Journal of Traumatic Stress

April 2015, 28, 8391

Meta-Analysis of Risk Factors for Secondary Traumatic Stress in

Therapeutic Work With Trauma Victims
Jennifer M. Hensel,1,2,3 Carlos Ruiz,1 Caitlin Finney,1 and Carolyn S. Dewa1,2
1
Centre for Research on Employment and Workplace Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
2
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
3
Department of Psychiatry at Womens College Hospital, Toronto, Ontario, Canada

Revisions to the posttraumatic stress disorder (PTSD) diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association, 2013) clarify that secondary exposure can lead to the development of
impairing symptoms requiring treatment. Historically known as secondary traumatic stress (STS), this reaction occurs through repeatedly
hearing the details of traumatic events experienced by others. Professionals who work therapeutically with trauma victims may be at
particular risk for this exposure. This meta-analysis of 38 published studies examines 17 risk factors for STS among professionals
indirectly exposed to trauma through their therapeutic work with trauma victims. Small significant effect sizes were found for trauma
caseload volume (r = .16), caseload frequency (r = .12), caseload ratio (r = .19), and having a personal trauma history (r = .19).
Small negative effect sizes were found for work support (r = .17) and social support (r = .26). Demographic variables appear to be
less implicated although more work is needed that examines the role of gender in the context of particular personal traumas. Caseload
frequency and personal trauma effect sizes were moderated by year of publication. Future work should examine the measurement of STS
and associated impairment, understudied risk factors, and effective interventions.

Professionals who work therapeutically with victims of
trauma are at risk for what has historically been called sec-
ondary traumatic stress (STS). STS occurs as a reaction to
secondary or indirect exposure to traumatic events experienced
by another (Bride, Radey, & Figley, 2007). Recent revisions to
the diagnostic criteria for posttraumatic stress disorder (PTSD)
in the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) have made explicit that repeated
exposure to the aversive details of a traumatic event during the
course of ones professional duties qualifies as a Criterion A
stressor (American Psychiatric Association, 2013).Therefore,
here we have treated STS, if appropriately severe, as a form
of PTSD where the exposure is listening repeatedly to the
details of a clients traumatic experience and the symptoms
are characterized by intrusive imagery related to the clients
trauma, avoidance, physiological arousal, distressing emotions,
and functional impairment (Bride, Robinson, Yegidis, & Figley,
Funding support was provided courtesy of Carolyn S. Dewas Canadian Insti-
tutes of Health Research Applied Public Health Chair.
Correspondence concerning this article should be addressed to Jennifer M.
Hensel, Department of Psychiatry, Womens College Hospital, 7th floor,
Rm 7122, 76 Grenville St, Toronto, Ontario, Canada, M5S 1B2. E-mail:
Jennifer.hensel@wchospital.ca
Copyright  C 2015 International Society for Traumatic Stress Studies. View
this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21998
2004). These symptoms impact the personal and working lives
of those affected, and extend to the quality of care delivered
(Bride, Radey, et al., 2007; Choi, 2011; Salston & Figley, 2003;
Sexton, 1999).
Various conceptually overlapping terms including STS,
compassion fatigue (CF), vicarious traumatization (VT), and
burnout have been used to refer to the effects of secondary
trauma exposure. Only STS and CF, however, will be used in
this review as they most closely reflect the symptoms of PTSD.
VT relates more to the transformation of the helpers inner ex-
perience resulting from empathic engagement with a clients
trauma and the resultant shift in cognitive schemas about one-
self, others, and the world (Bride, Radey, et al., 2007). Burnout,
on the other hand, is not specific to exposure to traumatic ma-
terial and can affect individuals in any professional role as it
develops in the setting of prolonged exposure to stressful de-
mands at work (Cieslak et al., 2014). In a meta-analysis of
published studies, Cieslak et al. (2014) has shown a high corre-
lation between burnout and STS (weighted r = .69) suggesting
that there may be a common predisposition or that one condition
may be a risk factor for the other.
Although some suggest that professionals may experience
mild STS symptoms not of clinical significance (Elwood, Mott,
Lohr, & Galovski, 2011; Ortlepp & Friedman, 2002), other
studies report moderate to high levels of STS, or PTSD, result-
ing from indirect exposure only. For example, a diagnosis of
STS was reported in 34% of child protective services workers

83
84
Records identified through database searching
(after duplicates removed) (n = 1,972)
Additional records identified through other sources
(n = 1)
Abstracts screened (n = 510)
Full-text articles assessed for
eligibility
(n = 140)
Articles included in meta-analysis
(n = 37; 38 studies)
Figure 1. Article inclusion flow diagram. STS = secondary traumatic stress.
(Bride, Radey, et al., 2007), and 15.2% of social workers (Bride,
2007). A study of relief workers following the September 11,
2001 (9/11) attacks on the United States found that those ex-
posed only secondarily had lower, but not insignificant levels
of PTSD compared to workers who were also directly exposed
to the trauma (4.6% compared to 6.4%; Zimering, Gulliver,
Knight, Munroe, & Keane, 2006).
Many risk factors have been studied in relation to STS;
however, studies have been heterogeneous in their definitions,
measurements, and populations studied (Ortlepp & Friedman,
2002). In a recent review of the STS literature, Elwood et al.
(2011) suggested that based on equivocal findings regarding
prevalence and severity of STS, systematic implementation of
prevention and treatment recommendations was not warranted
because of possible negative implications. Rather, recommen-
dations should be implemented on high-risk populations only.
As a result, there is a need to recognize vulnerability factors to
aid in the identification of high risk individuals and to inform
targeted prevention and intervention. A meta-analysis synthe-
sizes results from multiple studies into a single estimate thereby
making use of all available data and providing an overall effect
size for a given risk factor (Card, 2012). This study is a review
and meta-analysis of published articles that examined STS risk
factors in professionals who work therapeutically with victims
of trauma and are repeatedly exposed to the aversive details.
Method
Medline, PsycINFO, Embase, Web of Science, and Scopus were
searched using the following keywords in combination: (indi-
rect* trauma* OR second* trauma* OR vicarious* trauma* OR
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Hensel et al.
Full-text articles excluded (n = 103)
Reasons:
Full text not available (n = 17)
STS not assessed or not outcome
variable (n = 20)
Invalid outcome measure (n = 20)
Confounding primary exposure
(n = 12)
Exposure not clear and/or not linked to
outcome (n = 6)
Risk factors not examined or not linked
to outcome (n = 18)
Same sample as another included study
(n = 5)
Risk factors in too few studies (n = 3)
Insufficient data (n = 2)
(compassion fatigue AND trauma*) AND (professional*OR
clinician* OR worker* OR therapist* OR psychologist*OR
provider* OR counsellor* OR counselor*). An intentionally
broad search strategy was used because of the nonspecific use
of outcome measures across the various terms used in the litera-
ture. The search was filtered for journal articles only, published
on or before December 31, 2013, in English, French, Spanish,
Portuguese, or Polish languages (based on the ability of the au-
thors to read these languages). In addition, Google Scholar was
searched using the same keywords and published review arti-
cles on STS were surveyed to identify any appropriate articles
not found in the database search.
Selection of Articles
After duplicates were removed, 1,973 references were identi-
fied from the search strategy (see Figure 1 for inclusion flow).
Articles were selected for inclusion using criteria developed a
priori: (a) work role involved developing a therapeutic relation-
ship with traumatized clients resulting in indirect exposure to
trauma, (b) used validated outcome measure, (c) described and
measured any risk factor(s), and (d) provided an analysis of the
relationship between a risk factor and the outcome. To be in-
cluded in the analysis, we required that a risk factor be examined
in a minimum of three studies. Some authors have calculated
risk-factor effect-size estimates with only two studies (Trickey,
Siddaway, Meiser-Stedman, Serpell, & Field, 2012), but we felt
that this would be too vulnerable to bias given the small sample
sizes of many studies and the range of measures used. To be
included, the article had to report t test or F values, 2 , Z test,
correlations, or enough data for one of these statistics to be
 Secondary Traumatic Stress Risk Factors
generated: M, SD, and sample size. Where possible, authors
were contacted for additional data; one author responded
(Kulkarni, Bell, Hartman, & Herman-Smith, 2013). All titles
were independently reviewed by two raters. If either reviewer
felt the title should be included, the corresponding abstract was
reviewed. This produced 510 abstracts that were then screened
independently by two readers. Similar to the title review, if
either of the reviewers wanted to include the abstract, the cor-
responding full-text article was reviewed. Interrater reliability
was = .93 for titles and = .98 for abstracts. After ab-
stract review, 140 full-text articles were selected for review.
Again, each full text was independently reviewed by two read-
ers. Any discrepant or uncertain cases were discussed between
the two reviewers and agreement was achieved in all cases (the
issue was usually related to uncertainty about acceptability of
outcome measures or statistical analyses in a less experienced
reviewer). In total, 38 studies (37 articles) were included (see
the Appendix for a summary of the included studies).
Variables and Data Analysis
For the purpose of this review, STS referred to symptoms of
PTSD linked to exposure to aversive details of a clients trauma
in the course of ones professional duties. Suitable outcome
measures thus captured symptoms consistent with the symp-
tom clusters of PTSD and item responses were linked to oc-
cupational exposure. These included the CF subscale of the
Compassion Fatigue Self-Test (CFST; Figley, 1995; k = 6),
the CF/STS subscale of the Professional Quality of Life Scale
(ProQOL, versions IV; Stamm, 2010; k = 17), the Secondary
Traumatic Stress Scale (STSS; Bride et al, 2004; k = 11),
the Secondary Trauma Scale (Motta, Hafeez, Sciancalepore, &
Diaz, 2001; k = 1), the Impact of Event Scale-Revised (IES-R;
Weiss & Marmar, 1997; k = 3), the Los Angeles Symptom
Checklist (King, King, Leskin, & Foy, 1995; k = 1) and the
PTSD Checklist-Stressor Specific Version (PCL-S; Weathers,
Litz, Herman, Huska, & Keane, 1993; k = 1). To examine over-
all effect sizes, outcome measures were pooled across studies
given that they are highly correlated (e.g., IES-R and the CF
scale of ProQOL, r = .74; Carmel & Friedlander, 2009; CF
scale of the ProQOL and STSS, r = .66; Benler, 2010). For the
two studies that reported two separate outcome measures (STSS
and ProQOL, Borntrager et al., 2012; and IES-R and ProQOL,
Carmel & Friedlander, 2009), the STSS and IES-R were used
to calculate risk factor estimates given that they are more spe-
cific measures for the symptoms of PTSD (Bride, Radey, et al.,
2007). If a study reported only outcome subscales, for exam-
ple, the Intrusion, Avoidance, and Hyperarousal subscales of
the STSS, an effect size for the total score was calculated by
averaging the subscale effect sizes each weighted by its respec-
tive number of questionnaire items.
Seventeen risk factors were examined. Age and experience
were continuous or ordinal variables obtained from demo-
graphic questionnaire items. Ethnicity and gender were nominal
variables. Ethnicity was included only if it was reported as a
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
85
dichotomous variable and there was a similar comparison cat-
egory (the only repeated one being Caucasian) across studies.
Trauma training, a dichotomous variable, referred to whether or
not professionals had received specific training related to work-
ing with traumatized individuals. Trauma caseload referred to
the amount of work done with trauma clients. Recently, it has
been suggested that this risk factor is complex because of the
various ways that exposure can occur (Cieslak et al., 2013a).
Here we defined caseload volume as a count or specified range
of the number of traumatized clients encountered. Caseload
frequency was defined as the weekly or monthly frequency of
contact with traumatized clients. Caseload ratio was the esti-
mated proportion of ones caseload comprising time spent with
trauma clients specified as a continuous percentage or percent-
age range. Supervision was either a dichotomous variable or
a scaled variable corresponding to an amount of time. Stud-
ies were pooled regardless of how supervision was measured.
Supervision quality represented the perceived working alliance
or supervisees satisfaction with supervision and was evaluated
with the Supervision Working Alliance Inventory (Efstation,
Patton, & Kadash, 1990; k = 2), Multifactor Leadership Ques-
tionnaire (Bass & Avolio, 1988; k =1), Relational Health In-
dex (Liang et al., 2002; k = 1) or author-generated questions
(k =3). A personal trauma was most often a dichotomous vari-
able referring to any type of trauma. One study assessed ex-
posure to emotional and physical trauma separately (Nelson-
Gardell & Harris, 2003). In this case, an average correlation
was calculated and used in subsequent analyses. One study re-
ported a count of traumatic events (Rossi et al., 2012). If a
study reported an association between a specific type of trauma
that matched the client population (e.g., a history of domestic
violence in a domestic violence worker), that value was used to
calculate effect sizes for having a personal trauma the same as
the client. Emotional involvement captured the ability to sepa-
rate oneself emotionally from work with clients and was mea-
sured with author-generated questions (k =2), the Maintenance
of Emotional Separation Scale (Corcoran, 1983; k =1) or the
Emotion-management subscale of the Mayer Salovey Caruso
Emotional Intelligence Test (Mayer, Salovey, & Caruso, 2002;
k = 1). Posttraumatic growth was measured with the Posttrau-
matic Growth Inventory (Tedeschi, Park, & Calhoun, 1998)
and represented positive life changes resulting from trauma
exposure. Social support was measured with author questions
(k = 1), the Crisis Support Questionnaire (Joseph, Andrew,
Williams, & Yule, 1992; k = 1) or the Multidimensional Scale
of Perceived Social Support (Zimet, Dahlem, Zimet, & Far-
ley, 1988; k = 3). Work support was measured with the Work
Environment Scale (Moos, 1994; k = 1) or author-generated
questions (k = 4).
Most studies reported descriptive statistics, Pearsons r, t
test, or F statistics. Following the procedures outlined in Card
(2012), all statistics were converted to the common correla-
tion coefficient, r. If a study stated only that a finding was
not significant, the correlation coefficient was set to zero.
This is a quite conservative approach that will likely lead to
86 Hensel et al.

Table 1
Summary of Risk Factors for Secondary Traumatic Stress Across 38 Studies
Mean Failsafe
Risk factor k N 2 Q I2 (%) ES (r) 95% CI |Z| Na
Age 15 2,491 .00 19.09 27 .05 (.10, .00) 2.08* 11
CL Frequency 8 1,462 .01 23.70** 70 .12 (.02, .22) 2.32* 47
CL Ratio 4 1,138 .00 2.11 0 .19 (.14, .25) 6.61*** 58b
CL Volume 5 779 .00 6.62 40 .16 (.07, .26) 3.33*** 33
Emotional involvement 4 271 .14 26.18*** 88 .27 (.12, .58) 1.38 33b
Ethnicity (Caucasian vs. Other) 3 938 .01 7.19* 72 .06 (.09, .21) 0.81 2
Experience 16 2,429 .01 25.43* 41 .07 (.12, .01) 2.47* 39
Genderc 15 3,934 .01 45.74*** 69 .05 (.02, .11) 1.48 15
Personal trauma 11 1,972 .00 14.15 29 .19 (.14, .24) 6.89*** 339b
Trauma same as clients 3 411 .05 14.84*** 87 .24 (.02, .48) 1.80 22
Posttraumatic growth 4 676 .02 13.43** 78 .13 (.05, .30) 1.39 5
Social support 5 1,135 .01 10.13* 61 .26 (.35, .17) 5.38*** 130b
Supervision 5 704 .00 5.86 32 .02 (.08, .11) 0.35 0
Supervision quality 7 1,050 .01 15.31* 61 .09 (.19, .01) 1.80 14
Trauma training 6 2,395 .00 6.85 27 .05 (.10, .00) 2.04* 8
Work support 5 1,145 .03 27.89*** 86 .17 (.32, .02) 2.17* 41b
Note. Mean effect sizes were calculated with random effects models weighted by the inverse variance of each study where mean effect sizes were significant (p < .05).
k = number of studies; N = population size; 2 = measure of between study variability; Q = heterogeneity statistic; I2 = % heterogeneity; Mean ES (r) = mean random
effects effect size reported as the Pearson correlation coefficient; 95% CI = 95% confidence interval; Z = normal deviate; CL = caseload.
a Rosenthals Failsafe N (based on fixed effect model and assumption of null effect size). b Failsafe N exceeds cutoff for robustness (> 5k + 10). c Reference category is

female.
* p < .05. ** p < .01. *** p < .001.

underestimation of the true effect size; however, this approach
prevents these data from being completely excluded from the
analysis (Card, 2012). Fishers r-to-z transformation was used
in all calculations. Random effects models were generated for
each risk factor to account for heterogeneity and provide a more
generalizable result at the population level (Card, 2012). In ad-
dition, Rosenthals failsafe N was calculated for each significant
effect size. A finding is felt to be robust to publication bias if
Rosenthals N > 5k + 10 (Rosenberg, 2005). This is based on
fixed effect models, however, and should be interpreted with
caution against random effects findings (Card, 2012).
Moderator analyses were conducted to examine the effect
of the outcome measure used (measures reflecting core PTSD
symptomatology only [STSS, IES-R, PTSD checklists] vs. CF
measures that include additional items not directly reflecting
PTSD symptoms [CFST, ProQOL]), year published, and per-
centage of females in the study sample. The latter was included
because of the tendency for studies to have higher proportions
of females and the role that gender has been proposed to play in
reactions to trauma (Badger, Royse, & Craig, 2008). For each
moderator, mixed effect models using weighted full informa-
tion maximum likelihood general least squares regression were
generated to account for between-study variance (Card, 2012).
A minimum of five studies was set as the cutoff for testing
a single moderating variable provided heterogeneity (I2 ) was
less than 50%. The false-positive rate is less than 10% under
these conditions (Higgins & Thompson, 2004). As the number
of studies approaches 10 or more, the moderator estimate is
equally reliable across all levels of heterogeneity.
All analyses were conducted in SPSS using David Wil-
sons meta-analysis macros, which are publicly available for
download (Wilson, 2005). Effect sizes were calculated with
the META ES macro and moderation analyses were performed
with the METAREG macro.
Results
The 38 studies examined professional groups who experienced
indirect trauma in the workplace including volunteer and pro-
fessional counselors and therapists, school personnel, child pro-
tective or welfare workers, domestic violence workers, mental
health clinicians (including physicians and nurses), and chap-
lains. The majority of studies (k = 32) had mixed gender sam-
ples with distribution heavily weighted towards female partic-
ipants in most studies. One of the studies examined females
only and five studies did not describe a gender distribution. All
used cross-sectional survey designs, examined ongoing or re-
cent secondary trauma exposure, and reported continuous score
outcomes.
For each risk factor, Table 1 summarizes the random effects
results. Using Cohens criteria for evaluation of effect sizes
(Cohen, 1988) very small, but significant results (r < .10) were

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Secondary Traumatic Stress Risk Factors
Table 2
Significant Results for Moderating Effect of Year of Publication
Risk factor k B SE B 95% CI |Z|
Caseload frequency 8 0.02 0.01 (0.04,0.00) 2.04*
Personal trauma 11 0.01 0.01 (0.03,0.00) 2.08*
Note. Significant findings among results of moderation analyses. Results of mixed
effects models obtained with weighted full information maximum likelihood
general least squares regression are reported. k = number of studies; B = un-
standardized regression coefficient; SE B = standard error of B; 95% CI = 95%
confidence interval; Z = normal deviate.
* p < .05.
found for age, experience, and trauma training. There were
small but significant effect sizes (10 < r < 30) for all mea-
sures of caseload, personal trauma, work support, and social
support. Small but nonsignificant effect sizes were found for
personal trauma same as clients, emotional involvement, post-
traumatic growth, and supervision quality. All other risk factors
had negligible effect sizes.
Moderators were evaluated for eight risk factors: age,
caseload frequency, caseload volume, experience, gender, per-
sonal trauma, supervision, and trauma training. Significant find-
ings only are reported in Table 2. Advancing year of publica-
tion was modestly associated with lower STS scores for both
caseload frequency (B = .02, p < .05) and personal trauma (B
= .01, p < .05). On visual inspection of the data, correlations
appeared to decline around the year 2008. This was tested by
evaluating the mean effect size across studies published prior to
2008 and after 2008 with a Q test for analysis of variance (Card,
2012). The mean effect size was higher for caseload frequency
pre-2008, r (k = 3) = .24, compared to post-2008, r (k =5)
= .06, Q = 10.7, p = .001. With the exception of one study
(Ennis & Horne, 2003), this was also true for mean correlations
between personal trauma and STS outcomes post-2008, r (k =
6) = .15, compared to pre-2008, r (k =4) = .29, Q = 8.1, p <
.01.
Discussion
It has been argued that widespread organizational interventions
that address STS among professionals are not warranted due to
low prevalence and limited impairment (Elwood et al., 2011).
One cited concern is that discussing STS in the workplace will
result in increased distress and an overappraisal of the intensity
of therapist reactions. There is, however, a need to better un-
derstand and identify those professionals who are at the highest
risk and thus most likely to benefit from targeted interventions.
This need has heightened with revision of the PTSD diagnosis
in DSM-5. This meta-analysis synthesized the existing litera-
ture and showed small effect sizes for several risk factors in the
development of STS among professionals who were secondar-
ily exposed to traumatic material through their therapeutic work
with victims of trauma. Seventeen risk factors from 38 studies
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
87
were examined across combined samples ranging in size from
271 to 3,934.
Demographic factors appeared to have very little influence
on risk of STS. Where effect sizes were significant (age, ex-
perience), they were very small (r = .05 for age and r =
.07 for experience) and most likely attributable to the large
sample sizes. Trauma-related variables including occupational
exposure (i.e., caseload) and ones own personal trauma history
had small positive (r = .12.19) and significant mean effect
sizes. Here we examined three measures of caseload to reflect
the complexity of indirect exposure to trauma (Cieslak et al.,
2013a). The strongest effect size among these three was for
the caseload ratio (r = .19), suggesting that the proportion of
traumatized clients or proportion of time spent working with
trauma survivors may matter more than the actual number of in-
dividuals or frequency of support. This suggests that time doing
nontherapeutic work or serving clients who are not victims of
trauma may help to regulate a professionals likelihood of ex-
periencing STS. Moreover, there was a significant moderating
effect of the year the study was published on caseload fre-
quency. With advancing year of publication, the effect size de-
creased, most notably after 2008. It is possible that this reflects
increasing efforts to promote workplace balance or increasing
awareness about STS in recent years.
Having a personal trauma history, different or similar to the
clients, was positively related to STS in all included studies;
however, the strength of the association varied (r ranging from
.05.36). The role of past trauma may additionally be dependent
on the type of trauma, extent of exposure, and the professionals
gender. Among included studies, high effect sizes were reported
for personal trauma history among therapists who had a history
of sexual or domestic abuse and were supporting sexual or do-
mestic violence victims (r = .42; Jenkins & Baird, 2002) and
therapists with a history of childhood trauma supporting chil-
dren (r = .31; Nelson-Gardell & Harris, 2003) in contrast to
therapists with a history of personal exposure to terrorism (r =
.02; Dekel, Hantman, Ginzburg, & Solomon, 2007) providing
services to clients with the same. A therapist with a personal
history of being sexually assaulted may be more likely to ex-
perience potential reactivation of unresolved personal sexual
trauma based on a clients traumatic material related to a sim-
ilar experience (Salston & Figley, 2003). Given a higher rate
of sexual trauma among females, this type of exposure may
contribute to a higher burden of STS particularly if the major-
ity of the workforce is female (Badger et al., 2008), but more
research is needed to further elucidate this relationship and the
role that gender may play. This is relevant given that many
helping professionals identify this as a motivation for entering
the field (Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011).
This may be a factor that greatly enhances ones therapeutic
skill while simultaneously conferring vulnerability.
Of note, personal trauma history was also moderated by year
of publication, with effect size declining in more recent years,
which could reflect changes in definition or measurement of
trauma being used. For example, earlier studies more often used
88
CF measures that contain a number of items relating directly
to ones personal trauma history and to ones feelings about
themselves and their work, which may be more often negatively
endorsed by people with personal trauma histories.
Work and social support variables also had small signifi-
cant effect sizes. Which source of support, social (i.e., fam-
ily/friends) or work-related (i.e., supervisors and colleagues),
is most valuable to mitigate STS is not clear (Badger et al.,
2008; Slattery & Goodman, 2009). Moreover, in the PSTD lit-
erature, it has been suggested that the effect of social support
may be cumulative over time or most helpful in more severe
reactions to trauma (Ozer, Best, Lipsey, & Weiss, 2003).
Additional small, but insignificant effect sizes were found
for emotional involvement, posttraumatic growth, and supervi-
sion quality. These variables were represented in few studies
and some with substantial heterogeneity partly due to variable
measurement. Additional study of these variables would be im-
portant to determine the vulnerability for STS, if any, that these
factors confer.
Although there are a range of definitions and measures used
in the literature to assess STS, a number of steps were taken to
account for this limitation including a broad initial search, use
of PTSD symptom criteria, careful selection of articles based
on a common professional role, and evaluation of several mod-
erators. The similarity in items and the high intercorrelations
that have been demonstrated between the outcome measures
supported their combination, but in the future, some conver-
gence should be sought regarding the most appropriate mea-
sure for STS among professionals. PTSD measures, despite
frequent use, have been criticized because of lack of valida-
tion among individuals who have been secondarily exposed
to trauma (Elwood et al., 2011). Moreover, outside of using
established PTSD cutoff scores, there are not well-established
cutoffs for levels of STS that are clinically meaningful (Elwood
et al., 2011). Therefore, this study used correlations between the
risk factors and level of symptomatology, not diagnostic out-
comes. Moreover, only a handful of studies have assessed some
risk factors that may be of potential importance. These include
personality traits such as empathy, optimism and meaning, self-
efficacy and coping styles, and a number of work factors, such
as role, job demands, and organizational climate.
This study focused on professionals who engage with
traumatized clients through therapeutic work; however, there
may be differences between occupational groups. For example,
compared to a number of other professionals, child welfare
workers have been found to be more severely affected by
STS (Sprang, Craig, & Clark, 2011). In addition, a number of
articles could not be retrieved and only articles published in
English, Spanish, Portuguese, French, or Polish were selected
for inclusion. Finally, we did not report a quality assessment
due to lack of sufficient separation of studies on adapted quality
indicators with nearly all studies receiving a rating of moderate
quality.
Although this study highlighted risk factors for STS, it may
not be easy to identify those at highest risk within the workplace.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Hensel et al.
Professionals may be reluctant to disclose personal details due
to concerns about confidentiality and job security. Despite this,
supervision or team meetings (Sexton, 1999) may help to iden-
tify those who are struggling. Specific education about the po-
tential for STS may not be necessary, but teaching about the
importance of managing reactions to client material (often re-
ferred to as transference and countertransference reactions) is
already often included in the curricula of many therapist train-
ing programs (Sexton, 1999). Even if widespread education is
not initiated, it is pertinent for managers and supervisors to
have some awareness of STS and how it manifests to be able to
identify it and intervene when necessary.
As previously advocated for, additional quality research is
certainly needed (Elwood et al., 2011), in particular, consistency
in measurement of STS and what constitutes impairment in
the workplace which may or may not be the same as meeting
diagnostic criteria for PTSD. In addition, future studies should
further examine risk factors that have received less attention
and research on interventions and outcomes is required.
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Appendix: Summary of Studies included in Meta-analysis

Study Location n % Female Outcome Risk factor(s)

Badger et al., 2008 USA 121 - STSS EI, Ex, SS
Ben-Porat et al., 2011 Israel 143 85 STSS SuQ, TT
Birck, 2001 GER 25 60 CFST A, Ex, G, Su
Borntrager et al., 2012 USA 300 74 STSS, PQ PTx, WS
Bride et al., 2004 USA 287 - STSS A, CF, CR, Eth
Bride Jones et al., 2007 USA 187 83 STSS CV, Ex, PTx
Carmel & Friedlander, 2009 USA 106 53 IES-R, PQ A, Ex
Cieslak et al., 2013a USA 224 67 STSS A, CF, CR, CV, Ex, PTx, Su
Cieslak et al., 2013b USA 247 67 STSS PG, SS
Cieslak et al., 2013b POL 306 77 STSS PG, SS
Connally, 2012 USA 36 50 PQ A, Eth, G
Choi, 2011 USA 154 - STSS A, CF, Ex, PTx, SuQ
Craig & Sprang, 2010 USA 532 65 PQ G, TT
Deighton et al., 2007 GER 100 65 PQ CF, Ex, PTx
Austria
SWITZ
Dekel et al., 2007 Israel 144 - STS A, Ex, PTx/s, Su, TT
Devilly et al., 2009 AUS 152 70 STSS CR
Dunkley & Whelan, 2006 AUS 62 89 IES-R PTx, Su, SuQ
Ennis & Horne, 2003 USA 59 53 LASC CF, G, PTx
CAN
Furlonger & Taylor, 2013 AUS 75 66 IES-R A, CF, CV, Ex, G, SuQ
Galek et al., 2011 USA 331 45 CFST A, CF, Ex, G, SS, WS
CAN
Gibbons et al., 2011 UK 62 - PQ PG
Hatcher & Noakes, 2010 AUS 119 71 PQ A, G
Jenkins & Baird, 2002 USA 99 96 CFST PTx/s
Kulkarni et al., 2013 USA 236 95 PQ CF, Ex, G, PTx, SuQ
Nelson-Gardell & Harris, 2003 USA 166 89 CFST A, Ex, G, PTx, PTx/s
Olivares et al., 2007 Chile 113 68 STSS Ex, WS
Ortlepp & Friedman, 2002 S Africa 130 58 CFST SS
Rossi et al., 2012 Italy 245 67 PQ A, G, PTx, TT
Samios et al., 2012 AUS 61 84 PQ PG
Shalvi et al., 2011 Israel 41 78 PQ CV, EI, Ex
Simon et al., 2005 USA 21 95 CFST EI
Slattery & Goodman, 2009 USA 148 100 PCL-S SuQ, WS
Sodeke-Gregson et al., 2013 UK 253 72 PQ A, CV, Ex, G, PTx, Su, SuQ, TT, WS
Sprang et al., 2007 USA 1,121 70 PQ G
Sprang et al., 2011 USA 627 72 PQ Eth, G
CAN
Tosone et al., 2010 USA 481 80 PQ CR
Van Hook & Rothenberg, 2009 USA 175 78 PQ A, Ex, G
Zeidner et al., 2013 USA 89 73 PQ EI, G

Note. n = sample size. N/r = Not recorded; PQ = Professional Quality of Life Survey (any of versions IV); CFST = Compassion Fatigue Self-Test; STSS =
Secondary Traumatic Stress Scale; LASC = Los Angeles Symptom Checklist; PCL-S = Posttraumatic Stress Disorder ChecklistSpecific; A = age; CF = caseload
frequency; CR = caseload ratio; CV = caseload volume; EI = emotional involvement; Eth = ethnicity; Ex = experience; G = gender; PTx = personal trauma; PTx/s
= personal trauma same as clients; PG = posttraumatic growth; SS = social support; Su = supervision; SuQ = supervision quality; TT = trauma training; WS = work
support.

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