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SCIENTIFIC ARTICLE

Burnout, vicarious traumatization and its prevention

What is burnout, what is vicarious traumatization?

Christian Pross, MD*

Abstract evaluators are separated. Important factors for Previous studies on burnout and vicarious trau- burnout and vicarious traumatization are the matization are reviewed and summarized with lack of social recognition for caregivers and the a list of signs and symptoms. From the author’s financial and legal outsider status of many centers. own observations two histories of caregivers work- Therefore politicians and social insurance carriers ing with torture survivors are described which should be urged to integrate facilities for trauma- exemplify the risk, implications and consequences tized refugees into the general health care system of secondary trauma. Contributing factors in the and centers should work on more alliances with social and political framework in which caregiv- the medical mainstream and academic medicine. ers operate are analyzed and possible means of prevention suggested, particularly focussing on Key words: burnout, vicarious traumatization, care the conflict of roles when providing evaluations for caregivers on trauma victims for health and immigration authorities Introduction Caregivers working with victims of Symptoms of burnout include apathy, feel- carry a high risk of suffering from burnout and ings of hopelessness, rapid exhaustion, vicarious traumatization unless preventive factors disillusionment, melancholy, forgetfulness, are considered such as: self care, solid professional irritability, experiencing work as a heavy bur- training in , therapeutic self-aware- den,1 an alienated, impersonal, uncaring and ness, regular self-examination by collegial and external supervision, limiting caseload, continuing cynical attitude toward clients, a tendency to professional education and learning about new blame oneself coupled with a feeling of fail- concepts in trauma, occasional research sabbatic- ure2 (Table 1). Such phenomena are quite als, keeping a balance between and a familiar from the normal health care system. T proper professional distance to clients, protect- Who has not experienced, as a patient or ac- ORTURE ing oneself against being mislead by clients with companying family member in a doctor’s of- Volume 16, Number 1, 2006 fictitious PTSD. An institutional setting should fice or hospital, how impersonally and with be provided in which the roles of therapists and what disinterest one is at times treated, and in what an insensitive and cynical tone doc- *) tors speak of suffering and illness! Behandlungszentrum für Folteropfer GSZ Moabit A few years ago, a young doctor docu- Turmstr. 21 mented conversations between surgeons D-10559 Berlin and OR nurses during operations in British Germany [email protected] hospitals and found distressing incidents 2

SCIENTIFIC ARTICLE

of contempt and obscenity. Beyond the in- quiet and withdrawn, cannot regain previous dignation, the question arises of how this feelings of security, and are disillusioned by behavior can be explained. A certain amount humanity. These manifestations are known of professional cynicism, and this is true of as vicarious traumatization of members of other professions as well, apparently serves healing professions.3 to relieve tension and stress and helps deal Based on their studies on incest survivors with the accumulated misery and suffering Laurie Anne Pearlman and Karen Saakvitne with which personnel are confronted day define vicarious traumatization as a trans- after day in a medical environment. The line formation of the helper’s inner experience, is crossed when cynicism turns into brutali- resulting from emphatic engagement with a zation and contempt, which affects care and client’s trauma material.4 harms the patients. Helping has not only a noble and charitable side, but also an ag- gressive aspect. The following will discuss Studies of vicarious traumatization this in greater detail. There have so far been few studies of burn- Johan Lansen has pointed out that out and vicarious traumatization among people working with survivors of torture those who treat victims of extreme violence. experience symptoms that go far beyond the McCann and Pearlman5, who coined the usual burnout. In addition to burnout, such phrase “vicarious traumatization,” advocate aid workers, like their clients, may develop the “infection model.” The authors postu- symptoms of posttraumatic stress disorder late that the patients’ tormenting flood of (PTSD), with sleep disorders and threaten- memories, their nightmares, fears, despair ing nightmares. This results in feelings of and distrust, infect the therapist. As typical great vulnerability. Fears may arise in which symptoms of vicarious traumatization, they less significant daily events are suddenly see depression, cynicism, boredom, loss of experienced as threatening. A growing feel- sympathy and empathy, dejection. Danieli ing of alienation may set in, accompanied and Miller advocate a similar model, in the by withdrawal and isolation. The person no sense of “infectious trauma” or “emotional longer feels understood by friends and rela- infection.”6 Figley7 speaks of secondary tives and loses the confidence that good is traumatic stress reactions or “ still possible in the world; at home, they are fatigue” among therapists, manifested in feelings of faintness, confusion, and isolation Table 1. Signs and symptoms of burnout from friends and relatives, which can create (Lansen, Fineman and Maslach). the same symptoms as PTSD and distin-

guishes this from chronic burnout syndrome, Apathy Feeling of hopelessness which can occur in all aid professionals Rapid exhaustion (Table 2). Kleinman and Maeder call sec- Disillusionment ondarily-traumatized therapists “wounded Melancholy 8 Forgetfulness healers.” These are people who, through Irritability their own traumatic experiences, possess a Experiencing work as a heavy burden greater capacity for empathy; however, their Alienated, impersonal, uncaring and cynical

Volume 16, Number 1, 2006 Volume attitude towards clients need to heal others helps them avoid contact Tendency to blame oneself with their own unprocessed traumas. Feeling of failure ORTURE 9

T Wilson and Lindy see these occurrences 3

SCIENTIFIC ARTICLE

as lapses in the patient-therapist relationship shame and guilt by denying or downplaying with a summation of negative or positive the victim’s sufferings. countertransference reactions. On the one hand, this can manifest itself in too much 2) Rationalization. The evaluator’s attitude detachment on the part of the therapist, who seems open and well-meaning, but he then no longer shows empathy and withdraws finds no connection between the persecution into an intellectualizing, apparently neutral and the suffering from a scientific stand- posture. On the other hand, it can be ex- point. His lip service of understanding to the pressed in the therapist’s undistanced over- suffering helps to relieve his feelings of guilt, identification with the patient, which leads while the “objective” conclusions guarantee him or her to act in concert with the patient, recognition as a reasonable, unbiased evalu- a disabling exaggeration of care that results ator by the German authorities and German in mutual dependence. colleagues. Victims would associate this type Hoppe’s study of this dynamic focused of evaluator with the “nice SS man” who of- on the relationship between evaluators and fered them a cigarette during interrogation. test subjects based on his experience as an evaluator of concentration camp survivors in 3) Overidentification with the victim. The eval- the 1950s and 1960s. He distinguished four uator ties the victim to him and thus satisfies typical attitudinal patterns on the part of his own narcissistic and omnipotent needs. Be- evaluators: cause of his subjective and polemic statements, his evaluations are generally not recognized by 1) Total denial. The evaluator identifies with the reparations offices, and thus this type of the aggressor and fends off his own fear, evaluator disappoints the high hopes that he raises in the victims. Hidden behind his sym- Table 2. Signs and symptoms of vicarious traumatiza- tion (Lansen, Pearlman and Saakvitne, Wilson and pathy and exaggerated empathy with the survi- Lindy, Hoppe). vors is a hatred of the Nazis, who destroyed his

Symptoms of posttraumatic stress disorder: own hopes, as well as anger at himself for not – nightmares, sleeplessness, intrusions, avoidance fulfilling these hopes. behaviour, irritability

Denial of client’s trauma 4) Controlled identification. This position Overidentification with client No time and energy for oneself represents the ideal evaluator, who withholds Feelings of great vulnerability his own judgment, sees the unbelievable ex- Insignificant daily events are experienced as threatening periences of concentration camp survivors as Feelings of alienation

Social withdrawal possible and credible, does not shut himself T Disconnection from loved ones off from the unbearable terror of which he is ORTURE Loss of confidence that good is still possible in the world told, feels empathy, but also observes himself Generalized despair and hopelessness Volume 16, Number 1, 2006 Loss of feeling secure critically and perceives countertransference Increased sensitivity to violence phenomena and his own defense mechan- Cynicism isms.10 Feeling disillusioned by humanity Disrupted frame of reference Changes in identity, world view, Studies on helper personalities Diminished self capacities Impaired ego resources and burnout 11 Alterations in sensory experiences Studies by Hawkins and Shohet, Rioch, (intrusive imagery, dissociation, depersonalization) 12 et al., and Guggenbühl-Graig on helper 4 T ORTURE Volume 16, Number 1, 2006 paranoid fears, confusionanddespair. patients: hishiddenmurderousimpulses, controls hisdarksidewiththehelpof out ofunconsciousmotives, heactsoutand addictsmay havedrug donethis because, the careofviolentpsychotics, suicidesand own violentside. A helperwhohastakenon taboo,which isparticularly isaperson’s idolization bythankfulclients. A finalaspect, andhonor, for is narcissisticlustforglory Another darksideofthe “selfless” helper defend againsthisorherown neediness. throughaddictive overactivityis trying to andhelpofcolleagues,to acceptthesupport workloading underatoo-great andrefusing helper whotakesontoomany clients, groan- can helpward offfearofone’s own death. A child. careofacancerpatient Suchaltruistic essentially reducingthemtotheroleofa in hisorherroleastheomnipotentrescuer, fighting forthemwiththeauthorities, and, ness bydevoting hecticactivitytoclients, overcome hisorherown feelingsofhelpless- Thus, forexample, ahelperwillattempt to own feelingsofhelplessnessandincapacity. the helpertoconcealandavoid hisorher helpless” client. Power over theclient helps the “healthy” tothe onesuperior “sick and ofthehelper,urge forpower onthepart as They includeinthisdarksideahidden burnout, ifsuppressedandleftunprocessed. that canleadtoearly sides ofthepersonality ing profession, andshow that itisthedark ahelp- reasonsinentering purely altruistic burnout. They postulate that nooneactsfor ofthecauses understanding far-reaching makepossibleaneven more personalities practice. Until then, hehadpledfor afind- underwent inhisevaluation an about-face evaluation ofconcentration campsurvivors of practice, onthe In hislastyears anexpert 1 Case history Two examples

tors whogavetors outpositive evaluations asfa- asunreliable evalua-were publicly defamed ofthepsychopathology ofpersecution neers political andlegallevel. Heandother pio- punches pulled, bothprofessionallyandona debate foughtwithno his allinagrueling league sufferedfromburnout. He had given cal, but there ismuchevidencethat thiscol- in hislater Myremarksarehypotheti- years? zism. How couldoneexplainthisabout-face ofNa- they were spirit bytheracial-hygiene psychiatry,names inGerman infectedas 1960s and1970shadtakenonthebig called concentration campsyndromeinthe heated debates andscientificbattles over so- roleinthe he hadplayed animportant that thismanhadbeenapioneerinhisfield; thereafter.shortly Itmust alsobementioned tohiscolleaguesanddied allbridges burnt care.atric After hisretirementhebrusquely systemofpsychi- the anachronisticGerman in the unquestionedsuccessofhisreforms of hiswork anddownplayed asapsychiatrist quently expresseddoubtsabouttheresults he said, thedoctorinquestionhadfre- him believed hedetecteddepression. Thus, cants. A colleague who was relatively closeto was towards covertlyaggressive theappli- sional lectures. The toneofhisevaluations from colleaguesandinvitations toprofes- work, isolated andrefusedinquiries himself, withdrawn moreandfromclin that hehad inrecentyears leagues reported ered histendentiousevaluations. Hiscol- reparations officesaboutwhat theyconsid- complainedtothe centration camp survivors public attention andanorganization ofcon- ily bypersecution. Hisevaluations cameto temporar- which hadsimplybeenworsened ofneuroticdisturbance,age intheform involved dam- early-childhoodpsychological vivor syndrome, hewould concludethat they cases, but now, even inobviouscasesofsur- even indoubtful harms ing ofpersecution SCIENTIFIC ARTICLE ical 5 T ORTURE Volume 16, Number 1, 2006

14 The studies by Lansen, Hoppe and Hoppe and The studies by Lansen, In one of the big rallies in the mid 1990s Shohet help us to better understandShohet help us to better the The psy- cases. by these two traps illustrated chologist persecution who denies her own through her altruisticattempts to dedication trauma. other refugees to deal with her own impulses by needy She fends off her own driving herself brink to the of exhaustion she gains At the same time, for her clients. by her she is revered a narcissistic benefit: grateful clients like a cult figure and in this and friend- her need for love satisfies way help many The fact her evaluations that ship. residency in court status clients to achieve and fantasies of her a feeling of power gives this In turn, being an omnipotent rescuer. and of her clients, raises the expectations she is a life preserver gets around that word with She is overwhelmed for hopeless cases. and When her clients lead her astray clients. she she is exposed and exploited in court, this that is forced to the painful realization fall it will all that apart cannot end well, clients are not the and that sooner or later, her limit, she reaches Eventually her friends. she is ag- her altruistic changes, attitude clients and colleagues and gressive towards her over- Additionally, escapes into illness. with the and over-involvement identification by as in Hoppe, accompanied, victims was herselfanger at against for not doing enough violence and its consequences. and racist Neonazi against xenophobic istrative court, they suddenly gave different different gave they suddenly court, istrative stories their persecution about were that completely contrary med- to their previous She had difficulty explaining ical histories. and the plausibility of her evaluations, this, were in general, and thus her professionalism ebbed, Her initial zest called into question. frequently she lost her and more and more aggressive to colleagues and cli- was temper, suffered a long illness. and ultimately ents, He may have come to a point where come to a point where have He may 13 Case history 2 A psychologist who had made a name fighting refugees and traumatized evaluating the years, over with the authorities became, more and more the addressee for refugees who had problems with residency permits. In the country herself she came from, she had been subject to political persecution, spoke with evident disdain of her she but countrymen the majority that and claimed of and had not experiencedthem exaggerated particularly no She took persecution. grave only particu- from her homeland, patients Her larly difficult cases from other countries. She packed duringoffice was office hours. go through fire for her clients and for would took on the role of mother and friend. many for statements She took more applications Her than she could handle. and evaluations helped evaluations convincing very careful, For people gain residency permits. many she functioned as both thera- some clients, which led to unresolvable pist and evaluator, Like a typical conflicts of roles and loyalties. to the brink she worked of ex- workaholic, Her big-heartedness and eagernesshaustion. gave and she even exploited, to help were material assistance to those in particularly When she refused to give fur- great need. he ther help to an especially insistent client, of to pressure her with threats attempted appearing as an expertA few times, suicide. she felt compromised by her clients witness, during proceedings before the admin- when, he was tired of being an outsider and hoped tired of being an he was by the academic main- finally to be accepted had also been manipu- he Perhaps stream. A small number by some of his clients. lated of faked of persecution instances harms may and from then on triggered a backlash, have great each applicant with mis- he received . vors. SCIENTIFIC ARTICLE ARTICLE SCIENTIFIC 6 T ORTURE Volume 16, Number 1, 2006 their Naziparents. fromthesinsof toabsolve Germans grants can bereadasanappealtoforeignimmi- of theNaziparentgeneration. The slogan driven bythewishtomakeupforcrimes of thepostwar are generation inGermany against saying: pleaseprotectus „Dearforeigners asloganwas carried violence inGermany with torture victims andtraumatized refu- with torture today forcolleagueswhodeal same istrue few ofthemreceive academichonors. The one’sfurther career. Onlymuchlater dida subject was tabooinsociety, andit did not their own, withoutinstitutionalsupport. The mainstream. theirstudies on They pursued unrecognized bythemedicalacademic following thewar were asmallminority, immediately intheyears tion campsurvivors ofconcentra- who dealtwiththesuffering thedoctors casehistory: tothe first return health of thehelper.the psychological To salaries, plays amajorrolein nevertheless astitles,in thingsasprofane positionsand establishment. Suchrecognition, expressed recognition, especiallyintheprofessional matized peopleistheirlow level ofsocial whowork withtrau- inhelpers of burnout in thestudiesmentionedhere: Onecause I would liketoaddsomethingthat islacking Social aspects criteria for success must be set very low. forsuccessmustbesetvery criteria marked byfrequentsetbacks, andthat the instead that thelabourisoftenSisyphean, out expectations are notfulfilledanditturns whenthese disappointment allthegreater can becompletelyhealed. This makestheir of violenceingeneralorthat theirclients this work canhelpthembattle thecauses expectations. They arefullof illusionsthat offwithhighlyinflated danger ofstarting in thefieldofpsychotraumatology arein It is frequently observed that beginners that beginners It isfrequentlyobserved

these Germans!“ Many caregivers Many caregivers Germans!“ 15

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that canbeexpressedinconflicts amongcol- self-image inevitably breedsdisappointment ated intogoodandevil. This exaggerated side world isseenashostile, orflatly separ- develops inwhichtheout- elite teamspirit danger existsoflosingsight reality; an narcissistic overestimation oftheself. The idealist. This isseductive, anditpromotes for this, but alsodismissedasanexotic aboutthework.missionary Oneisadmired tims. There issomethingheroic, pioneering, vic- fortorture it toinstitutionslikecenters the responsibilityfordoingsomethingabout peopleand society.normal They delegate by taboo subjectthat isgivenawideberth ence alsohasitsfascinations. Torture isa positions intheprofession. because oftheiracademictitlesorimportant andagenciesmerely more crediblebycourts with thesespecificclients, but areconsidered colleagues whohave muchlessexperience gees oftenfindtheirevaluations nullifiedby fortraumatized refu- leagues fromfacilities in thefieldofpsychotraumatology? Col- arly views, tointerpret whohastheauthority society: theprevailing schol- whodetermines cidents. The issueispower andinfluencein sell, andtrafficac- suchasvictimsofcrime with clientpopulations that areeasierto whomakecareers ogy iscontrolledbyothers thesubjectofpsychotraumatol-the contrary: possibility ofprofessionaladvancement. On of theprofessionalworld. They have little neithertheinterestnorrecognition earn ence forwhichtheyarenotwell paid, and amountofknowledge andexperi- enormous on awheel. hard,They work very possessan the peoplewhowork therefeellikehamsters modestlyfinanced.staffed andvery Thus system andtheuniversities, andareunder- healthcare areaoutsideofthenormal gray that theirinstitutionsexistina fact the very gees. Their outsiderpositionisapparentin On theotherhand, thisoutsiderexist- SCIENTIFIC ARTICLE 7 T ORTURE Volume 16, Number 1, 2006 The temptation to take an overly biased an overly to take The temptation there are also too few As with treatment, ical and psychological test results. Especially Especially ical and psychological test results. one finds in psychology and psychosomatics, of probabilities. oneself here in the realm offices for Nazi per- Like the reparations the agencies however, secutees in the past, the federal office offices, foreigners’ – state and the refugees, for recognition of foreign formerpension offices (for East German “ob- political persecutes)– require so-called information and findings. jective” of the subject lies precisely position in favor role. of the evaluators’ in this overburdening feelings of guilt It also lies perhaps in latent for being confronted from a secure position of privilege in a rich country of refuge with a person who has lost everything, partly because of actions by the country of refuge re- economic assistance, sales, (weapons are under Evaluators strictive asylum laws). and the envy moral pressure and fear heavy of aggressive reaction of the subject in case also fear be- They may judgment. a negative ing seen as heartless for and being blamed deportation and delivery to his the subject’s transference where Negative tormentors. the the therapist finds himself in the role of perpetrator are particularly hard on therap- Not infre- with trauma victims. ists working in the process of colleagues who, quently, reach a result other than the an evaluation, and one desired by their subjects are berated One refugee re- morally pressured by them. the center took over jected by the treatment slept by the entrance, room for days, waiting into the colleagues’ forced his way repeatedly and complained to his scars, office to show being he was the director of the center that like an animal. treated facilities and experts reactive to evaluate All facilities are results. This lists. long waiting and have overbooked is partly given up because refugees who have leagues. In principle, a treatment center for a treatment In principle, leagues. torture service victims is a socio-medical like ad- like child protection centers, other, any cen- If such etc. pain clinics, diction clinics, ters part became of the normal and health reduce the ideal- this would welfare systems, expectations exaggerated and istic overload on the staff. ease the pressure In and would of traumatized treatment the Netherlands, integratedrefugees was years into the ago This form of general health care system. integrationsocial recognition and has led to noticeable relief and increased professionali- zation. The terrible stories confront therapists that of tortureand evaluators survivors create and a spontaneous feelings of sympathy to do One is tempted strong impulse to help. suffer- possible to ease the persons’ anything exile. ing and guarantee them a secure life in The risk detachment is of losing professional the evalu- of the subjects, In the eyes great. which can mean enormous has ator power, resi- in a residencylife or death procedure: deportationdency death. means means life, pressure on the doctor or This puts massive point from the subject’s psychologist and, shifts onto him a responsibility that of view, the high risk that of I believe is not his. burnout is of the traumatized for evaluators of the also a result of this extreme tension, role from the follow demands that excessive is thrust that of omnipotent judge and savior it is not his job to judge the Yet upon him. credibility or the plausibility of his subject’s story like a criminologist. of persecution, The The final decision is made by the judge. authority as a of the doctor or psychologist, in rec- consists exclusively clinical evaluator, and assessing diagnosing it, ognizing illness, history based on patient causation and clin- The overburdening of the evaluator The overburdening process in the residency role SCIENTIFIC ARTICLE ARTICLE SCIENTIFIC 8 T ORTURE Volume 16, Number 1, 2006 for free. that willadvisethem psychosocial facilities cannot affordalawyer, to andthereforeturn should actuallybedoing. Butmostclients for work that lawyers andrefugeecounselors help. areutilized andpsychologists Doctors tion orstatement fromsuchacentercan hope, because, supposedly, onlyanattesta- fortraumatized refugeesasalast to centers organizations sendtheirclients charitable that dealexplicitly withtorture. Lawyers and result isapullinthedirectionofinstitutions disorders, theyareunabletodeliver this. The cution. Often, becauseoftheirpsychological of perse- histories and coherentbiographical lum processthat requiresdetailed, consistent the povertyscaleareconfrontedwithanasy- themselves hereinexileat thelowest endof andfind intheirhomecountries everything Alliance withmedical mainstream andacademicmedicine Integration ofcenters intothegeneralhealthcare system Overcoming financialandlegaloutsiderstatusofcenters Social recognition forcaregivers andevaluatorsare separated Institutional settinginwhichtheroles oftherapists againstbeingmisleadbyclients withfictitiousPTSD professional distancetoclientsProtecting caregivers Keeping abalancebetweenempathyand aproper Opportunities forresearch andtrainingsabbaticals newconceptsintrauma Continuing professional about educationandlearning Limiting caseload supervision Regular self-examinationbycollegialandexternal Therapeutic self-awareness (psycho)therapy Solid professional trainingindiagnosisand family and friends Self Care –avoidworkoholism,timeforhobbies,leisure, Table 3. awareness throughatherapytrainingcourse. field ofpsychotraumaistherapeuticself- traumatization inthe andvicarious burnout meansofpreventing The mostimportant and vicarioustraumatization Preventing burnout

Factors ofprevention. PTSD for doctors andpsychologists, atPTSD fordoctors the fordiagnosis andtreatment of curriculum sible professionalassociations, conductsa andtherespon- together withotherfacilities Center forthe Treatment of Torture Victims, Berlin, thisstephasalready beentaken: the andtheresponsibleauthorities.funders In staff resources. Itshouldbedemandedfrom many duetolackoffinancialand facilities in has notbeendonetoasufficientdegree separation oftherapistandevaluator, which consists oftheinstitutionalandpersonal sistently over alongperiod. generallycannotbemaintained con- ories perspectives, hist- keepinginmindthat faked fromvarious into theincidentsdescribed statement orevaluation, includinginquiry a shouldbeheldbeforewriting terviews Several oforigin. detailedin- countries conditions,and prison includingdata on andtorture about methodsofpersecution organizationsknowledge ofhumanrights statements toagencies,with prior andthe information, bycomparisons by thirdparty tients’ shouldbesupplemented information sional distancemustbemaintained. The pa- deceiving helpers, limitsandproperprofes- training andself-awareness! misperceptions, cannotreplace supervision denial ofthetrauma. Butdespitecommon vered themselves intodetachedavoidance or detachment, orwhethertheyhave maneu- losingprofessional with theirclientsandrisk whether theyhave becomeoveridentified dark side. This would aidindetermining ers, inacontrolledenvironment, withtheir and treatment, inordertoconfronthelp- isessentialforbothevaluations supervision andexternal tion withthehelpofcollegial isinevitable.burnout Regularself-examina- be provided onthejob; otherwise, early (Table 3). Ifthisislacking, itshouldat least A further protection against burnout protectionagainstburnout A further To prevent clientsfromexploitingand SCIENTIFIC ARTICLE 9 T ORTURE Volume 16, Number 1, 2006 Buckingham: Open University Press, 2000:21. Press, Open University Buckingham: Countertransference and vicarioustherapist. in psychotherapy with incest traumatization LA. Pearlman Saakvitne KW, In: survivors. on vicarious A workbook the pain. Transforming Norton W.W. London: York, New traumatization. 1995. & Company, for understanding the psycho- a framework tion: Trauma J with victims. logical working effects of Stress 1990;3(1):131-49. oder Heiler verwundete Traumatisierung, tende intersubjektive Erfahrungdie unvermeidbare in Arbeit mit traumatisi- der psychotherapeutischen of the conference Lecture at erten Flüchtlingen. (Unpublished). 1999. Berlin, BAFF, secondary stress disorder in those who traumatic Brunner and York: New the traumatized. treat 1995. Mazel, Guilford Press, York: New of PTSD. treatment 1994. trists when confronting holocaust survivors of Psychoanalytic ed. Lindon J, In: persecution. Science House, York: New III. Vol. forum, 1969:187. Philo-Verlagsgesellschaft, Berlin: gegen die Opfer. 2001:168ff. been and details have Facts observations. changed. the 9th at Presentation refugees. traumatized Nordic Conference on Refugee Health Care in 1995. 19-21, May Bornholm/Denmark, 2000:21. 3. 3. & Shohet 2000. Lansen cited in Hawkins 4. and the Trauma Saakvitne KW. LA, Pearlman 5. Vicarious traumatiza- LA. Pearlman L, McCann 6. Stellvertre- Bustos E. cited in: Danieli and Miller 7. with , ed. Figley CR, 8. Kleinman and Maeder cited in Bustos 1999. 9. Countertransference in the Lindy JD. Wilson JP, The emotional reactions of psychia- Hoppe KD. 10. & Shohet 2000:8ff. Hawkins 11. & Shohet 2000. Cited in Hawkins 12. – Der KleinkriegWiedergutmachung Pross C. 13. own The examples are taken from the author’s 14. with of the past in our work The shadow Pross C. 15. & Shohet and Brodsky cited in Hawkins Edelwich 16. & Shohet 2000:21. Hawkins 17. Thus a work environment must must environment Thus a work 17 S, Gurris N, Pross C. Folter – an der Seite der Folter C. Gurris Pross S, N, Therapien. stützung und Unter Überlebenden. 1996:253-70. Beck, C.H. Verlag Munich: an Supervisionhet R. in the helping professions: group approach. and organizational individual, As a further means of prevention, it is As a further prevention, means of 2. 2. Sho- P, Hawkins Fineman and Maslach cited in: References and notes 1. Graessner mit uns? In: “es” tut Was Lansen J. important be solely individuals not that trauma- or treating with evaluating involved centers colleagues at Many tized patients. out of a healthy refugees, for traumatized reduced have instinct for self-preservation, their hours in recent years and set up offices with less-ill patients in which they also treat and social in- Politicians neurotic disorders. surance carriers should be urged to integrate facilities refugees into the for traumatized in as this would general health care system, follow-up the expensive the long run avoid psychiatriccosts of in-patient in chronic care from its ideological free the work cases, and its niche as an exotic charity, burdens and offer more opportunities for continuing infrequently, Not in other areas. education appear in helpers and disinterest in apathy the midst of their professional careers if they cease to continue their professional educa- and instead fall into the familiartion, rut of This is a further cause of burnout routine. rarely been mentioned in the lit- has that erature. end of which the participantsend of which certifi- receive this will increase the long term, Over cation. the hitherto very small number of evaluation to experts Berlin, of in the state operating be possible to separ- the point where it will functions. the two ate SCIENTIFIC ARTICLE ARTICLE SCIENTIFIC be created that encourages flexibility and that be created and promotes continuing educa- creativity for example in the tion and qualification, form for research projects and of sabbaticals publications.