Provider Load

  • Kotaro Shoji
  • Charles C. Benight
  • Shaun Stearns


This chapter summarizes the most relevant data we gathered related to prevalence of secondary trauma and burnout in military mental health providers as well as other trauma therapists. A number of published papers from our laboratory, as well as relevant research findings from other researchers, are provided. We compare our results with other published investigations of different provider populations offering important insights. We report on important differences between on-post and off-post providers. Important clinical implications related to how to help these military mental health providers based on our findings are offered. Lastly, suggestions for how these findings can help the broader therapeutic community close out this chapter.


Secondary traumatic stress Burnout Military mental health provider Social cognitive theory Conservation of resources theory 


  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed. – Text revision). Washington, DC: American Psychiatric Publishing.Google Scholar
  2. Arvay, M. J., & Uhlemann, M. R. (1996). Counsellor stress in the field of trauma: A preliminary study. Canadian Journal of Counselling, 30(3), 193–210.Google Scholar
  3. Baker, R. R., Menard, S. W., & Johns, L. A. (1989). The military nurse experience in Vietnam: Stress and impact. Journal of Clinical Psychology, 45(5), 736–744. doi: 10.1002/1097-4679(198909)45:5<736::AID-JCLP2270450508>3.0.CO;2-M.CrossRefPubMedGoogle Scholar
  4. Ballenger-Browning, K. K., Schmitz, K. J., Rothacker, J. A., Hammer, P. S., Webb-Murphy, J. A., & Johnson, D. C. (2011). Predictors of burnout among military mental health providers. Military Medicine, 176(3), 253–260. doi: 10.7205/MILMED-D-10-00269.CrossRefPubMedGoogle Scholar
  5. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W H Freeman/Times Books/Henry Holt & Co..Google Scholar
  6. Beck, C. T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25(1), 1–10. doi: 10.1016/j.apnu.2010.05.005.CrossRefPubMedGoogle Scholar
  7. Berger, R., & Gelkopf, M. (2011). An intervention for reducing secondary traumatization and improving professional self-efficacy in well baby clinic nurses following war and terror: A random control group trial. International Journal of Nursing Studies, 48(5), 601–610. doi: 10.1016/j.ijnurstu.2010.09.007.CrossRefPubMedGoogle Scholar
  8. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63–70.CrossRefPubMedGoogle Scholar
  9. Bride, B. E., & Figley, C. R. (2009). Secondary trauma and military veteran caregivers. Smith College Studies in Social Work, 79(3–4), 314–329. doi: 10.1080/00377310903130357.CrossRefGoogle Scholar
  10. Bride, B. E., Jones, J. L., & Macmaster, S. A. (2007). Correlates of secondary traumatic stress in child protective services workers. Journal of Evidence-Based Social Work, 4, 69–80. doi: 10.1300/J394v04n03_05.CrossRefGoogle Scholar
  11. Bride, B. E., Smith Hatcher, S., & Humble, M. N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105.CrossRefGoogle Scholar
  12. Brouwers, A., & Tomic, W. (2000). A longitudinal study of teacher burnout and perceived self-efficacy in classroom management. Teaching and Teacher Education, 16(2), 239–253. doi: 10.1016/S0742-051X(99)00057-8.CrossRefGoogle Scholar
  13. Burke, R. J., & Richardsen, A. M. (2001). Psychological burnout in organizations: Research and intervention. In R. T. Golembiewski (Eds.), Handbook of organizational behavior (2nd ed., rev. ed., and, exp. ed., pp. 327–363). New York: Marcel Dekker.Google Scholar
  14. Choi, G. Y. (2011). Secondary traumatic stress of service providers who practice with survivors of family or sexual violence: A national survey of social workers. Smith College Studies in Social Work, 81, 101–119. doi: 10.1080/00377317.2011.543044.CrossRefGoogle Scholar
  15. Cieslak, R., Anderson, V., Bock, J., Moore, B. A., Peterson, A. L., & Benight, C. C. (2013). Secondary traumatic stress among mental health providers working with the military: Prevalence and its work- and exposure-related correlates. The Journal of Nervous and Mental Disease, 201(11), 917–925. doi: 10.1097/NMD.0000000000000034.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Cordes, C. L., & Dougherty, T. W. (1993). A review and an integration of research on job burnout. The Academy of Management Review, 18(4), 621–656. doi: 10.2307/258593.Google Scholar
  17. Craun, S. W., Bourke, M. L., Bierie, D. M., & Williams, K. S. (2014). A longitudinal examination of secondary traumatic stress among law enforcement. Victims and Offenders, 9(3), 299–316. doi: 10.1080/15564886.2013.848828.CrossRefGoogle Scholar
  18. de Jonge, J., van Vegchel, N., Shimazu, A., Schaufeli, W., & Dormann, C. (2010). A longitudinal test of the demand–control model using specific job demands and specific job control. International Journal of Behavioral Medicine, 17(2), 125–133. doi: 10.1007/s12529-010-9081-1.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499–512. doi: 10.1037/0021-9010.86.3.499.CrossRefPubMedGoogle Scholar
  20. Deutsch, C. J. (1984). Self-reported sources of stress among psychotherapists. Professional Psychology: Research and Practice, 15(6), 833–845. doi: 10.1037/0735-7028.15.6.833.CrossRefGoogle Scholar
  21. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14(325). doi: 10.1186/1472-6963-14-325.
  22. Emerson, S., & Markos, P. A. (1996). Sings and symptoms of the impaired counselor. Journal of Humanic Education and Development, 34(3), 108–117. doi: 10.1002/j.2164-4683.1996.tb00335.x.CrossRefGoogle Scholar
  23. Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172(4), 359–363. doi: 10.7205/MILMED.172.4.359.CrossRefPubMedGoogle Scholar
  24. Fiabane, E., Giorgi, I., Sguazzin, C., & Argentero, P. (2013). Work engagement and occupational stress in nurses and other healthcare workers: The role of organisational and personal factors. Journal of Clinical Nursing, 22(17–18), 2614–2624. doi: 10.1111/jocn.12084.CrossRefPubMedGoogle Scholar
  25. Figley, C. R. (1978). Symptoms of delayed combat stress among a college sample of Vietnam veterans. Military Medicine, 143(2), 107–110.PubMedGoogle Scholar
  26. Ford, V. F., Swayze, S., & Burley, D. L. (2013). An exploratory investigation of the relationship between disengagement, exhaustion and turnover intention among IT professionals employed at a university. Information Resources Management Journal (IRMJ), 26(3), 55–68. doi: 10.4018/irmj.2013070104.CrossRefGoogle Scholar
  27. Gates, D., & Gillespie, G. (2008). Secondary traumatic stress in nurses who care for traumatized women. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(2), 243–249.CrossRefGoogle Scholar
  28. Gentry, J. E., Baggerly, J., & Baranowsky, A. (2004). Training-as-treatment: Effectiveness of the certified compassion fatigue specialist training. International Journal of Emergency Mental Health, 6(3), 147–155.PubMedGoogle Scholar
  29. Gray, A. M., Phillips, V. L., & Normand, C. (1996). The costs of nursing turnover: Evidence from the British National Health Service. Health Policy, 38(2), 117–128. doi: 10.1016/0168-8510(96)00854-8.CrossRefPubMedGoogle Scholar
  30. Hakanen, J. J., Schaufeli, W. B., & Ahola, K. (2008). The job demands-resources model: A three-year cross-lagged study of burnout, depression, commitment, and work engagement. Work and Stress, 22(3), 224–241. doi: 10.1080/02678370802379432.CrossRefGoogle Scholar
  31. Halbesleben, J. R. B., & Demerouti, E. (2005). The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work and Stress, 19(3), 208–220. doi: 10.1080/02678370500340728.CrossRefGoogle Scholar
  32. Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44(3), 513–524. doi: 10.1037/0003-066X.44.3.513.CrossRefPubMedGoogle Scholar
  33. Hobfoll, S. E. (2011). Conservation of resources theory: Its implication for stress, health, and resilience. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 127–147). New York: Oxford University Press.Google Scholar
  34. Holmqvist, R., & Jeanneau, M. (2006). Burnout and psychiatric staff’s feelings towards patients. Psychiatry Research, 145(213), 207. doi: 10.1016/j.psychres.2004.08.012.CrossRefPubMedGoogle Scholar
  35. Horoho, P. D. (2011). Army nursing: Transforming for a new century of caring. The United States Army Medical Department Journal, October - December 2011, 4–9.Google Scholar
  36. Huynh, J. Y., Xanthopoulou, D., & Winefield, A. H. (2013). Social support moderates the impact of demands on burnout and organizational connectedness: A two-wave study of volunteer firefighters. Journal of Occupational Health Psychology, 18(1), 9–15. doi: 10.1037/a0030804.CrossRefPubMedGoogle Scholar
  37. Innstrand, S. T., Langballe, E. M., Espnes, G. A., Falkum, E., & Aasland, O. G. (2008). Positive and negative work–family interaction and burnout: A longitudinal study of reciprocal relations. Work and Stress, 22(1), 1–15. doi: 10.1080/02678370801975842.CrossRefGoogle Scholar
  38. Jakupcak, M., Luterek, J., Hunt, S., Conybeare, D., & McFall, M. (2008). Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan war veterans seeking postdeployment VA health care. The Journal of Nervous and Mental Disease, 196(5), 425–428. doi: 10.1097/NMD.0b013e31817108ed.CrossRefPubMedGoogle Scholar
  39. Karasek, R. A., & Theorell, T. (1992). Healthy work: Stress, productivity, and the reconstruction of working life. New York: Basic Books.Google Scholar
  40. Kintzle, S., Yarvis, J. S., & Bride, B. E. (2013). Secondary traumatic stress in military primary and mental health care providers. Military Medicine, 178(12), 1310–1315. doi: 10.7205/MILMED-D-13-00087.CrossRefPubMedGoogle Scholar
  41. Lang, G. M., Pfister, E. A., & Siemens, M. J. (2010). Nursing burnout: Cross-sectional study at a large Army hospital. Military Medicine, 175(6), 435–441. doi: 10.7205/MILMED-D-09-00284.CrossRefPubMedGoogle Scholar
  42. Langballe, E. M., Innstrand, S. T., Aasland, O. G., & Falkum, E. (2011). The predictive value of individual factors, work-related factors, and work–home interaction on burnout in female and male physicians: A longitudinal study. Stress and Health, 27(1), 73–87. doi: 10.1002/smi.1321.CrossRefGoogle Scholar
  43. Lasalvia, A., Bonetto, C., Bertani, M., Bissoli, S., Cristofalo, D., Marrella, G., et al. (2009). Influence of perceived organisational factors on job burnout: Survey of community mental health staff. The British Journal of Psychiatry, 195(6), 537–544. doi: 10.1192/bjp.bp.108.060871.CrossRefPubMedGoogle Scholar
  44. Lee, R. T., & Ashforth, B. E. (1996). A meta-analytic examination of the correlates of the three dimensions of job burnout. Journal of Applied Psychology, 81(2), 123–133. doi: 10.1037/0021-9010.81.2.123.CrossRefPubMedGoogle Scholar
  45. Levin, A. P., Albert, L., Besser, A., Smith, D., Zelenski, A., Rosenkranz, S., & Neria, Y. (2011). Secondary traumatic stress in attorneys and their administrative support staff working with trauma-exposed clients. Journal of Nervous and Mental Disease, 199(12), 946–955. doi: 10.1097/NMD.0b013e3182392c26.CrossRefPubMedGoogle Scholar
  46. Llorens, S., Schaufeli, W., Bakker, A., & Salanova, M. (2007). Does a positive gain spiral of resources, efficacy beliefs and engagement exist? Computers in Human Behavior, 23(1), 825–841. doi: 10.1016/j.chb.2004.11.012.CrossRefGoogle Scholar
  47. Mancini, A. D., Moser, L. L., Whitley, R., McHugo, G. J., Bond, G. R., Finnerty, M. T., & Burns, B. J. (2015). Assertive community treatment: Facilitators and barriers to implementation in routine mental health settings. Psychiatric Services. doi: 10.1176/ps.2009.60.2.189.Google Scholar
  48. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2(2), 99–113. doi: 10.1002/job.4030020205.CrossRefGoogle Scholar
  49. Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. doi: 10.1146/annurev.psych.52.1.397.CrossRefPubMedGoogle Scholar
  50. Meffert, S. M., Henn-Haase, C., Metzler, T. J., Qian, M., Best, S., … & Marmar, C. R. (2014). Prospective study of police officer souse/partners: A new pathway to secondary trauma and relationship violence? PLoS One, 9(7), e100663. doi: 10.1371/journal.pone.0100663 Google Scholar
  51. Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 341–352. doi: 10.1007/s10488-011-0352-1.CrossRefPubMedPubMedCentralGoogle Scholar
  52. Perrewé, P. L., Hochwarter, W. A., Rossi, A. M., Wallace, A., Maignan, I., … & Van Deusen, C. A. (2002). Are work stress relationships universal? A nine-region examination of role stressors, general self-efficacy, and burnout. Journal of International Management,8(2), 163–187. doi: 10.1016/S1075-4253(02)00052-2 Google Scholar
  53. Priebe, S. (2004). Institutionalization revisited – With and without walls. Acta Psychiatrica Scandinavica, 110(2), 81–82. doi: 10.1111/j.1600-0047.2004.00386.x.CrossRefPubMedGoogle Scholar
  54. Qiao, H., & Schaufeli, W. B. (2011). The convergent validity of four burnout measures in a Chinese sample: A confirmatory factor-analytic approach. Applied Psychology, 60(1), 87–111. doi: 10.1111/j.1464-0597.2010.00428.x.CrossRefGoogle Scholar
  55. Rogala, A., Shoji, K., Luszczynska, A., Kuna, A., Yeager, C., Benight, C., & Cieslak, R. (2015). From exhaustion to disengagement via self-efficacy change: Findings from two longitudinal studies among human services workers. Organizational Psychology, 6(2032). doi: 10.3389/fpsyg.2015.02032.
  56. Rollins, A. L., Salyers, M. P., Tsai, J., & Lydick, J. M. (2009). Staff turnover in statewide implementation of ACT: Relationship with ACT fidelity and other team characteristics. Administration and Policy in Mental Health and Mental Health Services Research, 37(5), 417–426. doi: 10.1007/s10488-009-0257-4.CrossRefGoogle Scholar
  57. Rosenheck, R. A., & Fontana, A. F. (2007). Recent trends In VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs (Project Hope), 26(6), 1720–1727. doi: 10.1377/hlthaff.26.6.1720.CrossRefGoogle Scholar
  58. Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23(3), 449–480. doi: 10.1016/S0272-7358(03)00030-8.CrossRefPubMedGoogle Scholar
  59. Schauben, L. J., & Frazier, P. A. (1995). Vicarious trauma: The effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly, 19(1), 49–64. doi: 10.1111/j.1471-6402.1995.tb00278.x.CrossRefGoogle Scholar
  60. Seligman, M. E. P. (2002). Positive psychology, positive prevention, and positive therapy. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 3–9). New York: Oxford University Press.Google Scholar
  61. Shoji, K., Bock, J., Cieslak, R., Zukowska, K., Luszczynska, A., & Benight, C. C. (2014). Cultivating secondary traumatic growth among healthcare workers: The role of social support and self-efficacy. Journal of Clinical Psychology, 70(9), 831–846. doi: 10.1002/jclp.22070.CrossRefPubMedGoogle Scholar
  62. Shoji, K., Lesnierowska, M., Smoktunowicz, E., Bock, J., Luszczynska, A., Benight, C. C., & Cieslak, R. (2015). What comes first, job burnout or secondary traumatic stress? Findings from two longitudinal studies from the U.S. and Poland. PLoS One, 10(8). doi: 10.1371/journal.pone.0136730.Google Scholar
  63. Skorupa, J., & Agresti, A. A. (1993). Ethical beliefs about burnout and continued professional practice. Professional Psychology: Research and Practice, 24(3), 281–285. doi: 10.1037/0735-7028.24.3.281.CrossRefGoogle Scholar
  64. Smith Hatcher, S., Bride, B. E., Oh, H., Moultrie King, D., & Franklin Catrett, J. (2011). An assessment of secondary traumatic stress in juvenile justice education workers. Journal of Correctional Health Care, 17(3), 208–217. doi: 10.1177/1078345811401509.CrossRefPubMedGoogle Scholar
  65. Smoktunowicz, E., Baka, L., Cieslak, R., Nichols, C. F., Benight, C. C., & Luszczynska, A. (2015). Explaining counterproductive work behaviors among police officers: The indirect effects of job demands are mediated by job burnout and moderated by job control and social support. Human Performance, 28(4), 332–350. doi: 10.1080/08959285.2015.1021045.CrossRefGoogle Scholar
  66. Spector, P. E., & Jex, S. M. (1998). Development of four self-report measures of job stressors and strain: Interpersonal Conflict at Work Scale, Organizational Constraints Scale, Quantitative Workload Inventory, and Physical Symptoms Inventory. Journal of Occupational Health Psychology, 3, 356–367. doi: 10.1037/1076-8998.3.4.356.CrossRefPubMedGoogle Scholar
  67. Stretch, R. H., Vail, J. D., & Maloney, J. P. (1985). Posttraumatic stress disorder among army nurse corps Vietnam veterans. Journal of Consulting and Clinical Psychology, 53(5), 704–708. doi: 10.1037/0022-006X.53.5.704.CrossRefPubMedGoogle Scholar
  68. Thomas, R. B., & Wilson, J. P. (2004). Issues and controversies in the understanding and diagnosis of compassion fatigue, vicarious traumatization, and secondary traumatic stress disorder. International Journal of Emergency Mental Health, 6(2), 81–92.PubMedGoogle Scholar
  69. Thoreson, R. W., Miller, M., & Krauskopf, C. J. (1989). The distressed psychologist: Prevalence and treatment considerations. Professional Psychology: Research and Practice, 20(3), 153–158. doi: 10.1037/0735-7028.20.3.153.CrossRefGoogle Scholar
  70. Tosone, C., Lee, M., Bialkin, L., Martinez, A., Campbell, M., … & Stefan, A. (2003). Shared trauma: Group reflection on the September 11th disaster. Psychoanalytic Social Work, 10(1), 57–77. doi: 10.1300/j032v10n01_06 Google Scholar
  71. Tyson, J. (2007). Compassion fatigue in the treatment of combat-related trauma during wartime. Clinical Social Work Journal, 35(3), 183–192. doi: 10.1007/s10615-007-0095-3.CrossRefGoogle Scholar
  72. U.S. Department of Veterans Affairs. (2014). VA Mental Health Services: Public Report. Retrieved from:
  73. Van der Doef, M., & Maes, S. (1999). The Job Demand-Control (-Support) model and psychological well-being: A review of 20 years of empirical research. Work & Stress, 13(2), 87–114. doi: 10.1080/026783799296084.CrossRefGoogle Scholar
  74. Voss Horrell, S. C., Holohan, D. R., Didion, L. M., & Vance, G. T. (2011). Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician? Professional Psychology: Research and Practice, 42(1), 79.CrossRefGoogle Scholar
  75. Waldman, J. D., Kelly, F., Arora, S., & Smith, H. L. (2004). The shocking cost of turnover in health care. Health Care Management Review, 29(1), 2–7.CrossRefPubMedGoogle Scholar
  76. Xanthopoulou, D., Bakker, A. B., Dollard, M. F., Demerouti, E., Schaufeli, W. B., Taris, T. W., & Schreurs, P. G. (2007). When do job demands particularly predict burnout?: The moderating role of job resources. Journal of Managerial Psychology, 22(8), 766–786. doi: 10.1108/02683940710837714.CrossRefGoogle Scholar
  77. Yu, X., Wang, P., Zhai, X., Dai, H., & Yang, Q. (2015). The effect of work stress on job burnout among teachers: The mediating role of self-efficacy. Social Indicators Research, 122(3), 701–708. doi: 10.1007/s11205-014-0716-5.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2016

Authors and Affiliations

  • Kotaro Shoji
    • 1
  • Charles C. Benight
    • 1
  • Shaun Stearns
    • 1
  1. 1.Trauma, Health, and Hazards CenterUniversity of Colorado at Colorado SpringsColorado SpringsUSA

Personalised recommendations