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Social and
Behavioral
Procedia
Procedia - Social
- Social and Behavioral
and Behavioral Sciences
Sciences 00 (2011)
33 (2012) 000–000
438 – 442 Sciences
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PSIWORLD 2011

The relation of clinical empathy to secondary traumatic stress

Irina Crumpeia*, Ion Dafinoiua
a
Facultatea de Psihologie i tiine ale Educaiei, Universitatea “Al. I. Cuza”, Str. Toma Cozma, nr. 3, Iai,700554, Romania

Abstract

A growing body of empirical research shows that health professionals working with survivors of traumatic events
may develop traumatic symptoms themselves. Empathy is one of the main risk factors associated with clinical
competence and patient outcome. Seventy seven medical workers from emergency and intensive care units were
surveyed to determine the presence of secondary traumatic stress and explore the distinct relations to sympathy and
empathy. Sympathetic health professionals are most vulnerable. On the contrary, clinical empathy is not significantly
related to traumatic symptoms.
©
© 2012 PublishedbybyElsevier
2011 Published Elsevier B.V.
Ltd. Selection
Selection and and/or peer-review
peer-review under responsibility
under responsibility of PSIWORLD2011
of PSIWORLD 2011

Keywords: Secondary traumatic stress; empathy; sympathy; medical staff, trauma.

1. Introduction

The past few years have brought about the development and increased attention of the traumatology
field and the concept of traumatic stress. In the context of the studies naturally focused on reactions of
the direct victim after the traumatic event, it was gradually discovered that the victims can multiply over
time, even long after the event ended (Joinson, 1992; Figley, 1993; Hodgkinson & Shepard, 1994;
Schauben & Frazier, 1995; Kassam-Adams, 1995; Pearlman & Mac Ian, 1995; Steed & Bicknell 2001 ).
Joinson (1992) was the first to use the term compassion fatigue to describe the medical assistants’
experience when exposed to trauma in their work. The term has gained recognition by describing the
effects of working with survivors of trauma on clinicians and mental health specialists. Victims of
traumatic events might develop posttraumatic stress disorder showing intrusive, avoidance and arousal
symptoms. Family members, clinicians, emergency professionals or co-workers who are exposed to the
traumatic material of others put themselves at risk for developing similar symptoms (Figley, 1993).

*
Corresponding author. Tel.: +40-723712705;
E-mail address: irina_crumpei14@yahoo.com.

1877-0428 © 2012 Published by Elsevier B.V. Selection and/or peer-review under responsibility of PSIWORLD2011
doi:10.1016/j.sbspro.2012.01.159
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and Behavioral Sciences
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Because of the indirect exposure to the traumatic material, the syndrome was called secondary traumatic
stress (STS). In fact, the revised fourth edition of the Diagnostic and Statistic Manual of Mental Disorders
includes posttraumatic stress syndrome diagnostic criteria for situations where the person faces a
traumatic event or events that involved death threats or death or serious injury or threat of its own or
other’s body integrity. Considering that some professional groups are systematically confronted with
traumatic experiences of others, it’s not surprising that they experience symptoms of secondary traumatic
stress. Medical workers are one of the vulnerable professional groups. Emotional involvement and
patients suffering are among the most reported sources of stress by medical workers (Bratt et al., 2000).
Mealer et al (2007) explained the high traumatic symptomatology rates experienced by both medical
assistants and Vietnam War veterans pointing out that some of the tasks performed by medical personnel
included looking after corpses and providing assistance to traumatized victims as it happens in combat.
Figley (1993) argues that professionals who have a great capacity to feel and express empathy tend to
be more vulnerable to symptoms of STS resulting from the care of one traumatized or suffering person.
At the same time numerous studies show the importance of the medical workers’ empathy towards the
patient (Suchman et al., 1997; Stephan & Finlay, 1999; Halpern, 2001). Consequently, medical specialists
face a paradox. Omdahl & O’Donnell (1999) define empathy as empathic concern, willingness to
communicate and emotional contagion. Emotional contagion is the most controversial factor of the three.
On one side it is most valued by patients who feel appreciated and understood, on the other side it
threatens the specialist’s objectivity and health. Other definitions of empathy argue that emotional
contagion is rather part of compassion, while empathy means understanding patient’s emotions and
communicating that understanding (Bertakis et al; 1991; Hojat et al, 2001).
Firstly, the present study aimed to assess the impact of working with traumatized persons on the
medical workers of emergency and intensive care units. Secondly, considering the distinction between
compassion and empathy, we wanted to explore how the two concepts relate to secondary traumatic
stress.

2. Method

The research took place in several hospitals in the city of Iasi, Romania. A preliminary qualitative
study was conducted to identify the main sources of stress for different medical specialties. The results
were consistent with other research showing patient suffering as an important stress source (Healey &
McKay, 1999; McGowan, 2001; Stordeur et al., 2000). Therefore, the participants in this study are 77
medical workers from the Emergency and the Intensive Care units. 35 were physicians and 42 were
nurses. In order to observe the presence of STS among medical personnel, we also used a control group,
with similar characteristics formed from 60 pharmacists. All participants answered a set of questionnaires,
after signing a confidentiality contract. The Professional Quality of Life Scale (Stamm, 2005) is a revised
version of Figley’s self-administrated test, developed in 1995 to measure secondary traumatic stress. It
contains 3 sub-scales of 10 items each, which offer independent scores measuring different concepts:
compassion satisfaction (Į = .83), burnout (Į = .66) and secondary traumatic stress (Į = .73). The Impact
of Events Scale (Horowitz, Wilner and Alvarez, 1979) initially measured symptoms of direct trauma and
not of secondary trauma. In spite its original purpose, the scale is most frequently used to measure and
survey secondary traumatic stress symptoms. It has two subscales that measure avoidance with 8 items (Į
= .71) and intrusion with 7 items (Į = .89) and can be added to generate a total score (Į = .84). The
factors of the IPIP-NEO model described by Goldberg et al. (2006), represented the basis for operating
the Big Five plus questionnaire. To measure compassion we used the specific facet from the factor
agreeability (Į = .73). The Jefferson Scale of Physician Empathy (Hojat et al., 2001) used in the present
440 Irina Crumpei et
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study is the final form, designed to measure physicians’ empathy toward their patients and consists of 20
items (Į = .75).

3. Results

Independent Samples T Tests were conducted to compare the level of secondary traumatic stress in
medical workers and pharmacists. Both physicians and nurses had significantly higher scores for all the
subscales of the dependent variable. Even if medical workers (M = 35.64, SD = 6.85) have a significantly
higher level of compassion satisfaction in comparison to pharmacists (M = 31.41, SD = 6.56; t(135) =
3.65, p < .001 ), they also suffer from a higher level of secondary traumatic stress (t(135) = 6.058, p <
.001). The Impact of Events Scale indicates that the medical professionals (M = 33.25, SD = 12.10)
experience intrusive and avoiding symptoms which generate a significantly higher level of total distress
as compared to the pharmacists control group (M = 18.48, SD = 14.93; t(135) = 6.23, p < .001 ). These
results confirm our hypothesis. Medical personnel experience a significantly higher level of secondary
traumatic stress in comparison to other professionals who do not systematically interact with victims of
traumatic events. Pearson correlation coefficients were computed to assess the relationship between
secondary traumatic stress, empathy and compassion. None of the dependent variables correlated
significantly with clinical empathy.

Table 1. Pearson correlation: STS and Clinical Empathy

Compassion Burnout STS Intrusive Symptoms Avoidance Symptoms Total Distress

satisfaction
Clinical
.197 -.063 .102 .064 -.082 -.009
Empathy
Note. * = p ”.05, ** = p ”.01. N = 77 for all analysis.

However, the analysis indicates a significant positive correlation between reported levels of secondary
traumatic stress and compassion in medical staff. The Impact of Events Scale shows that more
compassionate medical workers report higher levels of intrusive symptoms (r = .342, N = 77, p < .01). On
the other hand, there is no significant relation between avoidance symptoms and compassion. More
compassionate professionals report being more burned-out. There is no significant correlation between
compassion satisfaction and compassion.

Table 2. Pearson correlation: STS and Compassion satisfaction

Compassion Burnout STS Intrusive Avoidance Total Distress

satisfaction Symptoms Symptoms

Compassion -.157 .283* .511** .342** .180 .322**

Note. * = p ”.05, ** = p ”.01. N = 77 for all results.

4. Discussions

The present paper had two main objectives. Firstly, we wanted to assess the level of STS in Romanian
medical workers. Therefore we compared the medical workers’ STS scores to those of the control group
consisted of pharmacists. We found significant differences in all of the subscales of the dependent
variable, both in relation to nurses and physicians. Other studies concerned with this issue reached similar
 Irina Crumpei and Ion
I. Crumpei Dafinoiu
et al. / Procedia
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- Social and Behavioral
and Behavioral Sciences
Sciences 33 (2012)
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conclusions. Dominguez-Gomez & Rutledge (2009) noticed that medical assistants working in the
emergency department are characterized by a significantly higher degree of risk of experiencing
secondary traumatic stress in comparison to social workers. Mealer et al. (2007) compared the intensity of
posttraumatic symptomatology experienced by medical assistants in the intensive therapy and general
practice departments. The first category is characterized by significantly higher scores. In addition, both
specialties report significantly higher levels of risk in comparison to managers working in the health
industry. These conclusions are not surprising. The amount of work, lack of support and traumatic stress
are burnout triggers identified by the medical assistants performing activities in the emergency, intensive
therapy and oncology departments. (Kash et al., 2000; Schwam, 1998, Maytum, Heiman, & Garwick,
2004). The problem is even greater in Romania, where the economic difficulties raise new challenges for
the medical system and the medical staff. Therefore, the relationship established with patients increases
the results on the compassion satisfaction scale. However, the professional achievements cannot counter-
balance the chronic exposure to pain and trauma.
Secondly, we tried to find a possible solution for the paradox of the clinical relationship. On one hand,
empathic medical professionals have better results in treatment, recovery and patient satisfaction, on the
other hand emotional involvement threatens decision objectivity and exposes the specialist to STS
symptoms (Figley, 1995). This study suggests that while compassionate medical workers report more
intrusive and avoidant symptoms, there is no relationship between clinical empathy and STS. Clinical
empathy was defined in this study as the ability and the willingness to understand the patient’s emotional
reactions, to see the situation through the patient’s eyes and to communicate this understanding (Hojat et
al., 2002). Emotional contagion refers to compassion and is separated from empathy. This
operationalization separates the cognitive side that refers to the understanding of the patient from the
affective side that implies emotional contagion. Figley (1995) uses the term compassion fatigue as
synonym to secondary traumatic stress showing that compassion rather than empathy could endanger the
specialist.
To conclude, these results could be used in STS prevention among the medical staff. Teaching
specialists to show their patients empathy while voiding compassion and emotional contagion could
reduce the STS incidence. Further research is needed to clarify the effects of such interaction on the
relationship between the medical specialist and the patient.

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