International Society for Traumatic Stress Studies

Telehealth for Prevention and Intervention of the Negative Effects of Caregiving

Posted 1 October 2002 in StressPoints by Debra Larsen, PhD, B. Hudnall Stamm and Kelly Davis, Pocatello, Idaho

In the most general form, telehealth can be defined as any health care activity that uses telecommunications in the service of health care (Laxminarayan, Stamm, in press; Nickelson, 1998). It includes providing clinical care from a distance using telecommunications (telemedicine), health education, administration and training. Much of the telehealth technology originally was developed by the U.S. military, NASA, Antarctic survey stations and offshore oil exploration rigs. But since then, telehealth has influenced the role of patients as participants in their care, while also influencing access to professionals and resources/support available to health care professionals (Darkins & Cary, 2000).

The professional support aspects of a telehealth network are especially important because they may influence negative effects of caregiving experienced by those who work in helping professions (Stamm, 1999; Stamm, in press). These professionals respond to many types of crises-individual, community, national or international. Connection to resources via technology can help improve some negative effects and perhaps reinforce the positive effects of helping in crises.

The Costs of Caring
Helpers often find satisfaction in assisting people who experience extremely stressful events (Stamm, 2002; Stamm, Varra, Pearlman & Giller, 2002), yet the stress associated with these efforts can have a negative impact on helpers (Figley, 1995; Figley, 2002; Jenkins & Maslach, 1994). One negative consequence of secondary exposure has been identified as vicarious traumatization or VT (Stamm, et al., 2002), which can be caused by repeatedly hearing horrible accounts of extremely stressful events. Secondary exposure such as VT can cause changes in how the individual experiences him- or herself and others-for example, changes in schemas about oneself and the world (Pearlman & Saakvitne, 1995).

Researchers have identified burnout as another negative consequence for the helping professions (Dieren-donck, Schaufeli & Buunk, 2001; Maslach, 1978; Maslach & Goldberg, 1998). If the negative consequences of caring escalate to the level of a disorder, symptoms can be similar to those suffered by a primary victim experiencing posttraumatic stress disorder (PTSD) and may include nightmares, intrusive images, dissociative experiences, emotional numbing and exaggerated startle responses (Figley, 1995; Figley, 2002; Motta, Kefer, Hertz & Hafeez, 1999).

Discerning the Nuances of the Costs of Caring
Figley (2002) suggests that VT has a conceptual relationship to burnout, with both VT and burnout as latent variables contributing to compassion fatigue (CF), yet this is hard to discern because compassion fatigue, secondary trauma (ST) and VT sometimes have been used inter-changeably.

If burnout and VT have latent relationships to CF, it is necessary to be able to differentiate between burnout and VT, but this has been difficult to understand. For example, the Compassion Satisfaction and Fatigue Test (Stamm & Figley, 1996), while a reliable measure, has not demonstrated the stable factor structure that would support the psychometric separation of these concepts as easily as the theoretical conceptualizations would want (Good, 1996; Figley & Stamm, 1996; Stamm, Davis, Knox, Higson-Smith & Rudolph, 2001; Stamm, Varra, Hudnall & Higson-Smith, 2001).

It is clear that burnout and S/VT, and even compassion fatigue, have many similar features, but burnout and S/VT have come to be viewed as differing primarily in the affective domains of self-inefficacy (burnout) and fear (S/VT) (cf Stamm, Varra, Hudnall & Higson-Smith, 2001).

How Can Telehealth Help?
Given the many similarities between the burnout and VT constructs, it is not surprising that they have several risk factors in common, including high caseload demands, a personal history of trauma, the nature of the trauma, access to supervision, a supportive work environment, a supportive social network and work environment safety (Adams, Mattos & Harrington, 2001; Meldrum, King & Spooner, 2002).

Professional isolation is believed to be a major risk factor for the development of S/VT or burnout (Stamm, 1999; Stamm, in press; Terry, 1999). This isolation can be the result of a number of factors including geography, climate, population density and social barriers such as race, class or war. Because of their location, many helping professionals are isolated from other providers, peer support, continuing education and access to new information. Rural areas and areas with severe terrain make travel to and from less isolated areas difficult.

In addition, access to both rural and severe-terrain locations often is restricted by extreme weather conditions-for example, blizzards in mountainous areas. This is illustrated by research indicating that rural mental health workers are more likely to report clinically significant VT symptoms than their metropolitan counterparts (Meldrum et al., 2002).

Maintaining professional helpers' professional quality of life requires systematic prevention that addresses individual and organization losses caused by turnover, S/VT and burnout (Stamm et al., 2002). Telehealth is an intervention that addresses professional isolation and has the potential to support professional quality of life in a variety of areas. This includes important aspects of the helping professionals' work, such as finding coverage for time off, supporting continuing education close to home and facilitating technology-mediated peer-to-peer relationships.

Moreover, telehealth gives caregivers, lay and professional, access to tools to help them maintain professional competency and control (Stamm, 1995/1999; Stamm, in press). Such resources also increase the probability of compassion satisfaction, which can increase protective factors associated with S/VT, burnout and compassion fatigue, regardless of the nuances of their existence.

For more information about telehealth, see www.isu.edu/irh.

References
Adams, K.B, Mattos, H.C., & Harrington, D. (2001). The traumatic stress institute belief scale as a measure of vicarious trauma in a national sample of clinical social workers. Families in Society: The Journal of Contemporary Human Services. 82 (4), 363-371.
Darkins, A.W., & Cary, M.A. (2000). Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls. New York: Springer Publishing.
Dierendonck, D.V., Schaufeli, W.B., & Buunk, B.P. (2001). Burnout and inequity among human service professionals: A longitudinal study. Journal of Occupational Health Psychology. 6 (1), 43-52.
Figley, C.R. (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner Mazel.
Figley, C.R. (2002). Introduction. In C. R. Figley (Ed.) Treating Compassion Fatigue. (pp. 1-14). New York: Brunner-Routledge.
Figley, C.R. & Stamm, B.H. (1996). Psychometric Review of Compassion Fatigue Self Test. In B.H. Stamm (Ed), Measurement of Stress, Trauma and Adaptation. Lutherville, MD: Sidran Press.
Good, D. A. (1996). Secondary traumatic stress in art therapists and related mental health professionals [dissertation]. University of New Mexico, Ph.D. dissertation; Dissertation Abstracts International 57/06-A: 2370.
Jenkins, S.R. & Maslach, C. (1994). Psychological health and involvement in interpersonally demanding occupations. Journal of Organization al Behavior. 15, 101-127.
Laxminarayan, S. & Stamm, B. H. (in press). Technology, Telemedicine and Telehealth: Quo Vadis. Business Briefing-Global Healthcare 2002 vol. 2. London: World Medical Association.
Maslach, C. (1978). The client role in staff burn-out. Journal of Social Issues. 34 (4), 111-124.
Maslach, C., & Goldberg, J. (1998). Prevention of burnout: New perspectives. Applied & Preventive Psychology, 7, 63-74.
Meldrum, L.; King, R.; Spooner, D. (2002). Secondary traumatic stress in case managers working in community mental health services. In C.R. Figley (Ed.). 85-106. Treating Compassion Fatigue. New York: Brunner Mazel.
Motta, R.W., Kefer, J.M., Hertz. M.D, & Hafeez, S. (1999). Initial evaluation of the secondary trauma questionnaire. Psychological Reports. 85, 997-1002.
Nickelson, D.W. (1998). Telehealth and the evolving health care system: Strategic opportunities for professional psychology. Professional Psychology: Research & Practice, 29 (6), 527-535.
Pearlman, L.A., & Saakvitne, K.W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton.
Stamm, B. H. (in press). Bridging the Rural-Urban Divide with Telehealth and Telemedicine. In B.H. Stamm, (Ed.). Behavioral Healthcare in Rural and Frontier Areas. Washington, DC: APA Books.
Stamm, B. H. (2002). Measuring Compassion Satisfaction as Well as Fatigue: Developmental History of the Compassion Fatigue and Satisfaction Test. In C.R. Figley (Ed.). 107-119. Treating Compassion Fatigue. New York: Brunner Mazel.
Stamm, B. H., Davis, K., Knox, T., Higson-Smith, C., & Rudolph, J. M. (2001, December). Psychometrics of the Compassion Satisfaction and Fatigue Test. 17th Annual Meeting of the International Society for Traumatic Stress Studies. New Orleans, LA.
Stamm, B. H., Varra, E. M., Hudnall, A. C. & Higson-Smith, C. (2001, December). Measuring the Helper's Power to Heal and To Be Hurt-Or Helped-By Trying. 17th Annual Meeting of the International Society for Traumatic Stress Studies. New Orleans, LA.
Stamm, B.H. (1999). Creating virtual community: Telehealth and self-care updated. In B.H. Stamm (Ed.) Secondary Traumatic Stress: Self Care Issues for Clinicians, Researchers, and Educators (2nd ed.) Lutherville, MD: Sidran Press.
Stamm, B.H., Varra, E.M., Pearlman, L.A., & Giller, E. (2002) The Helper's Power to Heal and To Be Hurt - Or Helped - By Trying. Washington, DC: Register Report: A Publication of the National Register of Health Service Providers in Psychology.

Debra Larsen, PhD, B. Hudnall Stamm, PhD, and Kelly Davis are from the Institute of Rural Health and the Department of Psychology, Idaho State University.