Experience of the Physiotherapist Working with People with Refugee Experience

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Original Editor - Giuseppe Daverio

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As for other health professionals, also physiotherapists treating refugee population are highly exposed to possible negative reactions related to several challenging aspects to face, i.e. the situation of generalized loss in which refugees often find themselves (Cross & Crabb, 2007, p. 275-285) the frequency of traumatic experiences (Cross & Crabb, 2007) and the difficulties related to cultural competency required when working with this population (Thomas, 2005). In particular, histories of trauma can be highly demanding for the untrained physiotherapist to deal with, due to their extremeness (Varvin, 2015). Narratives can be expressed by words or frequently witnessed as inscribed in bodies, reactions and behaviours. All these aspects can combine and result in challenging problems to face, that can make the physiotherapist feel inadequately trained or unskilled, putting her/him at risk for serious distress reactions (Thomas, 2005). Furthermore, clinicians’ personality traits or history of pre-existing trauma will also play an influence in these phenomena (Cross & Crabb, 2010, p. 283-4). A key aspect worth to name is empathy, that beyond being a core relational skill for humans in general, is also an important professional tool in healthcare yet often unspoken or unconsciously enacted. If unaware about his/her own empathy-regulation mechanism, and under demanding circumstances as those described, the healthcare professional can take inner positions of excessive closeness or excessive distance, both of them negatively affecting the therapeutic process; these are described respectively by the constructs ‘empathic enmeshment’ and ‘empathic repression’ (Cross & Crabb, 2010, p. 283). To balance the picture above given, it is important to remind that beyond negative reactions, working with refugee and in particular in trauma treatment, can also lead to positive development for the health professional. A look at the most relevant constructs on reactions phenomena, both negative and positive ones, is purposeful before describing self-care measures.

Negative Reactions

Constructs on negative reactions have been developed by different authors in past years. Burnout, Secondary Traumatic Stress [STS], Vicarious Traumatization [VT] and Compassion fatigue [CF] are widespread known and frequently recurring in scientific literature (Baird & Kracen, 2006; Elwood, Mott, Lohr, & Galovski, 2011; Hensel, Ruiz, Finney & Dewa, 2015; Smith, Kleijn, Trijsburg & Hutschemaekers, 2007). These constructs have often been used interchangeably, with a confounding effect on research findings (Elwood et al., 2011; Hensel et al., 2015). Synthetical descriptions and a summarizing table are given below, to highlight similarities and differences among them.


Introduced by Maslach in 1982, this construct is meant to describe an emotional exhaustion that can occur in any kind of profession, due to stress factors as excess of workload, organizational and personal conflicts, or similar (Elwood et al., 2011; Hernandez-Wolfe, Killian, Engstrom, & Gangsei, 2015). Applied to healthcare professions and in particular to trauma work it can include reactions as: “apathy, feelings of hopelessness, rapid exhaustion, disillusionment, melancholy, forgetfulness, irritability, experiencing work as a heavy burden, an alienated, impersonal, uncaring and cynical attitude toward clients, a tendency to blame oneself coupled with a feeling of failure.” (Pross, 2006).

Secondary Traumatic Stress

Figley coined this construct in 1995, parallelly to that of compassion fatigue described later (Baird & Kracen, 2006; Pross, 2006). STS describes the development of PTSD-similar symptoms in therapists but also in laymen as friends, family members and caregivers, a consequence of helping a traumatized subject (Elwood et al., 2011; Pross, 2006). The stressor is: “the exposure to knowledge about a traumatizing event experienced by another” (Elwood et al., 2011). Differently from VT and burn-out which occur through long exposure, STS can occur quickly, e.g. as a reaction to exposure to traumatic details in narratives, or again to dissociative reactions (Elwood et al., 2011; Baird & Kracen, 2006). Differently from VT that focuses on cognitive reactions, STS includes a wider bunch of symptoms similar to those of PTSD syndrome (Baird & Kracen, 2006). STS and CF constructs frequently overlap in literature, even if the first is intended more generically while the latter is supposed to pertain specifically to healthcare professions (Elwood et al., 2011).

Vicarious Traumatization (Synonym to Vicarious Trauma)

This construct, specifically fitted to trauma therapists, was created by McCann and Pearlman in 1991 to describe the harmful effects of traumatic material from the client on the clinician (Baird & Kracen, 2006; Elwood et al., 2011). Vicarious traumatization occurs due to cumulative exposure, gradually bringing disruptive changes in the therapists’ cognitive scheme in relation to oneself, to the other and to the world (Rasmussen & Bliss, 2014). In particular, five basic psychological human needs can affected; need for safety, trust, esteem, intimacy and control (Baird & Kracen, 2006).

Compassion Fatigue

CF is a construct introduced in 1995 by Figley, meant to be easier to accept for health professionals (Elwood et al., 2011). Even if not limited to trauma therapists, it has mainly been used in research on these practitioners (ibid, 2011). It focuses on cognitive, emotional and behavioral changes occurring when working with victims of trauma (Hernandez-Wolfe et al., 2015). These changes can impair the empathic skills of the clinician and result in affective disturbances, manifested with anxiety and fear reactions (ibid, 2015).

Table 1. 'Negative' Constructs
Construct Author, Year Related To Causes / Stressors Characteristics Duration
Burnout Maslach, 1982 work, all profession
  • excess of workload
  • organizational or personal conflicts on work
  • Emotional exhaustion
  • Apathy, hopelessness, exhaustion, disillusionment, melancholy, forgetfulness, irritability, alienation, cynicism, impersonality, self-blaming, failure feeling
Long Lasting
Secondary Traumatic Stress Figley, 1995 clinicians or any caregiver
  • Knowledge about a trauma event experienced by another
  • Exposure to trauma details in narratives or to dissociative phenomena
  • Development of PTSD-similar symptoms
  • Wider bunch of symptoms than vicarious traumatization
Can occur quickly
Vicarious Trauma / Traumatisation McCann & Pearlman, 1990 Therapists
  • Trauma material from patients
  • Empathic engagement
  • Disruptive changes in cognitive scheme
  • 5 Specific Areas; Psychological needs in relation to oneself, the other, the world: Need for Safety, Trust, Esteem, Intimacy and Control 
Cumulatitive, Long Lasting
Compassion Fatigue Figley, 1995 Healthcare Providers
  • Trauma material from patients 
  • Cognitive, emotional, behavioral changes
  • Reduction of empathic skill
  • Manifested with anxiety and fear

Somatic Reactions

Knowing about neurobiological processes and the phenomena of interception and body awareness can help clinicians to understand their bodily reactions and thus empower them in the adoption of protective strategies from negative reactions as those described. Neurological structures as mirror neurons, amygdala, sympathetic and parasympathetic systems, the hypothalamus-pituitary-adrenal axis, the left and right brain hemispheres and the insula are involved in stress reactions (Rasmussen & Bliss, 2014). Interoception is defined by Haase et al. as: “the process of sensing body-state relevant information within the context of homeostasis” (2015). This sensing is made possible by anatomical structures as those above named, among which insula is the area of the brain where informations are integrated and perceived as complex feeling state (ibid, 2015). The ability of the organism to maintain or restore homeostasis is a key factor in stress recovery, and low-resilience individuals seem to show lower awareness to interoceptive signals (ibid, 2015). The conclusion is that improving body-awareness can thus work as a protective factor for clinicians.

Positive Reactions

Healthcare professionals in trauma work can also experience positive outcomes. The most relevant constructs describing this phenomena are Vicarious Growth [VG], Vicarious Post-Traumatic Growth [VPTG] and Vicarious Resilience [VR] (Barrington & Shakespeare-Finch, 2013; Edelkott, Engstrom, Hernandez-Wolfe & Gangsei, 2016; Splevins et al., 2010). Before looking at them it’s purposeful to name the construct Post-Traumatic Growth [PTG], coined by Tedeschi and Calhoun in 1996 to describe the positive evolution of any subject that has suffered traumatic experiences in first person  (Manning-Jones, de Terte & Stephens, 2015). In PTG, improvements occur in three subjective domains; life philosophy, self-understanding and interpersonal relationships (Barrington & Shakespeare-Finch, 2013; Manning-Jones et al., 2015).

Vicarious Post-Traumatic Growth; Vicarious Growth

The two constructs VPTG and VG are in practice synonymous. They describe an outcome similar to that of PTG but related to indirect exposure to trauma e.g. in mental health workers or interpreters working with refugees (Barrington & Shakespeare-Finch, 2013; Manning-Jones et al., 2015; Splevins et al., 2010). The difference includes a more abstract form of growth and professional enhancement (Manning-Jones et al., 2015). 

Vicarious Resilience

This construct was introduced by Hernández, Gangsei & Engstrom in 2007 in a research on psychotherapists working with survivors of political violence in Colombia (ibid., 2007). Development of resilience in the clinician results from exposure to both traumatic material and resilience witnessed in patients (Edelkott et al., 2016; Hernandez-Wolfe et al., 2015). VR manifest itself in personal growth the areas of self-perception and worldview, spirituality, self-care, trauma work and connection with clients (ibid.). While the construct of VPTG focusses on the positive changes in self-perception, interpersonal relationships and philosophy of life, VR also encompasses positive changes in therapists’ practice or view on trauma work (Edelkott et al., 2016).

Table. 2 'Positive' Constructs
Construct Author, Year Related To Causes / Stressors Characteristics
Post Traumatic Growth Tedeschi & Calhoun 1996 Any person
  • Direct exposition to trauma
Growth / Positive changes occurs in 3 Domains:
  1. Life philosophy
  2. Self-Understanding,
  3. Interpersonal Relationships 
Vicarious Growth /Vicarious Post Traumatic Growth Arnold, Calhoun, Tedeschi & Cann 2005 Clinicians
  • Indirect exposition to trauma material 
  • Broader concept than post-traumatic growth:
  • Same changes in PTG three areas
  • More abstract form for growth
  • Professional enhancement
Vicarious Resilience Hernández, Gangsei & Engstrom 2007  Clinicians / Trauma Therapists
  • Exposure to patients’ trauma and resilience
  • Broader concept than vicarious post-traumatic growth
  • Dynamic process
  • Change in self-perception, outlook on the world, altered spirituality, self-care and new view on trauma work and connection with clients

Preventive Measures

Knowledge about constructs and neurobiological processes can thus help clinicians to cognitively understand the negative consequences related to stress and trauma work. Body-awareness oriented practices can help to ameliorate self-perception through lived, ‘embodied’ experience. There are many different forms of practices, old traditions and newer methods that can help improve body-awareness, the vast majority of them based on factors that are universally common though differently described and conceptualized (Mehling et al., 2011). Beyond this, it is worth to look at the robust experience of experts working with victims of grove traumas as in torture victims. Experts like Pross (2006) recommend that therapists working with these patients should protect themselves through personal and organizational measures, as those listed in Table 3 below.

Table 3 - Measures for Prevention of Burnout
  • Self Care - avoid workaholism, time for hobbies, leisure, family and friends
  • Solid professional training in diagnosis and (psycho)therapy
  • Therapeutic self-awareness
  • Regular self-examination by collegial and external supervision
  • Limiting Caseload
  • Continuing professional education and learning about new concepts in trauma
  • Opportunities for research and training sabbaticals
  • Keeping a balance between empathy and a proper professional distance to clients
  • Protecting caregivers against being misled by clients with fictitious PTSD
  • Institutional setting in which the roles of therapists and evaluators are separated
  • Social recognition for caregivers
  • Overcoming financial and legal outsider status of centers
  • Integration of centers into the general healthcare system
  • Alliance with medical mainstreams and academic medicine 

Inter-professional Teamwork Strategies

Preventive measures as team work, supervision and collegial support are furthermore purposeful because different perspectives can lead to creative solutions in facing complex problems and challenges, with protective effects for the practitioners (Thomas, 2007).