagery phase; that of individual differences tended to be greater in the delayed imagery phase. Of 29 participants, 7 reported intrusive memories of highly unpleasant stimuli at 1 year follow-up.

Vicarious traumatization: implications for the mental health of health workers?

It has been suggested that a unique feature of some mental heath practitioners' work is exposure through their role as therapists to clients' descriptions of and reactions to trauma, and that these experiences may actually indirectly cause distress and traumatization to the therapist. This proposed phenomenon has been termed "vicarious traumatization" (VT) and is the focus of the current review. The concept of VT, together with other related concepts such as "burnout," "compassion fatigue," "secondary traumatic stress" (STS), and "work stress" are appraised. Psychological mechanisms that might be theoretically involved in VT are considered. The measurement of VT is reviewed alongside the limited research evidence supporting its existence. Factors such as direct trauma exposure and the personal attributes of mental health workers, which have been suggested to be associated with VT, are also assessed. It is concluded that the evidence to support the existence of VT is meager and inconsistent. Future research needs to be directed at distinguishing VT from other sources of distress arising within the workplace. Finally, the organizational relevance of VT and its possible implications for the management of mental health workers are critically appraised.

Implicit memory bias and trait anxiety: a psychophysiological analysis.

The effect of threatening words and anxiety upon implicit memory performance was investigated. It was predicted that anxious individuals would show a bias to threat-related material. In addition, psychophysiological measures were obtained to assess the attentional and encoding processes that might underlie this cognitive bias. Forty participants were equally allocated to high and low trait anxious groups, according to pre-determined cut-offs. All participants were exposed to threat and non-threat words and following a filler task, were asked to complete primed and unprimed wordstems. Implicit memory performance was assessed in terms of accuracy and reaction time for completion. Heart rate and electrodermal responses were measured. Results demonstrated initial increased cardiac deceleration to threat stimuli, subsequent cardiac acceleration to non-threat stimuli, and an implicit memory bias to non-threat material by all participants. These findings are discussed in relation to the 'vigilance-avoidance' model of attention to threat stimuli.