Understanding & Mitigating Compassion Fatigue for Legal ... · Keeping Legal Minds Intact: Mitigating Compassion Fatigue Among Legal Professionals I. DISCIPLINARY RULES A. SCR 20:1.1

Understanding & Mitigating Compassion Fatigue for Legal Professionals

Speakers: Linda Albert, LCSW, CSAC

Presentation Outline

I. Defining compassion fatigue. What is it? How does it play out? II. What puts legal professionals at risk? III. Development of compassion fatigue; the brain keeps the score. IV. Interface between impairment and ethical violations. V. Mitigating compassion fatigue; what is the formula for staying fit to

practice. Linda Albert is a Licensed Clinical Social Worker and a Certified Alcohol and Drug Counselor. She received her Master’s Degree from UW-Madison in Social Work. She has professional assessment/treatment/referral competencies in the areas of addictions, eating disorders, depression, anxiety, trauma and illness impacted by stress. Linda has worked over the past 30 years as an administrator, consultant, trainer and psychotherapist in a variety of settings including providing services to impaired professionals. Linda has co-facilitated a research project on compassion fatigue and legal professionals resulting in two recent publications. She has done multiple presentations for conferences at the local, state and national level. Currently Linda is employed by the State Bar of Wisconsin as the WisLAP Coordinator

Compassion fatigue is defined as the cumulative physical, emotional and psychological effects of being continually exposed to traumatic stories or events when working in a helping capacity. It has been studied extensively in social workers, nurses, doctors and therapists who work with victims of trauma. The State Bar of Wisconsin holds the largest set of research data examining the impact upon legal professionals. This seminar will look at which legal professionals are most at risk, the development of compassion fatigue, the interface between attorney impairment and discipline and what individual and organizational measures can prevent and mitigate compassion fatigue.

Seminar Outline Keeping Legal Minds Intact: Mitigating Compassion Fatigue Among Legal Professionals

I. DISCIPLINARY RULES

A. SCR 20:1.1. Competence

A lawyer shall provide competent representation to a client. Competent representation requires the legal knowledge, skill, thoroughness and preparation reasonably necessary for the representation.

B. SCR 20:1.3. Diligence

A lawyer shall act with reasonable diligence and promptness in representing a client.

C. SCR 20:1.4 Communication

(a) A lawyer shall:

(1) Promptly inform the client of any decision or circumstance with respect to which the client's informed consent, as defined in SCR 20:1.0(f), is required by these rules; (2) reasonably consult with the client about the means by which the client's objectives are to be accomplished; (3) keep the client reasonably informed about the status of the matter; (4) promptly comply with reasonable requests by the client for information; and (5) consult with the client about any relevant limitation on the lawyer's conduct when the lawyer knows that the client expects assistance not permitted by the Rules of Professional Conduct or other law. (b) A lawyer shall explain a matter to the extent reasonably necessary to permit the client to make informed decisions regarding the representation.

C. SCR 20:1.16. Declining or terminating representation

(a) Except as stated in par. (c), a lawyer shall not represent a client or, where

representation has commenced, shall withdraw from the representation of a client if:

(1) the representation will result in violation of the Rules of Professional Conduct or other law;

(2) the lawyer's physical or mental condition materially impairs the lawyer's ability to represent the client; or

D. SCR 20:8.4.

It is professional misconduct for a lawyer to:

(a) violate or attempt to violate the Rules of Professional Conduct, knowingly assist or induce another to do so, or do so through the acts of another; ….

(c) engage in conduct involving dishonesty, fraud, deceit or misrepresentation;

(d) state or imply an ability to influence improperly a government agency or official or to achieve results by means that violate the Rules of Professional Conduct or other law;

…., or (f) violate a statute, supreme court rule, supreme court order or supreme court decision

regulating the conduct of lawyers;1

….

II. MEDICAL INCAPACITY

SCR 21.17. Medical incapacity suspension, conditions

The license of an attorney to practice law may be suspended indefinitely or conditions may be imposed on the attorney's practice of law with the attorney's consent or upon a finding that the attorney has a medical incapacity, pursuant to the procedure set forth in SCR chapter 22.

III. REPORTING

SCR 20:8.3 Reporting Professional Misconduct

(a) A lawyer having knowledge that another lawyer has committed a violation of the Rules of

Professional Conduct that raises a substantial question as to that lawyer’s honesty, trustworthiness or fitness as a lawyer in other respects, shall inform the appropriate professional authority.

(b) A lawyer having knowledge that a judge has committed a violation of applicable rules of

judicial conduct that raises a substantial question as to the judge’s fitness for office shall inform the appropriate authority.

(c) This rule does not require disclosure of any of the following:

(1) Information otherwise protected by Rule 1.6.

(2) Information acquired by one of the following:

(i) A member of any committee or organization approved by any bar association to assist ill or disabled lawyers where such information is acquired in the course of assisting an ill or disabled lawyer.

(ii) Any person selected by a court or any bar association to mediate or arbitrate disputes between lawyers arising out of a professional or economic dispute involving law firm dissolutions, termination or departure of one or more lawyers from a law firm where such information is acquired in the course of mediating or arbitrating the dispute between lawyers.

IV. ETHICS CASES

V. UNDERSTANDING COMPASSION FATIGUE AND MENTAL HEALTH CONDITIONS WHICH CORRELATE WITH ATTORNEY DISCIPLINE; BEST PRACTICES FOR STAYING FIT TO PRACTICE

VI. ASSISTANCE PROGRAMS

A. Wisconsin Lawyer’s Assistance Program (WISLAP)

WisLAP Manager: Linda Albert [email protected]

(800) 444-9404 ext. 6172

WisLAP Coordinator: Mary Spranger [email protected]

(800) 444-9404 Ex. 6159

24 hour helpline: (800) 543-2625

B. Ethics Hotline

State Bar's ethics counsel: Monday through Friday, 9 a.m. to 5 p.m.

Timothy Pierce [email protected]

(608) 250-6168 or (800) 444-9404, ext. 6168,

Aviva Kaiser [email protected]

(800) 444-9404 ext. 6158

C. Law Office Management Assistance Program

State Bar’s LoMAP counsel: Monday through Friday, 9 a.m. to 5 p.m.

Tison Rhine [email protected] (608) 250-6012 or (800)-444-9404 ext. 6012

CASE LAW

MEDICAL INCAPACITY CASES-GENERAL

In Matter Of Disciplinary Proceedings Against John Loew, 2010 WI 23 (60 day suspension for multiple counts of neglect. Attorney stated that after starting his own firm his practice mushroomed. Although he was offered assistance with office staff, he said he was too overwhelmed to take the time to train these individuals. Due to his inability to turn down new clients, Attorney Loew began working virtually around the clock, leading to a deterioration of his physical and mental health. He then began to practice from his home and began experiencing the onset of severe depression. Attorney Loew sought help from his primary physician in August 2007 and was diagnosed with anxiety and depression. He was given anti-depressant medication along with a recommendation for therapy. Attorney Loew consulted a psychiatrist in December 2007 and attended some therapy sessions beginning in early 2008. In August 2009 Dr. Gregory J. Van Rybroek, a licensed psychologist, conducted an independent psychological evaluation of Attorney Loew. Dr. Van Rybroek concluded, to a reasonable degree of professional certainty, that during the time Attorney Loew was retained in the misconduct cases he was in the throes of a major depressive episode primarily brought on by a workload he ultimately became unable to manage. Dr. Van Rybroek said it appeared the volume of Attorney Loew's workload, exacerbated by the death of a close friend, created overwhelming stress that led to serious depression. Dr. Van Rybroek opined that the situational stress led to the point where Attorney Loew became largely dysfunctional. Dr. Van Rybroek was of the opinion that Attorney Loew's depression symptoms were situational rather than driven by a genetic predisposition toward

professional certainty, that Attorney Loew's current level of functioning was much improved. Dr.

mailto:[email protected]






[email protected]

Van Rybroek was of the opinion that Attorney Loew could return to the practice of law, subject to certain conditions, including entering into a therapy relationship to assist with better self- understanding, specifically in learning more about the internal triggers that make it difficult for him to limit his workload; remain under the care of a psychiatrist for purposes of monitoring his medication; and he should not work in the solo practice of law but rather should work in a structured legal environment where his work can be monitored. While the referee said the fact that Attorney Loew was suffering from depression in late 2006 and early 2007 was well documented in the record, his testimony at the hearing made it clear that his difficulty in running a solo law practice began well before the onset of his depression. The referee said at most Attorney Loew's depression was a contributing factor to the events outlined in the OLR's complaint, not a causal factor. The OLR had sought a six-month suspension of Attorney Loew's license. The court agreed with the referee’s recommendation of a 60 day suspension and that for a period of five years following his resumption of the practice of law, the following conditions shall be imposed upon John R. Loew's practice of law: A. enter into a therapy relationship to assist with better self-understanding, specifically in learning more about the internal triggers that make it difficult for him to limit his workload; B. remain under the care of a psychiatrist, particularly for monitoring of his medication needs; C. shall engage in the practice of law under the direct supervision of a licensed attorney acceptable to and approved by the Office of Lawyer Regulation. Attorney Loew's supervising attorney shall have all the duties generally held by a supervising attorney under SCR 20:5.1(b); D. submit to the OLR, on a semiannual basis, a report from his treating psychiatrist outlining his ongoing treatment. The reports should disclose any recurrences of the depression, and if any, whether such recurrences pose an unreasonable risk to the public if John R. Loew is permitted to continue the practice of law; E. submit to the OLR, on a semi-annual basis, a report from his supervising attorney.

In Matter Of Disciplinary Proceedings Against Nunnery, 2009 WI 89, 769 N.W.2d 858 (3 year suspension for neglect and misrepresentation in multiple matters. Although Nunnery did not specifically argue mitigating factors here, the record discloses the referee's consideration of Attorney Nunnery's significant personal and physical problems during the relevant time periods, including his hospitalization, as well as the illness and death of a member of his family. The referee noted Attorney Nunnery admitted that, as a sole practitioner, he had taken on more work than he could handle effectively. Nunnery also claimed stressors of being caught in Hurricane Katrina, as well as being subjected to a $2.5 million malpractice verdict which was ultimately reversed on appeal and handling complex litigation. The court found that these factors did not excuse the misconduct but were considered in mitigation.

In Matter Of Disciplinary Proceedings Against Scott E. Hansen, 2009 WI 56, 768 N.W.2d 1 (9 month suspension for multiple counts of misconduct and conditions on reinstatement. Hansen claimed the misconduct was due to depression. The OLR indicated it considered Attorney Hansen's depression a mitigating factor, but noted that there was insufficient medical evidence submitted in this proceeding to substantiate the scope of his condition. The OLR observed that progressive discipline was warranted because of Attorney Hansen's disciplinary history. It noted that sanctions in other cases ranged from revocation to a six-month suspension for comparable misconduct. The OLR noted further that Attorney Hansen's failure to return unearned fees and his failure to cooperate with the OLR were aggravating factors not easily attributable to depression. The OLR eventually recommended a one-year suspension of Attorney Hansen's

for Attorney Hansen's claim that he has suffered from depression since 1994. Attorney Hansen did file a letter from a nurse that states that he has had a "major depressive disorder" for the past "several years." Moreover, the referee stated that he failed to "see how [Attorney Hansen]'s disorder can explain Attorney Hansen's attempts to deceive not only his clients but also the Court of Appeals and the Office of Lawyer Regulation. Nor can I see how this disorder would prevent Attorney Hansen from returning fees which he agrees were unearned and which

he promised to return." The referee then recommended a six-month suspension of Attorney Hansen's license describing his depression as "a partial mitigating factor." The court imposed a 9 motnh suspension and the following condition upon reinstatement: Hansen “shall undergo a medical evaluation by a medical professional selected by the Office of Lawyer Regulation and a copy of that evaluation shall be provided to the Office of Lawyer Regulation as a condition for reinstatement, with the understanding that Scott E. Hansen may also submit an evaluation performed by a medical professional of his choice. If this condition is not met, the license of Scott E. Hansen to practice law in Wisconsin shall remain suspended until further order of this court.”

In the Matter of Disciplinary Proceedings Against John E Raftery, 2007 WI 137, 306 Wis.2d 28, 742 N.W.2d 315 (6 month license suspension for multiple acts of neglect, failure to cooperate and failure to comply with rules regarding prior temporary suspension. Referee rejected assertion that all of the misconduct was the result of his longstanding chronic depression, for which he had received both inpatient and outpatient treatment. While the referee noted that Attorney Raftery's medical experts were of the opinion that Attorney Raftery had suffered from chronic depression for years, the referee said there was no evidence in the record that the medical experts related each and every count of misconduct that occurred in this case solely to the chronic depression. The referee pointed out that many of the counts of misconduct related to deliberate misrepresentations by Attorney Raftery to the OLR during its investigation of the various client grievances and to Attorney Raftery's failure to comply with supreme court rules following his temporary suspension. The referee concluded that this misconduct was not solely the result of Attorney Raftery's being "paralyzed" by depression, but rather was intentional misconduct undertaken in an effort to deceive the OLR and the public. Rather than viewing Attorney Raftery's chronic depression as an excuse for his misconduct, the referee found it to be a mitigating circumstance to be considered in recommending an appropriate discipline. Conditions imposed for a period of two years: A. law practice shall be monitored as set forth in the "Suggested plan for oversight and accountability filed by the attorney; B. shall be required to submit to OLR, on a quarterly basis, a report that he is in compliance with the "Suggested plan for oversight and accountability." The report shall disclose any patterns of neglect of client matters. Such quarterly reports shall include the written approval of the attorney; C. required to submit to OLR, on a semiannual basis, a report from his treating psychologist/psychiatrist outlining his ongoing treatment. The reports should disclose any recurrences of the depression, and if any, whether such recurrences pose an unreasonable risk to the public if he is then permitted to continue the practice of law; D. Should he, for any reason, leave the Ritger Law Office, he shall immediately inform OLR, and any continuance of his practice of law shall be subject to monitoring and a plan similar to the above.

Disciplinary Proceedings Against Shindell, 2002 WI 133, 258 Wis.2d 63, 654 N.W.2d 844 (1 year suspension added onto to existing suspension for various misconduct. The court noted that “the record demonstrates the existence of a number of mitigating factors, including the fact that Attorney Shindell suffered from serious personal and health problems and also had

administrative problems in her office which seemed to peak in early 1999. As the referee also noted, however, it would have been appropriate for Attorney Shindell to have obtained assistance from other attorneys in her office or brought in outside counsel during this time, and the absence of this assistance was not the fault of her clients, who were unaware of Attorney Shindell's problems.”

Alcohol & Drug Cases – Mitigation

In the Matter of Disciplinary Proceedings Against Compton 2010 WI 112 (2010) On May 6, 2010, the OLR filed a disciplinary complaint in this matter alleging that Attorney Compton committed criminal acts that reflect adversely on his honesty, trustworthiness, or fitness as a lawyer in other respects, in violation of SCR 20:8.4(b). Aggravating factors include Attorney Compton's prior disciplinary history, the pattern of misconduct, the potential vulnerability of K.L., and the harm to K.L. Mitigating factors include the fact that Attorney Compton has been "wholly cooperative in this matter," including entering into an agreement admitting his misconduct and agreeing to the level of discipline sought by the OLR. He acknowledged the wrongfulness of his conduct and offered to turn in his law license. He voluntarily entered into a drug treatment program and has expressed remorse for his conduct. The court is advised that Attorney Compton is undergoing voluntary monitoring and as of June 11, 2010, the monitor reported Attorney Compton's continued compliance with the requirements of his monitoring program.

We approve the stipulation and adopt the stipulated facts and legal conclusions of professional misconduct. We agree that a two-year suspension is appropriate and consistent with this court's past practice. We further agree that it is appropriate to order the suspension to commence on March 16, 2010, the date Attorney Compton's law license was summarily suspended by this court. The imposition of a two-year suspension will require Attorney Compton to complete successfully the formal reinstatement process in order to regain his license to practice law in Wisconsin.

In re Brandt, 766 N.W.2d 194 (Wisconsin 2009) The Office of Lawyer Regulation brought a complaint against Attorney Brandt for failure to properly supervise an employee and for multiple convictions of operating a motor vehicle while intoxicated. The Supreme Court found that the lawyer’s multiple drunk driving convictions did constitute a violation Wis. Sup. Ct. R. 20:5.3(b) because his convictions did demonstrate a serious lack of respect for the law and, therefore relate to his fitness as a lawyer. The court imposed a public reprimand. In this case, a sanction beyond a public reprimand was not necessary because they found that Attorney Brandt was the victim of his employees embezzlement, accepted responsibility for his failure to supervise his employee, had entered pleas to the drunk driving charges and served a significant jail sentence, paid substantial fines, had taken remedial action to address his drinking problem and sought treatment.

Disciplinary Proceedings Against Verlin Peckham, 115 Wis.2d 494, 340 N.W.2d 198 (1983) (The appellant argues that any suspension of his license should be stayed because his misconduct was caused by his alcoholism. He distinguishes his case from Disciplinary

Proceedings Against Glasschroeder, 113 Wis.2d 672 (1983), where the court denied a request for a stay of suspension and revoked the attorney's license. Unlike the appellant, Glasschroeder misappropriated a large sum of client money over a long period of time and uttered a forged check, for both of which he was criminally convicted. Also, Glasschroeder did not present evidence that his misconduct was causally related to his alleged drug dependency. The appellant contends that his recognition of his alcoholism and his efforts at rehabilitation render this case susceptible of a "new" discipline, one which has been recognized in other jurisdictions. He argues that the public can be adequately protected if the court conditions his continued practice on supervision by a practicing attorney, complete abstinence from alcohol, weekly attendance at Alcoholics Anonymous or Lawyers Concerned for Lawyers meetings, post treatment by his psychologist, and his maintenance of complete records concerning client funds and property coming into his possession. These conditions were imposed by the Minnesota Supreme Court in a disciplinary proceeding, Petition of Johnson, 322 N.W.2d 616 (1982), after the disciplinary agency and the attorney had stipulated to them. The referee considered the appellant's misconduct in light of the alcoholism defense and concluded: ". . . His conduct does appear to have been precipitated by a drinking problem rather than an intent on his part to deceive his clients or to convert their funds. This, however, does not afford him a recognizable defense. The trust account violations which came to light as the result of a board audit and which were not denied renders his misconduct extremely serious and warrants the discipline sought by the Board based upon similar cases in the past." We agree, and we adopt the findings, conclusions and recommendation of the referee).

Law and Human Behavior

The Effect of Attorneys' Work With Trauma-ExposedClients on PTSD Symptoms, Depression, and FunctionalImpairment: A Cross-Lagged Longitudinal StudyAndrew Levin, Avi Besser, Linda Albert, Deborah Smith, and Yuval NeriaOnline First Publication, April 2, 2012. doi: 10.1037/h0093993

CITATIONLevin, A., Besser, A., Albert, L., Smith, D., & Neria, Y. (2012, April 2). The Effect of Attorneys'Work With Trauma-Exposed Clients on PTSD Symptoms, Depression, and FunctionalImpairment: A Cross-Lagged Longitudinal Study. Law and Human Behavior. Advance onlinepublication. doi: 10.1037/h0093993

The Effect of Attorneys’ Work With Trauma-Exposed Clients on PTSDSymptoms, Depression, and Functional Impairment:

A Cross-Lagged Longitudinal Study

Andrew LevinWestchester Jewish Community Services,

Hartsdale, New York and Columbia University

Avi BesserSapir Academic College

Linda AlbertState Bar of Wisconsin, Madison, Wisconsin

Deborah SmithWisconsin State Public Defender’s Office,

Madison, Wisconsin

Yuval NeriaColumbia University and New York State Psychiatric Institute,

New York, New York

To date, few studies have examined mental health consequences among attorneys exposed to clients’traumatic experiences. A longitudinal, 2-wave, cross-lagged study was used in a cohort of attorneys(N � 107) from the Wisconsin State Public Defender’s Office. We assessed changes in posttraumaticstress disorder (PTSD), depression, and functional impairment over a 10-month period and tested theeffects of intensity of contact with trauma-exposed clients on symptom levels over time. Attorneysdemonstrated strong and significant symptom stability over time in PTSD, depression, functionalimpairment, and levels of exposure. Analyses involving cross-lagged panel correlation structural equa-tion modeling path models revealed that attorneys’ levels of exposure to trauma-exposed clients hadsignificant positive effects, over time, on PTSD, depression, and functional impairment. Gender, age,years on the job, and office size did not predict any of the outcomes. Level of exposure to trauma-exposedclients predicted reduction of weekly working hours over time, but there was no reciprocal relationshipbetween PTSD, depression, and functional impairment and level of exposure over time. These findingsunderscore the central role of exposure to trauma-exposed clients in predicting mental health outcomesand emphasize the need to support attorneys by managing the intensity of exposure as well as addressingemerging symptoms.

Keywords: attorneys, psychological trauma, posttraumatic stress disorder, depression, functional impairment

To date, few studies have examined the mental health conse-quences among attorneys exposed to clients who have experiencedor been directly involved in traumatic events (trauma-exposedclients). In addition, available quantitative studies of distress inattorneys have only been cross-sectional in nature. Focusing ondepression, Benjamin, Darling, and Sales (1990) and Eaton, An-thony, Mandel, and Garrison (1990) identified a 20% rate ofclinically significant depression in the attorneys surveyed, but

these findings were not related to work experiences. In a study of23 Canadian prosecutors using semistructured interviews, Gommeand Hall (1995) reported symptoms of demoralization, anxiety,helplessness, exhaustion, and social withdrawal. They linked thesesymptoms to high caseloads of “sensitive cases” such as domesticviolence and incest as well as long work hours. Lynch (1997)reported that public defenders ranked work overload, the unpre-dictability of trials, the frequent lack of a defense, harsh sentences,

Andrew Levin, Westchester Jewish Community Services, Hartsdale,New York; Department of Psychiatry, College of Physicians and Surgeons,Columbia University. Avi Besser, Department of Behavioral Sciences andCenter for Research in Personality, Life Transitions, and Stressful LifeEvents, Sapir Academic College, D. N. Hof Ashkelon, Israel. Linda Albert,Wisconsin Lawyers Assistance Program, State Bar of Wisconsin, Madison,Wisconsin. Deborah Smith, Assigned Counsel Division, Wisconsin StatePublic Defender’s Office, Madison, Wisconsin. Yuval Neria, Departmentof Psychiatry, College of Physicians and Surgeons, Columbia University;New York State Psychiatric Institute, New York, New York.

This study was supported by the State Bar of Wisconsin and theWisconsin State Public Defender’s Office. We thank Jeff Apothekerfor his critique of the original design and support of the submissionto the Westchester Jewish Community Services Research Committee,and Alex Zelenski for assistance in data gathering and management.Grateful thanks are also extended to all of the participants in thisstudy.

Correspondence concerning this article should be addressed to An-drew P. Levin, Medical Director, Westchester Jewish Community Ser-vices, 141 North Central Avenue, Hartsdale, NY 10530. E-mail:[email protected]

Law and Human Behavior © 2012 American Psychological Association2012, Vol. 00, No. 00, 000–000 0147-7307/12/$12.00 DOI: 10.1037/h0093993

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arguing with prosecutors, and dealing with angry clients andfamilies as the most frequent and intense sources of stress, but thestudy did not measure specific symptoms of stress. A pilot studyby Levin and Greisberg (2003) found that attorneys working infamily and criminal courts demonstrated higher levels of second-ary trauma and burnout compared with mental health professionalsand social service workers, and these measures of distress corre-lated with caseload. Comparing 50 attorneys working in criminalcourts with 50 working in the civil arena, Vrklevski and Franklin(2008) found more depressive symptoms, subjective stress, andchanges in sense of safety and intimacy among the criminalattorneys. A personal history of multiple traumas predicted higherscores on measures of vicarious trauma, posttraumatic stress, anddepression. In another study comparing criminal and civil attor-neys, Hasnain, Naz, and Bano (2010) also found that criminalattorneys reported higher levels of stress than civil attorneys. Thisdifference was seen among attorneys with more than 10 years’experience but was not observed in attorneys in training. Pi-wowarczyk et al. (2009) reported that among 57 attorneys special-izing in asylum cases, hours per week devoted to those casescorrelated with trauma score. All of these studies of attorneyssuggest a relationship between exposure to trauma and attorneys’symptoms but suffer from small sample size and, given theircross-sectional design, do not elucidate the course of the symptomsor the direction of effects between exposure and symptomatology.Studies of other human service professionals working with trauma-exposed clients such as social workers (Kassam-Adams, 1999),law enforcement officers (Follette, Polusny, & Milbeck, 1994),and psychotherapists (Pearlman & MacIan, 1995) are also limitedby cross-sectional design. Some of these studies have linked in-tensity of work-related exposure (Creamer & Liddle, 2005; Er-iksson, Kemp, Gorsuch, Hoke, & Foy, 2001; Kassam-Adams,1999) to secondary trauma symptoms, although other findingshave suggested the primary importance of organizational andwork-related factors (Baird & Jenkins, 2003; Devilly, Wright, &Varker, 2009; Regehr, Hemsworth, Leslie, Howe, & Chau, 2004)compared with exposure.

Recently, in a large cross-sectional study, our group examinedindicators of secondary trauma among attorneys (n � 238) andtheir administrative support staff (n � 109) and found that theattorneys demonstrated significantly higher levels of posttraumaticstress disorder (PTSD) symptoms, depression, secondary traumaticstress, burnout, and functional impairment compared with admin-istrative support staff (Levin et al., 2011). In addition, we foundthat the difference in symptoms was mediated by attorneys’ longerwork hours and greater exposure to trauma-exposed clients andwas not related to other variables such as gender, years on the job,office size, or personal history of trauma. The present study useda longitudinal design in a subsample of attorneys from ourpreviously reported cohort of the Wisconsin State Public De-fender’s Office (Levin et al., 2011) to assess changes in symp-toms of PTSD, depression, and functional impairment over a10-month period. In addition, our design sought to measure therelative contributions of caseload of trauma-exposed clients andhours worked to symptom and functional impairment levelsover time and the direction of effects between caseload oftrauma-exposed clients, hours worked, and symptoms and func-tional impairment.

Method

Participants and Procedure

We conducted a longitudinal follow-up study on a sample ofattorneys working in the 38 offices of the Wisconsin State PublicDefender’s Office (Levin et al., 2011). In that study, we collecteddata in March 2010 via the Wisconsin State Public Defender’sOffice intranet to 307 attorneys, with an initial response of 238attorneys (78%). The data for the current study were based on afollow-up survey that was distributed in December 2010 to allattorneys working in the office. This resulted in 142 responses, ofwhich 107 were attorneys who had also completed the originalsurvey, representing 45% of the 238 who initially responded. The107 attorneys (51 men and 56 women) were in their mid-40s (M �45.72 years, SD � 11.0), with almost 16 years’ experience on thejob (M � 15.89, SD � 11.03), working on average in local offices(total staff) of more than 10–20 people (M � 2.40, SD � 1.0).Preliminary analyses indicated that the means for hours worked,t(236) � 0.81, ns, caseload of trauma-exposed clients, t(236) �0.20, ns, size of local office, t(236) � 0.09, ns, and backgroundvariables of gender (�2 � 0.59 ns), age, t(236) � 0.11, ns, years onthe job, t(236) � 0.55, ns, as well as the outcome variables ofintrusion, t(236) � 0.44, ns, avoidance, t(236) � 1.42, ns, hyper-arousal, t(236) � 0.79, ns, depression, t(236) � 0.22, ns, andfunctional impairment, t(236) � 0.47, ns, did not differ at theinitial survey in March 2010 between the subset that followed up(n � 107) and the remaining 131 participants.

Survey materials were made available online by the surveyoffice of the State Bar of Wisconsin. Potential participants re-ceived an e-mail providing the necessary link to the questionnairesand were encouraged to complete the survey from personal com-puters on the job site. All participants received information regard-ing the study in the form of an informed consent cover letter at thestart of the online survey packet. Proceeding to the questionnaireindicated consent. Participation was voluntary and anonymous andthere was no remuneration for participation. The research proposalwas reviewed and approved by the Westchester Jewish Commu-nity Services Research Committee as well as its board of directorsand chief executive officers. Leadership at both the WisconsinPublic Defender’s Office and the Wisconsin Bar also reviewed andapproved the study.

Measures

Background and trauma exposure assessments. Demo-graphic and personal information included age, gender, number ofyears on the job, average number of hours worked per week (forthe prior 3 months), and size of local office (total staff) specifiedon a 1–4 scale, ranging from 1 (fewer than 10), 2 (10–20), 3(21–40), and 4 (more than 40). Because participants expressed astrong need to protect their anonymity, information regarding thespecific office where the participant worked as well as ethnicorigin were omitted.

The attorneys routinely interact closely with defendants in localjails, prisons, courthouses, and in their own offices. Cases run thegamut from mild violence or substance abuse to homicide andsexual offenses such as rape or child abuse allegedly perpetratedby the attorneys’ clients. In addition to hearing first-hand accounts,

2 LEVIN, BESSER, ALBERT, SMITH, AND NERIA

the attorneys review reports and photographs and have contactwith physical evidence (e.g., bloody clothing). Exposure to clienttrauma was assessed at baseline (Time 1) and 10 months later(Time 2) by asking, “How many clients have you worked withwithin the last three months who had experienced or been directlyinvolved with trauma such as death, physical assault or abuse,domestic violence, rape, violence or fire?” Participants were in-structed to select the closest number on a 0–5 scale: 0 (none), 1(1–20), 2 (21–40), 3 (41–60), 4 (61–80), and 5 (81 or more). Weelected to use six categories rather than a precise number becauseour pilot study indicated that attorneys were not able to report anexact number based on their recollection of the prior 3 months.However, it is important to note that five response categories arebelieved to represent an interval level of measurement. The use ofthe six categories in our study does not violate the axiom oftransitivity for the ordinal scale; the intervals between the scalepoints (number of clients represented by each category) corre-spond to empirical observations in our pilot study (see, e.g.,Dawes, 2008).

Outcome variables.PTSD symptoms. The Impact of Event Scale—Revised

(IES–R; Weiss & Marmar, 1997) was used to assess symptoms ofPTSD at Time 1 and Time 2. This instrument comprises 22 itemsderived from the PTSD criteria of the Diagnostic and StatisticalManual of Mental Disorders (4th ed.; DSM–IV; American Psychi-atric Association, 1994). Respondents were asked to rate each itemon a scale of 0 (not at all), 1 (a little bit), 2 (moderately), 3 (quitea bit), and 4 (extremely), according to how distressed they hadbeen by symptoms of intrusion, hyperarousal, and avoidance overthe past 7 days. All participants were asked to specifically link thesymptoms to traumatic material related to a case or cases they hadencountered as part of their work. No timeframe was specifiedregarding when the material was encountered. The IES–R hasgood psychometric properties (Creamer, Bell, & Failla, 2003) andhas good convergent validity with other measures of PTSD(Ljubotina & Muslic, 2003). In the present study, we obtainedinternal consistency Cronbach’s reliability coefficients of � � .79,.80, and .85, and � � .80, .78, and .86, for avoidance, hyper-arousal, and intrusion subscales, at Time 1 and Time 2, respec-tively.

Depressive symptoms. The Center for Epidemiological Stud-ies Depression Scale (CES–D; Radloff, 1977) is a 20-item scaledesigned to measure severity of current depression in the generalpopulation and was used at Time 1 and Time 2. The items, each ofwhich is assessed on a scale from 0 to 3, measure depressed mood,feelings of guilt and worthlessness, feelings of helplessness andhopelessness, psychomotor retardation, loss of appetite, and sleepdisturbances (Radloff, 1977). All participants were asked to reportsymptoms they had experienced in the past week. The CES–D isin wide use and has acceptable levels of internal consistency(Radloff, 1977). Extensive evidence from a variety of samplesattests to the reliability and validity of the CES–D (Eaton, Mun-taner, Smith, Tien, & Ybarra, 2004). In the present sample, theestimates of internal consistency Cronbach’s reliability coeffi-cients were � � .91 and � � .93 at Time 1 and Time 2, respec-tively.

Functional impairment. The Sheehan Disability Scale (SDS;Sheehan, Harnett-Sheehan, & Raj, 1996) was used to assess theextent to which exposure to clients’ traumatic material interfered

with functioning in three spheres at Time 1 and Time 2. Partici-pants rated the following question (in three forms): “My feelingsabout the clients and cases at work have disrupted my (work, sociallife/leisure, or family life/home responsibilities)” on a visual ana-logue scale ranging from 0 (none), 1–3 (mild), 4–6 (moderate),7–9 (severe), to 10 (very severe). In the present sample, theestimates of internal consistency Cronbach’s reliability coeffi-cients were � � .91 and � � .90 at Time 1 and Time 2, respec-tively.

Data Analysis

Mean scores for exposure to traumatic clients and hours at workas well as for IES–R, CES–D, and SDS scores were calculated andcompared between times (repeated measure) using t tests andstability of symptoms was assessed using Pearson correlationamong same assessments over time. We then performed a bivariateanalysis correlating demographics, work variables, and exposurewith the symptoms scales at each time point.

Following these initial tests, we tested our hypotheses regardingthe role of work-related exposure (exposure to client trauma andhours at work) for the outcome variables using multivariate anal-yses. We used cross-lagged panel correlation path models to ex-plore the causal sequence between exposure to traumatic clientsand work hours at Time 1 and symptomatology at Time 2 (PTSDor CES–D or SDS), using structural equation modeling (SEM) thatassessed measurement errors for the dependent and independentvariables (Hoyle & Smith, 1994) with AMOS software (Version18.0.0; Arbuckle, 2009) and the maximum likelihood method.Several components of these models are noteworthy. First, theyinclude two time points, and the effects of exposure and hours atwork on PTSD, depression, and functional impairment are esti-mated. These aspects of the models are referred to as cross-laggedeffects. Second, the model also includes the influence of exposureand hours at work at the first time point on exposure and hours atwork at the later time point. The same is true for PTSD, depres-sion, and functional impairment. These aspects of the model,called autoregressive effects, can be thought of as indicators of thetemporal stability of the measures. Estimations of these parametersin the model control for the stability of the variables. Thus, anycross-lagged effects can be considered effects that add predictivepower over and above that which can be simply obtained from thestability of the measures. Finally, note that exposure, hours atwork, PTSD, depression, and functional impairment are each al-lowed to intercorrelate within each time point. These aspects of themodel are called synchronous correlations. Estimating these errorsin the model allows for correlations between variances in PTSD ordepression or functional impairment and exposure and hours atwork that are not already explained by the influences of thevariables from earlier time points.

A nonsignificant chi-square has traditionally been used as acriterion for not rejecting an SEM; a nonsignificant chi-squareindicates that the discrepancy of the matrix of the parametersestimated based on the model being evaluated is not different fromthe one based on the empirical data. Given the restrictiveness ofthe chi-square approach for assessing model fit (Jöreskog & Sör-bom, 1993; Kenny & McCoach, 2003; Landry, Smith, Swank, &Miller-Loncar, 2000), we also used alternative criteria that reflectthe real-world conditions of clinical research in addition to the

3ATTORNEYS WORKING WITH TRAUMA-EXPOSED CLIENTS

overall chi-square test of exact fit to evaluate the proposed models:(a) the �2/df ratio, (b) the root mean square error of approximation(RMSEA), (c) the comparative fit index (CFI), and (d) the non-normed fit index (NNFI). A model in which �2/df was � 2, CFIand NNFI were greater than 0.95, and the RMSEA index wasbetween 0.00 and 0.08 (Hu & Bentler, 1999) was deemed accept-able. These moderately stringent acceptance criteria clearly rejectinadequate or poorly specified models, but accept for considerationmodels that meet real-world criteria for reasonable fit and repre-sentation of the data (Kelloway, 1998). Effect sizes were computedusing Cohen’s d (Cohen, 1992).

Results

Descriptive Statistics

On average, participants had almost 16 years on the job (M �15.89 years, SD � 11.03), were working more than 46 hr/week(M � 46.07, SD � 6.61), were from offices of (total staff) morethan 10–20 people (M � 2.40, SD � 1), and were exposed to41–60 clients within the past 3 months who had experienced orbeen directly involved with trauma such as death, physical assaultor abuse, domestic violence, rape, violence, or fire (M � 3.16,SD � 1.23).

Baseline to Follow-up Differences in PTSD,Depression, and Functional Impairment

As shown in Table 1, no significant changes were found inmean scores of baseline and follow-up for average number ofhours worked per week, depression, functional impairment, andhyperarousal symptoms. However, participants reported signif-icantly lower mean scores of work-related exposure, intrusion,and avoidance at Time 2. As can also be seen from Table 1,correlations indicate that all symptom scores reported at Time 1were significantly and strongly associated with the correspond-ing symptom scores reported at Time 2, indicating strong andsignificant stability. Moreover, significant strong stability was

also demonstrated for average number of hours worked as wellas for level of exposure to trauma-exposed clients.

Fifteen percent and 9% of the sample met screening criteria forPTSD at Time 1 and Time 2, respectively (p � .18). A cutoff of1.5 (equivalent to a total score of 33) was found to provide thehighest levels of sensitivity/specificity when comparing the IES–Rwith the PTSD Checklist (Creamer et al., 2003) and was used as acutoff for preliminary diagnosis of PTSD (see, e.g., Weiss, 2007).Forty-three percent and 40.2% of the sample met screening criteriafor depression at Time 1 and Time 2, respectively. A score of �16has been used as the cutoff point for high likelihood of clinicallysignificant depression (Radloff, 1977). Finally, 74.8% and 73.8%of the sample met screening criteria for functional impairment atTime 1 and Time 2, respectively. A score of �5 for any of thethree questions is associated with significant functional impair-ment (Sheehan et al., 1996).

Bivariate Associations

Table 2 provides a summary of the zero-order correlations forthe study variables. Gender, age, years on the job, and size oflocal office did not significantly correlate with any of theoutcome variables at either time point. Work-related exposurewas significantly correlated with depression (r � .24, d � 0.49,and r � .22, d � 0.45) and impairment (r � .27, d � 0.56, andr � .33, d � 0.70) at both time points and at Time 2 withintrusion (r � .24, d � 0.49) and hyperarousal (r � .27, d �0.56) symptoms. Average number of hours worked per weekcorrelated with depression (r � .27, d � 0.56), functionalimpairment (r � .31, d � 0.65), intrusion (r � .34, d � 0.72),and hyperarousal (r � .30, d � 0.63) at Time 1 but not with anyof the outcome variables at Time 2.

Multivariable Analyses: Cross-Lagged Models

Prediction of PTSD symptoms (IES–R). At each time point,we defined the latent PTSD construct (factor) using participants’intrusion, avoidance, and hyperarousal scores as its indicators

Table 1Number of Working Hours, Caseload of Trauma-Exposed Clients, and Outcome Variables at Time 1 and Time 2

Variable

Time 1 Time 2

t(106)

95% CI

Cohen’s da r (Time 1 and 2)M SD M SD LL UL

Average number of hours working 46.06 6.61 46.01 6.97 �0.22, ns �1.33 1.06 .58��

Work-related exposureb 3.17 1.23 2.89 1.10 2.76�� 0.080 0.49 0.27 .59��

PTSDIES–R Intrusion 0.76 0.59 0.43 0.55 6.30�� 0.23 0.43 0.63 .58��

IES–R Avoidance 0.76 0.70 0.55 0.57 3.44�� 0.093 0.34 0.34 .52��

IES–R Hyperarousal 0.61 0.65 0.61 0.61 �0.06, ns �0.11 0.10 .62��

CES–D 14.54 10.51 15.67 9.59 �1.43, ns �2.67 0.43 .68��

SDS 10.17 6.95 9.82 6.78 0.57, ns �0.84 1.53 .62��

Note. N � 107. PTSD � posttraumatic stress disorder; IES–R � Impact of Event Scale—Revised; CES–D � Center for Epidemiological StudiesDepression Scale; SDS � Sheehan Disability Scale; CI � confidence interval; LL � lower limit; UL � upper limit.a Cohen’s d has been corrected for dependence between means using Morris and DeShon’s (2002) Equation 8. b “How many clients have you workedwith, within the last three months, who had experienced or been directly involved with trauma such as death, physical assault or abuse, domestic violence,rape, violence or fire?” Participants were instructed to select the closest number on a 0–5 scale, where 0 � none, 1 � 1–20, 2 � 21–40, 3 � 41–60, 4 �61–80, and 5 � 81 or more.�� p � .01. �� p � .001 (two-tailed).


while controlling for the autocorrelations among same measureserrors (within-subject repeated measures). This cross-lagged SEM(see Figure 1) fit the observed data well, �2(21) � 14.90, p � .83,�2/df � 0.71; NNFI � 1.0; CFI � 1.0; RMSEA � 0.0001, 95% CI[0.000, 0.05]. This model showed a nonsignificant effect of Time1 PTSD symptoms on Time 2 exposure or hours at work, � � –.06,t � –0.65, ns, and � � –.06, t � �1.39, ns, respectively, as wellas nonsignificant effects of Time 1 hours at work on Time 2exposure or PTSD symptoms, � � .07, t � 0.82, ns, and � � –.04,t � –0.46, ns, respectively. In contrast, Time 1 exposure had anoteworthy and statistically significant follow-up effect on PTSDsymptoms, exposure, and hours at work, such that higher levels ofexposure at one time point were related to an increased level ofPTSD symptoms, � � .28, t � 3.43, p � .001, d � 0.67, and adecreased level of hours at work, � � –.18, t � �2.17, p � .03,d � 0.42, at the subsequent time point, as evidenced by thestatistically significant cross-lagged parameters. These findingsindicate that exposure significantly predicted or affected attor-neys’ PTSD symptomatology and hours spent at work Time 2,and that attorneys’ PTSD symptomatology or hours spent atwork at Time 1 did not predict or affect levels of exposure atTime 2. Moreover, hours at work at Time 1 affected exposureand PTSD symptoms at Time 2 indirectly through its associa-tion with exposure at Time 1. These associations were notaltered when we controlled for gender, age, years on the job,and size of local office and their associations with predictorsand outcomes.

Prediction of depressive symptoms (CES–D). At each timepoint, we defined the observed variable overall CES–D scores.This cross-lagged path model had zero degrees of freedom; thus,fit indices could not be estimated (see Figure 2). This modelshowed a nonsignificant effect of Time 1 CES–D symptoms onTime 2 exposure or hours at work, � � –.07, t � –0.82, ns, and� � .03, t � 0.36, ns, respectively, as well as nonsignificant

effects of Time 1 hours at work on Time 2 exposure or CES–Dsymptoms, � � .07, t � 0.76, ns, and � � .10, t � 1.37, ns,respectively). In contrast, Time 1 exposure had a noteworthy andstatistically significant follow-up effect on CES–D symptoms,exposure, and hours at work, such that higher levels of exposure atone time point were related to an increased level of PTSD symp-toms, � � .20, t � 2.70, p � .01, d � 0.53, and a decreased levelof hours at work, � � –.19, t � �2.26, p � .02. d � 0.44, at thesubsequent time point, as evidenced by the statistically significantcross-lagged parameters. These findings indicate that exposuresignificantly predicted or affected attorneys’ CES–D symptom-atology and hours spent at work at Time 2, and that attorneys’CED–D symptomatology or hours spent at work at Time 1 did notpredict or affect levels of exposure at Time 2. Moreover, hours atwork at Time 1 affected exposure and CES–D symptoms at Time2 indirectly through its association with exposure at Time 1. Theseassociations were not altered when we controlled for gender, age,years on the job, and size of local office and their associations withpredictors and outcomes.

To obtain the most parsimonious model and allow the evalua-tion of the overall goodness of fit of the path model, we calculatedthe final model in which we removed the nonsignificant pathsfound in the full model (i.e., of Time 1 hours at work on Time 2CES–D and exposure and of Time 1 CES–D on Time 2 exposureand hours at work). This model fit the observed data well, �2(4) �3.14, p � .54, �2/df � 0.79; NNFI � 1.0; CFI � 1.0; RMSEA �0.0001, 95% CI [0.000, 0.08].

Prediction of functional impairment (SDS). At each timepoint, we defined the observed variable overall SDS scores. Thiscross-lagged path model had zero degrees of freedom; thus, fitindices could not be estimated (see Figure 3). This model showeda nonsignificant effect of Time 1 SDS symptoms on Time 2exposure or hours at work, � � –.09, t � �1.08, ns, and � � –.04,t � –0.53, ns, respectively, as well as nonsignificant effects of

Table 2Correlations Between Predictors and Outcome Variables at Time 1 and Time 2

Predictor

PTSD subscale

CES–D SDSIntrusion Avoidance Hyperarousal

Time 1Gendera �.14 �.26 �.19 �.23 �.23Age .05 �.06 �.00 �.03 .05Years on the job .00 �.03 �.04 �.07 .00Size of local office .16 �.03 .19 �.03 .06Average number of hours working .34�� .16 .30�� .27�� .31��

Work-related exposure .13 .07 .20 .24�� .27��

Time 2Gendera �.15 �.07 �.17 �.11 �.21Age .08 .12 .05 .11 .00Years on the job .00 .08 �.00 .07 �.08Size of local office .03 .10 �.12 �.001 �.03Average number of hours working .05 .11 .07 .18 .18Work-related exposure .24�� .16 .27�� .22� .33��

Note. N � 107. PTSD � posttraumatic stress disorder; IES–R � Impact of Event Scale—Revised; CES–D �Center for Epidemiological Studies Depression Scale; SDS � Sheehan Disability Scale.a Gender is a binary-coded variable (0 � women, 1 � men).To ensure that the overall chance of a Type I error remained less than .05, we applied a full Bonferronicorrection.�� p � .01 (two-tailed).


Time 1 hours at work on Time 2 exposure or SDS symptoms, � �.07, t � 0.83, ns, and � � .05, t � .54, ns, respectively. In contrast,Time 1 exposure had a noteworthy and statistically significantfollow-up effect on SDS symptoms, exposure, and hours at work,such that higher levels of exposure at one time point were relatedto an increased level of SDS symptoms, � � .20, t � 2.39, p � .01,d � 0.47, and a decreased level of hours at work, � � –.18, t ��2.15, p � .03, d � 0.42, at the subsequent time point, asevidenced by the statistically significant cross-lagged parameters.These findings indicate that exposure significantly predicted oraffected attorneys’ SDS symptomatology and hours spent at workat Time 2, and that attorneys’ SDS symptomatology or hours spentat work at Time 1 did not predict or affect levels of exposure atTime 2. Moreover, hours at work at Time 1 affected exposure andSDS symptoms at Time 2 indirectly through its association withexposure at Time 1. These associations were not altered when wecontrolled for gender, age, years on the job, and size of local officeand their associations with predictors and outcomes.

To obtain the most parsimonious model and allow the evalua-tion of the overall goodness of fit of the path model, we calculatedthe final model in which we removed the nonsignificant pathsfound in the full model (i.e., of Time 1 hours at work on Time 2

SDS and exposure and of Time 1 SDS on Time 2 exposure andhours at work). This model fit the observed data well, �2(4) �1.67, p � .80, �2/df � 0.42; NNFI � 1.0; CFI � 1.0; RMSEA �0.0001, 95% CI [0.000, 0.09].

Discussion

To our knowledge, this study reports one of the first investiga-tions in attorneys (or any helping professionals) examining longi-tudinal changes in mental health outcome measures includingPTSD, depression, and functional impairment and the relationshipof these symptoms to work with trauma-exposed clients. Theparticipants, 107 attorneys working in the Wisconsin State PublicDefender’s Office, experienced continued stress over a 10-monthperiod as demonstrated by similar levels of depression, functionalimpairment, and PTSD hyperarousal at both time points. Further-more, the percentage of attorneys who exceeded clinical thresholdsfor depression and functional impairment was unchanged over theperiod of the study. Although there was a modest but significantdecrease in the PTSD symptoms of intrusion and avoidance overthe 10-month period, there was no significant change in the num-ber of attorneys who scored above the threshold of clinically

Figure 1. The cross-lagged model for the prediction of posttraumatic stress disorder (PTSD) symptoms.Rectangles indicate measured variables and large circles represent latent constructs. Small circles reflectresiduals (e) or disturbances (d); bold numbers above or near endogenous variables represent the amount ofvariance explained (R2). Bidirectional arrows depict correlations and unidirectional arrows depict hypothesizeddirectional or “causal” links. Standardized maximum likelihood parameters are used. Bold estimates arestatistically significant. The dotted paths indicate nonsignificant, “causal” links/associations. N � 107. � p � .05.�� p � .01. �� p � .001 (two-tailed). When we controlled for the effects of gender, age, years on the job, andsize of local office, the significant and nonsignificant effects, as presented in this figure, were not altered. Theseeffects were removed to simplify the figure.


significant PTSD. Total hours worked per week were unchanged,but caseload of trauma-exposed clients did show a small butsignificant decrease. These decreases in the PTSD symptoms andcaseload of trauma-exposed clients may suggest that the attorneyswho participated in the follow-up survey were initially in lessdistress, but there were no statistical differences found on any ofthe symptom measures at baseline between the participants who

followed up with those who did not. Overall, these findings indi-cate significant stability in levels of symptomatology over a 10-month period.

Bivariate analysis revealed that average caseload of trauma-exposed clients significantly correlated with depression and func-tional impairment measures at both time points, whereas hoursworked per week only correlated with these measures at baseline.

Figure 2. The cross-lagged model for the prediction of depressive symptoms (Center for EpidemiologicalStudies Depression Scale [CES–D]). Rectangles indicate measured variables. Small circles reflect residuals (e).Bold numbers above or near endogenous variables represent the amount of variance explained (R2). Bidirectionalarrows depict correlations and unidirectional arrows depict hypothesized directional or “causal” links. Stan-dardized maximum likelihood parameters are used. Bold estimates are statistically significant. N � 107. � p �.05. �� p � .01. �� p � .001 (two-tailed). When we controlled for the effects of gender, age, years on the job,and size of local office, the significant and nonsignificant effects, as presented in this figure, were not altered.These effects were removed to simplify the figure.

Figure 3. The cross-lagged model for the prediction of functional impairment symptoms (Sheehan DisabilityScale [SDS]). Rectangles indicate measured variables. Small circles reflect residuals (e). Bold numbers aboveor near endogenous variables represent the amount of variance explained (R2). Bidirectional arrows depictcorrelations and unidirectional arrows depict hypothesized directional or “causal” links. Standardized maximumlikelihood parameters are used. Bold estimates are statistically significant. N � 107. � p � .05. �� p � .01.�� p � .001 (two-tailed). When we controlled for the effects of gender, age, years on the job, and size of localoffice, the significant and nonsignificant effects, as presented in this figure, were not altered. These effects wereremoved to simplify the figure.


Furthermore, average caseload correlated with intrusion and hy-perarousal at follow-up but not at baseline. These inconsistentcorrelations between outcome variables and exposure measured byhours worked and trauma-exposed client caseload mirror theequivocal findings in the general secondary trauma literature (e.g.,Kassam-Adams, 1999, and Creamer & Liddle, 2005, vs. Bosca-rino, Figley, & Adams, 2004) and contrast with our earlier report(Levin et al., 2011) in which both factors correlated with symp-toms in the larger sample surveyed at the initial time point.Piwowarczyk et al. (2009), in a small sample, also found a rela-tionship between caseload of trauma-exposed clients and increasedsymptoms in asylum attorneys. Gender, age, years on the job, andsize of office were not correlated with any of the outcome mea-sures at either time point.

Consistent with our previous findings (Levin et al., 2011), theseresults on balance show that attorneys were more likely to exhibitincreased levels of symptomatology when working with trauma-exposed clients. However, the current study’s follow-up findingsindicate cross-lagged effects in which exposure had a significanteffect over time on both hours worked and symptomatology suchthat higher levels of exposure at Time 1 were related to increasedsymptoms and decreased hours worked 10 months later. Stateddifferently, the cross-lagged findings indicate that over and abovethe continued levels PTSD, depression, and functional impairment,there was an additional unique effect of exposure on these outcomemeasures over time. Furthermore, no reciprocal effects werefound, that is, whereas higher levels of exposure predicted in-creased levels of symptoms and decreased hours at work 10months later, PTSD, depression, and functional impairment did nothave any effects on exposure over time.

Our findings suggest several possible conclusions. First, theyprovide strong evidence that exposure to trauma-exposed clientsmay be a vulnerability factor, given that higher levels of exposureresulted in increased severity of symptoms and reduced time spentat work 10 months later. Furthermore, the lack of reciprocal effectssuggests that the attorneys surveyed may have ignored their symp-toms of distress in making decisions about working hours andcaseload. We might speculate that attorneys decreased their workhours over the 10-month period in response to study participationand the accompanying increased awareness of the phenomenon ofsecondary trauma and not because of how they felt. At the sametime, they did not (or were unable to) decrease their caseloads oftrauma-exposed cases. In this regard, a number of participants ofthe study stated (sometimes quite emphatically) in a commentsfield at the end of the survey that they felt “powerless” to managetheir caseloads. Thus, alternatively, we might speculate that con-tinued high caseloads of trauma-exposed clients were unavoidable.

Our results and the results of other studies of professionalsworking with perpetrators suggest a need to expand Figley’s(1995) formulation that secondary trauma is “the stress resultingfrom helping or wanting to help a traumatized or suffering person”(p. 7). The present study, as well as our earlier study (Levin et al.,2011), and the studies of Gomme and Hall (1995) with prosecutorsand Vrklevski and Franklin (2008) with criminal defense attor-neys, illustrate that work with perpetrators precipitates secondarytraumatic stress responses. Likewise, studies of sexual offendertherapists document secondary traumatic responses similar tothose seen in therapists treating victims (see review by Moulden &Firestone, 2007). The only study comparing these two groups of

therapists reported similar levels of symptoms in both groups(Way, VanDeusen, Martin, Applegate, & Jandle, 2004). Mouldenand Firestone (2007) concluded that work with perpetrators pre-cipitates symptoms in therapists via the same mechanisms (e.g.,constructivist self-development theory) thought to cause symp-toms in any professional exposed to traumatic material. In light ofthese findings, it appears that exposure to traumatic material,regardless of the relationship with the client, precipitates symp-toms. It should be noted that our questionnaire asked the attorneysto quantify the number of clients who “had experienced or beendirectly involved with trauma.” Given that criminal defendants arethemselves often victims of trauma, the clients were most likely tobe both perpetrators and victims. The attorneys in our studycommented that they frequently experienced negative feelingstoward the people they were assigned to defend. Future researchshould attempt to tease out the effects of sympathy versus revul-sion toward the client as well as the effects of perpetrator versusvictim status on the development of symptoms.

Although our prior report (Levin et al., 2011) identified the needto support attorneys by addressing their work hours and theircaseloads, this study suggests that given limited resources to effectchange, the focus should be on the attorneys with the largestcaseloads of trauma-exposed clients. In addition to developingstrategies to decrease the size of these caseloads, perhaps byrotation of attorneys who receive these cases, the present studysuggests that resources such as counseling and education should beconcentrated on supporting these attorneys. Although the efficacyof traditional approaches for assisting professionals who experi-ence secondary trauma exposure (e.g., Gentry, Baranowsky, &Dunning, 2002) including education about trauma and develop-ment of personal resilience have been challenged (Bober & Re-gehr, 2006), the current findings again tilt toward more specificemphasis on the work with the trauma-exposed clients rather thansimply addressing general working conditions. Longitudinal stud-ies of primary victims of trauma suggest that social support (Galeaet al., 2002; Neria, Besser, Kiper, & Westphal, 2010) and copingstrategies (Mayou, Ehlers, & Bryant, 2002) affect long-term out-come in victims beyond the intensity of exposure, highlighting theneed to examine these factors in future studies of outcomes inhelping professionals working with trauma-exposed populations.

The present study has several limitations. First, the study used asample confined to attorneys who work as public defenders whowere demographically homogeneous, thus limiting generalizabilityto other attorneys and other helping professionals. Second, al-though this is the only study we are aware of that has surveyedattorneys longitudinally, the sample of attorneys who repeated thesurvey (N � 107) was relatively small. One factor contributing tothe follow-up rate of 45% may have been the lack of remuneration.The validity of our findings in this limited sample is bolstered bythe lack of difference on any variables between the participantsand the attorneys who did not repeat the study. A future studyshould examine responses in a larger, more diverse sample acrossa range of attorney types, that is, defense, prosecution, civil, andeven corporate, and if possible, compare them with other profes-sionals with different levels of exposure. A further limitation is thelack of a precise characterization of the specific types and frequen-cies of trauma (assault, homicide, rape, fire, etc.) encountered bythe public defenders. This is a general limitation in the legal field;for example, Gomme and Hall (1995) characterized the impact of


work with domestic violence and incest on prosecutors, but theydid not quantify this caseload nor did they have a comparison withprosecutors working, for instance, in homicide. This is another richarea for future exploration.

Despite these limitations, our study investigated a unique phe-nomenon, focusing on longitudinal exposure and symptoms thatmay well have significant ecological validity. The study focusedon participants who reported on their experiences as they wereoccurring over a 10-month period. Moreover, to our knowledge,the present study represents the first attempt toward understandingthe relationships between attorneys’ exposure to trauma-exposedclients and symptomatology, over time, through the use of across-lagged design. An important next step will be to use longi-tudinal designs to explore the underlying mechanisms of attorneys’exposure-related symptoms. For example, one possible directionwould be to examine the longitudinal role of various affect regu-lation strategies, coping mechanisms, and social support as poten-tial mediators and/or moderators of the effects of exposure overtime. Taken as a whole, the present study points to the central roleof attorneys’ individual differences in exposure to trauma-exposedclients in the development of symptoms of PTSD, depression, andfunctional impairment.

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Received October 13, 2011Revision received December 23, 2011

Accepted February 16, 2012 �


ISCONSIN

The

WDEFENDER

Winter/Spring 2009Volume 17, Issue 1

Keeping Legal Minds Intact:Mitigating Compassion Fatigue among Government LawyersBy Linda Albert*, LCSW, CSACWisLAP Coordinator

What is compassion fatigue?There are several different terms often used to refer to the same phenomenon; to name a few: compassionfatigue, vicarious trauma, secondary traumatic stress, second hand shock and secondary stress reaction.Compassion fatigue is defined as the cumulative physical, emotional and psychological effects of beingcontinually exposed to traumatic stories or events when working in a helping capacity. It has been studiedextensively in social workers, nurses, doctors and therapists who work with victims of trauma. Recentlyresearchers have begun to examine the impact upon legal professionals including lawyers doing criminal lawor family law and judges. Compassion fatigue involves a cluster of symptoms such as, but not limited to,sleep disturbance, anxiety, intrusive thoughts, a sense of futility or pessimism about people, lethargy, isolationand irritability. The development of compassion fatigue involves neurophysiology and is best addressedfrom both the neurobiological and the social psychological research and perspectives.

Who is most at risk?Levin et al (2003) found that attorneys and judges who work in the field of criminal or family law areconsidered at higher risk of developing compassion fatigue compared to those who work in other areas ofthe law. These legal professionals listen day after day to stories of human induced violence. They read andre-read detailed documentation of the traumatic material within cases. Attorneys are often times in long termrelationships with their clients thereby witnessing the impact of the trauma upon their client or their clients’victim. They observe domestic violence victims re-entering into risky environments without regard forsafety and throughout their work with victims, offenders and the system are expected to perform at the topof their game without being impacted by the traumatic material. After all, lawyers are taught not to showweakness, to deny, defend and deflect vulnerability, while staying emotionally detached at all times.

The reality is that government lawyers are human beings. Any person regardless of professionalcompetence can develop compassion fatigue. The struggle for government lawyers is the assumption (boththeir own and that of others) that they will not be impacted by the work that they do. The reality can bequite different. Lawyers that are exposed to traumatic stories and events may have physiological reactions

*Linda Albert is a Licensed Clinical Social Worker and a Certified Alcohol and Drug Counselor. Shereceived her Master’s Degree from UW-Madison in Social Work. She has professional assessment/treatment/referral competencies in the areas of addictions, eating disorders, depression, anxiety, traumaand illness impacted by stress. Linda has worked over the past 25 years as an administrator, consultant,trainer and psychotherapist in a variety of settings including providing services to impaired professionals.She has done multiple presentations for conferences at the local, state and national level. Currently Lindais employed by the State Bar of Wisconsin as the WisLap Coordinator.

Reprint permission granted by theWisconsin Defender Magazine

such as increased heart rate, breathing rate and muscle tension. They can have emotional responses such assadness, anger or fear. They may also experience changes in their assumptions about life, other people andissues of safety. Often lawyers will be unaware of these reactions or ignore or dismiss them as unimportant.These reactions are indicative of the physiological and psychological changes occurring within the mind/bodydue to the processes of empathy or identification, reactions of the autonomic nervous system and patterns ofthinking. If left unchecked and unattended to these reactions wear on the mind and the body resulting in theabove mentioned cluster of symptoms known as compassion fatigue. The results can be varying degrees ofimpairment for the attorney.

What places government lawyers at increased risk?Levin et al. (2003) found that compared to mental health providers and social service workers attorneyswho worked with domestic violence and criminal defendants had “significantly higher levels of secondarytraumatic stress and burnout”. Researchers went on to state that this is likely due to higher case loads, lackof supervision or support and lack of education in regards to the impact of ongoing exposure to traumaticmaterial and events. Osofsky et al. (2008) also identified similar organizational and job issues whichcontribute to the development of compassion fatigue. Factors included high caseloads, minimal supportfrom supervisors, lack of peer support, excessive paperwork, inadequate resources to meet demands andlimited job recognition. These researchers also reported the impact of compassion fatigue upon the workenvironment listing such issues as increased absenteeism, impaired judgment, low motivation, lowerproductivity and high staff turnover.

These factors coupled with the culture of practicing law may discourage government lawyers fromrecognizing the signs of distress, disclosing if they are struggling or prevent them from seeking assistance. Incontrast social service and mental health workers are educated about the potential impact of the work upontheir mental and physical health and are encouraged to talk about it and address how the work affects themin order to lessen the impact. This is often done in a safe, confidential and supportive environment.Government lawyers and their office managers universally state they do not have this provision built in totheir work environment, that they are bound by confidentiality and would lack the resources, time or energyto create this environment for themselves. However, some recognize the need for it.

Those working as public defenders or prosecutors may identify with some of the above. For example,prosecutors or public defenders involved in a long, arduous trial are seldom afforded the time to replenishand restore themselves following the trial. Instead they are likely to go forward the next day into anotherformidable case without the ability to take pause and reflect upon how the work is impacting themphysically, emotionally or mentally. One lawyer stated, “I am expected to operate like a machine, oftengetting notices to be at four places at the same time and go from trial to trial with no regard for what I canreasonable do or what the impact might be on myself as a professional or a person”. Another lawyerexpressed, “I am supposed to take it all in and not be affected by it; it’s like mental battering”.

What can legal organizations do?A review of the literature suggests that organizations that employ government lawyers first and foremostneed to recognize and acknowledge that compassion fatigue exists and identify how it impacts the lawyerand the organization. Prevention strategies include reducing caseloads due to the correlation between highcaseloads and the prevalence of compassion fatigue and educating government lawyers about whatcompassion fatigue is and how a person may be impacted while working with traumatic stories and events.Supervisors and managers would be astute to address this issue, educate their legal staff and encourage staffto debrief their high trauma cases on a regular basis in a supportive atmosphere. With the current culture of

budget deficits, limited space and resources and increasing caseloads it is imperative (albeit difficult) formanagers and organizations to adopt a strategy of how offices can address and mitigate this versus why theycannot.

What can legal professionals do?Whether an attorney, judge, doctor or a mental health professional the recommendations to mitigate or treatcompassion fatigue are similar.

Awareness. It is important for government lawyers to understand what compassion fatigue is, be assessingfor it through utilizing a survey, checklist or other instrument on a regular basis.

Debriefing. Talking on a regular basis with another government lawyer who understands and is supportiveis seen as helpful. This involves talking about the traumatic material, how one thinks and feels about it,acknowledging how one is personally affected by it and putting a plan in place for balance.

Balance. Working on balance in all areas of one’s life is emphasized throughout the research on mitigatingcompassion fatigue. Because of the physiological changes that occur a holistic approach is best. Yes, thismeans establishing a healthy diet, sleep and exercise program (argh) which we all talk about but few of usactually attend to. Exercise and relaxation work can be beneficial in counteracting the impact on theautonomic nervous system. Working on healthy interpersonal relationships is also a good idea (even if wehave been married or divorced a zillion years and live with small children, adolescents or have aging parentsgiving us the excuse to say “balance is impossible”). Most of us give up on finding balance as work andpersonal life just keeps pouring it on but the truth is there are probably steps we can take to simplify, to doless of, to ask for help or just plain stop trying to be all things to all people, including our clients. Soundfamiliar? Start thinking about how you can work on balance versus why you cannot.

Be intentional. If your life is out of whack, you have compassion fatigue, depression, anxiety, substanceabuse problems or are just plain overwhelmed, put a plan in place for change. Work with your thoughts.Recognize and acknowledge that the skills you possess which contribute to your success as an attorney(motivated, perfectionist, achievement oriented, driven, fixer,) and the environment in which you work inmay contribute to an imbalance in your life. Seeking balance encompasses a change in lifestyle whichrequires hard work addressing thoughts, emotions and behaviors. Intentionally seek assistance to helpyourself implement change and redirect the thoughts that tell you, “I should be able to do this by myself”.Your new mantra can become, “I don’t have to do it all by myself”.

The good news: WisLAP can be a resource specifically for you.If you want to consult with a mental health professional or work with a trained attorney consider calling theWisconsin Lawyers Assistance Program (WisLAP). WisLAP specializes in understanding and addressingthe issues which face today’s legal professionals. The program offers free in house educational sessions orone on one consultation or assistance for problems like compassion fatigue, depression, anxiety, addictionsor other challenges.

What is WisLAP?

WisLAP is a member service of the State Bar of Wisconsin. The program utilizes trained Wisconsin judgesand attorneys who provide confidential assistance to judges, lawyers, law students and their families. Eachrequest for help is treated with the same confidentiality as the lawyer-client relationship. WisLAP is exempt

from reporting professional misconduct to the Office of Lawyer Regulation (OLR) or to the JudicialCommission. WisLAP does not ask callers to disclose their identity and does not keep case records. Theprogram is designed to help members build on their strengths and provide support through the enhancementof physical, mental and emotional health. Confidential support is available 24/7 by calling 800-543-2625.Or contact Linda Albert, WisLAP Coordinator directly at 800-444-9404 ext 6172 or [email protected].

ReferencesFigley, C.R., Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treatthe Traumatized. New York: Brunner/Mazel, (1995)

Jaffe, P., Crooks, C., Dunford-Jackson, B., & Town, M. Vicarious Trauma in Judges: The PersonalChallenge of Dispensing Justice. 54 Juv. & Fam. Ct. J. 1-9 (2003)

Levin, A.P., & Greisberg, S. Vicarious Trauma in Attorneys. Pace Law Review, 24, 245-252, (2003).

Murry, D., & Royer, J. Vicarious Traumatization: The Corrosive Consequences of Law Practise forCriminal Justice and Family law Practitioners, (2003).

Osofsky, J., Putnam, F., & Lederman, C. How to Maintain Emotional Health When Working with Trauma.Juv and Fam Court J. 58, no. 4 (2008).

Rothschild, B. Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma.New York: W.W. Norton & Company, (2006)

Trippany, R., White Kress, V., & Wilcoxon, S.A. Preventing Vicarious Trauma: What Counselors ShouldKnow When Working with Trauma Survivors. J of Counsel. & Devel. Vol 82, Winter (2004).

Vrklevski, L., & Franklin, J., Vicarious trauma: The Impact on Solicitors of Exposure to TraumaticMaterial. Traumatology, 14; 106 (2008) Online version found at http://tmt.sagepub.com/cgi/content/abstract/14/1/106.

Secondary Traumatic Stress in Attorneys and Their AdministrativeSupport Staff Working With Trauma-Exposed Clients

Andrew P. Levin, MD,*Þ Linda Albert, LCSW,þ Avi Besser, PhD,§ Deborah Smith, JD,|| Alex Zelenski, MBA,þStacey Rosenkranz, PhD,¶ and Yuval Neria, PhDÞ#

Abstract: Although secondary trauma has been assessed in various groups ofmental health professionals, few studies, to date, have examined secondarytrauma among attorneys exposed to clients’ traumatic experiences. This studyexamined indicators of secondary trauma among attorneys (N = 238) and theiradministrative support staff (N = 109) in the Wisconsin State Public DefenderOffice. Attorney participants demonstrated significantly higher levels of post-traumatic stress disorder symptoms, depression, secondary traumatic stress, burn-out, and functional impairment compared with the administrative support staff.This difference was mediated by attorneys’ longer work hours and greater con-tact with clients who had experienced or had been directly involved with trauma.Sex, age, years on the job, office size, and personal history of trauma did notpredict symptoms. These findings suggest a need to support attorneys experi-encing these symptoms and to address high workloads as well as the intensityof contact with trauma-exposed clients.

Key Words: Attorneys, secondary traumatic stress, PTSD, depression,functional impairment, burnout.

(J Nerv Ment Dis 2011;199: 946Y955)

T he phenomenon of Secondary Traumatic Stress (STS; Figley,1995) or Vicarious Traumatization (VT; McCann and Pearlman,

1990) have been described since the mid-1980s, roughly coincidingwith the growth in treatments focused on clients who were victims oftrauma. Originally described in therapists, secondary trauma occurswhen the professional develops intrusive thoughts, avoidance andwithdrawal, and symptoms of tension and disturbed sleep related toexposure to traumatic material presented by the client (Figley, 1995).In addition, the professional may develop alterations in ‘‘basic assump-tions’’ about themselves, people, society, and safety (McCann andPearlman, 1990). In addition to STS and VT, professionals workingintensely with clients develop Burnout (BO), an accumulation ofstress and the erosion of idealism characterized by fatigue, poor sleep,headaches, anxiety, irritability, depression, hopelessness, aggression,cynicism, and substance abuse (Farber and Heifetz, 1982). In thisstudy, we examined the impact of work with clients who have expe-rienced or have been directly involved in trauma on attorneys and theiradministrative support staff in the Wisconsin State Public DefenderOffice.

Available research among mental health and social serviceproviders has identified several risk factors for the development of

STS and VT including female sex (Kassam-Adams, 1999), intensityof the exposure (Creamer and Liddle, 2005; Erikson et al., 2001;Kassam-Adams, 1999), history of previous trauma (Brady et al., 1999;Bride et al., 2007; Kassam-Adams, 1999), and less experience on thejob (Pearlman and Mac Ian, 1995). Subsequent studies have suggestedthe primary importance of organizational and work-related factorscompared with exposure (Baird and Jenkins, 2003; Devilly et al., 2009;Regehr et al., 2004) and have found no relationship with personaltrauma history (Boscarino et al., 2004; Ortlepp and Friedman, 2002;Schnaube and Frazier, 1995). Risk factors for BO include female sex,overwork, the slow and erratic pace of the work, lack of success, andthe tendency of the work to raise personal issues (Jenkins and Baird,2002; Maslach et al., 2001).

Drawing on the concepts of STS and VT, the ‘‘clinical’’(practice-related) law literature was the first to address the impact oflawyer-client relationship on the attorney (Meier, 1993; Silver, 1999)and the need for increased training of attorneys in managing the‘‘face-to-face, long-term, and intensely personal relationship’’ thatdevelops between client and attorney (Allegretti, 1993, p. 7). Earlyquantitative studies of attorneys focused on rates of depression, iden-tifying a 20% rate of clinically significant depression in the attorneyswho were surveyed (Benjamin et al., 1990; Eaton et al., 1990).

Only a handful of studies have attempted to characterize andquantify secondary trauma and BO symptoms experienced by attorneysand delineate their relationship to risk factors. Using semistructuredinterviews of 23 Canadian prosecutors working with ‘‘sensitive cases’’involving domestic violence and incest, Gomme and Hall (1995)found symptoms of demoralization, anxiety, helplessness, exhaustion,and social withdrawal that were qualitatively linked to high caseloadsand long work hours. Lynch (1997) reported that public defendersranked work overload, the unpredictability of trials, the frequent lackof a defense, harsh sentences, arguing with prosecutors, and interac-tions with angry clients and families as the most frequent and intensesources of job stress but did not relate these to any symptommeasures.More recently, Levin and Greisberg (2003) compared 55 attorneysworking in family and criminal court with 87 mental health profes-sionals and 25 social service workers. Their results indicated thatcompared with the other groups, attorneys demonstrated higher levelsof secondary trauma and BO that were correlated with caseload.Comparing 50 attorneys working in criminal courts with 50 workingin the civil arena, Vrlevski and Franklin (2008) found more depres-sive symptoms, subjective stress, and changes in sense of safety andintimacy among the criminal attorneys. A personal history of multipletraumas predicted higher scores on measures of vicarious trauma, post-traumatic stress, and depression. Piwowarcyzy et al. (2009) reportedthat among 57 attorneys specializing in asylum cases, the hours perweek devoted to those cases correlated with trauma score. All three ofthese studies of distress in attorneys suggest a relationship betweenexposure to trauma and distress but suffer from small sample size,selection bias involving convenience samples, and relatively low per-centage responses from the pool of possible subjects (Levin andGreisberg, 2003; Piwowarcyzy et al., 2009; Vrlevski and Franklin,2008).

The current study sought to address those limitations in a rel-atively larger study, assessing the relationships between exposure to

ORIGINAL ARTICLE

946 www.jonmd.com The Journal of Nervous and Mental Disease & Volume 199, Number 12, December 2011

*Westchester Jewish Community Services, Hartsdale, NY; †Department of Psychia-try, College of Physicians and Surgeons, Columbia University, New York, NY;‡Wisconsin Lawyers Assistance Program, State Bar of Wisconsin, Madison, WI;§Department of Behavioral Sciences and Center for Research in Personality,Life Transitions, and Stressful Life Events, Sapir Academic College, D. N. HofAshkelon, Israel; ||Assigned Counsel Division, Wisconsin State Public DefenderOffice,Madison,WI; ¶WeillMedical College, Cornell University, NewYork, NY;and #New York State Psychiatric Institute, New York, NY.

Send reprint requests to Andrew P. Levin, MD, Westchester JewishCommunity Services, 141 North Central Avenue, Hartsdale, NY 10530.E-mail: [email protected].

Copyright * 2011 by Lippincott Williams & WilkinsISSN: 0022-3018/11/19912<0946DOI: 10.1097/NMD.0b013e3182392c26

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

clients’ traumatic experiences and a range of outcomes includingposttraumatic stress disorder (PTSD) symptoms, depression, func-tional impairment, and STS and BO symptoms in attorneys andadministrative support staff working at the Wisconsin State PublicDefender Office. In light of previous studies, we hypothesized thata) the average number of hours working and the caseload of trauma-exposed clients would predict higher symptom load and b) attorneyswould experience greater symptoms than would administrative sup-port staff because of their greater client involvement. Moreover, weconceptualized attorneys’ work-related exposure (hours per week work-ing and number of trauma-exposed clients) as mediating variables1

based on our interpretation of the literature on both exposure andSTS. As such and consistent with the literature on exposure, ourprimary hypothesis was that c) work-related exposurewould serve as avehicle through which being directly versus indirectly exposed toclients who had experienced or had been directly involved in trauma isassociated with psychological symptoms. Specifically, attorneys, incomparison with administrative support staff, were expected to reporthigh levels of exposure, which, in turn, would be associated with theirsignificantly higher levels of PTSD symptoms, depression, functionalimpairment, STS, and BO symptoms. Lastly, the study explores therelationship between personal characteristics such as age, sex, yearson the job, office size, and personal trauma history and the outcomevariables. Given that the findings have varied for these factors inprevious studies, we did not predict specific effects for these inde-pendent variables.

METHODS

Participants and ProceduresWe sampled participants for this study from the Wisconsin

State Public Defender Office. At the time of the study (in early 2010)there were a total of 474 potential participants, including 307 attor-neys and 167 administrative support staff, in the 38 offices across thestate. The attorneys routinely interact closely with defendants in localjails, prisons, courthouses, and in their own offices. Cases run thegamut from mild violence or substance abuse to homicide and sexualoffenses such as rape or child abuse. In addition to hearing first-handaccounts, the attorneys review reports and photographs and havecontact with physical evidence such as bloody clothing. Administra-tive support staff typically performs brief financial eligibility eva-luations in their offices and at times, at the jail. On occasion,defendants spontaneously relate details of their offense to the supportstaff, who also have contact with reports and photographs.

Potential participants received encouragement to participate inthe study from the Wisconsin State Public Defender Office and theState Bar of Wisconsin as part of a program to raise awareness aboutstress. Survey materials were made available online by the surveyoffice of the State Bar of Wisconsin. Potential participants received anemail providing the necessary link to the questionnaires and wereencouraged to complete the survey from personal computers on thejob site. All subjects were provided with informed consent in the formof a cover letter at the start of the online survey packet. Proceeding tothe questionnaire indicated consent. Participation was voluntary andanonymous. The research proposal was reviewed and approved by theWestchester Jewish Community Services Research Committee as well

as its board of directors and chief executive officers. Leadership atboth the Wisconsin Public Defenders Office and the Wisconsin Baralso reviewed and approved the study. The final sample contains 347participants (an overall response rate of 73.20%) including 238 at-torneys (response rate of 77.52%) and 109 administrative support staff(response rate of 65.27%).

Measures

Background and Trauma Exposure AssessmentsDemographic and personal information included age, sex, job

description (attorney versus administrative support staff), number ofyears on the job, average number of hours worked per week (for theprevious 3 months), and size of local office (total staff) specified on a1-to-4 scale: less than 10 (1), 10 to 20 (2), 21 to 40 (3), and greaterthan 40 (4). Because participants expressed a strong need to protecttheir anonymity, information regarding the specific office where theparticipant worked as well as ethnic origin was omitted.

Personal history of trauma was gathered by asking, ‘‘Have youbeen a victim of any of the following types of trauma? Please estimatenumbers of incidents from childhood/adolescence (up to age 15).’’Types of trauma were divided into six groups: a) physical assault orabuse, b) sexual assault or abuse, c) witness to violence, d) other crimevictim, e) fire, and f) natural disaster. The question was repeated forage 16 years and older. Sum scores were generated for each of the ageperiods for the a) total number of physical and sexual assault or abuseincidents and b) total number of nonphysical/nonsexual traumaincidents.

Exposure to client trauma was assessed by asking, ‘‘How manyclients have you worked with, within the last three months who hadexperienced or been directly involved with trauma such as death,physical assault or abuse, domestic violence, rape, violence or fire?’’Participants were instructed to select the closest number on a 0-to-5scale: none (0), 1 to 20 (1), 21 to 40 (2), 41 to 60 (3), 61 to 80 (4), and81 or more (5).

Outcome VariablesPTSD symptoms

The Impact of Events ScaleYRevised (IES-R;Weiss andMarmar,1997) was used to assess the symptoms of PTSD. This instrumentis composed of 22 items derived from the PTSD criteria according tothe DSM-IV (American Psychiatric Association, 1994). Respondentswere asked to rate each item on a scale of 0 (not at all), 1 (a little bit),2 (moderately), 3 (quite a bit), and 4 (extremely), according to howdistressed they had been by symptoms of intrusion, hyperarousal, andavoidance over the past 7 days. All participants were asked to specifi-cally link the symptoms to traumatic material related to a case or casesthey had encountered as part of their work. No time frame was speci-fied regarding when the material was encountered. The IES-R has goodpsychometric properties (Creamer et al., 2003) and has good conver-gent validity with other measures of PTSD (Ljubotina and Muslic,2003). In the present study, we obtained internal consistency Cronbach’salpha reliability coefficients of > = 0.80, 0.82, and 0.87, for avoidance,hyperarousal, and intrusion, respectively. The maximum score for thescale is 88; a cutoff of 1.5 (equivalent to a total score of 33) was foundto provide the best diagnostic accuracy (Creamer et al., 2003).

Depressive symptomsThe Center for Epidemiological Studies Depression Scale

(CES-D; Radloff, 1977) is a 20-item scale designed to measure theseverity of current depression in the general population. The items,each of which is assessed on a scale from 0 to 3, measure depressedmood, feelings of guilt and worthlessness, feelings of helplessness andhopelessness, psychomotor retardation, loss of appetite, and sleep

1Baron and Kenny (1986) characterize mediation as a case in which a variable,such as exposure, functions as a Bgenerative mechanism through which a focalindependent variable [such as attorney vs. support staff] is able to influence thedependent variable of interest[ (p. 1173; see also Frazier et al., 2004). Mediationoccurs when an external variable such as exposure better explains a relationshipbetween a predictor, such as being directly (attorneys) versus indirectly (adminis-trative support staff) exposed to trauma-exposed clients, and an outcome, suchas various symptoms (Frazier et al., 2004).

The Journal of Nervous and Mental Disease & Volume 199, Number 12, December 2011 Secondary Traumatic Stress in Attorneys

* 2011 Lippincott Williams & Wilkins www.jonmd.com 947


disturbances (Radloff, 1977). All participants were asked to reportsymptoms they had felt in the past week. The CES-D is in wide useand has acceptable levels of internal consistency (Radloff, 1977).Extensive evidence from a variety of samples attests to the reliabilityand validity of the CES-D (Eaton et al., 2004). In the present sample,the estimate of internal consistency Cronbach’s alpha reliability co-efficient was 0.90. A score of 16 or higher (of a possible maximumof 60) has been used as the cutoff point for high likelihood of clini-cally significant depression (Radloff, 1977).

Functional impairment levelsThe Sheehan Disability Scale (SDS; Sheehan et al., 1996) was

used to assess the extent to which exposure to clients’ traumaticmaterial interfered with functioning in three spheres. Participantsrated the following question (in three forms): ‘‘My feelings about theclients and cases at work have disrupted my (work, social life/leisure,or family life/home responsibilities)’’ on a 0-to-10 visual analoguescale with the following descriptions: none (0), mild (1 to 3), moderate(4 to 6), severe (7 to 9), and very severe (10). In the present sample,the estimate of internal consistency Cronbach’s alpha reliability co-efficient was 0.92. According to the scale’s authors, a score of 5 orhigher for any of the three questions is associated with significantfunctional impairment (Sheehan et al., 1996).

Levels of STS and BOThe Professional Quality Of Life Scale Version 5 (ProQOL5;

Stamm, 2010) is a 30-item questionnaire broken into three 10-itemgroups measuring Compassion Satisfaction (CS), STS, and BO. TheCS dimension (CS) ‘‘is about the pleasure you derive from beingable to do your work well’’ (Stamm, 2010, p. 12), with higher scoresindicating greater work satisfaction. STS items measure fear, sleepdifficulties, intrusive images, or avoiding reminders of the person’straumatic experiences. BO items measure feelings of hopelessnessand difficulties in dealing with work. Higher scores on these dimen-sions indicate more distress. Participants were instructed to answerquestions with respect to their reactions and symptoms in the previous30 days as related to work at the Wisconsin State Public DefenderOffice. Responses were scored on a 1-to-5 visual analogue scale, withnever (1), rarely (2), sometimes (3), often (4), and very often (5). In thepresent sample, the estimates of internal consistency Cronbach’s alphareliability coefficients were 0.90, 0.85, and 0.83 for CS, STS, and BO,respectively. These are similar to alpha coefficients reported by Stamm(2010): 0.88, 0.81, and 0.75 for CS, STS, and BO, respectively.Analysis of the scale produces Z scores that are then converted toT-scores, with a mean (SD) of 50 (10). A T-score greater than 57 forCS or greater than 56 for STS and BO are above the 75th percentilein samples used in the development of the scale (Stamm, 2010).

Data AnalysisDescriptive statistics were first calculated for demographics,

trauma history, and work and exposure variables and compared be-tween groups using t-tests. Groups were compared regarding sexdifferences using chi-square analyses. Mean scores for the IES-R,CES-D, SDS, and the three subscales of the ProQOL5 were calculatedand compared between groups using t-tests. In addition, the cutoffscores for each of the measures for the two groups were comparedusing chi-square analyses. We then performed a bivariate analysiscorrelating demographics, work variables, exposure and trauma his-tory with the symptoms scales.

After these initial tests, we tested our hypotheses regarding themediating role of work-related exposure for the outcome variablesusing multivariate analyses with an structural equation modeling(SEM; Hoyle and Smith, 1994) strategy that assessed measurementerrors for the dependent and independent variables using AMOSsoftware (Version 18.0.0; Arbuckle, 2009) and the maximum likeli-hood method. A nonsignificant chi-square value has traditionally been

used as a criterion for not rejecting an SEM model; a nonsignificantchi-square value indicates that the discrepancy of the matrix of theparameters estimated based on the model being evaluated is notdifferent from the one based on empirical data. Because of the re-strictiveness of the chi-square approach for assessing model fit (Bentlerand Bonnet, 1980; Joreskog and Sorbom, 1993; Kenny and McCoach,2003; Landry et al., 2000), we also used alternate criteria that reflect thereal-world conditions of clinical research, in addition to the overall chi-square test of exact fit to evaluate the proposed models: a) the chi-square/df ratio, b) the root mean square error of approximation(RMSEA), c) the comparative fit index (CFI), and d) the nonnormed fitindex (NNFI). A model in which the chi-square/df was 2 or less, CFIand NNFI were greater than 0.95, and the RMSEA index was between0.00 and 0.06 with confidence intervals between 0.00 and 0.08 (Hu andBentler, 1999) was deemed acceptable. These moderately stringentacceptance criteria clearly reject inadequate or poorly specified modelswhile accepting for consideration models that meet real-world criteriafor reasonable fit and representation of the data (Kelloway, 1998).

RESULTS

Group DifferencesWe first compared the attorneys and the administrative support

staff groups on background and work characteristics (Table 1), work-related exposure and personal history of previous trauma (Table 1),and the study outcome variables (Table 2). No significant differenceswere found with regard to age and size of local office. However, asshown in Table 1, the administrative support staff group has signifi-cantly fewer men than the attorneys group, and participants in theattorneys’ group reported significantly more years on the job and ofhours per week working compared with the administrative supportstaff group. No significant differences were found for childhood oradulthood-related exposure variables. However, as shown in Table 1,participants in the attorneys group reported working with significantlymore clients who experienced or were directly involved in traumacompared with the administrative support staff group.

Comparing attorneys and support staff on outcome variables(Table 2), attorneys had significantly higher mean scores on allmeasures except CS, the latter being lower among attorneys thanamong administrative support staff. Furthermore, significantly moreparticipants in the attorney group met screening criteria for PTSD(11% vs. 1%), depression (39.5% vs. 19.3%), functional impairment(74.8% vs. 27.5%), BO (37.4% vs. 8.3%), and STS (34% vs. 10.1%)compared with the administrative support group. Only a minority ofattorneys (19.3%) and administrative supports staff (25.7%) reportedCS above the 75th percentile level (the groups did not differ) com-pared with norms for the ProQOL5 CS.

Bivariate AssociationsTable 3 provides a summary of the zero-order correlations for

all of the study variables. Sex, age, years on the job, size of localoffice, and a personal history of childhood or adult trauma did notsignificantly correlate with any of the outcome variables. Groupmembership (attorneys vs. administrative support staff) was signifi-cantly associated with all outcomes, except with the ProQOL5 CSscale, with attorneys reporting higher scores for symptoms and im-pairment. In addition, work-related exposure as measured by the av-erage number of hours working and the number of clients worked within the last 3 months who experienced or were directly involved withtrauma were both significantly and positively correlated with symp-tommeasures, again with the exception of the ProQOL5 CS scale. Foreach of the three variables with significant correlations to outcomevariables, the strongest correlations were consistently seen with BOand functional impairment.

Levin et al. The Journal of Nervous and Mental Disease & Volume 199, Number 12, December 2011

948 www.jonmd.com * 2011 Lippincott Williams & Wilkins


Multivariable Analyses

The Mediating ModelsIn testing our primary hypothesis that work-related exposure

variables mediate the relationships between groups and PTSD symp-toms (IES-R), depressive symptoms (CES-D), functional impartment(SDS), and levels of STS and BO (ProQOL5), we followed Baron andKenny’s (1986) criteria for mediation, according to which, a) theremust be a significant association between the predictor and criterionvariables; b) in an equation including both the mediator and the cri-terion variable, there must be a significant association between thepredictor and the mediator, and the mediator must be a significantpredictor of the criterion variable; and c) there must be a decrease inthe direct relationship between the independent and the dependentvariables (Baron and Kenny, 1986; Kenny et al., 1998). If the sig-nificant direct relationship between the predictor and the criterionvariables decreases when both the mediator and the predictor variableare included in the equation, then the obtained pattern is consistentwith the mediation hypothesis. If the direct association approacheszero, the mediator fully (although not necessarily exclusively)accounts for the relation between the predictor and the criterion(Baron and Kenny, 1986). As a further test of mediation, MacKinnonet al.’s (2002) z¶ test was used to examine the significance of theindirect relationship between the independent variable and the de-pendent variable via the hypothesized mediator.

Models for the Prediction of PTSD symptoms (IES-R)Direct association model

We first confirmed the existence of a significant direct relationbetween groups and PTSD symptoms. We defined the latent PTSDconstruct (factor) using participants’ intrusion, avoidance, and hy-perarousal scores as its indicators. This model fit the observed datawell (W2[2] = 2.081, p = 0.35, W2/df = 1.04, NNFI = 1.0, CFI = 1.00,RMSEA = 0.01 [confidence interval (CI), 0.000 to 0.08]). As pre-dicted, attorneys were significantly associated with high levels of

PTSD symptoms (A = 0.26, t = 4.833, p G 0.0001). This modelsignificantly explained 7% of the variance in PTSD symptoms.

Mediational association modelWe tested whether work-related exposure (the mediators) sig-

nificantly reduced (accounted for) the direct relation between groupsand PTSD symptoms (the outcome). To do this, we specified a modelin which groups had a direct path to PTSD symptoms, as well as anindirect path through work-related exposure variables (controlling forthe shared variance among mediators). The mediational model fit theobserved datawell (W2[6] = 6.346, p = 0.386, W2/df = 1.06, NNFI = 1.0,CFI = 1.0, RMSEA = 0.01 [CI, 0.000 to 0.07]). As noted earlier, thedirect path from groups to PTSD symptoms was significant. However,this path became significantly weaker (A = 0.09, t = 1.46, not signifi-cant [ns]) when hours at work (z¶ = 3.06, p G 0.01) and exposure totrauma-exposed clients (z¶ = 3.003, p G 0.01) were included in themodel. As shown in Figure 1, attorneys were significantly associatedwith higher hours at work (A = 0.50; t = 10.71, p G 0.0001), which, inturn, was associated with PTSD symptoms (A = 0.20; t = 3.18, p G0.001); moreover, attorneys were significantly associated with higherexposure to trauma-exposed clients (A = 0.39; t = 7.76, p G 0.0001),which, in turn, was associatedwith PTSD symptoms (A = 0.19; t = 3.23,p G 0.001). Therefore, the work-related exposure variables mediated(albeit not exclusively) the attorneys’ vulnerability to PTSD symptoms.This model significantly explained 14% of the variance in PTSDsymptoms. Therefore, when work-related exposure (the mediators) wasincluded in the model, it added a significant 7% to the explained var-iance in PTSD symptoms.

Models for the Prediction of Functional ImpairmentLevels (SDS)Direct association model

We first confirmed the existence of a significant direct relationbetween groups and functional impairment. We defined the latentSDS construct (factor) using the participants’ SDS scales scores as its

TABLE 1. Background and Trauma Exposure Variables Among Attorneys and Administrative Support Staff

Background Variables Attorney (N = 238)Administrative

Support Staff (N = 109) Statistic

SexFemale 132 94Male 106 13 W

2 = 34.29**

Mean SD Mean SD t (df = 343) Effect Size (d )

Age 45.72 11.00 45.07 11.32 0.50, ns 0.06Years on the job 15.22 10.26 12.11 8.47 2.65* 0.31Average number of hours working 46.43 9.08 34.73 9.74 10.72** 1.24Size of local office 2.39 1.02 2.53 1.00 j1.17, ns j0.14Trauma exposure variables

Childhood traumaPhysical and sexual abuse 3.16 15.37 3.27 15.13 j0.60, ns j0.07Not physical and sexual abuse 4.02 16.37 1.50 5.90 1.54, ns 0.18

Adulthood traumaPhysical and sexual abuse 4.90 15.43 3.96 11.26 0.57, ns 0.07Not physical and sexual abuse 3.59 13.79 1.78 5.88 1.31, ns 0.15

Work-related traumaNumber of clients working with in the last 3 mos whoexperienced or were directly involved with trauma

3.20 1.299 1.98 1.455 7.70** 0.89

*p G 0.01 (two-tailed).**p G 0.001 (two-tailed).ns indicates not significant.




indicators. This model fit the observed data well (W2[2] = 0.70, p =0.71, W2/df = 0.35, NNFI = 1.0, CFI = 1.00, RMSEA = 0.000 [CI,0.000 to 0.07]). As predicted, attorneys were significantly associated

with high levels of functional impairment symptoms (A = 0.44, t =8.370, p G 0.0001). This model significantly explained 20% of thevariance in SDS.

TABLE 3. Correlations Between Predictors and Outcome Variables

PTSD (IES-R) ProQOL5

Intrusion Avoidance Hyper-Arousal CS BO STS CES-D SDS

Groupa 0.24* 0.24* 0.23* j0.12 0.42* 0.34* 0.24* 0.42*Sexb j0.00 j0.07 j0.04 0.07 0.02 j0.09 j0.04 j0.05Age 0.01 j0.06 j0.05 0.07 j0.03 j0.05 j0.09 j0.07Years on the job 0.10 0.04 0.05 0.00 0.09 0.09 0.03 0.08Average number of hours working 0.29* 0.26* 0.25* j0.05 0.38* 0.37* 0.26* 0.40*Size of local office 0.12 0.01 0.10 0.10 j0.02 j0.00 0.04 0.07Childhood physical and sexual abuse 0.12 0.11 0.16 j0.04 0.10 0.15 0.13 0.15Childhood not physical and sexual abuse j0.01 j0.01 0.06 j0.03 0.08 0.07 0.05 0.04Adulthood physical and sexual abuse 0.02 j0.02 0.04 j0.03 0.05 0.05 0.03 j0.00Adulthood not physical and sexual abuse j0.00 j0.04 0.02 j0.02 0.04 0.02 0.01 j0.02Work-related exposure 0.24* 0.28* 0.27* j0.17 0.38* 0.31* 0.30* 0.37*

To ensure that the overall chance of a type I error remained less than 0.05; we applied a full Bonferroni correction.aGroup is a binary-coded variable (0, administrative support staff; 1, attorney).bSex is a binary-coded variable (0, women; 1, men).*p G 0.001 (two-tailed).PTSD indicates posttraumatic stress disorder; IES-R, Impact of Events ScaleYRevised; CES-D, Center for Epidemiological Studies Depression Scale; SDS, Sheehan Disability Scale;

ProQOL5, Professional Quality of Life Scale version 5; CS, Compassion Satisfaction; BO, Burnout; STS, Secondary Traumatic Stress.

TABLE 2. Means, SDs, and Prevalence of Cutoff Scores for Outcome Variables

Attorney(N = 238; 69%)

Administrative SupportStaff (N = 109; 31%)

Mean SD Mean SD t (df = 343) Effect Size (d )

PTSDIES-R intrusion 0.73 0.58 0.46 0.34 4.52** 0.52IES-R avoidance 0.65 0.65 0.33 0.49 4.42** 0.51IES-R hyperarousal 0.55 0.65 0.25 0.44 4.31** 0.50G33 212 108 W

2 = 10.21**933 26 (11%) 1 (0.92%)

CES-D 14.08 10.27 8.91 7.68 4.66** 0.54G16 144 88 W

2 = 13.11**916 94 (39.5%) 21 (19.3%)

SDS 9.80 6.77 3.61 4.57 8.58** 0.99G5 60 79 W

2 = 66.30**95 178 (74.8%) 30 (27.5%)

ProQOL5a-CS 34.92 6.53 36.62 6.46 2.24* 0.26G57 192 81 W

2 = 2.05, ns957 46 (19.3%) 28 (25.7%)

ProQOL5a-BO 27.36 6.09 21.57 5.36 8.47** 0.98G56 149 100 W

2 = 34.99**956 89 (37.4%) 9 (8.3%)

ProQOL5a-STS 21.20 5.91 16.82 4.80 6.73** 0.78G56 157 98 W

2 = 21.30**956 81 (34%) 11 (10.1%)aAt the 75th percentile.*p G 0.05 (two-tailed).**p G 0.001 (two-tailed).PTSD indicates posttraumatic stress disorder; IES-R, Impact of Events ScaleYRevised; CES-D, Center for Epidemiological Studies Depression Scale; SDS, Sheehan Disability Scale;

ProQOL5, Professional Quality of Life Scale version 5; CS, Compassion Satisfaction; BO, Burnout; STS, Secondary Traumatic Stress; ns, not significant.





nificantly reduced (accounted for) the direct relation between groupsand functional impairment symptoms (the outcome). To do this, wespecified a model in which groups had a direct path to SDS symp-toms, as well as an indirect path through work-related exposurevariables (controlling for the shared variance among mediators). Themediational model fit the observed data well (W2[6] = 6.103, p =0.412, W2/df = 1.02, NNFI = 1.0, CFI = 1.0, RMSEA = 0.007 [CI,0.000 to 0.07]). As noted earlier, the direct path from groups to SDSsymptoms was significant. However, this path became significantlyweaker (A = 0.25, t = 4.24, p G 0.0001) when hours at work (z¶ =3.83, p G 0.001) and exposure to clients’ traumatic events (z¶ = 3.60,p G 0.001) were included in the model. As shown in Figure 2,attorneys were significantly associated with higher hours at work(A = 0.50; t = 10.69, p G 0.0001), which, in turn, was associated withSDS symptoms (A = 0.21; t = 4.09, p G 0.0001); moreover, attorneyswere significantly associated with higher exposure to trauma-exposedclients (A = 0.39; t = 7.78, p G 0.0001), which, in turn, was associatedwith SDS symptoms (A = 0.19; t = 4.03, p G 0.0001). Therefore, work-related exposure variables mediated (albeit not exclusively) the attor-neys’ vulnerability to functional impairment symptoms. This modelsignificantly explained 29% of the variance in SDS. Therefore, whenwork-related exposure (the mediators) was included in the model, itadded a significant 9% to the explained variance in SDS.

Models for the Prediction of Levels of STS andBO (ProQOL5)Direct association model

We first confirmed the existence of a significant direct relationbetween groups and ProQOL5 STS and BO. We defined the latentProQOL5 construct (factor) using participants’ STS and BO scalesscores as its indicators. This model has zero degrees of freedom; thus,fit indices could not be estimated. As predicted, attorneys were sig-nificantly associated with high levels of STS and BO symptoms (A =0.45, t = 6.74, p G 0.0001). This model significantly explained 20%of the variance in ProQOL5 STS and BO.


nificantly reduced (accounted for) the direct relation between groupsand STS and BO symptoms (the outcome). To do this, we specified amodel in which groups had a direct path to ProQOL5 symptoms, aswell as an indirect path through work-related exposure variables (con-trolling for the shared variance among mediators). The mediationalmodel fit the observed data well (W2[2] = 2.939, p = 0.23, W2/df = 1.47,NNFI = 1.0, CFI = 1.0, RMSEA = 0.004 [CI, 0.000 to 0.08]). Asnoted earlier, the direct path from groups to ProQOL5 symptoms wassignificant. However, this path became significantly weaker (A = 0.24,t = 3.866, p G 0.0001) when hours at work (z¶ = 3.60, p G 0.001) and

FIGURE 1. Mediational model for PTSD symptom levels(IES-R). Rectangles indicate measured variables and largecircles represent latent constructs. Small circles reflectresiduals (e) or disturbances (d); bold numbers above ornear endogenous variables represent the amount of varianceexplained (R2). Unidirectional arrows depict hypothesizeddirectional or ‘‘causal’’ links. Standardized maximumlikelihood parameters are used. Bold estimates are statisticallysignificant. GROUPS is a binary-coded variable (0, administrativesupport staff; 1, attorney). IES-R indicates Impact of EventsScaleYRevised.

FIGURE 2. Mediational model for functional impairment levels(SDS). Rectangles indicate measured variables and large circlesrepresent latent constructs. Small circles reflect residuals (e)or disturbances (d); bold numbers above or near endogenousvariables represent the amount of variance explained (R2).Unidirectional arrows depict hypothesized directional or‘‘causal’’ links. Standardized maximum likelihood parametersare used. Bold estimates are statistically significant. GROUPSis a binary-coded variable (0, administrative support staff;1, attorney). SDS indicates Sheehan Disability Scale.




exposure to trauma-exposed clients (z¶ = 3.85, p G 0.001) were in-cluded in the model. As shown in Figure 3, attorneys were signifi-cantly associated with higher hours at work (A = 0.50; t = 10.70,p G 0.0001), which, in turn, was associated with ProQOL5 symp-toms (A = 0.23; t = 3.81, p G 0.0001); moreover, attorneys were sig-nificantly associated with higher exposure to trauma-exposed clients(A = 0.39; t = 7.80, p G 0.0001), which, in turn, was associated withProQOL5 symptoms (A = 0.25; t = 4.38, p G 0.0001). Therefore, work-related exposure variables mediated (albeit not exclusively) the attor-neys’ vulnerability to STS and BO symptoms. This model significantlyexplained 32% of the variance in ProQOL5 STS and BO. Therefore,when work-related exposure (the mediators) was included in the model,it added a significant 12% to the explained variance in ProQOL5 STSand BO.

Models for the Prediction of DepressiveSymptoms (CES-D)Direct association model

We first confirmed the existence of a significant direct relationbetween groups and depressive symptoms. We defined the observedvariable CES-D scores. This model has zero degrees of freedom; thus,fit indices could not be estimated. As predicted, attorneys were signif-icantly associated with high levels of depressive symptoms (A = 0.24,

t = 4.67, p G 0.0001). This model significantly explained 6% of thevariance in CES-D symptoms.


nificantly reduced (accounted for) the direct relation between groupsand depressive symptoms (the outcome). To do this, we specified amodel in which groups had a direct path to CES-D symptoms, as wellas an indirect path through work-related exposure variables (con-trolling for the shared variance among mediators). This model (Fig. 4)has zero degrees of freedom; thus, fit indices could not be estimated.As noted earlier, the direct path from groups to CES-D symptoms wassignificant. However, this path became significantly weaker (A = 0.08,t = 1.39, ns) when hours at work (z¶ = 2.45, p G 0.05) and exposure totrauma-exposed clients (z¶ = 3.20, p G 0.01) were included in themodel. As shown in Figure 4, attorneys’ were significantly associatedwith higher hours at work (A = 0.50; t = 10.72, p G 0.0001), which,in turn, was associated with CES-D symptoms (A = 0.15; t = 2.51, p G0.05); moreover, attorneys were significantly associated with higherexposure to trauma-exposed clients (A = 0.39; t = 7.76, p G 0.0001),which, in turn, was associated with CES-D symptoms (A = 0.22;t = 3.90, p G 0.0001). Therefore, work-related exposure variablesmediated (albeit not exclusively) the attorneys’ vulnerability to de-pressive symptoms. This model significantly explained 12% of thevariance in CES-D symptoms. Therefore, when work-related exposure

FIGURE 3. Mediational model for secondary traumatic stressand burnout levels (ProQOL5). Rectangles indicate measuredvariables and large circles represent latent constructs. Smallcircles reflect residuals (e) or disturbances (d); bold numbersabove or near endogenous variables represent the amountof variance explained (R2). Unidirectional arrows depicthypothesized directional or ‘‘causal’’ links. Standardizedmaximum likelihood parameters are used. Bold estimates arestatistically significant. GROUPS is a binary-coded variable(0, administrative support staff; 1, attorney). ProQOL5 indicatesProfessional Quality of Life Scale version 5.

FIGURE 4. Mediational Model for Depressive SymptomsLevels (CES-D). Rectangles indicate measured variables andlarge circles represent latent constructs. Small circles reflectresiduals (e) or disturbances (d); bold numbers above or nearendogenous variables represent the amount of varianceexplained (R2). Unidirectional arrows depict hypothesizeddirectional or ‘‘causal’’ links. Standardized maximum likelihoodparameters are used. Bold estimates are statistically significant.GROUPS is a binary-coded variable (0, administrative supportstaff; 1, attorney). CES-D indicates Center for EpidemiologicalStudies Depression Scale.




(the mediators) was included in the model, it added a significant 6%to the explained variance in CES-D symptoms.

DISCUSSIONTo our knowledge, this is the largest study of attorneys’ emo-

tional responses to work with clients who have experienced or havebeen directly involved with trauma. Our data, collected from 238 attor-neys and 109 administrative support staff of the Wisconsin State PublicDefender Office, indicated a significant level of distress among theattorneys compared with administrative support staff. Measures ofPTSD symptoms, depression, functional impairment, BO, and STSwere consistently higher among attorneys compared with adminis-trative support staff, which was predicted given the longer work hoursand higher level of exposure to clients with a history of trauma amongthe attorneys. Bivariate analysis demonstrated that these measures ofdistress were, in fact, significantly correlated with hours worked perweek and the number of trauma-exposed clients. Subsequent SEMmodeling illustrated that work-related exposure variables (hours atwork and number of trauma-exposed clients) were significant, albeitnot exclusive, mediators of the differences of group membership onsymptoms. Therefore, although both attorneys and administrative sup-port staff were exposed to trauma-exposed clients, the attorneys’ longerwork hours and greater direct contact with these clients associated withtheir vulnerability to PTSD symptoms, depression, functional impair-ment, STS, and BO compared with the administrative support staff’sindirect exposure to these trauma-exposed clients.

The findings of this study confirmed the results of earlier smallstudies (Levin and Greisberg, 2003; Vrlevski and Franklin, 2008) andalso demonstrated a significant relationship between work and expo-sure variables and depression and functional impairment. Specifically,we found significant impairment in the attorney group, with 74.8%scoring above threshold on the SDS, 39.5% demonstrating significantsymptoms of depression (compared with the earlier findings of a 20%rate of depression in attorneys [Benjamin et al., 1990; Eaton et al.,1990]), more than a third scoring above the 75th percentile on STS andBO, and 11% with clinically significant PTSD symptoms. In a recentreview of secondary trauma, Elwood et al. (2011) pointed out that thesecondary trauma literature has largely failed to characterize impair-ment in professionals experiencing secondary trauma. It appears thatat least for attorneys working in the public defender setting, PTSD,secondary trauma, and BO symptoms are accompanied by significantimpairment and rates of depression (Kessler et al., 1994) and PTSD(Kessler et al., 1995) greater than those reported in community samples.

In addition, the attorneys reported less compassion satisfactionon the ProQOL5 compared with administrative support staff, and onlya minority in both groups reported high levels of satisfaction withtheir work. Linley and Joseph (2007), also using the ProQOL, foundthe therapeutic bond was the best predictor of compassion satisfactionin a sample of therapists. This suggests a need to better characterizethe relationship between public defenders and their clients and itsimpact on work satisfaction, particularly given Lynch’s (1997) findingthat public defenders felt stressed by encountering angry clients andfamilies.

Our SEM analysis raises a question concerning the relativecontribution of general workload as measured in hours per weekcompared with that of exposure to traumatized clients, given that eachmade nearly equal contributions to the outcome measures. AlthoughFigley (1995) proposed that secondary trauma is ‘‘the stress resultingfrom helping or wanting to help a traumatized or suffering person’’(p. 7), Regehr et al. (2004) found that work load stressors such asdocumentation and lack of resources, as well as public scrutiny andorganizational issues, played a stronger role in mediating STS anddepression compared with client exposure. The stress of the worksetting itself, particularly a public legal setting where attorneys have

high caseloads, are often not valued by clients, the justice system, orsociety and generally lack sufficient resources appears to make at leastan equal contribution to overall distress (see also Lynch, 1997). Futurestudies are needed to better characterize the relationships betweenthese stressors and attorneys’ symptoms and functioning.

In contrast with the previous study by Vrlevski and Franklin(2008), no relationships were found between personal trauma anddistress variables. Given that the literature for mental health providersis inconsistent (Brady et al., 1999 versus Boscarino et al., 2004), ourfinding is expectable. The disparate findings across studies may berelated to the challenges of accurately measuring past trauma, that is,the subjects’ hesitancy to record this information and their widelyvarying interpretations of this type of question. The two other findingswere the lack of impact of sex or years on the job. Because previousliterature studying therapists has found female sex predictive of STS(Kassam-Adams, 1999) our finding raises questions about differencesbetween attorneys and their administrative support staff and mentalhealth professionals. Regarding years on the job, available results arecontradictory, at times indicating greater risk of symptoms of STS andBO with increasing years on the job (e.g., Jaffe et al., 2003) versus aprotective effect of greater experience (Maslach et al., 2001; Pearlmanand Mac Ian, 1995), suggesting that this variable is multidimensionaland that its effects vary in different settings.

What emerges is that similar to mental health professionals,attorneys working as public defenders with clients who have experi-enced or have been directly involved in trauma are at high risk ofdeveloping clinically significant symptoms of secondary trauma andBO as well as depression and functional impairment. Our study addsa potential mechanism by which this high vulnerability is a result ofthe intensity of their exposure and the length of work hours. Thesefindings point to the need to support attorneys in identifying the de-velopment of these symptoms and to implement interventions to re-duce them. The current trend is to encourage professionals with STSand BO to seek peer and supervisory support, increase leisure andphysical activity, seek counseling and psychiatric treatment as needed,and develop a variety of resiliency skills (e.g., Gentry et al., 2002).However, Bober and Regher (2006) found that these individual ap-proaches did not reduce traumatic stress scores. Instead, they recom-mended institutional interventions. Our findings reinforce this morenuanced picture and suggest that emphasis must be placed on reducinglong work hours as well as on the extent of client exposure such as therotation of attorneys between different types of services. Given thatpublic defender services are underfunded and overloaded, these typesof institutional changes remain a significant challenge.

There are several limitations to this study. Our study’s cross-sectional nature limits any assignment of causality; our model cannotprovide a definitive answer to the question of the direction of theobserved effects. One might argue that mediation variables may havebeen affected by the outcome variables, that is, attorneys with moresymptoms and impairment may have worked longer hours because oflow efficiency or may have been attracted to work with clients whohad experienced trauma. Second, the administrative support staff maynot have represented the best comparison group. Although this groupdid provide a good comparator because of differences in work andexposure variables, another group of attorneys working with clientswith no trauma exposure (e.g., corporate attorneys) may have been abetter comparison, particularly given that attorneys and support staffdiffer in education and responsibilities. The administrative supportstaff group also had significantly fewer men than the attorney group,although the absence of a relationship between sex and outcomessuggests that this difference did not affect the study’s findings.

Despite these limitations, our naturalistic study investigated aunique phenomenon that may well have significant ecological valid-ity. To the best of our knowledge, the present study represents the firstattempt to apply SEM analysis to the association between indicators




of STS symptoms and to examine the mediating role of work-relatedexposure in attorneys and administrative support staff. Our findingshighlight the importance of theoretical models that include job-relateddescription (direct versus indirect exposure to clients’ traumatic events)and related job exposure (intensity and amount of exposure) and theirrole in the development of symptoms and impairment.

CONCLUSIONSAttorneys working in the Wisconsin State Public Defender

Office demonstrated significantly higher levels of PTSD symptoms,depression, STS, BO, and functional impairment compared with ad-ministrative support staff. This difference was mediated by attorneys’longer work hours and greater contact with clients who had experi-enced trauma. These findings suggest a need to support attorneys andadministrative support staff experiencing these symptoms and to ad-dress high workloads as well as the intensity of contact with trauma-exposed clients.

ACKNOWLEDGMENTSThe authors thank Beth Stamm, PhD, for her input on the use

and scoring of the ProQOL5 as well as the overall design and JeffApotheker, PhD, for his critique of the original design and supportof the submission to the research committee. They also thank all ofthe participants in this study. Finally, they thank the reviewers fortheir constructive suggestions and comments on an earlier draft ofthis paper.

DISCLOSUREThis study was supported by the State Bar of Wisconsin and

the Wisconsin State Public Defender Office.The authors have nothing to disclose.

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