507135

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JIV29810.1177/0886260513507135Journal of Interpersonal ViolenceRobinson-Keilig

Article
Journal of Interpersonal Violence
2014, Vol. 29(8) 1477­–1496
Secondary Traumatic © The Author(s) 2013
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DOI: 10.1177/0886260513507135
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Functioning Among
Mental Health Therapists

Rachael A. Robinson-Keilig, PhD1

Abstract
Disruptions within interpersonal relationships are often cited as a symptom
of secondary traumatic stress (STS) and vicarious trauma among mental
health therapists. However, the primary evidence to support these claims
is based on theoretical explanations and limited descriptive data. The
current study sought to test the theoretical model of STS and to extend
prior research by directly measuring interpersonal and sexual disruptions
and their association with STS symptomology. The study hypothesized
that mental health therapists with higher levels of intrusion, avoidance,
and arousal symptoms would also report disruptions in their interpersonal
relationships. A total of 320 licensed mental health therapists completed
the online study questionnaire. Results of the current study were mixed.
Higher levels of STS symptoms showed a significant association with lower
relationship satisfaction, lower social intimacy, less use of constructive
communication patterns, and more use of avoidance communication and
demand-withdrawal communication patterns. These relationships remained
after controlling for gender, years of counseling experience, and exposure
level to trauma clients. However, no association was found between STS,

1University of Oklahoma–Tulsa, USA

Corresponding Author:
Rachael A. Robinson-Keilig, Assistant Professor, Department of Human Relations, Women’s
and Gender Studies Program, University of Oklahoma–Tulsa, 4502 East 41 Street, Tulsa, OK
74135-2553, USA.
Email: rrkeilig@ou.edu
1478 Journal of Interpersonal Violence 29(8)

sexual activity interest, and sexual relationship satisfaction. Implications of

these findings are reviewed.

Keywords
secondary traumatic stress, vicarious trauma, interpersonal functioning

Therapists who provide psychological treatment to victims of trauma fre-

quently encounter vivid descriptions of traumatic events, unsettling accounts
of human cruelty and abuse, and direct witnessing of strong emotional
expressions from their clients (Figley, 1995b; Pearlman & Saakvitne, 1995a;
Resick & Calhoun, 2001). Many consider this type of exposure to traumatic
material indirectly from clients to be an occupational hazard of conducting
clinical work with traumatized populations (Bride, 2004, 2007; Deighton,
Gurris, & Traue, 2007; Figley, 1995b; Kassam-Adams, 1995). In a survey of
446 female psychotherapists, 72% reported exposure to graphic details of
trauma either “sometimes” or “frequently” in their work with clients (Brady,
Guy, Poelstra, & Brokaw, 1999). In a separate survey of 221 mental health
professionals, 69.6% reported moderate to profound amounts of exposure to
traumatic material (Kadambi & Truscott, 2004). As a result, therapists may
be at risk of developing their own trauma-related symptoms, including pro-
found changes in personal functioning and the emergence of clinical symp-
toms (Figley, 2002; McCann & Pearlman, 1990; Pearlman & Saakvitne,
1995a).
The impaired psychological and physical response to trauma exposure by
therapists was first recognized by Figley (1983) and labeled secondary cata-
strophic stress. Today in the literature, the psychological community com-
monly refers to this phenomenon as either vicarious traumatization and/or
secondary traumatic stress (STS; Bride, 2007; Dunkley & Whelan, 2006;
Newell & MacNeil, 2010). Vicarious traumatization is the terminology used
most often when referring to alterations that occur in the cognitive schemas
of trauma therapists. Cognitive schemas constitute thoughts, beliefs, and
interpretations about one’s self, others, and the world, and in regard to vicari-
ous trauma, the cognitive schemas of safety, trust, esteem, control, and inti-
macy are viewed as most vulnerable. It is believed that exposure to trauma
clients and their trauma experiences fundamentally alter how therapists con-
struct these five core schemas (McCann & Pearlman, 1990, 1991). In con-
trast, STS is the terminology used most often when referencing the presence
of intrusion, avoidance, and arousal symptoms. STS Disorder is conceptual-
ized to mirror that of Post-Traumatic Stress Disorder (PTSD) apart from the
Robinson-Keilig 1479

source of the trauma being the client’s trauma, rather than the therapist’s own
(Figley, 1983).
To date, research on vicarious trauma and STS has focused predominantly
on the measurement of these two clusters of symptoms, with more compel-
ling evidence emerging for the presence of elevated intrusion, avoidance, and
arousal symptoms as part of STS among trauma therapists (Adams, Matto, &
Harrington, 2001; Arvay & Uhlemann, 1996; Bober & Regehr, 2006; Bride,
2007; Chrestman, 1995; Cunningham, 2003; Ghahamanlou & Brodbeck,
2000; Kadambi & Truscott, 2004; McLean, Wade, & Encel, 2003; Pearlman
& MacIan, 1995; Schauben & Frazier, 1995; VanDeusen & Way, 2006; Way,
VanDeusen, Martin, Applegate, & Jandle, 2004).
Relevant literature however also identifies disruptions within interper-
sonal relationships as symptoms of STS and vicarious traumatization (Collins
& Long, 2003; Dutton & Rubinstein, 1995; Yassen, 1995). These assertions
in the literature regarding the occurrence of interpersonal disruptions primar-
ily cite anecdotal accounts or reference back to theory as evidence (Canfield,
2005; Figley, 2002; Herman, 1992; Maltz, 1991; McCann & Pearlman, 1990;
Pearlman, 1995; Pearlman & Saakvitne, 1995b; Rosenbloom, Pratt, &
Pearlman, 1995). Empirically, there is little evidence to support these claims
(Marmaras, Lee, Siegel, & Reich, 2003; Sabin-Farrell & Turpin, 2003).
Among the research that is available, only limited descriptive information
has been reported. In their survey of 215 mental health professionals, Follette,
Polusny, and Milbeck (1994) reported that 24.2% utilized “withdrawing from
others” as a coping strategy when working with child sexual abuse survivors.
Rich (1997) surveyed 135 therapists and health professionals who worked
with trauma clients and who also self-identified as vicariously traumatized.
Within this group, 35.7% reported feeling “removed from friends and fam-
ily,” and 36.1% felt that their sex lives were less satisfying since starting their
work as a trauma therapist.
More recently, a study of 515 mental health social workers found that over
half of the sample (53.3%) felt that secondary trauma was having a “negative
effect” on their personal and professional lives (Ting, Jacobson, Sanders,
Bride, & Harrington, 2005). Finally, Bride (2007) found that in a sample of
294 social workers, 23.3% reported feeling “detached from others” in their
lives as a symptom of STS. No prior studies have been located that specifi-
cally address the interpersonal disruptions experienced by mental health
therapists as part of the symptomology of vicarious traumatization and STS.
Research to date has largely ignored interpersonal disruptions. Instead,
researchers have focused primarily on the measurement of cognitive schema
disruptions and intrusion, avoidance, and arousal symptomology. Given the
theoretical premise that includes interpersonal disruptions as part of the
1480 Journal of Interpersonal Violence 29(8)

vicarious trauma and STS response, this omission needs to be addressed. The
present study addresses this omission by examining disruptions in interper-
sonal functioning among mental health therapists who also reported intru-
sion, avoidance, and arousal symptoms indicative of STS. Intrusion,
avoidance, and arousal symptoms were selected due to the stronger evidence
base related to these symptoms at this time. In addition, demographic vari-
ables of gender, years of counseling experience, and exposure to trauma cli-
ents were included due to their association with elevated levels of STS in
prior research (Adams et al., 2001; Bober & Regehr, 2006; Chrestman, 1995;
Deighton et al., 2007; Kassam-Adams, 1995; McLean et al., 2003; Schauben
& Frazier, 1995; Sprang, Clark, & Whitt-Woosley, 2007; Way et al., 2004). It
was hypothesized that mental health therapists with elevated levels of STS
symptoms would also report more disruptions in their interpersonal relation-
ships in the areas of relationship satisfaction, social intimacy, communication
patterns, sexual activity interest, and sexual relationship satisfaction.

Method
Participants
The age range for study participants was 25 to 89 with a mean age of 51.20
(SD = 12.26). The mean number of years in practice for participants was
17.84 (SD = 11.20) with a range of 1 year to 55 years in practice. The partici-
pants’ current caseload averaged 56.13% trauma clients, and participants on
average conducted 43.87 hours (SD = 36.60) of therapy with trauma clients
within the prior month of completing the survey. A total of 67 participants
identified as male, 249 identified as female, one participant identified as
transgendered, and three participants failed to identify their gender. The self-
identified ethnicities for participants in this study were 91.5% European
American, 2.5% Latina/Latino, 2.8% African American, 0.3% Multi-racial,
0.6% Asian American, 0.3% American Indian, and 1.9% “Other.” The major-
ity of participants (63.6%) identified their highest education level as a mas-
ter’s degree (MA, MS, MEd, MSW) followed by 28.5% of participants with
a PhD, 6.9% with a PsyD, and 0.9% with a Medical Degree.

Procedure
Following university Institutional Review Board (IRB) approval, the
researcher identified study participants through the following organizations:
the American Mental Health Counselors Association, the Nebraska
Counseling Association, the Nebraska Psychological Association, members
Robinson-Keilig 1481

of APA Division 42 (Psychologists in Independent Practice), members of

APA Division 56 (Trauma Psychology), members of the EMDR Association,
and professionals via community mental health centers in Kansas and
Nebraska. Individuals self-selected to participate in the current study and, per
email instructions, accessed a web-based survey site that met industry stan-
dards for Internet security as well as IRB standards for the protection of
human subjects. Participants completed a total of five measures, including
one demographic questionnaire.
A total of 417 individuals participated in the study between January and
June 2009. Of this group, 35 respondents were excluded because of the
inability to determine study eligibility. An additional 56 respondents were
excluded because they failed to hold a professional license, failed to meet
minimum education criteria, or were not actively seeing clients. Finally, six
respondents were not eligible for the study because they were not currently in
a romantic relationship. The final sample for the study was 320 licensed men-
tal health professionals. To achieve a power of .95 with a medium effect size
(.15) and an alpha of .05, a sample size of 132 was needed to detect a signifi-
cant model (Erdfelder, Faul, & Buchner, 1996).

Measures
Secondary Traumatic Stress Scale (STSS).  The STSS (Bride, Robinson, Yegidis,
& Figley, 2003) is a 17-item, self-report instrument designed to measure
intrusion, avoidance, and arousal symptoms in practitioners who have expe-
rienced traumatic stress through their clinical work with traumatized clients.
A 5-point Likert-type scale is used for responses ranging from 1 (never) to 5
(very often). Sample items for the STSS include (1) “I had trouble sleeping,”
(2) “I was less active than usual,” and (3) “I was easily annoyed.” Full scale
and subscale scores are obtained by summing the respective items for each
scale, with higher scores representing greater severity of PTSD symptoms
due to STS.
Bride (2007) suggests using interpretative categories based on percentiles.
Scores at the 50th percentile or below are interpreted as little to no STS,
scores at the 51st to 75th percentile are mild STS, scores at the 76th to 90th
percentile are moderate STS, scores at the 91st to 95th percentile are high
STS, and scores above the 95th percentile are severe STS. Bride (2007) sug-
gests that the score at the lower end of the moderate range (76th to 90th per-
centile) serve as the cut-off point for determining PTSD due to STS. In Bride
(2007), a sensitivity of .93 and a specificity of .91 was obtained with this
approach in accurately identifying those who met core criteria for PTSD. In
the current study, the Cronbach’s alpha coefficient was .91 for the Full STSS,
1482 Journal of Interpersonal Violence 29(8)

.73 for the Intrusion subscale, .82 for the Avoidance subscale, and .80 for the
Arousal subscale.

Relationship Assessment Scale (RAS).  The RAS (Hendrick, 1988) is a seven-

item self-report instrument designed to measure global satisfaction in roman-
tic relationships (Vaughn & Matyastik Baier, 1999). Individual item responses
range from 1 (poorly) to 5 (extremely well) on a 5-point Likert-type scale. All
seven items are summed to obtain the total scale score, with a possible total
score range of 7 (low satisfaction) to 35 (high satisfaction). Sample items
include (1) “How well does your partner meet your needs?” and (2) “How
much do you love your partner?” In the current study, the Cronbach’s alpha
coefficient was .92.

Miller Social Intimacy Scale (MSIS).  The MSIS (Miller & Lefcourt, 1982) is a
17-item, self-report instrument designed to assess intimacy in adult relation-
ships by measuring intimate behaviors (6 items) and intensity of emotions
within the relationship (11 items). Respondents indicate on a 5-point, Likert-
type scale from 1 (very rarely or not much) to 5 (almost always or a great deal),
which best describes their current intimate relationship. Sample items include
(1) “How often do you show him/her affection?” (2) “How often are you will-
ing to understand his/her feelings?” and (3) “How important is it to you that he/
she show you affection?” The overall score is the sum of items 1 through 17
with higher scores indicating a greater amount of social intimacy in the rela-
tionship. In the current study, the Cronbach’s alpha coefficient was .92.

Communication Patterns Questionnaire (CPQ).  The CPQ (Christensen & Sulla-

way, 1984) is a self-report questionnaire that aims to measure an individual’s
perception of communication within an intimate relationship during three
phases of conflict discussion (the presentation of a problem, the discussion of
a problem, and post discussion of a problem). Respondents rate each item on
a 9-point, Likert-type scale, indicating the likelihood of the particular pattern
occurring when addressing a problem in the relationship (1 = very unlikely, 9
= very likely).
The current study used three subscales from the CPQ, including Mutual
Constructive Communication (MCC), Mutual Avoidance and Withholding
(MAW), and Total Demand-Withdrawal Communication (DWC). A total of
16 items were included, with higher subscale scores indicating the higher
likelihood of the particular pattern occurring when engaged in a conflict dis-
cussion. Sample items include (1) “When some problem in the relationship
arises, both members avoid discussing the problem”; (2) “During a discussion
Robinson-Keilig 1483

of a relationship problem both members express their feelings to each other”;

and (3) “After a discussion of a relationship problem, both withdraw from
each other after the discussion.” In the current study, the Cronbach’s alpha
coefficients for the subscales were MCC, alpha = .78; DWC, alpha = .80; and
MAW, alpha = .76.

Brief Sexual Function Questionnaire (BSFQ).  The BSFQ is a self-report inven-

tory of sexual interest and satisfaction modified from the original Brief Sex-
ual Function Questionnaire for Men (BSFQ-M; Reynolds et al., 1988). This
study used two subscales of the BSFQ-M, the Sexual Interest Subscale
(BSFQ-Interest), and the Sexual Relationship Satisfaction Subscale (BSFQ-
Satisfaction) modified to use gender-neutral language. Respondents rate each
item on a 7-point, Likert-type scale with higher scores indicating more inter-
est in sexual activity or more sexual relationship satisfaction. Sample items
include (1) “During the past month, how frequently have you felt sexual
drive? and (2) “Overall, during the past month, how satisfied have you been
with your sex life?” For the current study, the Cronbach’s alpha coefficient
for the interest subscale was .86 and for the satisfaction subscale was .87.

Results
Missing Data and Tests for Violations of Assumptions
Three survey items reported missing values over 5%, and were evaluated for
potential patterns (Tabachnick & Fidell, 2001). A pattern for age for two
items among those cases with missing values was detected. Participants with
missing values were significantly older than those without missing values;
however, the magnitude of this difference was small for both items (η2 = .02).
Missing values in the current study were addressed via mean value substitu-
tion (Tabachnick & Fidell, 2001). Bivariate scatterplots were reviewed to
assess for violations of linearity and homoscedasticity, while skewness and
kurtosis values were evaluated for normality. Three study variables displayed
substantial negative skewness and were transformed using reflect and loga-
rithm to improve the distribution.

Symptoms
Means, ranges, and standard deviations for each of the study variables are
presented in Table 1. Total scores on the STSS (Bride et al., 2003) ranged
from 17 to 67 with a total score mean of 32.05 (SD = 9.99).
1484 Journal of Interpersonal Violence 29(8)

Table 1.  Descriptive Statistics (N = 320).

Scale Range M SD
STS 17-67 32.05 9.99
STS–Intrusion 5-18 8.90 2.75
STS–Avoidance 7-31 13.49 4.71
STS–Arousal 5-20 9.66 3.50
Relationship satisfaction 7-35 27.48 5.99
Social intimacy 24-85 71.51 10.02
Constructive communication −28-23 11.96 9.99
Avoidance communication 3-27 9.27 5.30
Demand-withdrawal communication 6-54 19.71 9.41
Interest in sexual activity 2-14 8.34 2.70
Sexual relationship satisfaction 3-21 14.29 5.05

Note. STS = secondary traumatic stress.

Correlations Among Demographic Variables and STS

Significant correlations between STS and the demographic variables of gen-
der, years in practice, and percentage of trauma clients on the therapists’ case-
loads were found. Gender showed a significant positive correlation to STS
(r = .135, p < .05), while years in practice showed a significant negative cor-
relation (r = −1.98, p < .01) to STS, and percentage of trauma clients showed
a significant positive correlation (r = .173, p < .01) to STS. Being female,
having fewer years of experience, and a greater number of trauma clients on
the therapists’ caseloads was each associated with higher levels of STS with
shared variance among these variables between 1.8% and 3.9%.

Correlations Among Symptoms

Hypothesis.  The hypothesis for this study was that mental health therapists
with more severe STS symptoms would also report more severe disruptions
in their interpersonal relationships. This hypothesis was partially supported.
Six out of the seven interpersonal functioning variables demonstrated a small
correlation with STS (see Table 2). Higher levels of STS were related to
lower levels of relationship satisfaction, social intimacy, constructive com-
munication patterns, and interest in sexual activity. Higher levels of STS
were also related to higher levels of avoidance communication and demand-
withdrawal communication. Shared variance among STS and interpersonal
functioning variables ranged from 1.2% to 9.4%. Only sexual relationship
satisfaction showed no relationship to STS.
 Table 2.  Pearson Zero-Order Correlations: STS and Interpersonal Functioning.

Scale 1 2 3 4 5 6 7 8 9 10 11
 1. STS — .848** .942** .919** .132* .173** .231** .212** .307** −.113* −.078
 2. STS–Intrusion — .694** .699** .001 .043 .087 .123* .180** −.109 −.008
 3. STS–Avoidance — .797** .180** .209** .263** .245** .312** −.123* −.086
 4. STS–Arousal — .133* .180** .236** .179** .316** −.070 −.100
 5. Relationship satisfactiona — .699** .569** .472** .417** −.112* −.392**
 6. Social intimacya — .650** .568** .479** −.172** −.328**
 7. Constructive communicationa — .654** .723** −.225** −.303**
 8. Avoidance communication — .635** −.117* −.304**
 9. Demand-withdrawal communication — −.155** −.247**
10.  Interest in sexual activity — .092**
11.  Sexual relationship satisfaction —

Note. STS = secondary traumatic stress.

aReflect log transformation.

*p < .05. **p < .01.

1485
1486 Journal of Interpersonal Violence 29(8)

Elevated levels of specific STS symptoms showed differential patterns

related to interpersonal functioning. Specifically, only higher levels of intru-
sion symptoms showed a significant relationship with increased levels of
avoidance communication and DWC patterns. A partial correlation was also
conducted to explore the relationship between STS and interpersonal func-
tioning, while controlling for the effects of gender, years in practice, and the
percentage of trauma clients on the therapists’ caseloads. Partial correlations
among these variables are presented in Table 3. In general, controlling for
gender, years in practice, and the percentage of trauma clients on the thera-
pists’ caseloads had very little effect on the strength of the relationships
between STS and the interpersonal functioning variables. Shared variance
among these variables ranged from 1.4% to 8.6%. Only interest in sexual
relationship satisfaction was no longer significant, indicating that the initial
relationship with STS was spurious.

Discussion
The current study hypothesized that mental health therapists with more
severe STS symptoms would also report more severe disruptions in their
interpersonal relationships. This study was designed to test the theoretical
assumption that disruptions within interpersonal relationships are part of the
expected trauma response for STS (Figley, 1995a, 1995b, 1995c, 2002). The
results of the current study partially support the hypothesis. While relation-
ship satisfaction, social intimacy, and communication pattern disruptions
were each related to STS symptoms, sexual intimacy and sexual relationship
satisfaction were not.
It is believed that STS symptoms that develop in therapists are often simi-
lar to those symptoms displayed by the victims they work with (Figley,
1995c). While interpersonal disruptions on the part of the clients were not
measured in the current study, it is quite common for disruptions to interper-
sonal functioning to be part of a general trauma response for victims. Research
on combat exposure has found that individuals with PTSD are at elevated risk
for relationship dissatisfaction (Cook, Riggs, Thompson, Coyne, & Sheikh,
2004; Dekel & Solomon, 2006), intimacy problems (Cook et al., 2004; Riggs,
Byrne, Weathers, & Litz, 1998; Roberts et al., 1982), and communication
difficulties with significant others (Carroll, Rueger, Foy, & Donahoe, 1985;
Cook et al., 2004). Victims of sexual and non-sexual trauma also report dis-
ruptions in relationship intimacy (Hall, 2007; Mills & Turnbull, 2004; Thelen,
Sherman, & Borst, 1998). The presence of high levels of interpersonal dis-
ruptions among the therapists in the current study who also reported intru-
sion, avoidance, and arousal symptoms are consistent with the theoretical
premise of STS.
 Table 3.  Pearson Third-Order Correlations Controlling for Gender, Years in Practice, and Percentage of Trauma Clients in
Caseload.

Scale 1 2 3 4 5 6 7 8 9 10 11
 1. STS — .839** .939** .917** .117* .179* .217** .209** .293** −.084 −.082
 2. STS–Intrusion — .677** .687** −.018 .047 .067 .120* −.161** −.067 −.012
 3. STS–Avoidance — .790** .168** .217** .252** .243** .298** −.101 −.091
 4. STS–Arousal — .120* .181** .226** .173** .304** −.051 −.102
 5. Relationship satisfactiona — .704** .567** .472** .413** −.100 −.394**
 6. Social intimacya — .663** .567** .487** −.202** −.326**
 7. Constructive communicationa — .660** .721** −.208** −.309**
 8. Avoidance communication — .638** −.139* −.302**
 9. Demand-withdrawal communication — −.142* −.251**
10. Interest in sexual activity — .115*
11. Sexual relationship satisfaction —

Note. STS = secondary traumatic stress.

aReflect log transformation.

*p <  .05 **p < .01.

1487
1488 Journal of Interpersonal Violence 29(8)

Interpersonal disruptions specific to sexual interest and sexual relation-

ship satisfaction, however, were not found to be associated with STS and thus
do not support the study hypothesis. These results may suggest that disrup-
tions to sexual activity interest and sexual relationship satisfaction are not
part of STS symptomology. However, these results are preliminary and
should be tempered with the acknowledgment that sexual functioning is
broader than the two constructs of sexual interest and sexual relationship
satisfaction measured in the current study (Meston & Derogatis, 2002). In
addition, the scales used to assess for these constructs contained a small num-
ber of total items, which can increase measurement error and the likelihood
of a Type II error.
Exposure level to trauma clients has also been studied as a relevant factor
in the development of STS and is directly rooted in the theoretical assump-
tions of both STS and vicarious trauma. The exposure to a client’s traumatic
material in session is viewed as the impetus for the therapist’s own trauma
symptom development. Figley (1995c) describes an interplay between expo-
sure to the client’s trauma and empathetic engagement with the client as the
mechanisms through which a therapist comes to experience emotions and
symptoms similar to his or her client. Alternatively, McCain and Pearlman
(1990) outline a process based on exposure to the memories of a trauma cli-
ent. The therapist subsequently internalizes these client memories resulting in
alterations to the therapist’s own memory system and challenging core cogni-
tive schemas. The threshold amount of exposure required for the develop-
ment of STS symptoms is less clear. However, several studies cite more
exposure to trauma clients as associated with higher levels of STS (Bober &
Regehr, 2006; Brady et al., 1999; Chrestman, 1995; Creamer & Liddle, 2005;
Deighton et al., 2007; Kassam-Adams, 1995; Schauben & Frazier, 1995).
Findings in the current study support this trend, wherein therapists who
reported a higher percentage of trauma clients on their caseloads within the
past month also reported higher levels of STS symptoms.
Participants in the current study reported STS symptoms with a mean
score of 32.05 (SD = 9.99). This average symptom level is not statistically
different from that reported in other studies, including Bride (2007; M =
29.69, SD = 10.74), t(601) = .268, p > 1.96, and Choi (2011b; M = 32.07, SD
= 10.39), t(473) = −.0019, p > 1.96. While participants in Bride (2007) and
Choi (2011b) were predominantly social workers, 56.6% and 72.1% of par-
ticipants were involved in direct mental health counseling. Comparatively, all
participants in the present study were mental health therapists currently
involved in clinical work with clients. Figley (1995b, 1995c) has identified a
wide range of helping professionals as susceptible to the development of
Robinson-Keilig 1489

STS. Mental health therapists are considered especially vulnerable due to the
empathic engagement they cultivate with their trauma clients.
Finally, previous research has reported mixed findings regarding the asso-
ciation of gender and years of counseling experience to STS symptoms. The
general trend in the literature has been that female gender and fewer years of
experience are each related to elevated levels of STS (Adams et al., 2001;
Arvay & Uhlemann, 1996; Choi, 2011a; Kadambi & Truscott, 2004; McLean
et al., 2003; Sprang et al., 2007; Way et al., 2004). The results of the current
study support this trend.

Limitations
The results of the current study need to be interpreted within the context of
several identified limitations. The operationalized definition of interpersonal
and sexual disruptions by the respective measures used for each construct
represents a potential limitation. Interpersonal functioning encompasses
more than the isolated aspects addressed in this study (i.e., relationship satis-
faction, social intimacy, and communication patterns). Likewise, sexual
functioning encompasses more than the isolated aspects of sexual interest
and sexual relationship satisfaction. There may be other areas of interper-
sonal functioning associated with STS, and this study did not assess those
aspects.
Another limitation of the study is the omission of possible moderating
variables such as self-care activities, general social support, and the personal
trauma histories of the therapists. While changes in self-care and the loss of
social support are both potential symptoms of STS, they may also serve as
protective practices and could potentially moderate the overall impact of
trauma client exposure (Choi, 2011a; Figley, 1995b; Sexton, 1999). A thera-
pist’s own personal trauma history is another possible moderating variable;
although, findings in the literature are currently mixed as to the overall impact
a therapist’s own trauma history has on STS symptom development (Adams,
Boscarino, & Figley, 2006; Adams & Riggs, 2008; Bober & Regehr, 2006;
Creamer & Liddle, 2005; Deighton et al., 2007; Follette et al., 1994; Kadambi
& Truscott, 2004; Kassam-Adams, 1995; Pearlman & MacIan, 1995).
The cross-sectional design of the study also presents as a limitation. The
theoretical premise of STS is that interpersonal disruptions occur as symp-
toms along side intrusion, avoidance, and arousal symptoms. This study was
unable to establish temporal sequencing to explore for the possibility of cur-
rent interpersonal disruptions sensitizing a therapist to subsequent develop-
ment of STS. Finally, the use of a non-random sample of mental health
therapists limited the external validity of the current study. Participants in the
1490 Journal of Interpersonal Violence 29(8)

current study were self-selected, which introduced the potential for selection
bias among the study participants.

Implications
The results of the current study are relevant to both understanding and
expanding current theories of STS and vicarious traumatization. Prior refer-
ences to interpersonal disruptions as symptoms of STS and vicarious trauma
were based on anecdotal claims and limited research. The current findings
begin an empirical foundation for future research as it relates to STS and
vicarious trauma theories and interpersonal disruptions as symptomology.
The results are also important given that seeking interpersonal support is
often cited as a key resource and coping strategy for managing the stress and
pressures of a therapy practice (Baker, 2003; Coster & Schwebel, 1997;
Rupert & Kent, 2007). When therapists struggle with STS and their interper-
sonal relationships suffer, they lose an important coping resource.
Finally, as researchers’ knowledge of the symptoms associated with STS
and vicarious trauma grows, this information can inform and improve educa-
tion and training practices for mental health therapists who work with trauma
clients. Knowledge regarding occurrence and associated symptoms can
impact how clinicians correctly identify and treat STS. The literature specu-
lates that STS is one reason why therapists leave the mental health field pre-
maturely (Bride, 2007). Given that fewer years of experience is related to
higher symptom levels, reaching out to early career therapists with targeted
training and education may be beneficial.

Suggestions for Future Research

DWC showed the strongest association with STS, accounting for 8.6% shared
variance after controlling for gender, years in practice, and percentage of
trauma clients in caseload. The DWC variable was the only variable in the
study that addressed relationship conflict or conflict behaviors (i.e., criticiz-
ing, demanding, and nagging one’s partner). All other interpersonal variables
were global assessments of satisfaction within a relationship or assessed the
presence/absence of positive behaviors. Future studies need to assess specifi-
cally for relationship conflict or conflict behaviors and their association with
STS.
Moreover, the current study measured intrusion, avoidance, and arousal-
related symptoms as part of STS, not cognitive schema disruptions. It is pos-
sible that interpersonal and sexual disruptions show a stronger association
with disruptions to cognitive schemas. McCann and Pearlman (1990, 1991)
Robinson-Keilig 1491

proposed that cognitive schema disruptions (in the areas of safety, trust,
esteem, control, and intimacy) are hallmark symptoms of vicarious trauma.
Future research also needs to address the temporal sequencing of symp-
toms and the inclusion of more moderating variables. For example, social
support may mitigate the development of STS or may be a factor that is
altered as a result of STS. Lastly, because STS is hypothesized to develop as
a cumulative result of repeated exposure to the traumatic material of clients
and the empathetic engagement with clients and this material, better overall
conceptualization and measurement of these constructs is needed to further
refine the theories behind this phenomenon.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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Author Biography
Rachael A. Robinson-Keilig is an assistant professor in the Department of Human
Relations and Women’s and Gender Studies Program for the University of Oklahoma–
Tulsa. She received her PhD in counseling psychology with a specialization in
Women’s and Gender Studies from the University of Nebraska–Lincoln. Her other
research interests include violence against women with a specific emphasis on repro-
ductive coercion and control within intimate partner violence, the assessment of
trauma and mental health outcomes, qualitative methodology, and the scholarship of
teaching and learning.