Secondary Trauma in Adopted Parents

Trauma is one of the most important issues for adoptive families to be thinking about, but unfortunately also one of the terms with the least consistency in agreement – something that is especially problematic given its central role in the ASGSF. I have worked in the National Adoption & Fostering Clinic for over 20 years and, on occasion, have had people describe traumatic events as little more than the on-going existential trauma of being alive, but also more worryingly, that terrible and catastrophic events, including the violent physical and sexual abuse of children, even ones leaving lifelong, life-changing physical legacies, are not traumatic events. I was once told by a health commissioner denying funding for PTSD treatment for an adopted 8 year-old that as they were “only 5 when it happened, they won’t remember it” – but the child most certainly did ‘remember it’ and had a full set of very clear PTSD symptoms. Unfortunately, long experience tells me it can be very tricky to get agreement about “trauma” across different systems and professionals.

It is not surprising there is such a lack of consensus if we look at how the word “trauma” is defined in English language dictionaries e.g., the Oxford English for the UK and the Merriam-Webster in the States. In those you will find trauma means a lot of different things, from damage to the body, similar to its original meaning from Greek; but also terrible events; as well as the psychological legacies that might follow from those events. A physically abused child may suffer a physical trauma to their body, from the traumatic experiences of abuse, that could lead to a traumatic legacy of distress in the short, medium or even long term. Our primary linguistic reference points for what trauma means aren’t much help. And the examples of traumatic events given in those dictionaries are very broad, ranging from the death of a child through divorce to an executive not living up to expectations – albeit not so far as encompassing the existential trauma of existence. We have to ask each other, carefully and with respect, what we mean by trauma if we hope to get a shared understanding to work with. The first thing I do in the clinic is try to understand explicitly what a person means by trauma, not to catch them out with formal definitions and certainly not to deny anybody's experience, but so we can speak about it constructively together.

In mental health services there is clarity about trauma-related difficulties provided by the diagnosis of post-traumatic stress disorder, PTSD, i.e., some terrible events may leave some degree of post-traumatic stress on some people, and we can characterise that through clearly defined symptoms about the psychological legacies of exposure to traumatic events [e.g., https://uktraumacouncil.org/trauma/ptsd-and-complex-ptsd ]. The definitions allow the traumatic event to be directly or indirectly experienced, including witnessing, or in some circumstances hearing about, terrible things happening to someone else. You can get PTSD without having been the direct victim of the traumatic event. This has been recognised for a long time in relation to professionals working in traumatic settings, e.g., therapists working with trauma victims, who through their everyday practise will hear about the awful things that have happened to their clients with whom they are trying to build empathic and compassionate relationships. This is described variously as either secondary or vicarious trauma, and for professionals indirect exposure to their clients’ traumatised histories is related to issues of burnout and compassion fatigue, like they have nothing left in their emotional reservoir [https://www.bma.org.uk/advice-and-support/your-wellbeing/vicarious-trauma/vicarious-trauma-signs-and-strategies-for-coping]. So it seems fairly straightforward to extend the idea of secondary trauma to adopted parents caring for children for whom in many cases their life story includes traumatic histories, and with whom the parents are committed to developing a compassionate and caring relationship.

About 10 years ago we explored these issues in relation to foster carers and found similar rates of post-traumatic stress disorder-like symptoms, i.e., secondary trauma, as has been found in other trauma professionals, including first responders [Hannah & Woolgar, 2018  https://bit.ly/3TsL9PD or here for open access]. Presumably due to their caregiving role to previously maltreated children. Other research groups have also reported similar findings – so we can be pretty sure that caring for children with these histories is associated with increased risk of secondary trauma. We also found elevated rates of burnout and compassion fatigue, and that an intention to leave the profession was correlated with these symptoms of clinically significant distress.

More recently we asked similar, but not exactly the same, questions of adopted parents. One reason the question couldn’t be the same is because being an adoptive parent is not a role or profession one opts into or out of in the same way. We were also concerned whether this was only due to knowing about the bad things that happened to their child (indirect trauma) or whether directly experienced events, in the here and now, such as child-parent violence (CPV) might also be traumatising. Finally, we looked at PTSD itself as well as PTSD-like secondary trauma, because we were interested if there was a meaningful distinction between them [Duncan, Fearon & Woolgar, 2024 http://bit.ly/3ZqHaqr or here for open access ]. The brief answer is that adoptive parents reported similar very elevated rates of secondary trauma, that this was largely indistinguishable from the clinical diagnosis of PTSD, and that both knowing about the child’s early traumatic history as well current lived experience of negative events, such as CPV, increased the severity of PTSD symptoms.  

These are real traumatising processes, that can affect adoptive parents, and which arise partly due to knowing about the traumatic events in the life story but also partly due to ongoing challenges of looking after those children. So it is more complicated than with therapists who are also hearing difficult stories, because the therapist typically goes home at the end of the day to a safer context. That is not to trivialise the challenges of working therapeutically with maltreated children, but it must be even more challenging for parents being in a therapeutic role with their adopted children 24-7. Services should be open to the possibility that there are things happening in the here and now that could be contributing to very clinically significant rates of PTSD and other stresses, including depression and anxiety in adopted parents.

Recognising the different pathways to PTSD and other distress in adoptive parents also means services need to be aware that different mechanisms may operate for different families. For some parents these clinically significant challenges may be very much to do with thinking about their child's early experiences, an understandable tendency to be stuck ruminating about those events. Another parent, while the early history may be a contributing factor, could be living in a situation in which they are experiencing violence in the home, feeling unable to escape, could have the very same PTSD symptoms, but need a different kind of help. Ideally, the first things you want to do with PTSD is to ensure they feel safe in the here and now [that is not always possible, unfortunately], and it is preferrable to begin therapeutic work when they have at least some increased sense of security in their everyday life. So, for those families where they are experiencing significant child parent violence, services need to prioritise their feelings of safety, which means addressing the violence effectively.

Not everyone is equally likely to develop traumatic stress in the caregiving relationship. This is entirely consistent with research on the development of PTSD more generally, in children, adults and also in animal studies. Similar experiences are processed differently in different people and so more likely to lead to clinically significant distress in some people than others. There are some known risk factors for predicting whether a traumatic event causes a legacy of post traumatic distress, but even these factors vary in their impact in different people. This is important for thinking about the development of maltreated and neglected children generally [Woolgar & Simmons, 2019, here ], but also important for the adults looking after them. For example, some well-established psychological coping strategies are associated with a greater risk of developing and continuing with PTSD. You can't just push away traumatic memories, and a coping strategy of trying to suppress distressing thoughts, is associated with higher levels of clinical distress and with the condition persisting. We also found that this type of thought-suppression predicted increased distress in foster carers and adoptive parents.

But what might be the interventions that help, assuming the issues have been correctly identified? To be honest, there is not yet high-quality research addressing trauma symptoms in carers specifically. For PTSD, the treatment of choice would be trauma focused CBT [TF-CBT], but that may be hard to access and for many parents trauma symptoms might not present as pure PTSD, and I fear that many services, overwhelmed with trauma survivors might not consider such traumatic events to be the ‘right kind’ to qualify for treatment. Other related ‘third way’ approaches such as Acceptance & Commitment Therapy [ACT] or Compassion Focussed Therapy [CFT] may be especially helpful to address some of the coping strategies that keep a person stuck in their distress, and to help them work on the kind of life they want to live going forward.

Conclusions

Trauma is a complicated term, even in the dictionaries. We know that clinically significant post-traumatic stress symptoms, which may reach the criteria for a diagnosis of PTSD, can arise from both direct and indirect experiences of traumatic events. While it has long been acknowledged that indirect or secondary trauma can have an impact on therapeutic professionals, there is now evidence from a number of studies that parents of traumatised children may also develop these issues. After all, they too are in a therapeutic role, but 24-7. For adoptive parents research suggests problems can be driven by direct experience of traumatic events in the here and now, as well as the indirect experience of their children’s traumatic life stories. So there are a probably a significant number of adoptive parents who have full blown PTSD, as well as other forms of clinical distress like anxiety or depression, arising from their caregiving roles and this should be taken seriously, because there are treatments that can help. However, because of the way in which trauma is so widely understood/misunderstood there may still be barriers for adoptive parents getting the support they need. But be reassured the evidence is that these can be very real symptoms that require appropriate, evidence-based interventions.