HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Nikos KaldirimitzianPsychologist, Mental Health Center of Samos

Periklis Antoniou Photo


The paper’s issues are trauma and resilience which are “transmitted” by refugees to helpers. The aim of this paper is to inform experts and volunteers about the challenges and the results of working with refugees. The issue is considered as topical and important not only because large numbers of people are involved in the support system for refugees but also because it is connected with economic, social and political processes.

Firstly, the concept of trauma and resilience (also resiliency) are defined. Emphasis is given on the systemic approach. Next, “Trauma Grid” is described. A therapist can use this concept as a tool for comprehensive understanding. Also, the stages of refugee trauma are clarified. In addition, certain technical terms are presented about the transmission of trauma and resilience to therapists. Furthermore, examples and researches focus on the interaction among helpers (workers, therapists, volunteers etc) and refugees. Next, ways of coping with symptoms of vicarious trauma and good practices are recorded which occurred in refugee care organizations. Finally, conclusions and recommendations about future researches are formulated.

The concept of Trauma

Pomini (2011) reports that the word "trauma" originates from the ancient Greek verbs «τρίβω», «τιτρώσκω» και «τείρω» (Latin tero, terere). These verbs incorporate concepts such as causing a wound, insulting, cutting, fraying and separating. It is noted that concepts of friction and abrasion are translated with the Greek word «τριβή».

James and Mac Kinnon (2012) say that “Trauma can be “big-T” or “small-t”, simple or complex”. “Trauma with big T” meets Post Traumatic Stress (PTSD) criteria. It is related with events of death, threat of death, injury, etc. Individuals in these events react with feelings of terror and fear. In addition, an individual may be is trapped in a helpless situation. A person is not able to help himself or to receive help from others. “Trauma with small t” does not threaten life but is related with events that cause great inconvenience and have negative effects on the way that one thinks about himself or others. Insults and punishments are examples of  “small t trauma”. Terms as “simple” and “complex” trauma are used in order to distinguish the severity of events. Sometimes people hurt others to a limited extent. Others cause trauma with their acts or omissions. It may also be that they did not offer protection to victims. (James και Mac Kinnon, 2012)

Linear Models approach phenomena according to their causes and effects. A traumatic event is considered as a cause which induced a terrible result. This approach, albeit well intentioned, focuses on the catastrophic dimension of direct consequences. For example, reports about victims of extreme natural phenomena, violent conflicts, terror attacks etc. (Conors, 2016)

The systemic approach considers PTSD sufferers not as helpless reactors but as active participants in shaping their reality and as partners in therapy. Also the systemic approach is oriented to the creation of a desired future. In addition, the systemic approach favours living life from a creative viewpoint. Systemic thinking helps us in understanding psychotraumatization in a multi-perspective, trans-disciplinary way. "Trauma" may reflect dysfunctions in different interrelated systems (biological, family, social, etc.) and may therefore be presented as an individual, familial or social problem. PTSD problems can be understood and changed by understanding the structures of interdependencies within different systems. Full recovery occurs after alleviating the “negative” and fostering the “positive” processes in a system. A person with PTSD is part of a feedback process, not existing apart from it. There are two types of feedback processes: reinforcing (positive feedback) and balancing (negative feedback). Reinforcing can lead to “vicious” and “virtuous” cycles. Mental and spiritual posttraumatic growth is associated with a process of “virtuous” cycles. In cases of “vicious” cycles, processes start off badly and grow worse. Balancing processes are associated with discovering sources of stability and resilience. On the biological level, there are feedbacks which help heal the trauma, while on the social level there are other feedbacks supporting posttraumatic recovery and resilience. Recovery occurs when a new balance is established between resilience on one side and damage on the other. In this way, the victim’s mission, purpose and quality of life is enriched by recovery. (Jakovjevic et al 2012)

The dominant narrative of a refugee’s trauma includes a landmark. Time seems to be distinguished before and after the traumatic events. Yet exploring the issue reveals more aspects. Papadopoulos (2002) reports that “if we were to examine more carefully the sequence of the ‘refugee trauma’, we would discern a number of distinct phases that are not all about the devastating events that may have occurred”.

Firstly, the phase of “expectation” appears before the traumatic events. In this phase, people hear about an imminent danger and have to decide on the best option. This decision will influence not only their lives (or those of their loved ones) but also the prospects for subsequent generations. As a result, the pressure is great.  Decisions may lead to thoughts like “if I had decided differently …”, which can torment refugees for life.

The next phase covers the period of atrocities or traumatic events. It is worth noting that some refugees never experienced traumatic events because they fleed a dangerous zone in time.

In addition, the “survival” phase follows traumatic events. In this period, life may not be threatened by hostile actions but it is not without gret misery. Refugees can often be disoriented, weakened and helpless. In other words, “survival” may be a traumatic phase for some refugees.

The final phase is that of “adaptation”. Adaptation covers the period after the arrival in countries which offer opportunities for a new life. Refugees’ expectations and hopes are often thwarted by reality, and some of them express bitterness, anger, or ambivalence towards anyone trying to help them. (Papadopoulos, 2002)

Grid of Trauma

Refugee therapists had to take into account the whole of individual experience and how it links to the wider network of relationships. This led to inventing the concept of "Grid of Trauma" which is the therapist’s tool in order to understand the complexity of trauma. Papadopoulos (2007) notes that “the grid offers a framework of three possible effects of trauma –positive, negative and neutral- and assists the therapist to hold in mind the totality of each individual’s experiences as they relate to the wider network of interrelationships across the different defending contexts”.

Negative results can be classified into three categories depending on their severity:

A) Ordinary Human Suffering: The experience of a refugee is one of suffering, but suffering is not always a pathological situation which needs medical aid.

B) Distressful Psychological Reaction. In this situation, no intervention by specialists is necessary. Human resilience alone can deal with such challenges.

C) Psychiatric Disorder. Mental disorders (reactive depression, psychosis, etc.) may occur as a result of traumatic events. The most common is Post Traumatic Stress Disorder (PTSD).

Apart from negative, there may be neutral or even positive results. “Adversity-activated development” is an example of positive result, and “resilience” is a neutral one. Resilience has a positive sign but is classified as neutral because it focuses on characteristics that preexisted the traumatic events. In Trauma Grid, these results are investigated at individual, familial, social and cultural levels. (Papadopoulos, 2011)

The healing work is enhanced when therapists not only identify difficulties, problems, pathology, trauma, but also focus on the advantages or functions of "Adversity Activated Development". It is also good to identify functions of refugees which are associated with resilience. Fine manipulations are needed to address the issues of resilience and the other positive effects of trauma. It is necessary to respect the pain experienced by refugees. Only within a framework of respect can ideas of positive results from an unbearable suffering be introduced. Only within a framework of respect can ideas of positive results of an unbearable suffering be introduced. And this must be done at the right time and with the appropriate language. (Papadopoulos, 2007)

The concept of Resilience

Resilience (also resiliency) is a word with Latin root. According to Windle (2011), it comes from the word "resilire" (to bounce back). Sing and Kaur (2016) claim that “the term “resilience” owes its origin to Latin word  resilio , which means “to restore a bent or a stretched object to its original shape”. There is no single universally accepted definition of "resilience", but in general it is considered as the individual’s ability to overcome or adjust successfully to negative experiences, life cycle transitions or difficult situations. (Pahud et al 2009).

Resilience was initially used as a term in Physics and Engineering, and was introduced in psychiatry and psychology in the 1970s (Singh and Kaur, 2016). In the same period, resilience is first used in a systemic context, specifically in relation with ecosystems (Folke, 2006). Holling (1973) stated that “Resilience determines the persistence of relationships within a system and is a measure of the ability of these systems to absorb changes of state variables, driving variables, and parameters, and still persist. In this definition resilience is the property of the system and persistence or probability of extinction is the result”.

Many papers about system resilience have focused on the ability to absorb shock and retain their functions. One other aspect of resilience regarding the ability to renew, reorganize and develop (Folke, 2006). It is noteworthy that resilience has its roots in systemic thinking, which emphasizes feedback loops rather than linear causality (Kransy and Tidball, 2009)

Schweitzer et al (2007) conducted a survey about refugee resilience and the factors which helped refugees to cope with difficulties before, during and after relocation. Friends, host community, compatriots, nuclear and extended family supported refugees at the emotional and social level. Some refugees report that religious faith helped them. Some of them received material help from church as well. Beliefs and attitudes helped in facing the difficulties. A final coping strategy was the comparison with others who were less fortunate, which made them feel lucky and hopeful.

Concepts about transmission of trauma and resilience to experts

There is a controversy in the bibliography, not about the existence of trauma caused by listening narratives of traumatic events, or helping people who suffer from trauma, but about how this phenomenon is called (Avielly et al, 2005). Several terms are used in the bibliography to describe this situation, and many of these overlap. (Middleton, 2015)

In particular, Simpson and Starkey (2006) reported the definition of Figley about compassion fatigue as “a state of exhaustion and dysfunction – biologically, psychologically, and socially – as a result of prolonged exposure to compassion stress”. Middleton (2015) states that according to Figley compassion fatigue "involves two parts: burnout and secondary trauma."

In secondary trauma (or secondary traumatic stress disorder), some individuals suffer from symptoms of post traumatic stress disorder although they have not experienced traumatic events themselves but have only listened to the stories of trauma sufferers (Figley, 2002).

In addition, there is the concept of “vicarious trauma”. Hernandez et al (2015) note that “Vicarious trauma (VT) refers to the cumulative effect of working with traumatized clients, involving interference with the therapist’s feelings, cognitive schemas and worldview, memories, self-efficacy, and/or sense of safety”.

In addition, what is transmitted during interaction is not only trauma but positive elements associated with it as well. Consequently, concepts such as vicarious or secondary trauma are insufficient to describe the range of effects on professionals. (Guhan και Liebling-Kalifani, 2011).

Hernandez et al (2007) focused on “vicarious resilience” and noticed that “This process is characterized by a unique and positive effect that transforms therapists in response to client trauma survivors’ own resiliency. In other words, it refers to the transformations in the therapists’ inner experience resulting from empathetic engagement with the client’s trauma material”. The change of therapists through the resilience of their clients may have a positive dimension, but it is certainly not painless. (Hernandez et al, 2015).

Also, the concept of "Vicarious Posttraumatic Growth" refers to positive changes resulting from indirect traumatic exposure, e.g. hearing details of traumatic events rather than experiencing them. (Manning – Jones και συν., 2015).

The Interaction between refugees and volunteers

North Aegean residents helped an enormous gefugee population, without having prior expeence and recourses. Great or small stories of solidarity were written by them. But some stories of compassion fatigue were reported as well. For example, there were rumors aboutpeople who avoided sea rescues afret a "traumatic" rescue operation. Also,some volunteers who helped in feeding refugees felt anger and guilt while doing this and wanted to quit. One example is "X", who was actively involved in the creation of a voluntary group that provided food, clothes and  services in order to help refugees. The group earned the trust of the local community and provided significant help to refugees. "X" noticed a woman during a common meal. This woman queued up many times. "X" scolded her when she realized that food was not enough for all. After a while, "X”" saw her giving food to her children. "X" felt that she had wronged the woman, realising that this was a mother who wanted to get more food to feed her children. "X" felt guilty and apologized to her. Such incidents were frequent. After a few months, "X" noticed that she no longer felt satisfied but was tired and frustrated.

The study of Psarros et al. (2016) illuminates the impairment on the mental health of people who offer services to refugees. The sample consisted of 57 volunteers who helped refugees, for 70 days (on average), at the hotspot of Moria, in the island of Lesvos. 90% of them experienced sleep disorder and 37% post traumatic stress disorder (PTSD) according to the ICD 10 criteria. The conclusion of this survey was that caregivers and rescue staff, without proper training and Psychological support, may be at risk of psychological impairment. (Psarros et al, 2016)

**Effects on employees and professionals **

“A” and “B” worked at a hot spot. They were friendly to refugees while other workers had xenophobic attitudes. Many times they had taken initiatives in order to help refugees. The Refugee camp was crowded for a few months. This difficult situation was aggravated by bad weather. One day, “A” saw the members of a family suffering. When she realized that she couldn’t help them immediately, she started to cry.

“B” met a family at the refugee camp. The father suffered from diabetes. Accommodation and food were not appropriate for his special needs. B collaborated with NGO members **, ** the father was recognized as a member of a vulnerable group and the family was given accommodation in a local hotel. This family lives in Western Europe today. Family members thanked “B” for his help. In this case, B felt satisfaction. But his work was not easy. “B” was exhausted after a few months. He stated “…they (refugees) have a different way ofthinking. They didn’t trust, they didn’t know and I often felt that we couldn’t communicate. As a result, it was very stressful”.

During a scientific meeting, the writer was informed by professionals who worked with refugees and immigrants about their emotions. Their stories spoke of fear, frustration and fatigue. For example, one of them feared that a riot could break out over such trifles as the lack of enough shampoo for all refugees. Also, in other narratives, it was obvious that the great vulnerability of certain individuals made them feel inadequate to provide any help. Someone else cited the difficulty of communicating and coordinating between various organizations in order to service incidents. A heavy silence fell upon the room. Next, the writer asked them if they had any successes that made them proud. Then, with joy and enthusiasm, they described cases of psychosocial help to victims of trafficking. Also, there was a thrilling narrative about an "unaccompanied" adolescent. With the immediate actions of professionals and the cooperation of several agencies and organizations, the child's father came from a European country and returned there with his child. In the international literature, there are many surveys about therapists and caregivers. These surveys focus on the positive and negative effects on professionals who work with refugees. Professionals are affected by working and communicating with refugees.It is worth noting that clinicians, despite their special training, are not "invulnerable", and pressing or traumatic stories affect them as well.  (Barington and Shakespeare, 2013).

A survey conducted in 2001 on members of humanitarian organizations who participated in international missions and returned to their homeland showed that 30% of them had severe PTSD symptoms. Another survey, about workers in Kosovo, notes that post-traumatic stress rates for local workers were higher than for workers from other countries. (Cardoso, 2004).

Lor (2012) conducted a survey about camp interpreters and stated that “From the available literature, there is a consensus that interpreting for refugees and asylees frequently has an emotional impact on interpreters”. For example M, who worked as interpreter at a refugee camp in an Aegean island, could not listen to death stories.

Experts who worked in primary care and offered counseling services to refugees reported greater moral dilemmas than those who offered services to anon-refugeepopulation. They also reported disillusion, helplessness, frustration and exhaustion (Guhan and Liebling, 2011).

Gohan and Liebling (2011) reported that “several staff commented on the fact that clients could at times be violent and aggressive. Staff spoke of being threatened, shouted at and having things thrown at them”. Also, there was a great difficulty for staff when they had to cooperate with other agencies and organizations. The staff considered the cooperation with the asylum system to be particularly negative and pressing. (Guhan and Liebling, 2011).

Barrington and Shakespeare (2013) reported that "Although a number of issues reportedly caused distress amongst the clinicians (e.g., working with interpreters, dealing with government bodies) hearing the traumatic stories was the primary instigator of VT symptoms". This conclusion resulted from interviews with professionals who offered services to refugees.

There are noteworthy results and conclusions of research projects about the onset period of vicarious trauma symptoms. According to these, the vicarious trauma of interpreters occurs during the period of adaptation to their role. The same symptoms are a natural response for clinicians during their early working stages as well. (Barrington και Shakespeare-Finch, 2013)

Rodrigo (2005) gives meaning to “vicarious trauma” symptoms using the “Contextual Therapy” Theory. Symptoms of "vicarious trauma" are considered as evidence of the therapist's loyalty to the system he/she belongs to. Perhaps there is a connection between the therapist’s vicarious trauma symptoms and elements of his/ her personality. For example, he/she thinks that he/she can always help people effectively.

However, the therapist may feel unable to help people who are in a situation of high vulnerability. Maybe the therapist feels guilty because he/she can’t respond to the request for help. They must do something in order to relieve the guilt. Sometimes a therapist can’t take positive action in order to cope with his/her client’s trauma. In this case a therapist develops symptoms similar to those of his/her clients. As a result, therapists express their loyalty to the system to which they belong, in an indirect way. Another message of the therapist’s symptoms is the call for effectively help. The therapist is loyal to both the client and the system (Rodrigo, 2005).

Giving meaning to clinicians’ work contributes to changing their experience from vicarious trauma to vicarious resilience and development (Barington and Shakespeare, 2013). Moreover, giving meaning to refugee’s behavior contributes to this change as well. (Guhan and Liebling- Kalifani, 2011)

Vicarious trauma is a precursor to vicarious growth. In other words, if a professional is to experience development they must first experience trauma through working with refugees. Some professionals reported that they have gained more understanding and have become less critical since they started working with refugees. (Barrington και Shakespeare-Finch, 2013)

According to a survey, staff reported that there are benefits from working with refugees, such as the sense of uphlding personal values, the satisfaction when they observe a change in refugees or when asylum seekers express gratitude. According to staff members, these benefits counterbalance the most difficult and emotional aspects of their work. (Guhan and Liebling - Kalifani, 2011). Another research suggested that the development of refugees gave meaning to the work of specialists. (Barrington and Shakespeare-Finch, 2013).

Facing vicarious trauma

In the international literature, there is a variety of strategies for alleviating symptoms to experts—most notably the importance of maintaining a balance between personal and professional life. Another one is psychotherapeutic help about counter transference issues relating to personal history and secondary trauma. Peer consultation, supervision and vocational training are also proposed to reduce the sense of isolation and increase the sense of effectiveness. Finally, therapists are advised to reduce the number of trauma-sufferers they treat. (Bober and Regehr, 2005)

A survey about the effectiveness of facing vicarious trauma strategies, conducted by Bober and Regehr (2005), shoed that although believed in self care they did not spend time on it. Participants also believed in the effectiveness of supervision, spent time on it but it was not a protective factor against the symptoms of intense stress. What was proved to be a protective factor for therapists was the number of trauma cases they undertook; therefore, facing secondary trauma is a structural rather than a personal matter. Finally, resilience was correlated to the existence of personal meaning. (Bober and Regehr, 2005)

Papadopoulos (2008) reported his experience from a refugee camp in Africa where staff members complained of fatigue.Firstly, a circular pattern of communication was obserbed between refugees and staff. Staff tend to perceive refugees as being “greedy”, and refugees tend to perceive staff as being “detached”. The more the refugees asked for the more the staff became detached, and vice-versa. Staff felt that they could not face the refugees’ endless “greed”. Refugees tried to ask more from staff because they felt that staff didn’t care them enough. There was a vicious cycle of accusations. Refugees and staff co-constructed each other’s attitude. In addition, “victim identity” and “dependency syndrome” are two stable behavioral patterns of refugees that affected the relationship between refugees and staff. The staff felt uncomfortable with the refugees who seemed very passive and dependent. The only thing that most refugees had was a document that officially described their misery, e.g., that they were victims of rape. It was their only “official” identity. Staff members felt frustrated when refugees communicated with them only through a “victim identity” and in no other direct way.

Staff were encouraged to think about the broader context of power relationships in the camp. In this context, refugees were absolutely helpless, weak and dependent on staff for their survival. For example, the food card, a necessary document for their survival, carried only a number— no name, no photo. The refugees’ weakness and anonymity were in stark contrast to the staff’s omnipotence and identity. In this context, the refugees’ behavior was meaningful. The refugee confirmed the “victim” role in order to activate the staff members’ role of “rescuers”. In this way refugees gained the most benefits. A supportive program for the staff proposed new ways of behavior in order to stop “victim” role and “dependency syndrome”. Some actions occurred  after this program. Refugees participated in it in an active way, abandoning their former “passive” positions. In particular, refugees actively participated in welcoming new refugee populations. As part of the contact between new and old refugees, there wasan information meeting about their positive and negative experiences from staying in the camp. A genuine spirit of cooperation was created. Refugees were free to use any method that they considered appropriate. Thus, messages were being transmitted in various ways — through storytelling, dancing events etc. Also, there were previous good practices. For example, refugees trained on counseling skills from Camp’s Counseling Unit in order to create a “para-counselors” team.  “Para-counselors” helped as interpreters and offered basic counseling in their community. (Papadopoulos, 2008)


The painful feeling of helplessness may be associated with trauma. Refugees are "traumatized" when they feel totally unable to protect themselves and their loved ones. Perhaps trauma is transmitted to volunteers or to professionals when they are unable to provide any help to refugees or they feel that their work is meaningless **. ** Humans seem to have a spontaneous "impulse" to help others in need. Giving help is accompanied with a feeling of deep satisfaction. This natural process, however, can be "blocked" and the refugee's trauma may affect those interacting with him. Volunteers and workers began offering services with enthusiasm, but refugees seem to have  endless needs. Helpers are often unable to satisfy the refugees' needs. As a result, helpers become frustrated and disillusioned. These feelings occur at the early stages of providing help. Should the organization change, help providers would go on to acquire vicarious resilience.

The transmission of trauma from the users of mental health services to therapists is a phenomenon in the context of counter-transference. It occurs through the narration of events, which becomes cyclical: as it heals one, it hurts another. The refugee's trauma is "transmitted" to the therapist. If the refugee is helped by the therapist to formulate a new narrative, it will be contribute to therapist’s development as well.

Yet in some of the reported examples there were none or only a few narratives. The professionals’ or volunteers’ discomfort was obviously due to a chaotic situation of lack of information, lack of education, lack of resources, lack of coordination and poor management.This does not come as a surprise, because these regions were prepared to receive tourists, not refugees. It would be worth exploring the extent to which administrative initiatives could prevent phenomena associated with burnout, secondary trauma etc. Professionals and volunteers are influenced by factors associated with their working conditions and not with listening to stories (working with interpreters, communicating with agencies or organization, etc.). The recognition and impact of these work factors on vicarious trauma and vicarious post-traumatic development may be the subject for future research.

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ARTICLE 5/ ISSUE 11, October 2017

Types of Domestic Violence and Family Systems Therapy: Initial Observations and Considerations

, Eufrosyni Spanea, Psychologist, Consultation Centre Athens for family violence. General Secretariat for Gender Equality. Greek Ministry of Interior, Graduate of Systemic Family and Couple Psychotherapy Training Course, University Mental Health Research Institute, Athens, Greece.,
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