Psychological Trauma: Theory, Research, Practice, and Policy 2016, Vol. 8, No. 1, 80 – 87
© 2015 American Psychological Association 1942-9681/16/$12.00 http://dx.doi.org/10.1037/tra0000066
Predicting Professional Quality of Life Among Professional and Volunteer Caregivers Hila Avieli
Sarah Ben-David
Ariel University and Haifa University
Ariel University and Bar-Ilan University
Inna Levy This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Ariel University and Zefat Academic College This study is one of the few that has compared volunteers’ professional quality of life (PQL), which includes secondary traumatic stress (STS), burnout, and compassion satisfaction (CS), to those of professional caregivers. In addition, the research compared the ethical behavior of volunteers with that of professional therapists and examined the connection between years of experience, ethical behavior, and PQL. One hundred eighty-three volunteers and professional caregivers filled out a sociodemographic questionnaire, an Ethical Behavior Questionnaire and the Professional Quality of Life (ProQOL) questionnaire. The results indicated that professional caregivers report lower levels of STS and burnout, and higher levels of CS and ethical behavior compared with volunteer caregivers. Moreover, the findings suggest that ethical behavior correlates with STS, burnout, and CS. Ethical behavior has a protective value for mental health caregivers. The discussion emphasizes the value of a professional code of ethics and ethical training for professional and volunteering caregivers. Keywords: burnout, ethical behavior, secondary traumatic stress Supplemental materials: http://dx.doi.org/10.1037/tra0000066.supp
can Psychiatric Association, 2013), but differs from PTSD with regard to the source of the trauma. An individual suffering STS symptoms does not experience direct exposure to a traumatic event, but experiences it through caring for a trauma victim (Hope, 2006; Huggard, 2003). Another negative consequence of therapeutic work is burnout. Burnout is a syndrome that includes emotional exhaustion, depersonalization, and a feeling of low personal accomplishment (Jackson, Schwab, & Schuler, 1986). Contrary to STS, which is considered to result from caring for victims of critical life events (Figley, 1999, pp. 6 –11), the term burnout relates to minor daily stressors (Etzion, Eden, & Lapidot, 1998), workplace conditions and workload (Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011). Radey and Figley (2007) proposed that studies on the helping professions should examine positive feelings such as compassion satisfaction (CS) in addition to negative consequences such as STS and burnout. They claimed that compassion stress has potential for turning into positive energy and culminating in CS. CS refers to the sense of fulfillment and pleasure that caregivers derive from helping others (Stamm, 2005). Therefore, a growing number of recent studies (e.g., Sprang, Clark, & Whitt-Woosley, 2007; Van Hook & Rothenberg, 2009) have examined the wellbeing of mental health caregivers through the concept of PQL, which incorporates STS, burnout, and CS (Stamm, 2005).
Volunteers play an import role in the provision of health and welfare services (Field & Johnson, 1993). However, aiding people in need, especially trauma victims, results in emotional, physical, and spiritual costs (Figley, 1995; Shapiro, Brown, & Biegel, 2007) and may jeopardize the volunteers’ professional quality of life (PQL; Thomas, 2013). The main aim of the current study is to examine whether volunteers are more vulnerable than professional therapists to the effects of therapeutic encounters with trauma victims, and whether years of experience and ethical behavior may contribute to PQL among professional therapists and volunteers.
Professional Quality of Life (PQL) The past two decades of research on the helping professions are characterized by a growing awareness of the possible threats to caregivers’ PQL (Thomas & Otis, 2010). Initial studies focused on the negative aspects of working with trauma victims, such as secondary traumatic stress (STS) and burnout. The term STS refers to the same group of symptoms that are present in posttraumatic stress disorder (PTSD): intrusion, avoidance and arousal (AmeriThis article was published Online First June 29, 2015. Hila Avieli, Department of Criminology, Ariel University and School of Criminology, Haifa University; Sarah Ben-David, Department of Criminology, Ariel University and Department of Criminology, Bar-Ilan University; Inna Levy, Department of Criminology, Ariel University and Department of Multidisciplinary Studies, Zefat Academic College. Correspondence concerning this article should be addressed to Inna Levy, Department of Multidisciplinary Studies, Zefat Academic College, 11 Jerusalem Street, Zefat 13206, Israël. E-mail: [email protected]
The Effects of Helping Victims of Trauma and PQL Research on the effects of helping trauma victims mostly examined STS symptoms among therapists, and their findings clearly indicate a significant relationship between helping trauma victims 80
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and STS (Choi, 2011; Samios, Rodzik, & Abel, 2012; Thomas, 2013). Studies also show a positive correlation between burnout and CS (Eastwood & Ecklund, 2008), and that a sense of meaning from one’s job is an ameliorative factor against burnout (Savicki, 2002). However, professional therapists are not the only ones who assist trauma victims. Volunteers make a significant contribution in the field (Field & Johnson, 1993), and thus it is important to examine the influences of victim assistance on volunteers. Most studies that examined this issue indicate that volunteers helping disaster victims tend to experience negative psychological effects (Hagh-Shenas, Goodarzi, Dehbozorgi, & Farashbandi, 2005; Sim, 2011; see the review by Thormar et al., 2010). The literature review shows that only two of the few studies conducted on volunteers compared the intensity of volunteers’ stress symptoms to those of professional or trained helpers (such as firefighters, soldiers, nurses) and found that professional helpers suffered more than volunteers (Dean, Gow, & Shakespeare-Finch, 2003; Paton, 1994). The external validity of these findings, however, is limited. Dean, Gow, and Shakespeare-Finch (2003) stated that the slightly higher distress symptoms among professional firefighters were mainly attributable to the significant difference in years of experience between professional and volunteering firefighters. Paton’s (1994) results also showed that professionals report higher levels of distress. However, the data from volunteers were gathered immediately after a rescue operation and from the career firefighters a few months later. It is possible that low levels of stress among volunteers were attributable to the delay in the manifestations of trauma symptoms (Solomon, Mikulincer, Waysman, & Marlowe, 1991). All other studies reported higher emotional vulnerability among volunteers than among professionals. Volunteers experience higher levels of PTSD (Cetin et al., 2005; Hagh-Shenas et al., 2005), report higher emotional distress (Mitchell, Griffin, Stewart, & Loba, 2004), and are more prone than professionals to develop diseases and general health problems (Hagh-Shenas et al., 2005). In the mental health sector there are only a limited number of studies that address the reaction of volunteers to victims’ trauma. In a study conducted on volunteers in crisis call centers, Cyr and Dowrick (1991) found that the subjects experienced nightmares, intrusive thoughts, and negative emotions. Eberth (1989) found that the influence of victim assistance on volunteers was related to the volunteers’ prior victimization. Similarly, Hargrave, Scott, and McDowall (2006) found that volunteers’ STS levels were related to past trauma resolution. Volunteers who had resolved their past victimization were less affected by working with victims than those who had not. Baird and Jenkins (2003) compared volunteers and therapists who helped sexual assault and domestic violence victims, but found no significant differences in STS or burnout between these two groups. However, other studies (e.g., Glass & Hastings, 1992; Payne, 2002) found that volunteers tend to report higher levels of burnout and related symptoms compared to professionals (e.g., Glass & Hastings, 1992; Payne, 2002). Finally, although CS plays an important role in mitigating the negative effects of trauma work (Conrad & Kellar-Guenther, 2006), there are no studies on CS among volunteers, and research on volunteers’ general satisfaction is scarce (Wilson, 2012). Thus, it seems that our knowledge on STS, burnout, and CS among volunteers in the mental health sector is inadequate. In light of the existing research on STS and burnout among career and volunteering rescuers (Cetin et al., 2005; Hagh-Shenas et al., 2005; Kulik, 2006;
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Payne, 2002), the question arises whether volunteers in the mental health sector are also more vulnerable than professional therapists to the effects of caring for and helping trauma victims, and if so, what are the factors that differentiate between the two groups and contribute to the volunteers’ vulnerability.
Ethical Behavior One of the factors that may distinguish between professional and volunteer mental health caregivers, and possibly contribute to volunteer vulnerability, is ethical behavior. Previous studies on ethical behavior and PQL among therapists found a significant correlation between these variables (Everall & Paulson, 2007; Munroe, 1995; Williams & Sommer, 1995), but considered poor ethical behavior as an additional outcome of STS (Everall & Paulson, 2007). The current research hypothesizes that unethical behavior is not a result of STS, but rather a possible source of STS and burnout. This assumption is based on the nature of ethical codes in the mental health professions (Campbell, Vasquez, Behnke, & Kinscherff, 2010; Workers, 2008). The main source of ethical behavior is a professional ethical code (DiFranks, 2008; Pope & Vasquez, 2010). Ethical codes usually incorporate core professional values and the appropriate rules of conduct (Frankel, 1989). In the mental health professions, in addition to ensuring that therapists prioritize their patients’ best interest (Campbell et al., 2010; Everall & Paulson, 2007; Workers, 2008), ethical codes stress the importance of maintaining differentiation and boundaries between patients and their therapists (Campbell et al., 2010; Workers, 2008). The ability to establish emotional differentiation while remaining empathically engaged is an important feature in trauma therapy (Wilson & Lindy, 1994) and may serve as “professional armor” (Caplan, 1961) in therapeutic encounters with victims. Because ethical behavior ensures maintaining appropriate emotional boundaries between therapists and clients, it is possible that ethical behavior contributes to healthy PQL among caregivers who aid trauma victims. Because ethical codes usually address a specific profession (Becker, 1962; Freidson, 1994; Peterson, 1976) and volunteers are mostly nonprofessionals (Vitner, Shalom, & Yodfat, 2005), the notion of ethical behavior among volunteers seems somewhat questionable. Nevertheless, even though volunteers are not obligated to a specific professional group, this does not mean that they are exempt from respecting their clients, maintaining confidentiality and considering their clients’ best interest, and so forth. All these obligations are manifested in most of volunteering organizations’ codes of ethics (Delworth, Moore, Millick, & Leone, 1974; Nyhof-Young, Friedman, Jones, & Catton, 2003). Thus, people who volunteer in the mental health sector are required to uphold ethical standards. The literature on ethical behavior and ethical training among volunteers is scarce. Studies have mostly focused on volunteers’ business decision-making (Warburton & Terry, 2000), the ethics of volunteer organizations (Herman, 2011), and ethical behavior in specific situations, such as cross-cultural volunteering (Cho, Edge, & Keng, 2012). With regard to the ethical training among volunteers, research shows that training programs for volunteers are usually short and dedicated mostly to basic knowledge (Wilkinson & Wilkinson, 1986). Thus, it is not surprising that most training programs for volunteers do not include any kind of ethical behav-
AVIELI, BEN-DAVID, AND LEVY
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ior training (DeHart, 1999), and only 10% of the volunteers in a large organization undergo ethical training (Vitner, Shalom, & Yodfat, 2005). Despite the lack of sufficient ethical training for volunteers, there seems to be a consensus with regard to its importance. Thus, Pinto and Upshur (2009) argue that all organizations sending their volunteers on help and rescue missions across the globe should conduct ethical preparation. Cho et al. (2010) warn that without sufficient ethical awareness and relevant ethical skills volunteers can cause potential harm to patients and to the volunteers themselves. Insufficient ethical training among volunteers (DeHart, 1999; Vitner, Shalom, & Yodfat, 2005; Wilkinson & Wilkinson, 1986) may be related to differences in ethical behavior between professional and volunteering caregivers. Some studies show that volunteers feel less connected than professionals to the values of the organization they work for (e.g., Cnaan & Cascio, 1998). Because volunteers are not bound by professional codes, they are more autonomous in their ethical decisions than are professional caregivers (Payne, 2002). This autonomy causes volunteers to struggle with ethical boundaries more than professional caregivers do (Payne, 2002). It is possible that in the absence of clear ethical demands the volunteers may feel somewhat confused about the amount of closeness they should feel and express toward their patients, and about the amount of obligation and differentiation needed. It is important to clarify that the present research does not consider volunteers’ behavior as unethical. However, because volunteers lack the benefits of an official ethical code, we assume that they will report more instances of unethical behavior than professional therapists.
Work Experience In addition to addressing ethical behavior as a buffer against the influence of exposure to victim traumas, we also explored the influence of work experience. The literature review shows that years of experience affect the therapists’ understanding and interpretation of ethical codes. In an examination of therapists’ attitudes toward dual professional relationships, Borys and Pope (1989) found that more experienced therapists rated dual professional relationships as more ethical than did less experienced therapists. Haas, Malouf, and Mayerson (1988) examined therapists’ reactions in cases involving possible harm to a third party. They presented therapists with vignettes that addressed issues of confidentiality and of informed consent, loyalty conflicts, exploitation, and whistleblowing. For example, one of the vignettes described a client who tells his therapist that he is planning to kill his girlfriend. Results showed that the less experienced therapists were more likely to report the issue to the proper authorities. They explained their findings by the fact that the ethical duty to intervene was relatively new at the time of their research and therefore experienced therapists may have been less inclined to apply it (Haas, Malouf, & Mayerson, 1988). Similarly, Conte, Plutchik, Picard, and Karasu (1989) found that more experienced therapists tended to be more conservative regarding therapist–patient confidentiality when patients threatened violence. It seems that these studies were conducted at the time when the ethical codes were changed, and therefore experienced therapists’ attitudes were less in accordance with new ethical standards. These studies also examined therapists’ perceptions and responses with regard to
specific aspects of ethical behaviors: dual professional relationships and duty to intervene or report. The current study examines the frequency of ethical and unethical behaviors and addresses all major aspects of ethical codes in the mental health professions. In light of the differences between previous studies and our research, we have based our hypothesis on Kohlberg’s (1981) theory of moral development, which suggests that individuals may experience moral maturation over the course of their life cycle. Therefore we predict that more mature and experienced caregivers will behave more ethically. Studies conducted on work experience and emotional health are scant. Pearlman and MacIan (1995) reported that inexperienced therapists suffered the highest levels of personal distress. Regarding volunteers, some studies found that STS and experience are unrelated, because the most distressed individuals tend to quit volunteering and only the resilient volunteers remain over time (Hargrave, Scott, & McDowall, 2006; Hytten & Hasle, 1989). These findings require further examination because it is possible that more distressed professionals also quit earlier and a similar selection bias exists among professionals as well. In summary, it seems that there is a need for further research on the impact of work experience on caregivers’ ethical behavior and mental health.
Research Aims and Hypotheses The main aim of the present study was to explore differences in PQL between professional therapists and volunteer caregivers. Although researchers have examined PQL elements among professional therapists (Alkema et al., 2008; Baird & Jenkins, 2003) and volunteers (Claxton-Oldfield & Claxton-Oldfield, 2007), comparative studies on the differences between the two groups are scarce. Based on existing research on STS and burnout among volunteers (Cetin et al., 2005; Hagh-Shenas et al., 2005; Kulik, 2006; Payne, 2002) we hypothesized that volunteers are more vulnerable than are professional therapists in all three PQL elements. We also hypothesized that vulnerability to trauma work is related to caregivers’ ethical standards and years of experience. Ethical standards help mental health practitioners maintain appropriate emotional boundaries (Campbell et al., 2010; Workers, 2008) in therapeutic encounters with trauma victims, and thus serve as armor (Caplan, 1961) to protect therapist PQL. Unlike professional therapists, volunteers are not bound by a professional code ethics (Holm, 2002), and their ethical training is usually insufficient (Vitner, Shalom, & Yodfat, 2005). As a result, volunteers may struggle with ethical dilemmas more than professional therapists do, and thus volunteers may be more exposed to the adverse influences of trauma work. In addition, according to Kohlberg’s (1981) theory of moral development, the more experienced caregivers are expected to behave more ethically. In conclusion, we assume that ethical behavior may help mental health workers to reduce the harmful effects of treating trauma victims, whereas work experience may promote ethical behavior. Therefore, the hypothesized structural model (see Figure 1) presents years of experience as a predictor of ethical behavior, which in turn may serve as ‘professional armor’ for caregivers against increased STS and burnout. We also hypothesized the following:
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Figure 1. Theoretical model for predicting PQL by years of experience and ethical behavior.
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PQL. Professional quality of life was measured using the Hebrew version of Stamm’s (2005) ProQOL questionnaire. The questionnaire was back-translated (Brislin, 1970), and the final version included 30 items related to three subscales: STS, burnout, and CS. Psychometric properties for the three subscales were shown to be reliable in the past (Connally, 2012) and proved reliable in the present study, with reliability coefficients of .97 for STS and CS scales and .94 for burnout.
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Procedure 1. A difference exists between professional therapists and volunteers. Specifically: a. Compared with professionals, volunteers will express higher levels of STS and burnout and lower levels of CS. b. Compared with professionals, volunteers will report lower levels of ethical behavior. 2. STS, burnout, CS, and ethical behavior vary with job experience: those with less experience will report lower levels of STS and burnout and higher levels of CS.
Method Participants The current research included 183 mental health caregivers working in Israel, of whom 43% are professional therapists and 57% volunteers. Most caregivers in the sample are female (78%) and highly educated: 49% have an undergraduate degree (BA), and 41% have a postgraduate degree. The therapist group consisted of criminologists, psychologists and social workers and the volunteer group consisted of students, clerks, photographers, and others.
Measures Demographic questionnaire. This questionnaire gathered information about gender, education, job description, years of experience, and the existence of therapeutic encounters with victims of traumatic experience. Ethical behavior questionnaire. This questionnaire was originally devised by Pope, Tabachnick, and Keith-Spiegel (1987) and was translated into Hebrew using the double translation method (Brislin, 1970) for the purpose of the current research. The items presented situations that are considered unethical according to the APA code of ethics (“accepting gifts from patients” or “discussing patients’ personal lives with friends”). We adjusted the questionnaire by omitting questions irrelevant to the Israeli culture (“addressing client by his first name”) and questions that were not suitable to the specific research population (“making custody evaluation without seeing the child”). The final questionnaire included 54 of the original 83 behaviors. Participants were asked to rate each behavior in terms of two categories: (a) the extent to which they had engaged in the behavior in their practice, and (b) the extent to which they consider the practice ethical. The answers we given on 5-level Likert scale, where 1 means very often for the first category and ethical for the second, and 5 meant rarely and unethical accordingly. Because factor analysis showed that both scales belong to the same factor, we combined them by adding the two scores together. The final reliability coefficient was ␣ ⫽ .98
We recruited volunteer caregivers for the study through several victim assistance organizations, and participants filled in the questionnaires during their weekly meetings. It took approximately half an hour to fill in the questionnaires. Professional therapists were approached individually through personal connections (snowball sampling). The study was approved by the ethical committee. Participants signed an informed consent form, were assured of anonymity, and were told that they may refuse to participate in this study or drop out at any stage. A total of 210 questionnaires were collected, but 27 of these (13%) were disqualified for being incomplete. We analyzed the data through various statistical programs: SPSS 20, AMOS20, and Modprobe. To assess the model fit, we used the indices proposed by Hu and Bentler (1999).
Results Caregiver Type To examine our hypotheses that ethical behavior and PQL varies according to the caregiver type (professional/volunteer), we conducted a series of independent samples t tests. The results demonstrate a significant difference between professional practitioners and volunteers in ethical behavior, t(181) ⫽ ⫺6.65, p ⬍ .01, d ⫽ .99, and in all three components of PQL: STS, t(160.5) ⫽ 5.31, p ⬍ .001, d ⫽ .79, burnout, t(161.8) ⫽ 5.73, p ⬍ .001, d ⫽ .87, and CS, t(154.4) ⫽ ⫺6.09, p ⬍ .001, d ⫽ .92. Professional therapists are characterized by higher ethical standards (M ⫽ 7.42, SD ⫽ 2.09) than volunteers (M ⫽ 5.35, SD ⫽ 2.08). With regard to PQL, volunteers’ levels of STS (M ⫽ 3.36, SD ⫽ 1.21) and burnout (M ⫽ 3.41, SD ⫽ 1.04) were higher than professional practitioners’ levels of STS (M ⫽ 2.46, SD ⫽ 1.05) and burnout (M ⫽ 2.54, SD ⫽ 0.97); and volunteers’ levels of CS (M ⫽ 2.36, SD ⫽ 1.07) were lower than those of professional practitioners (M ⫽ 3.3, SD ⫽ 0.98).
Years of Experience To examine the relationship between years of experience, ethical behavior, and the elements of PQL (STS, burnout and CS) among mental health caregivers, the participants were divided into three equal groups according to the to the values of 33.33rd and 66.66th percentiles. A few months to one year of working in the field was defined as ‘short experience’; one to five years was defined as ‘moderate experience’; and more than five years was defined as ‘long experience.’ The results of one-way ANOVA expose a significant effect of length of experience on ethical behavior, F(2, 180) ⫽ 11.95, p ⬍ .01, p2 ⫽ .12: caregivers with long experience reported higher ethical standards (M ⫽ 7.55,
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SD ⫽ 1.99) than caregivers with moderate (M ⫽ 6.45, SD ⫽ 2.33) and short experience (M ⫽ 5.62, SD ⫽ 2.23). Post hoc comparisons using the Scheffé test show no significant differences between practitioners with short and moderate experience. The results also show that years of experience have a significant effect on STS, F(2, 180) ⫽ 11.84, p ⬍ .01, p2 ⫽ .12) and on burnout, F(2, 180) ⫽ 9.92, p ⬍ .01, p2 ⫽ .10. Practitioners with the long experience reported lower levels of STS (M ⫽ 2.31, SD ⫽ 0.99) and burnout (M ⫽ 2.47, SD ⫽ 0.91) than practitioners with the moderate (M ⫽ 2.91, SD ⫽ 1.19 for STS; M ⫽ 2.94, SD ⫽ 1.11 for burnout) and the short experience (M ⫽ 3.3, SD ⫽ 1.21 for STS; M ⫽ 3.31, SD ⫽ 1.09 for burnout). And finally, the result indicate that years of experience significantly affects CS, F(2, 180) ⫽ 14.2, p ⬍ .01, p2 ⫽ .14: practitioners with long experience had higher levels of CS (M ⫽ 3.43, SD ⫽ 0.93) than those with moderate (M ⫽ 2.86, SD ⫽ 1.11) and short experience (M ⫽ 2.42, SD ⫽ 1.11). Post hoc comparisons using the Scheffé test show no significant differences between practitioners with the shortest and those with moderate experience in all three element of PQL.
Years of Experience, Ethical Behavior, and PQL Elements—SEM Structural equation modeling analysis (SEM) was used to test whether the hypothesized model presented in Figure 1 was concordant with the collected data. The variables’ means, standard deviations, and correlations are presented in Table 1 (Supplement materials), and it appears that the correlations among variables are consistent with the expectations. Given the differences in training and education between the volunteer and professional practitioners, we applied multigroup structural equation modeling to compare the two groups. The unconstrained model appeared to fit the data well, 2(6) ⫽ 8.04, p ⫽ .24, 2/df ⫽ 1.34, NFI ⫽ 0.99, CFI ⫽ 0.997, RMSEA ⫽ 0.043. As predicted for both groups, the model presented a strong negative correlation between ethical behavior and STS and burnout, and a strong positive correlation between ethical behavior and CS. Additionally, the model (Figure 1S, supplement materials) presented strong correlations in both groups between STS, burnout and CS, whereby the correlation between STS and burnout was positive and the correlation between CS and STS and burnout was negative. Indeed, the difference between volunteers and professionals was indicated in the relationship between years of experience and ethical behavior. For both groups the model predicted a weak correlation between years of experience and ethical behavior; however, this correlation proved positive in the sample of professional caregivers and negative in the volunteers’ sample. To explore this difference, we imposed a cross-group equality restriction upon standardized regression coefficients. The overall fit was good, 2(10) ⫽ 11.68, p ⫽ .31, 2/df ⫽ 1.17, NFI ⫽ .98, CFI ⫽ 0.998, RMSEA ⫽ .03, suggesting that the relationship between years of experience and ethical behavior is similar across the two groups. In addition, we used the SPSS feature MODPROBE to examine whether the grouping variable (volunteers/professionals) may be moderating the influence of years of experience on ethical behavior. The analysis results reveal no significant interaction ( ⫽ 0.15, t ⫽ 1.46, p ⫽ .15). Thus the model that appears to fit the data most (see Figure 2) is that which refers to all the participants— both volunteers and professionals, 2(3) ⫽ 2.52, p ⫽ .47,
Figure 2. behavior.
SEM for prediction of PQL by years of experience and ethical
2/df ⫽ .838, NFI ⫽ 0.997, CFI ⫽ 1.00, RMSEA ⫽ 0.00. This model presents a statistically significant positive relationship between years of experience and ethical behavior. All other variables correlate similarly to the previous models.
Discussion The main aim of this study was to study the factors influencing the PQL of trauma therapists, including elements such as STS, burnout, and CS. Based on the literature reviewed, we constructed a model that included factors related to therapist professionalism, such as ethical behavior and work experience, as variables that contribute to the prediction of STS, burnout and CS levels among professional therapists and volunteers. We examined the model via SEM. Similar to the results of Ray, Wong, White, and Heaslip (2013), we found a link between STS, burnout, and CS. Furthermore, our findings indicate that therapists’ ethical behavior may predict their levels of PQL. Among both volunteer caregivers and professional therapists, ethical behavior correlated negatively with STS and burnout and positively with CS. This finding confirms theoretical claims (Everall & Paulson, 2007; Munroe, 1995) regarding the association between ethical issues, STS, and burnout, though it presents this connection from a different perspective. Rather than regarding unethical behavior as resulting from STS and burnout (as per Everall & Paulson, 2007), the current model presents ethical behavior as predicative of therapists’ PQL. The negative correlation between STS, burnout, and ethical behavior implies that ethical behavior may mitigate the effects of encounters with trauma victims among caregivers. Although the primary aim of ethical codes is to protect patients from therapists’ amoral or harmful behavior (Workers, 2008; Campbell et al., 2010), our findings imply that ethical codes provide protective value for therapists as well. The results of this study suggest that when professional and volunteering caregivers maintain ethical behavior, they may prevent or minimize the risk of enmeshment with their clients, thus contributing to the prevention of STS and burnout and preserving healthy levels of CS. These findings echo Lahad’s (2000) claim that ‘differentiation rituals’ may help the therapist to avoid STS by preserving emotional differentiation. Furthermore, our model demonstrates that years of experience predicts ethical behavior and that these variables correlate positively. Apparently, with years of experience therapists develop higher ethical behavior standards. In addition to the SEM model, we examined the differences according to the duration of professional years of experience (short/moderate/long). This comparison revealed that senior therapists were characterized as having higher levels of the ethical behavior, higher levels of CS, and lower levels of STS and burnout than less experienced therapists. Although these findings contradict some of the literature on the topic (Borys & Pope, 1989; Haas et al., 1988), they correspond to the findings of Conte et al. (1989) and to
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Kohlberg’s (1981) theory of moral development. The difference between our findings and those in previous studies may result from variations in the respective definitions of the ethical behavior. Whereas the previous studies focused on specific ethical issues, the current research examined ethical standards regarding the broad spectrum of behaviors that may occur in the therapeutic relationship. Moreover, this research investigated the much-neglected comparison between volunteer caregivers and professional therapists. We compared their respective levels of ethical behavior, years of experience, and PQL. Regarding ethical behavior, we found that volunteers reported lower standards than did professional therapists. This finding is in line with Payne’s (2002) claim that volunteers tend to feel less obligated than professional therapists to a specific ethical code. Because volunteers are not obliged to abide by a specific ethical code (Berry & Planalp, 2009), and their training programs usually do not elaborate on ethical issues (Pope, 2003; Sewpaul & Jones, 2004), it is quite understandable that volunteers scored lower on the ethical behavior scale than did professional therapists. Another important difference between professional therapists and volunteers involves vulnerability to vicarious exposure to a trauma. In this regard volunteers reported higher levels of STS and burnout and lower levels of CS than professional therapists. These results contradict the claim by Hargrave and colleagues (2006) that STS risk factors do not apply to volunteers. However, their study did not compare between professional therapists and volunteers. Our results suggest that volunteering with trauma victims can take a severe emotional toll on caregivers and lead to relatively high levels of STS and burnout. Potentially, higher vulnerability among volunteers may relate to their lower level of ethical behavior, as we have demonstrated. As discussed earlier, ethical behavior appears to minimize the risk of developing STS, burnout and the loss of CS. While contributing both theoretically and empirically to the literature regarding PQL among professional therapists and volunteer caregivers, the present study has a few limitations. One of the study limitations is the self-report nature of our data. Because the ethical behavior is self-reported, it may be influenced by social desirability. With regard to the sample size, the limited number of participants in this study represents the difficulty in recruiting mental health volunteers and professionals who work with trauma victims. The final sample size is in accordance with Kline’s (2005, pp. 111, 178) suggestion that the minimum sample size should be no less than 5 to 20 times the number of parameters to be estimated. Yet, future research should replicate SEM results with a larger sample to determine whether additional models might also be helpful. The problem of recruiting these specific types of mental health caregivers also made it impossible to use random sampling. Snowball sampling does not allow a true representation of professionals, thus limiting the external validity of our findings. We therefore propose that future studies on this subject should apply random sampling and consider different research designs that include prepost comparisons, vignettes, or actual therapist–victim interaction to further explore the influence of experience and ethical awareness on negative outcomes for therapists. In conclusion, this study presents a unique perspective on the connection between ethical behavior and PQL, focusing on volunteers and their special characteristics. The study’s contribution is both theoretical and practical. It contributes to the body of literature on ethics in therapy by introducing ethical behavior as the factor that may
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reduce the risk of developing STS and burnout. This new point of view on ethical behavior incorporates in itself possible practical implications with regard to professional therapists’ and volunteers’ quality of life and the prevention of STS and burnout. It emphasizes not only the value of ethical codes and expansion of ethical training for volunteers, but also the importance of ethical behavior among mental health caregivers in general. Thus, implementing ethical guidelines as an integral component of training and guidance could benefit both volunteers and professionals.
References Alkema, K., Linton, J. M., & Davies, R. (2008). A study of the relationship between self-care, compassion satisfaction, compassion fatigue, and burnout among hospice professionals. Journal of Social Work in Endof-Life & Palliative Care, 4, 101–119. http://dx.doi.org/10.1080/ 15524250802353934 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Baird, S., & Jenkins, S. R. (2003). Vicarious traumatization, secondary traumatic stress, and burnout in sexual assault and domestic violence agency staff. Violence and Victims, 18, 71– 86. http://dx.doi.org/ 10.1891/vivi.2003.18.1.71 Becker, H. S. (1962). The nature of a profession. In national society for the study of education (Ed.), Education for the professions (pp. 27– 46). Chicago, IL: University of Chicago Press. Berry, P., & Planalp, S. (2009). Ethical issues for hospice volunteers. American Journal of Hospice and Palliative Medicine, 25, 458 – 462. http://dx.doi.org/10.1177/1049909108322291 Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, 20, 283–293. http://dx.doi.org/10.1037/0735-7028.20.5.283 Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural Psychology, 1, 185–216. http://dx.doi.org/10.1177/ 135910457000100301 Campbell, L., Vasquez, M., Behnke, S., & Kinscherff, R. (2010). APA ethics code commentary and case illustrations. Washington, DC: American Psychological Association. Caplan, G. (1961). An approach to community mental health. New York, NY: Grune & Stratton. Cetin, M., Kose, S., Ebrinc, S., Yigit, S., Elhai, J. D., & Basoglu, C. (2005). Identification and posttraumatic stress disorder symptoms in rescue workers in the Marmara, Turkey, earthquake. Journal of Traumatic Stress, 18, 485– 489. http://dx.doi.org/10.1002/jts.20056 Cho, R., Edge, J., & Keng, A. (2010). Crossing borders and pushing boundaries: The ethics of international volunteering. The Meducator, 1, 19 –21. Cho, R., Edge, J., & Keng, A. (2012). Crossing borders and pushing boundaries: The ethics of international volunteering. The Meducator, 1, 10. Retrieved from http://digitalcommons.mcmaster.ca/cgi/viewcontent .cgi?article⫽1205&context⫽meducator Choi, G. Y. (2011). Secondary traumatic stress of service providers who practice with survivors of family or sexual violence: A national survey of social workers. Smith College Studies in Social Work, 81, 101–119. http://dx.doi.org/10.1080/00377317.2011.543044 Claxton-Oldfield, S., & Claxton-Oldfield, J. (2007). The impact of volunteering in hospice palliative care. American Journal of & and Palliative Medicine, 24, 259 –263. http://dx.doi.org/10.1177/1049909106298398 Cnaan, R. A., & Cascio, T. A. (1998). Performance and commitment: Issues in management of volunteers in human service organizations. Journal of Social Service Research, 24(3– 4), 1–37. http://dx.doi.org/10 .1300/J079v24n03_01
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Received September 26, 2014 Revision received April 24, 2015 Accepted April 29, 2015 䡲
© 2015 American Psychological Association 1942-9681/16/$12.00 http://dx.doi.org/10.1037/tra0000066
Predicting Professional Quality of Life Among Professional and Volunteer Caregivers Hila Avieli
Sarah Ben-David
Ariel University and Haifa University
Ariel University and Bar-Ilan University
Inna Levy This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Ariel University and Zefat Academic College This study is one of the few that has compared volunteers’ professional quality of life (PQL), which includes secondary traumatic stress (STS), burnout, and compassion satisfaction (CS), to those of professional caregivers. In addition, the research compared the ethical behavior of volunteers with that of professional therapists and examined the connection between years of experience, ethical behavior, and PQL. One hundred eighty-three volunteers and professional caregivers filled out a sociodemographic questionnaire, an Ethical Behavior Questionnaire and the Professional Quality of Life (ProQOL) questionnaire. The results indicated that professional caregivers report lower levels of STS and burnout, and higher levels of CS and ethical behavior compared with volunteer caregivers. Moreover, the findings suggest that ethical behavior correlates with STS, burnout, and CS. Ethical behavior has a protective value for mental health caregivers. The discussion emphasizes the value of a professional code of ethics and ethical training for professional and volunteering caregivers. Keywords: burnout, ethical behavior, secondary traumatic stress Supplemental materials: http://dx.doi.org/10.1037/tra0000066.supp
can Psychiatric Association, 2013), but differs from PTSD with regard to the source of the trauma. An individual suffering STS symptoms does not experience direct exposure to a traumatic event, but experiences it through caring for a trauma victim (Hope, 2006; Huggard, 2003). Another negative consequence of therapeutic work is burnout. Burnout is a syndrome that includes emotional exhaustion, depersonalization, and a feeling of low personal accomplishment (Jackson, Schwab, & Schuler, 1986). Contrary to STS, which is considered to result from caring for victims of critical life events (Figley, 1999, pp. 6 –11), the term burnout relates to minor daily stressors (Etzion, Eden, & Lapidot, 1998), workplace conditions and workload (Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011). Radey and Figley (2007) proposed that studies on the helping professions should examine positive feelings such as compassion satisfaction (CS) in addition to negative consequences such as STS and burnout. They claimed that compassion stress has potential for turning into positive energy and culminating in CS. CS refers to the sense of fulfillment and pleasure that caregivers derive from helping others (Stamm, 2005). Therefore, a growing number of recent studies (e.g., Sprang, Clark, & Whitt-Woosley, 2007; Van Hook & Rothenberg, 2009) have examined the wellbeing of mental health caregivers through the concept of PQL, which incorporates STS, burnout, and CS (Stamm, 2005).
Volunteers play an import role in the provision of health and welfare services (Field & Johnson, 1993). However, aiding people in need, especially trauma victims, results in emotional, physical, and spiritual costs (Figley, 1995; Shapiro, Brown, & Biegel, 2007) and may jeopardize the volunteers’ professional quality of life (PQL; Thomas, 2013). The main aim of the current study is to examine whether volunteers are more vulnerable than professional therapists to the effects of therapeutic encounters with trauma victims, and whether years of experience and ethical behavior may contribute to PQL among professional therapists and volunteers.
Professional Quality of Life (PQL) The past two decades of research on the helping professions are characterized by a growing awareness of the possible threats to caregivers’ PQL (Thomas & Otis, 2010). Initial studies focused on the negative aspects of working with trauma victims, such as secondary traumatic stress (STS) and burnout. The term STS refers to the same group of symptoms that are present in posttraumatic stress disorder (PTSD): intrusion, avoidance and arousal (AmeriThis article was published Online First June 29, 2015. Hila Avieli, Department of Criminology, Ariel University and School of Criminology, Haifa University; Sarah Ben-David, Department of Criminology, Ariel University and Department of Criminology, Bar-Ilan University; Inna Levy, Department of Criminology, Ariel University and Department of Multidisciplinary Studies, Zefat Academic College. Correspondence concerning this article should be addressed to Inna Levy, Department of Multidisciplinary Studies, Zefat Academic College, 11 Jerusalem Street, Zefat 13206, Israël. E-mail: [email protected]
The Effects of Helping Victims of Trauma and PQL Research on the effects of helping trauma victims mostly examined STS symptoms among therapists, and their findings clearly indicate a significant relationship between helping trauma victims 80
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PREDICTING PROFESSIONAL QUALITY OF LIFE
and STS (Choi, 2011; Samios, Rodzik, & Abel, 2012; Thomas, 2013). Studies also show a positive correlation between burnout and CS (Eastwood & Ecklund, 2008), and that a sense of meaning from one’s job is an ameliorative factor against burnout (Savicki, 2002). However, professional therapists are not the only ones who assist trauma victims. Volunteers make a significant contribution in the field (Field & Johnson, 1993), and thus it is important to examine the influences of victim assistance on volunteers. Most studies that examined this issue indicate that volunteers helping disaster victims tend to experience negative psychological effects (Hagh-Shenas, Goodarzi, Dehbozorgi, & Farashbandi, 2005; Sim, 2011; see the review by Thormar et al., 2010). The literature review shows that only two of the few studies conducted on volunteers compared the intensity of volunteers’ stress symptoms to those of professional or trained helpers (such as firefighters, soldiers, nurses) and found that professional helpers suffered more than volunteers (Dean, Gow, & Shakespeare-Finch, 2003; Paton, 1994). The external validity of these findings, however, is limited. Dean, Gow, and Shakespeare-Finch (2003) stated that the slightly higher distress symptoms among professional firefighters were mainly attributable to the significant difference in years of experience between professional and volunteering firefighters. Paton’s (1994) results also showed that professionals report higher levels of distress. However, the data from volunteers were gathered immediately after a rescue operation and from the career firefighters a few months later. It is possible that low levels of stress among volunteers were attributable to the delay in the manifestations of trauma symptoms (Solomon, Mikulincer, Waysman, & Marlowe, 1991). All other studies reported higher emotional vulnerability among volunteers than among professionals. Volunteers experience higher levels of PTSD (Cetin et al., 2005; Hagh-Shenas et al., 2005), report higher emotional distress (Mitchell, Griffin, Stewart, & Loba, 2004), and are more prone than professionals to develop diseases and general health problems (Hagh-Shenas et al., 2005). In the mental health sector there are only a limited number of studies that address the reaction of volunteers to victims’ trauma. In a study conducted on volunteers in crisis call centers, Cyr and Dowrick (1991) found that the subjects experienced nightmares, intrusive thoughts, and negative emotions. Eberth (1989) found that the influence of victim assistance on volunteers was related to the volunteers’ prior victimization. Similarly, Hargrave, Scott, and McDowall (2006) found that volunteers’ STS levels were related to past trauma resolution. Volunteers who had resolved their past victimization were less affected by working with victims than those who had not. Baird and Jenkins (2003) compared volunteers and therapists who helped sexual assault and domestic violence victims, but found no significant differences in STS or burnout between these two groups. However, other studies (e.g., Glass & Hastings, 1992; Payne, 2002) found that volunteers tend to report higher levels of burnout and related symptoms compared to professionals (e.g., Glass & Hastings, 1992; Payne, 2002). Finally, although CS plays an important role in mitigating the negative effects of trauma work (Conrad & Kellar-Guenther, 2006), there are no studies on CS among volunteers, and research on volunteers’ general satisfaction is scarce (Wilson, 2012). Thus, it seems that our knowledge on STS, burnout, and CS among volunteers in the mental health sector is inadequate. In light of the existing research on STS and burnout among career and volunteering rescuers (Cetin et al., 2005; Hagh-Shenas et al., 2005; Kulik, 2006;
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Payne, 2002), the question arises whether volunteers in the mental health sector are also more vulnerable than professional therapists to the effects of caring for and helping trauma victims, and if so, what are the factors that differentiate between the two groups and contribute to the volunteers’ vulnerability.
Ethical Behavior One of the factors that may distinguish between professional and volunteer mental health caregivers, and possibly contribute to volunteer vulnerability, is ethical behavior. Previous studies on ethical behavior and PQL among therapists found a significant correlation between these variables (Everall & Paulson, 2007; Munroe, 1995; Williams & Sommer, 1995), but considered poor ethical behavior as an additional outcome of STS (Everall & Paulson, 2007). The current research hypothesizes that unethical behavior is not a result of STS, but rather a possible source of STS and burnout. This assumption is based on the nature of ethical codes in the mental health professions (Campbell, Vasquez, Behnke, & Kinscherff, 2010; Workers, 2008). The main source of ethical behavior is a professional ethical code (DiFranks, 2008; Pope & Vasquez, 2010). Ethical codes usually incorporate core professional values and the appropriate rules of conduct (Frankel, 1989). In the mental health professions, in addition to ensuring that therapists prioritize their patients’ best interest (Campbell et al., 2010; Everall & Paulson, 2007; Workers, 2008), ethical codes stress the importance of maintaining differentiation and boundaries between patients and their therapists (Campbell et al., 2010; Workers, 2008). The ability to establish emotional differentiation while remaining empathically engaged is an important feature in trauma therapy (Wilson & Lindy, 1994) and may serve as “professional armor” (Caplan, 1961) in therapeutic encounters with victims. Because ethical behavior ensures maintaining appropriate emotional boundaries between therapists and clients, it is possible that ethical behavior contributes to healthy PQL among caregivers who aid trauma victims. Because ethical codes usually address a specific profession (Becker, 1962; Freidson, 1994; Peterson, 1976) and volunteers are mostly nonprofessionals (Vitner, Shalom, & Yodfat, 2005), the notion of ethical behavior among volunteers seems somewhat questionable. Nevertheless, even though volunteers are not obligated to a specific professional group, this does not mean that they are exempt from respecting their clients, maintaining confidentiality and considering their clients’ best interest, and so forth. All these obligations are manifested in most of volunteering organizations’ codes of ethics (Delworth, Moore, Millick, & Leone, 1974; Nyhof-Young, Friedman, Jones, & Catton, 2003). Thus, people who volunteer in the mental health sector are required to uphold ethical standards. The literature on ethical behavior and ethical training among volunteers is scarce. Studies have mostly focused on volunteers’ business decision-making (Warburton & Terry, 2000), the ethics of volunteer organizations (Herman, 2011), and ethical behavior in specific situations, such as cross-cultural volunteering (Cho, Edge, & Keng, 2012). With regard to the ethical training among volunteers, research shows that training programs for volunteers are usually short and dedicated mostly to basic knowledge (Wilkinson & Wilkinson, 1986). Thus, it is not surprising that most training programs for volunteers do not include any kind of ethical behav-
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ior training (DeHart, 1999), and only 10% of the volunteers in a large organization undergo ethical training (Vitner, Shalom, & Yodfat, 2005). Despite the lack of sufficient ethical training for volunteers, there seems to be a consensus with regard to its importance. Thus, Pinto and Upshur (2009) argue that all organizations sending their volunteers on help and rescue missions across the globe should conduct ethical preparation. Cho et al. (2010) warn that without sufficient ethical awareness and relevant ethical skills volunteers can cause potential harm to patients and to the volunteers themselves. Insufficient ethical training among volunteers (DeHart, 1999; Vitner, Shalom, & Yodfat, 2005; Wilkinson & Wilkinson, 1986) may be related to differences in ethical behavior between professional and volunteering caregivers. Some studies show that volunteers feel less connected than professionals to the values of the organization they work for (e.g., Cnaan & Cascio, 1998). Because volunteers are not bound by professional codes, they are more autonomous in their ethical decisions than are professional caregivers (Payne, 2002). This autonomy causes volunteers to struggle with ethical boundaries more than professional caregivers do (Payne, 2002). It is possible that in the absence of clear ethical demands the volunteers may feel somewhat confused about the amount of closeness they should feel and express toward their patients, and about the amount of obligation and differentiation needed. It is important to clarify that the present research does not consider volunteers’ behavior as unethical. However, because volunteers lack the benefits of an official ethical code, we assume that they will report more instances of unethical behavior than professional therapists.
Work Experience In addition to addressing ethical behavior as a buffer against the influence of exposure to victim traumas, we also explored the influence of work experience. The literature review shows that years of experience affect the therapists’ understanding and interpretation of ethical codes. In an examination of therapists’ attitudes toward dual professional relationships, Borys and Pope (1989) found that more experienced therapists rated dual professional relationships as more ethical than did less experienced therapists. Haas, Malouf, and Mayerson (1988) examined therapists’ reactions in cases involving possible harm to a third party. They presented therapists with vignettes that addressed issues of confidentiality and of informed consent, loyalty conflicts, exploitation, and whistleblowing. For example, one of the vignettes described a client who tells his therapist that he is planning to kill his girlfriend. Results showed that the less experienced therapists were more likely to report the issue to the proper authorities. They explained their findings by the fact that the ethical duty to intervene was relatively new at the time of their research and therefore experienced therapists may have been less inclined to apply it (Haas, Malouf, & Mayerson, 1988). Similarly, Conte, Plutchik, Picard, and Karasu (1989) found that more experienced therapists tended to be more conservative regarding therapist–patient confidentiality when patients threatened violence. It seems that these studies were conducted at the time when the ethical codes were changed, and therefore experienced therapists’ attitudes were less in accordance with new ethical standards. These studies also examined therapists’ perceptions and responses with regard to
specific aspects of ethical behaviors: dual professional relationships and duty to intervene or report. The current study examines the frequency of ethical and unethical behaviors and addresses all major aspects of ethical codes in the mental health professions. In light of the differences between previous studies and our research, we have based our hypothesis on Kohlberg’s (1981) theory of moral development, which suggests that individuals may experience moral maturation over the course of their life cycle. Therefore we predict that more mature and experienced caregivers will behave more ethically. Studies conducted on work experience and emotional health are scant. Pearlman and MacIan (1995) reported that inexperienced therapists suffered the highest levels of personal distress. Regarding volunteers, some studies found that STS and experience are unrelated, because the most distressed individuals tend to quit volunteering and only the resilient volunteers remain over time (Hargrave, Scott, & McDowall, 2006; Hytten & Hasle, 1989). These findings require further examination because it is possible that more distressed professionals also quit earlier and a similar selection bias exists among professionals as well. In summary, it seems that there is a need for further research on the impact of work experience on caregivers’ ethical behavior and mental health.
Research Aims and Hypotheses The main aim of the present study was to explore differences in PQL between professional therapists and volunteer caregivers. Although researchers have examined PQL elements among professional therapists (Alkema et al., 2008; Baird & Jenkins, 2003) and volunteers (Claxton-Oldfield & Claxton-Oldfield, 2007), comparative studies on the differences between the two groups are scarce. Based on existing research on STS and burnout among volunteers (Cetin et al., 2005; Hagh-Shenas et al., 2005; Kulik, 2006; Payne, 2002) we hypothesized that volunteers are more vulnerable than are professional therapists in all three PQL elements. We also hypothesized that vulnerability to trauma work is related to caregivers’ ethical standards and years of experience. Ethical standards help mental health practitioners maintain appropriate emotional boundaries (Campbell et al., 2010; Workers, 2008) in therapeutic encounters with trauma victims, and thus serve as armor (Caplan, 1961) to protect therapist PQL. Unlike professional therapists, volunteers are not bound by a professional code ethics (Holm, 2002), and their ethical training is usually insufficient (Vitner, Shalom, & Yodfat, 2005). As a result, volunteers may struggle with ethical dilemmas more than professional therapists do, and thus volunteers may be more exposed to the adverse influences of trauma work. In addition, according to Kohlberg’s (1981) theory of moral development, the more experienced caregivers are expected to behave more ethically. In conclusion, we assume that ethical behavior may help mental health workers to reduce the harmful effects of treating trauma victims, whereas work experience may promote ethical behavior. Therefore, the hypothesized structural model (see Figure 1) presents years of experience as a predictor of ethical behavior, which in turn may serve as ‘professional armor’ for caregivers against increased STS and burnout. We also hypothesized the following:
PREDICTING PROFESSIONAL QUALITY OF LIFE
Figure 1. Theoretical model for predicting PQL by years of experience and ethical behavior.
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PQL. Professional quality of life was measured using the Hebrew version of Stamm’s (2005) ProQOL questionnaire. The questionnaire was back-translated (Brislin, 1970), and the final version included 30 items related to three subscales: STS, burnout, and CS. Psychometric properties for the three subscales were shown to be reliable in the past (Connally, 2012) and proved reliable in the present study, with reliability coefficients of .97 for STS and CS scales and .94 for burnout.
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Procedure 1. A difference exists between professional therapists and volunteers. Specifically: a. Compared with professionals, volunteers will express higher levels of STS and burnout and lower levels of CS. b. Compared with professionals, volunteers will report lower levels of ethical behavior. 2. STS, burnout, CS, and ethical behavior vary with job experience: those with less experience will report lower levels of STS and burnout and higher levels of CS.
Method Participants The current research included 183 mental health caregivers working in Israel, of whom 43% are professional therapists and 57% volunteers. Most caregivers in the sample are female (78%) and highly educated: 49% have an undergraduate degree (BA), and 41% have a postgraduate degree. The therapist group consisted of criminologists, psychologists and social workers and the volunteer group consisted of students, clerks, photographers, and others.
Measures Demographic questionnaire. This questionnaire gathered information about gender, education, job description, years of experience, and the existence of therapeutic encounters with victims of traumatic experience. Ethical behavior questionnaire. This questionnaire was originally devised by Pope, Tabachnick, and Keith-Spiegel (1987) and was translated into Hebrew using the double translation method (Brislin, 1970) for the purpose of the current research. The items presented situations that are considered unethical according to the APA code of ethics (“accepting gifts from patients” or “discussing patients’ personal lives with friends”). We adjusted the questionnaire by omitting questions irrelevant to the Israeli culture (“addressing client by his first name”) and questions that were not suitable to the specific research population (“making custody evaluation without seeing the child”). The final questionnaire included 54 of the original 83 behaviors. Participants were asked to rate each behavior in terms of two categories: (a) the extent to which they had engaged in the behavior in their practice, and (b) the extent to which they consider the practice ethical. The answers we given on 5-level Likert scale, where 1 means very often for the first category and ethical for the second, and 5 meant rarely and unethical accordingly. Because factor analysis showed that both scales belong to the same factor, we combined them by adding the two scores together. The final reliability coefficient was ␣ ⫽ .98
We recruited volunteer caregivers for the study through several victim assistance organizations, and participants filled in the questionnaires during their weekly meetings. It took approximately half an hour to fill in the questionnaires. Professional therapists were approached individually through personal connections (snowball sampling). The study was approved by the ethical committee. Participants signed an informed consent form, were assured of anonymity, and were told that they may refuse to participate in this study or drop out at any stage. A total of 210 questionnaires were collected, but 27 of these (13%) were disqualified for being incomplete. We analyzed the data through various statistical programs: SPSS 20, AMOS20, and Modprobe. To assess the model fit, we used the indices proposed by Hu and Bentler (1999).
Results Caregiver Type To examine our hypotheses that ethical behavior and PQL varies according to the caregiver type (professional/volunteer), we conducted a series of independent samples t tests. The results demonstrate a significant difference between professional practitioners and volunteers in ethical behavior, t(181) ⫽ ⫺6.65, p ⬍ .01, d ⫽ .99, and in all three components of PQL: STS, t(160.5) ⫽ 5.31, p ⬍ .001, d ⫽ .79, burnout, t(161.8) ⫽ 5.73, p ⬍ .001, d ⫽ .87, and CS, t(154.4) ⫽ ⫺6.09, p ⬍ .001, d ⫽ .92. Professional therapists are characterized by higher ethical standards (M ⫽ 7.42, SD ⫽ 2.09) than volunteers (M ⫽ 5.35, SD ⫽ 2.08). With regard to PQL, volunteers’ levels of STS (M ⫽ 3.36, SD ⫽ 1.21) and burnout (M ⫽ 3.41, SD ⫽ 1.04) were higher than professional practitioners’ levels of STS (M ⫽ 2.46, SD ⫽ 1.05) and burnout (M ⫽ 2.54, SD ⫽ 0.97); and volunteers’ levels of CS (M ⫽ 2.36, SD ⫽ 1.07) were lower than those of professional practitioners (M ⫽ 3.3, SD ⫽ 0.98).
Years of Experience To examine the relationship between years of experience, ethical behavior, and the elements of PQL (STS, burnout and CS) among mental health caregivers, the participants were divided into three equal groups according to the to the values of 33.33rd and 66.66th percentiles. A few months to one year of working in the field was defined as ‘short experience’; one to five years was defined as ‘moderate experience’; and more than five years was defined as ‘long experience.’ The results of one-way ANOVA expose a significant effect of length of experience on ethical behavior, F(2, 180) ⫽ 11.95, p ⬍ .01, p2 ⫽ .12: caregivers with long experience reported higher ethical standards (M ⫽ 7.55,
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SD ⫽ 1.99) than caregivers with moderate (M ⫽ 6.45, SD ⫽ 2.33) and short experience (M ⫽ 5.62, SD ⫽ 2.23). Post hoc comparisons using the Scheffé test show no significant differences between practitioners with short and moderate experience. The results also show that years of experience have a significant effect on STS, F(2, 180) ⫽ 11.84, p ⬍ .01, p2 ⫽ .12) and on burnout, F(2, 180) ⫽ 9.92, p ⬍ .01, p2 ⫽ .10. Practitioners with the long experience reported lower levels of STS (M ⫽ 2.31, SD ⫽ 0.99) and burnout (M ⫽ 2.47, SD ⫽ 0.91) than practitioners with the moderate (M ⫽ 2.91, SD ⫽ 1.19 for STS; M ⫽ 2.94, SD ⫽ 1.11 for burnout) and the short experience (M ⫽ 3.3, SD ⫽ 1.21 for STS; M ⫽ 3.31, SD ⫽ 1.09 for burnout). And finally, the result indicate that years of experience significantly affects CS, F(2, 180) ⫽ 14.2, p ⬍ .01, p2 ⫽ .14: practitioners with long experience had higher levels of CS (M ⫽ 3.43, SD ⫽ 0.93) than those with moderate (M ⫽ 2.86, SD ⫽ 1.11) and short experience (M ⫽ 2.42, SD ⫽ 1.11). Post hoc comparisons using the Scheffé test show no significant differences between practitioners with the shortest and those with moderate experience in all three element of PQL.
Years of Experience, Ethical Behavior, and PQL Elements—SEM Structural equation modeling analysis (SEM) was used to test whether the hypothesized model presented in Figure 1 was concordant with the collected data. The variables’ means, standard deviations, and correlations are presented in Table 1 (Supplement materials), and it appears that the correlations among variables are consistent with the expectations. Given the differences in training and education between the volunteer and professional practitioners, we applied multigroup structural equation modeling to compare the two groups. The unconstrained model appeared to fit the data well, 2(6) ⫽ 8.04, p ⫽ .24, 2/df ⫽ 1.34, NFI ⫽ 0.99, CFI ⫽ 0.997, RMSEA ⫽ 0.043. As predicted for both groups, the model presented a strong negative correlation between ethical behavior and STS and burnout, and a strong positive correlation between ethical behavior and CS. Additionally, the model (Figure 1S, supplement materials) presented strong correlations in both groups between STS, burnout and CS, whereby the correlation between STS and burnout was positive and the correlation between CS and STS and burnout was negative. Indeed, the difference between volunteers and professionals was indicated in the relationship between years of experience and ethical behavior. For both groups the model predicted a weak correlation between years of experience and ethical behavior; however, this correlation proved positive in the sample of professional caregivers and negative in the volunteers’ sample. To explore this difference, we imposed a cross-group equality restriction upon standardized regression coefficients. The overall fit was good, 2(10) ⫽ 11.68, p ⫽ .31, 2/df ⫽ 1.17, NFI ⫽ .98, CFI ⫽ 0.998, RMSEA ⫽ .03, suggesting that the relationship between years of experience and ethical behavior is similar across the two groups. In addition, we used the SPSS feature MODPROBE to examine whether the grouping variable (volunteers/professionals) may be moderating the influence of years of experience on ethical behavior. The analysis results reveal no significant interaction ( ⫽ 0.15, t ⫽ 1.46, p ⫽ .15). Thus the model that appears to fit the data most (see Figure 2) is that which refers to all the participants— both volunteers and professionals, 2(3) ⫽ 2.52, p ⫽ .47,
Figure 2. behavior.
SEM for prediction of PQL by years of experience and ethical
2/df ⫽ .838, NFI ⫽ 0.997, CFI ⫽ 1.00, RMSEA ⫽ 0.00. This model presents a statistically significant positive relationship between years of experience and ethical behavior. All other variables correlate similarly to the previous models.
Discussion The main aim of this study was to study the factors influencing the PQL of trauma therapists, including elements such as STS, burnout, and CS. Based on the literature reviewed, we constructed a model that included factors related to therapist professionalism, such as ethical behavior and work experience, as variables that contribute to the prediction of STS, burnout and CS levels among professional therapists and volunteers. We examined the model via SEM. Similar to the results of Ray, Wong, White, and Heaslip (2013), we found a link between STS, burnout, and CS. Furthermore, our findings indicate that therapists’ ethical behavior may predict their levels of PQL. Among both volunteer caregivers and professional therapists, ethical behavior correlated negatively with STS and burnout and positively with CS. This finding confirms theoretical claims (Everall & Paulson, 2007; Munroe, 1995) regarding the association between ethical issues, STS, and burnout, though it presents this connection from a different perspective. Rather than regarding unethical behavior as resulting from STS and burnout (as per Everall & Paulson, 2007), the current model presents ethical behavior as predicative of therapists’ PQL. The negative correlation between STS, burnout, and ethical behavior implies that ethical behavior may mitigate the effects of encounters with trauma victims among caregivers. Although the primary aim of ethical codes is to protect patients from therapists’ amoral or harmful behavior (Workers, 2008; Campbell et al., 2010), our findings imply that ethical codes provide protective value for therapists as well. The results of this study suggest that when professional and volunteering caregivers maintain ethical behavior, they may prevent or minimize the risk of enmeshment with their clients, thus contributing to the prevention of STS and burnout and preserving healthy levels of CS. These findings echo Lahad’s (2000) claim that ‘differentiation rituals’ may help the therapist to avoid STS by preserving emotional differentiation. Furthermore, our model demonstrates that years of experience predicts ethical behavior and that these variables correlate positively. Apparently, with years of experience therapists develop higher ethical behavior standards. In addition to the SEM model, we examined the differences according to the duration of professional years of experience (short/moderate/long). This comparison revealed that senior therapists were characterized as having higher levels of the ethical behavior, higher levels of CS, and lower levels of STS and burnout than less experienced therapists. Although these findings contradict some of the literature on the topic (Borys & Pope, 1989; Haas et al., 1988), they correspond to the findings of Conte et al. (1989) and to
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PREDICTING PROFESSIONAL QUALITY OF LIFE
Kohlberg’s (1981) theory of moral development. The difference between our findings and those in previous studies may result from variations in the respective definitions of the ethical behavior. Whereas the previous studies focused on specific ethical issues, the current research examined ethical standards regarding the broad spectrum of behaviors that may occur in the therapeutic relationship. Moreover, this research investigated the much-neglected comparison between volunteer caregivers and professional therapists. We compared their respective levels of ethical behavior, years of experience, and PQL. Regarding ethical behavior, we found that volunteers reported lower standards than did professional therapists. This finding is in line with Payne’s (2002) claim that volunteers tend to feel less obligated than professional therapists to a specific ethical code. Because volunteers are not obliged to abide by a specific ethical code (Berry & Planalp, 2009), and their training programs usually do not elaborate on ethical issues (Pope, 2003; Sewpaul & Jones, 2004), it is quite understandable that volunteers scored lower on the ethical behavior scale than did professional therapists. Another important difference between professional therapists and volunteers involves vulnerability to vicarious exposure to a trauma. In this regard volunteers reported higher levels of STS and burnout and lower levels of CS than professional therapists. These results contradict the claim by Hargrave and colleagues (2006) that STS risk factors do not apply to volunteers. However, their study did not compare between professional therapists and volunteers. Our results suggest that volunteering with trauma victims can take a severe emotional toll on caregivers and lead to relatively high levels of STS and burnout. Potentially, higher vulnerability among volunteers may relate to their lower level of ethical behavior, as we have demonstrated. As discussed earlier, ethical behavior appears to minimize the risk of developing STS, burnout and the loss of CS. While contributing both theoretically and empirically to the literature regarding PQL among professional therapists and volunteer caregivers, the present study has a few limitations. One of the study limitations is the self-report nature of our data. Because the ethical behavior is self-reported, it may be influenced by social desirability. With regard to the sample size, the limited number of participants in this study represents the difficulty in recruiting mental health volunteers and professionals who work with trauma victims. The final sample size is in accordance with Kline’s (2005, pp. 111, 178) suggestion that the minimum sample size should be no less than 5 to 20 times the number of parameters to be estimated. Yet, future research should replicate SEM results with a larger sample to determine whether additional models might also be helpful. The problem of recruiting these specific types of mental health caregivers also made it impossible to use random sampling. Snowball sampling does not allow a true representation of professionals, thus limiting the external validity of our findings. We therefore propose that future studies on this subject should apply random sampling and consider different research designs that include prepost comparisons, vignettes, or actual therapist–victim interaction to further explore the influence of experience and ethical awareness on negative outcomes for therapists. In conclusion, this study presents a unique perspective on the connection between ethical behavior and PQL, focusing on volunteers and their special characteristics. The study’s contribution is both theoretical and practical. It contributes to the body of literature on ethics in therapy by introducing ethical behavior as the factor that may
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reduce the risk of developing STS and burnout. This new point of view on ethical behavior incorporates in itself possible practical implications with regard to professional therapists’ and volunteers’ quality of life and the prevention of STS and burnout. It emphasizes not only the value of ethical codes and expansion of ethical training for volunteers, but also the importance of ethical behavior among mental health caregivers in general. Thus, implementing ethical guidelines as an integral component of training and guidance could benefit both volunteers and professionals.
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Received September 26, 2014 Revision received April 24, 2015 Accepted April 29, 2015 䡲
