Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior.
Research indicates that mental health social workers risk being
confronted with fatal and nonfatal client suicidal behaviors during
professional practice. Although reactions to client suicidal behavior
have been documented, there is little empirical evidence about coping
behaviors and available supports following client suicidal behavior.
This study explores types of supports available, perceived effectiveness
of support resources, and coping behaviors of 285 mental health social
workers who experienced either fatal or nonfatal client suicidal
behavior. Factors predicting positive and negative coping were also
explored. Predictors of positive coping included increased levels of
secondary traumatic stress, the availability of family and friends,
group therapy, religion, older age, and male gender. Predictors of
negative coping were increased levels of secondary traumatic stress,
male gender, having support from family and friends, and the lack of
administrative support. Future research recommendations and implications
for social work administrators and practitioners are discussed.
KEY WORDS: client suicidal behavior; clinician-survivor; coping; social worker; support
Mental health (Demographic aspects)
Mental health (Management)
Social workers (Health aspects)
Social workers (Psychological aspects)
Psychiatric social work (Management)
Psychiatric social work (Influence)
Counselor and client (Psychological aspects)
Jacobson, Jodi M.
|Publication:||Name: Social Work Publisher: National Association of Social Workers Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2008 National Association of Social Workers ISSN: 0037-8046|
|Issue:||Date: July, 2008 Source Volume: 53 Source Issue: 3|
|Topic:||Event Code: 200 Management dynamics Canadian Subject Form: Suicidal behaviour Computer Subject: Company business management|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Mental health social workers provide a significant proportion of
services to emotionally fragile clients, many of whom are at risk of
suicide. Studies indicate that between 28 percent to 33 percent of
mental health social workers have experienced fatal client suicidal
behavior, whereas over 50 percent have experienced nonfatal client
suicidal behavior (Jacobson, Ting, Sanders, & Harrington, 2004;
Sanders, Jacobson, & Ting, 2005). Research supports that social
workers have varied personal and professional reactions following client
suicidal behavior (Jacobson et al., 2004; Sanders et al., 2005);
however, research on social workers' coping behaviors, strategies,
and sources of support following client suicidal behavior could not be
located at the time of this study. Thus, the purpose of the current
study is to address the lack of knowledge on the coping behaviors and
supports available to social work clinician-survivors, a term used to
describe professionals surviving the fatal or nonfatal suicidal
behaviors of clients (Farberow, 2005).
Theoretically, coping is defined as conscious and intentional responses to an unexpected trauma or series of stressful events, as opposed to defense mechanisms, which are defined as unconscious and unintentional responses (Cramer, 2000). There has been debate over whether coping behaviors are stable, similar to personality styles, or prone to change depending on the specific stressful situation and an individual's cognitive assessment of the stressor, past experiences, and beliefs (Folkman & Lazarus, 1984) .Typically, coping behaviors, styles, or strategies have been dichotomized as positive and negative, repressive/avoidant and sensitization/approach, or problem focused and emotion focused (Byrne, 1961, Endler & Parker, 1990; Folkman & Lazarus, 1984; Roth & Cohen, 1986; Ruzek, 2005). However, most would agree that coping strategies are not always mutually exclusive; instead, different types of coping strategies are often used simultaneously (Roth & Cohen, 1986). For example, an individual might seek emotional support while trying to repress painful thoughts. In this exploratory study, both positive and negative coping reported by social workers were examined under the theoretical orientation that coping behaviors, though distinct, could be used concurrently after the traumatic event of fatal and nonfatal client suicidal behavior.
Traditionally, research on client suicidality examined reactions from samples of psychiatrists and psychologists (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989; Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988; Ellis & Dickey, 1998; Kleespies, Penk, & Forsyth, 1993) despite the fact that social workers are just as likely to work with suicidal clients. Prior research has also focused on suicide assessment and prevention and predictive characteristics and behaviors of suicidal individuals (Appleby, 1992; Callahan, 1996; Norlev, Davidsen, Sundaram, & Kjoller, 2005; Weyrauch, Roy-Byrne, Katon, & Wilson, 2001). Recently, several large national studies assessed the prevalence of suicidal behavior among clients of mental health social workers (Jacobson et al., 2004; Sanders et al., 2005). Using both qualitative and quantitative methods, researchers have also examined social workers' reactions, education or training needs, and perceptions toward suicide assessment and clinical tools, such as no-suicide contracts (Freedenthal & Feldman, 2004; Sanders et al., 2005). The following section briefly summarizes available research from the social work field.
Reactions to Fatal and Nonfatal Client Suicidal Behavior
Jacobson and colleagues (2004),in a national random sample of mental health social workers (N = 697), found that 52.5 percent experienced fatal and nonfatal client suicidal behaviors, rates that are comparable to those experienced by psychiatrists and psychologists. Gender differences indicated men reported more avoidant reactions and behaviors and women reported more intrusive reactions and higher levels of secondary traumatic stress (Jacobson et al., 2004). Sanders and colleagues (2005) reported the professional and personal reactions of 145 social workers who experienced client suicidal behaviors. Personal reactions included feelings of sadness, depression, anger, and irritability. Professional reactions included feelings of professional failure and self-blame. Longterm effects included feelings of continued sadness and guilt as well as changes in clinical practice. Additional findings from a qualitative study of 25 mental health social workers provided in-depth information on reactions reported after fatal client suicidal behaviors (Ting, Sanders, Jacobson, & Power, 2006). Reactions included avoidance, intrusion, shock, denial, guilt, self-blame, and anger toward the client and agencies involved as well as feelings of isolation, responsibility, and justification. When agency support was readily available, respondents felt less isolated, experienced less self-blame, and did not personally bear as much of the weight of responsibility for the client suicidal behavior.
Coping with Trauma
When working with suicidal clients, the traumatic event is the fatal or nonfatal client suicidal behavior. Coping responses to trauma, not limited to client suicidal behaviors, can be classified as either positive and adaptive or negative and maladaptive (Aldwin, & Yancura, 2004; Ruzek, 2005). Ruzek defined positive coping as behaviors that help reduce anxiety and distress. Positive coping contributes to improving the situation without causing further harm. Examples include physical exercise, prayer or meditation, and seeking social support. Negative coping, although a possible mitigator of immediate anxiety and distress, often contributes to future problems and not to long-term healthy outcomes; for example, increased substance use may initially seem to reduce stress or anxiety, but over time it can contribute to a worse outcome (Ruzek,
Coping with trauma is different from coping with everyday stress partly because of the unexpectedness and lack of control associated with the traumatic event (Aldwin, 1999) and the possibility of developing long-term negative outcomes. In addition, coping with trauma entails a need to make sense of the unexpected, which often results in permanent cognitive changes to one's belief system (McCann & Pearlman, 1990; Mikulincer, & Florian, 1996). Despite multiple studies on coping and trauma, the majority of research focuses on primary victims and has not embraced the notion that clinicians are also victims by the nature of their work. Given the current paucity of studies on social work clinician-survivors and coping, related research was reviewed on reactions and coping among other mental health professionals following exposure to traumatic events and traumatic client material, including, but not limited to, client suicidal behaviors.
Australian psychologists (N = 437) reported their most effective coping strategies after fatal client suicidal behavior were decreasing one's sense of responsibility, talking with colleagues and a supervisor, and increasing one's acceptance of suicide as a possible outcome (Trimble, Jackson, & Harvey, 2000). In the study by Grad, Zavasnik, and Groleger (1997), gender differences emerged among hospital staff following fatal client suicidal behavior; women reported talking with colleagues as the most effective coping method; men reported concentrating more on work and that speaking with colleagues was helpful only after returning to work. Farberow (2005) noted the most common coping strategy used by therapists in private-practice settings following client suicidal behavior is to speak with colleagues, family members, and friends.
Kleespies et al. (1993) surveyed 292 psychology interns and found supervisory support was more important than support from peers, family, and friends. In fact, without adequate supervisory support, the clinician-survivor was often left with feelings of unresolved grief, guilt, anxiety, and shame, which can lead to self-doubt and questions regarding competency as a professional. Ellis and Dickey (1998) indicated that having training and procedures in place at agencies to deal with client suicidal behavior increase the supportive responses to psychology and psychiatric interns and improves subsequent coping. Goodman (1997) reported the responses from 296 psychologists after client suicidal behaviors, finding that having had training on suicide in graduate school was not notably helpful in terms of coping; instead, coping responses varied and were mediated by the severity of the suicidal behaviors; short-term responses involved problem-focused coping behaviors, whereas long-term responses were more emotion focused.
Studies on clinicians' responses to traumatic events indicated that both positive and negative coping strategies were used concurrently. Among mental health professionals working with child abuse survivors (N = 225), positive coping strategies included consultation with colleagues, education about abuse, and humor, whereas negative coping strategies included increased drug or alcohol use, withdrawal from others, and attempts to forget the traumatic client material (Follette, Poulsny, & Milbeck, 1994). For clinicians working with trauma victims, the amount of time spent with victims was a significant predictor of secondary trauma symptoms and distress (Bober & Regehr, 2006).
Despite the lack of research in the social work field on coping after fatal and nonfatal client suicidal behaviors, findings from related fields have demonstrated the importance of understanding the link between coping after traumatic events and subsequent outcomes. Following a client fatal or nonfatal behavior, knowledge about coping behaviors and understanding what sources of support are available, which are frequently used, and which are perceived as effective by social workers have implications for social work education. For this study, three research questions were asked:
1. What is the prevalence of positive and negative coping behaviors used by mental health social workers following client suicidal behavior?
2. What are the available sources of support for mental health social workers following client suicidal behavior, and which of these supports are perceived as most effective for promoting positive coping?
3. What factors predict the use of positive or negative coping behaviors among mental health social workers following client suicidal behavior?
Five hundred fifteen mental health social workers participated in an anonymous survey about their work with suicidal clients. A subsample was used for the current analyses comprising 285 respondents (55.3 percent of N = 515) who reported either experiencing a fatal or a nonfatal client suicidal behavior. Women made up more than three-quarters of the sample used for this analysis (76.1 percent, n = 217), and men made up 23.9 percent (n = 68). The mean age was 51.9 (SD = 8.6) and is representative of the total NASW population. The majority was white (92 percent, n = 261). Over 90 percent (n = 259) had an MSW degree, and 9.1 percent (n = 26) had a PhD/DSW. A significant percentage (46.7 percent, n = 133) reported working in private practice settings and with adults (86.7 percent, n = 247). The mean number of years of practice was 19 (SD = 8.1). Suicidal clients who received services from the social workers sampled were predominantly women (59.3 percent, n = 162), with a mean age of 33 (SD = 14), and were diagnosed with affective/mood disorder (53.8 percent, n = 147).
T tests and chi-square tests of significance were conducted to compare respondents who experienced no client suicidal behaviors (n = 230) with respondents who experienced fatal or nonfatal client suicide behaviors (n = 285). Results indicate that mean age, years in practice, gender, race, and education level did not significantly differ between the two groups (p < .05). The only significant difference was the type of client population served. Although both groups predominantly worked with adults as compared with children or adolescents, social workers who were more likely to work with suicidal clients were also more likely to work with adult clients [[chi square] (2, N = 515) = 25.903, p < .0001; 86.7 percent and 70.1 percent, respectively].
After university Institutional Review Board approval, surveys were mailed to a randomly generated list of 1,000 MSW-level mental health social workers in the NASW database, which contained approximately 50,000 self-designated mental health social workers throughout the United States. To maximize the number of direct practitioners, self-designated mental health social workers were the selection criteria. A five-page self-report questionnaire was mailed with a cover letter defining the purpose of the study, ensuring complete anonymity, and explaining implied consent. A total of 515 surveys were returned (52 percent response rate), with no follow-up mailings.
In addition to demographic questions, the survey examined secondary traumatic stress reactions in response to client suicidal behavior. Respondents were also asked about their coping behaviors, supports available for coping, and professional training regarding suicide. The specific traumatic event used in this survey was the client fatal or nonfatal suicidal incident that respondents indicated affected them the most.
The Secondary Traumatic Stress Scale (STSS) (for more information see Bride, Robinson, Yegidis, & Figley, 2004) was used to assess reactions following the client fatal or nonfatal suicidal behavior that affected the social workers the most. The STSS is a 17-item self-report scale measuring intrusion, avoidance, and arousal reactions, feelings commonly found with posttraumatic stress and secondary trauma survivors. Higher scores indicate more traumatic stress. The STSS has been used with mental health professionals and found to have good reliability (Bride et al., 2004; Ting, Jacobson, Sanders, Bride, & Harrington, 2005). The total STSS score was used, and Cronbach's alpha was .94.
Coping and types of support available were measured through questions developed for the study. Respondents were asked to indicate which of seven different types of supports were available to them following the fatal or nonfatal client suicidal behavior and to indicate which type of support was most effective in helping them cope. Sources of support included professional support (support group, individual therapy), personal support (family and friends, religious support/clergy), and workplace support (agency administration, clinical supervision, peers/ colleagues). Coping was measured through the respondent's self-endorsement of positive and negative types of coping behaviors used immediately after the traumatic event. We used the definitions of positive and negative coping behaviors of previous researchers (Follette et al., 1994; Ruzek, 2005), wherein positive coping behaviors included the increased use of prayer, meditation, exercise, and seeking social support, and negative coping behaviors included the increased use of social isolation, angry outbursts, overeating or binge eating, illicit or prescription drug use, smoking, and increased alcohol use. Two separate composite scores were calculated. Positive coping was scored by summating the number of individual positive coping behaviors used (range = 0 through 4), and negative coping was scored by summating negative coping behaviors (range = 0 through 7). The higher the score, the more negative or positive coping was indicated.
Prevalence of Positive and Negative Coping Behaviors
Of the 271 social workers responding to the coping questions, 35.8 percent (n = 97) indicated the use of some form of positive coping behavior; the most common behavior reported was an increase in prayer/meditation (19.2 percent n = 52). Negative coping behavior was used by 37.2 percent (n = 101), with the most common behavior reported as the increased use of alcohol (16.2 percent, n = 44). See Table 1 for a complete list of coping behaviors used by the social workers.
Sources of Support
Of the 285 social workers who experienced fatal or nonfatal client suicidal behaviors, 271 (95.1 percent) reported having some form of support available; the mean number of available supports was 2.8 (SD = 1.2), with clinical supervision as the most commonly cited type of support available (66.8 percent, n = 181), followed by the availability of family and friends (63.8 percent, n = 173). Support was also available from clergy/religion, agency administration, and peers/colleagues (39.5 percent, n = 107; 32.8 percent, n = 87, and 29.2 percent, n = 79, respectively). See Table 1 for a list of all supports available to the social workers.
After identifying the most traumatic incident of client suicidal behavior, respondents were asked to indicate which available support was most effective for their coping. Although over two-thirds reported having supervision available, only 39 percent considered it most effective. Peer support was available to only 29 percent of the sample; however, 80 percent of those who had peer support available reported it as most effective. Approximately one-third of each of those who had support groups, formal or informal, family and friends, and individual therapy available reported it to be most effective.
Predicting Coping Behaviors
Hierarchical multiple regressions were used to explore whether positive and negative coping behaviors could be predicted. Demographics (age, race, gender, and education) were entered on step 1 of the model as differences in traumatic stress, grief reactions, and coping behaviors have been correlated with gender as well as with age and education level (Follette et al., 1994; Lucero, 2003; Vingerhoets & Van Heck, 1990). Coping and help-seeking behaviors may also differ by race, although findings have not been consistent (Haley et al., 2004; Mainous, Smith, Acierno, & Geesey, 2005). Years in practice at the time of the client suicidal incident, practice setting, and whether prior training or education on suicidality was received were entered on step 2, as an individual's experience and training have been found to affect levels of secondary traumatic stress and outcomes (Follette et al., 1994; Goodman, 1997), whereas practice settings vary in levels of available supervision and administrative support, which could also affect coping. The type of client suicidal behavior, fatal or nonfatal, was entered on step 3, and the level of secondary traumatic stress (total score) was entered on step 4, as prior research has indicated therapists' reactions may differ on the basis of the outcome of the client suicidal behavior and the emotional and cognitive perceptions of the level of trauma experienced (Goodman, 1997; Kleespies, 1993). The seven types of available supports were entered on step 5 to determine whether available supports affected coping. Following Stevens' (2002) guidelines, we considered the sample sufficiently large, with adequate power for the analyses. All statistical assumptions were met.
The overall model was significant for positive coping [F(16, 227) = 5.095, p < .0001], accounting for 26.4 percent of the total variance. The standardized and unstandardized coefficients from the final step of the model are presented in Table 2. The total score on the STSS, participation in group therapy, support of family/friends, and availability of religious support were statistically significant (p < .05). Specifically, reporting increased levels of secondary traumatic stress and participation in group therapy, support of family and friends, and available religious support were predictive of more positive coping. Gender and age approached significance (p < .10) and are interpreted in the exploratory context. Being older and being a man were predictive of the use of more positive coping.
The overall model was also significant for negative coping [F(16,227) = 2.373, p = .003]; however, the total variance accounted for by the model was only 14.3 percent; therefore, results should be interpreted cautiously. See Table 3 for the standardized and unstandardized coefficients from the final step of the model. For negative coping, the total score on the STSS was significant (p < .0001); higher levels of secondary traumatic stress were associated with negative coping. Gender, support of family and friends, and available agency support approached statistical significance (p < .10). Being a man, having family and friends available, and not having agency administrative support were separately predictive of more negative coping.
This is the first empirical study to explore the prevalence and coping behaviors of social work clinician-survivors of fatal and nonfatal client suicidal behaviors. Prevalence studies on coping behaviors have been scarce; thus, the ability to compare findings from this sample to other studies of mental health professionals is limited. Yet it is important to note for intervention planning that over one-third of the current sample admitted to the use of some form of negative coping. Also, over two-thirds had clinical supervision available as a source of support, and almost one-third had support from family and friends. Although these sources of support were available, respondents did not indicate they were the most effective. This is a unique finding given that other studies of psychologists and psychiatrists suggest the importance of supervision and social support (Ellis & Dickey, 1998; Kleespies et al., 1993). One explanation may be that though supervision is available, the quality of the supervision may not have been perceived as supportive. Ting and colleagues (2006) reported social workers often felt blamed by supervisors; because of agency preoccupation with potential legal ramifications, social workers also reported feelings of anger toward the agency for only being concerned about administrative record keeping and not concerned about the loss of a client's life or the social worker's personal reactions.
In a similar vein, although family and friends were reported as available sources of support, they may not have been considered effective because they were not in an equal position to truly empathize with the social worker's professional and personal reactions of working with suicidal clients. Furthermore, professionals often do not want to burden loved ones with the pain associated with their work or are constrained in their ability to discuss a case given confidentiality issues. Thus, relying on friends and family members may not be most effective when attempting to cope with client suicidal behavior. On the other hand, peer supervision was less readily available, yet compared with other more commonly available sources of support, was more frequently reported as effective. Again, one can hypothesize about the similarities of circumstances between peers that make their support feel more empathetic and genuine.
Positive Coping Behaviors
The availability of group therapy, family and friends, religious support, and higher levels of secondary traumatic stress, as well as increased age and being a man predicted positive coping. Bober and Regehr (2006) found that higher trauma scores were significantly associated with more help seeking among trauma therapists. Experiencing more trauma increases distress and the need to cope, which subsequently, could lead to more help-seeking behaviors; thus in an attempt to gain some semblance of order and relief from traumatic stress, more coping strategies are used.
Coping may entail the use of many sources of support. Groups have long been known as sources of support (Schulman, 2006), where mutual aid is the goal, allowing members to decrease their sense of isolation. The American Association for Suicidology has information on grief and support groups for clinician-survivors and is an effective resource not only for practitioners, but also for social work supervisors and administrators (http://mypage.iusb.edu/~jmcintos/therapists_mainpg.htm).
The general importance of supportive structures such as family and friends have been noted in the coping literature (Folkman & Lazarus, 1984), and the positive role of perceived family support in resiliency to posttraumatic stress disorder has also been indicated (Lucero, 2003). Positive outcomes have also been associated with beliefs in a supportive God as opposed to a punitive or abandoning God in times of need (Philips, Pargament, Lynn, & Crossley, 2004). During times of stress, religion has been identified as a positive coping method (Koenig, George, & Siegler, 1988; McRae, 1984) to "provide order and understanding to an otherwise chaotic and unpredictable world" (Carone & Barone, 2001, p. 992). Following a client's suicidal behaviors, religious belief in a higher being may free the therapist from the need to control the situation, thereby allowing "people to maintain hope for themselves and loved ones and regulate negative emotions when no active coping strategy seems possible" (Carone & Barone, p. 992).
Although some theorists suggest that older adults may be more vulnerable and less able to cope after trauma, citing the cumulative effects of loss and negative life events, others have promoted age as a protective factor against the development of posttraumatic reactions, especially when past trauma was successfully overcome (Eysenck, 1983; Gibbs, 1989) and resilience developed with positive coping outcomes. For social workers, increasing age and life experiences may allow one to cope with work's challenges by putting things in perspective and by using positive behaviors previously found to be helpful (Follette et al., 1994; Lucero, 2003).
Being a man was predictive of positive coping and was surprising as men tend to be more avoidant after loss and trauma and to use more negative coping behaviors (Bennett, Hughes, & Smith, 2005; Jacobson et al., 2004). An explanation for this interesting finding may be in the way coping has been defined for this study. Both positive and negative coping are behaviorally defined and action oriented (for example, increased use of alcohol, drugs, exercise, prayer, isolation). Men, compared with women, tend to actively seek behavioral outlets, whereas women tend to cope more emotionally, yet such types of internal coping behaviors (for example, crying, talking) were not measured in the current definitions of coping. Thus one way to interpret the results is to indicate that being a man is more predictive of active coping behaviors, regardless of whether these behaviors are positive or negative.
Negative Coping Behaviors
A significant predictor of negative coping was higher level of secondary traumatic stress. Although appearing contradictory, a possible explanation for trauma predicting both positive and negative coping is that for those with higher reported levels of secondary traumatic stress, both types of coping were used in an attempt to alleviate distress. Researchers have indicated that individuals do not use mutually exclusive coping behaviors. Thus, perhaps in more stressful situations, additional coping strategies and behaviors are simultaneously activated and used, regardless of whether they are positive or negative.
Compared with women who use more emotion-focused and passive coping (Endler & Parker, 1990), men tend to have smaller social networks and use more active, problem-solving strategies (Stroebe, Stroebe, & Abakoumkin, 1999) and negative behaviors such as substance use (Zisook, Shuchter, & Mulvihill, 1990). Therefore, it is not surprising that being a man was predictive of negative coping. In addition, with client suicidal behaviors (or other situations beyond their control), problem-focused coping strategies are not always possible, which may result in men resorting to the use of more negative action-oriented behaviors, such as substance use and social isolation.
Although counterintuitive, the availability of family and friends as supports was a predictor for negative coping. However, in times of crisis, family support, even when perceived as "helpful," can increase anxiety and distress; Spilman (2006) reported that for parents of abducted children, despite the availability of family support, distress increased, perhaps as a result of perceived criticism of how one is handling the situation or because of unrealistic expectations. For social workers, this may also be an explanation as family or friends might have unrealistic expectations toward the professional and might lack acceptance or show impatience with the length of the recovery process. Clinicians, not wanting to cause their family or friends additional concern, may keep their own personal and professional worries, reactions, and needs to themselves. The fanny member or friend, despite being available, may be perceived as an additional source of stress and as someone to protect rather than someone on whom to depend.
The availability of agency support was important in the aftermath of client suicidal behavior; however, there was no information on the type of agency supports available. Prior research has indicated the importance of supervisory support and agency structures in mitigating negative reactions following client suicidal behaviors (Ellis & Dickey, 1998; Kleespies et al., 1993; Ting et al., 2006) and has reinforced current findings on the need to have available and appropriate administrative support.
CONCLUSION AND IMPLICATIONS FOR FUTURE RESEARCH
The current study explores coping and support in social work clinician-survivors of client suicidal behavior. Results indicate that over 95 percent of the social workers in our sample have had some form of support available, and over one-third have used some type of negative coping behavior in the aftermath of working with suicidal clients. Predictive models for positive and negative coping using respondent characteristics and available supports yielded thought-provoking results and raised new questions for future research. Specifically, results highlighted the need for more in-depth, detailed information on the quality, types, utilization, and effectiveness of the supports available and the need to more comprehensively define and measure coping.
When interpreting the results from this study, several limitations should be considered. The sample of self-designated mental health social workers may not be representative of all social work practitioners, despite having been drawn from the NASW database, as not all practitioners are members. Another limitation, the reliance on self-report data, may bias the results. The researchers recommend that future studies include multiple sources of data collection when possible and the use of standardized measures assessing multiple coping strategies, including both internal and external coping mechanisms. In an effort to minimize respondent burden, the researchers developed and used a short measure of coping with composite scores from single items, which limited interpretability and comparison between samples. However, the strengths of the study should also be noted, namely, having a large national, random sample with a good response rate and being the first empirical study to explore this area of social work practice.
Although there are general recommendations and policy implications for educators and agency administrators to consider, it is important to note that there is not one overarching method to assist social workers in terms of coping. This is because coping is multifaceted and strategies involve behavior, cognition, and emotions. Coping continues to be a difficult construct to measure; even researchers who have used standardized measures have found conflicting results regarding the best way to measure coping (Billings & Moos, 1984; Endler & Parker, 1990; McCrae & Costa, 1986), and debate continues regarding whether coping is situationally defined, is a state trait, or is defined by personality (Fleishman, 1984; Folkman & Lazarus, 1984). Previous research has shown also that personal perception of the severity of client suicidal behavior may influence subsequent coping behaviors; for example, more passive coping and resignation is associated with more severe client suicidal behavior (Goodman, 1997).
For now, administrators need to keep in mind the importance of being available and supportive while being aware of the challenges in implementing any "one size fits all" type of response to clinician-survivors. At a minimum, we recommend that agencies establish and encourage the use of peer support networks or groups, debriefings, and psychological autopsies to allow individuals and involved agency staff to process the traumatic event. The focus of interventions following client suicidal behavior must be individualized, geared toward the needs of the particular clinician-survivor, and take into account factors such as age, gender, and prior experience. Previous coping styles and strategies should be assessed to determine the best direction for supervision.
This study created more questions than perhaps it answered, and we hope that future researchers will continue to explore and build on these preliminary results. Working with suicidal clients is a common experience for social workers; the types of supports and coping behaviors used by social workers in the aftermath of client suicidal behavior is an important area of study that has not received adequate attention. What is known is that unresolved secondary and vicarious trauma, as well as maladaptive coping strategies, can have long-term negative effects for social work clinician-survivors (Bober & Regher, 2006; Figley, 2002), thereby fueling the need for research on how to best care for our own clinicians, which in turn will help improve outcomes for clients and family members.
Original manuscript received August 9, 2006
Final revision received April 3, 2007
Accepted April 3, 2007
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Laura Ting, PhD, LCSW-C, is assistant professor, School of Social Work, University of Maryland, Baltimore County, 1000 Hilltop Circle, Academic IV 364, Baltimore, MD 21250: e-mail: LTing@umbc.edu. Jodi M. Jacobson, PhD, LCSW-C, is assistant professor, School of Social Work, University of Maryland, Baltimore. Sara Sanders, PhD, LSW, is assistant professor, School of Social Work, University of Iowa.
Table 1: Reported Coping Behaviors and Sources of Support Available (N = 271) Sample Variable % n Coping Behavior Positive Prayer 19.2 52 Exercise 16.6 45 Meditation 18.1 49 Help seeking 8.5 23 Negative Alcohol 16.2 44 Illegal drugs 1.8 5 Overeating 15.9 43 Prescription drugs 5.2 14 Isolation 17.0 46 Smoking 12.5 34 Angry outburts Support Available Supervision 66.8 181 Administration/agency 32.8 9 Individual therapy 19.6 53 Support group 10.2 29 Family/friends 63.8 173 Clergy/religion 39.5 107 Peers/colleagues 29.2 79 Table 2: Hierarchical Regression of Positive Coping after Client Suicidal Behavior (N = 244) Coefficients Unstandardized Standardized Variable B SE B [beta] t Age .012 .007 .125 1.852 Race -.021 .180 -.007 -.115 Gender -.219 .116 -.114 1.895 Education -.208 .164 -.075 1.267 Years in practice .009 .006 .092 1.407 Prior training .049 .101 .030 .489 Practice setting -.069 .110 -.042 -.629 Fatal or nonfatal behavior .166 .102 .099 1.625 Total STSS score .016 .004 .222 3.537 Clinical supervision .071 .109 .040 .650 Administrative support .096 .116 .054 .828 Group therapy .587 .252 .140 2.325 Individual therapy -.055 .133 -.026 -.414 Family/friends .214 .107 .122 2.007 Religious support .495 .102 .292 4.870 Peer/colleagues -.064 .110 -.035 -.577 Variable p Age .065 ** Race .909 Gender .059 ** Education .206 Years in practice .161 Prior training .626 Practice setting .530 Fatal or nonfatal behavior .106 Total STSS score <.001 Clinical supervision .516 Administrative support .408 Group therapy .021 Individual therapy .679 Family/friends .046 * Religious support <.001 * Peer/colleagues .565 Notes: Coefficients are reported from the final step of the regression model. STSS = Secondary Traumatic Stress Scale. * p < .05. ** p < .10. Table 3: Hierarchical Regression of Negative Coping after Client Suicidal Behavior (N = 244) Coefficients Unstandardized Standardized Variable B SE B [beta] t Age .003 .011 .017 .235 Race .385 .302 .080 1.273 Gender -.350 .194 -.117 -1.802 Education -.163 .275 -.038 -.593 Years in practice -.007 :011 -.050 -.703 Prior training .248 .169 .096 1.465 Practice setting .241 .185 .093 1.304 Fatal or nonfatal behavior .020 .171 .008 .117 Total STSS score .032 .007 .290 4.276 Clinical supervision .034 .183 .013 .188 Administrative support -.325 .194 -.119 -1.676 Group therapy -.318 .423 -.049 -.751 Individual therapy -.164 :224 -.050 -.731 Family/friends .343 .179 .125 1.916 Religious support -.196 .170 -.074 -1.150 Peer/colleagues .260 .185 .092 1.406 Variable p Age .815 Race .204 Gender .073 ** Education .554 Years in practice .483 Prior training .144 Practice setting .194 Fatal or nonfatal behavior .907 Total STSS score <.001 Clinical supervision .851 Administrative support .095 ** Group therapy .453 Individual therapy .456 Family/friends .057 ** Religious support .252 Peer/colleagues .161 Notes: Coefficients are reported from the final step of the regression model. 5755 = Secondary Traumatic Stress Scale. * p <.05. ** p<.10.
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