Self Care for Rehabilitation Professionals Working with Displaced Persons
Original Editor - Kamal Khalifa, Wala’a Awwad from The Center for Victims of Torture and Giuseppe Daverio as part of the PREP Content Development Project
Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson, Stacy Schiurring and Carin Hunter , Ilona Fricker from The Center for Victims of Torture
Introduction[edit | edit source]
Working with people who have experienced displacement is often rewarding meaningful work, but it can also be challenging, especially to the physical and psychological health of the individual working in this field. Rehabilitation professionals treating displaced persons are often exposed to possible negative reactions related to several challenging aspects they face in this work. They are confronted daily by suffering and grief and the situation of generalised loss in which refugees often find themselves. In particular, histories of survivors of trauma can be highly demanding for the untrained rehabilitation professional to deal with, due to their extreme nature often involving torture and/or violence. Additionally, there can be difficulties related to cultural competency required when working with this population.
All these aspects can combine and result in challenging problems to face that can make the rehabilitation professional feel inadequately trained or unskilled, putting them at risk for serious distress reactions. Rehabilitation professionals in this field talk of how their work can sometimes leave them feeling numb, disconnected, isolated, overwhelmed, and depressed. For these reasons, self-care is crucial. Studies on rehabilitation professionals are limited, but have shown that they are also subject to serious distress reactions, with one study showing 45.8% of the physiotherapists were affected by burnout or at a high risk of developing the syndrome.
What is Self-Care[edit | edit source]
Self-care is any activity that we do deliberately, in order to take care of our own mental, emotional and physical health. It’s “something that refuels us, rather than takes from us”.
It is a broad concept encompassing hygiene (general and personal), nutrition (type and quality of food eaten), lifestyle (sporting activities, leisure etc), environmental factors (living conditions, social habits, etc.) socio-economic factors (income level, cultural beliefs, etc.) and self-medication.
Why Self-Care is Important[edit | edit source]
- Working with people with experience of displacement can be emotionally difficult for individuals working in this field.
- Embedding self-care activities in daily life helps in identifying, managing, and reducing stress and anxiety. It helps maintain and enhance short- and longer-term health and well-being.
- It can help prevent negative reactions (explained below) such as secondary trauma, compassion fatigue or burnout.
- It helps improve quality of life, and supports achieving a healthy balance between life and work.
- Taking care of yourself will allow you to continue providing care to those you support in your work and at home.
Understanding Stress[edit | edit source]
At the most basic level, stress is our body’s response to pressures from a situation or life event. Stress can be viewed in two ways: as eustress and distress. Eustress is positive stress in our lives and distress is negative stress in our lives. Usually when we talk about stress, we are talking about distress.
Eustress differs from distress with the following characteristics:
- it only lasts in the short term
- it energises and motivates
- it is perceived as something within our coping ability
- it feels exciting
- it increases focus and performance
On the other hand, distress, or negative stress, is characterised by:
- lasting in the short as well as in the long term
- triggering anxiety and concern
- surpassing our coping abilities
- generating unpleasant feelings
- decreasing focus and performance
- contributing to mental and physical problems
What contributes to stress can vary hugely from person to person and differs according to our social and economic circumstances, the environment we live in and our genetic makeup. Some common features of things that can make us feel stress include experiencing something new or unexpected, something that threatens your feeling of self, or feeling you have little control over a situation.
Common Sources of Stress as a Rehabilitation Professional [edit | edit source]
Sources of stress can be divided into external and internal.
External Stress Sources[edit | edit source]
Examples of external stressors are:
- a chaotic work environment
- work overload
- tight deadlines and stressed coworkers
- feeling overwhelmed by unmet needs
- overload of administrative work
- little possibility of promotion at work
- communication difficulties due to personality and cultural differences
- facing moral and ethical dilemmas
- inadequate working space
- unrealistic expectations of patients and their families
- daily unforeseen and unplanned situations
Other non-work specific factors could include:
- travel difficulties and delays
- lack of social support
- major life changes: a new marriage, pregnancy, the death of a loved one or a divorce
- environment: things that overwhelm our natural senses such as building work next door to you, sunlight in your eyes while at work in your office
- social: negative family dynamics, new interactions
Internal Stress Sources[edit | edit source]
Examples of internal stressors are:
- fears; such as fear of failure or public speaking or of flying
- uncertainty and lack of control; job uncertainty or waiting for the results of a test
- beliefs; these might be attitudes, opinions or expectations such as the anticipation of a perfect holiday or differing political beliefs with family or friends
- negativity and pessimism
- previous experience with trauma or very stressful events
Stress Physiology [edit | edit source]
Our bodies judge a situation and decide whether or not it is stressful. This decision is made based on sensory input and processing (i.e. the things we see and hear in the situation) and also on stored memories (i.e. what happened the last time we were in a similar situation). When we perceive an event that is stressful or frightening to us, our body is stimulated to produce stress hormones that trigger a ‘flight or fight’ response (also known as the acute stress response). These responses are evolutionary adaptations and help us to respond quickly and increase our chances of survival in threatening situations.
- Information from the senses is sent to the amygdala, an area of the brain that contributes to emotional processing.
- The amygdala interprets the images and sounds. If danger is perceived, it instantly sends a distress signal to the hypothalamus.
- The hypothalamus communicates with the rest of the body through the autonomic nervous system, which controls such involuntary body functions as breathing, blood pressure, and heartbeat.
- The autonomic nervous system has two components, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal in a car, providing the body with a burst of energy so that it can respond to perceived stressors/dangers. The parasympathetic nervous system acts like a brake. It promotes the "rest and digest" response that calms the body down after the danger has passed.
- The hypothalamus activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping the hormone epinephrine, also known as adrenaline, into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes.
|Body System||Physiological Effect||Consequence|
|Heart||Increased heart rate
Dilation of coronary blood vessels
|Increase in blood flow
Increased availability of oxygen and energy to the heart
|Circulation||Dilation of blood vessels serving muscles
Constriction of blood vessels serving digestion
|Increased availability of oxygen to skeletal muscles
Blood shunted to skeletal muscles and brain
|Lungs||Dilation of bronchi
Increased respiration rate
|Increased availability of oxygen in blood|
|Liver||Increased conversion of glycogen to glucose||Increased availability of glucose in skeletal muscle and brain cells|
|Skin||Skin becomes pale or flushed as blood flow is reduced||Increased blood flow to muscles and away from non-essential parts of the body such as the periphery|
|Eyes||Dilation of the pupils||Allows in more light so that visual acuity is improved to scan nearby surroundings|
Chronic Stress[edit | edit source]
Long-term stress is regulated by the Hypothalamic Pituitary-Adrenal (HPA) system which allows an adaptive response to any stressor. The hypothalamus signals the pituitary gland to produce a hormone, which in turn signals the adrenal glands, located above the kidneys, to increase the production of cortisol. Cortisol is known as the stress hormone. It increases the level of energy fuel available by mobilising glucose and fatty acids from the liver. During a stressful event, an increase in cortisol can provide the energy required to deal with prolonged or extreme challenges. However, chronically, if our stress response is activated repeatedly, or it persists over time, the effects can result in wear and tear on the body and can cause us to feel permanently in a state of ‘fight or flight’. Rather than helping us push through, this pressure can make us feel overwhelmed or unable to cope.
Impact of Chronic Stress becomes Pathological Affecting Multiple Body Systems[edit | edit source]
Stress affects the whole body. It can have several physical or psychological symptoms, which can make functioning on a daily basis more challenging. The type and severity of symptoms vary considerably from person to person. Signs and symptoms of stress can include:
High Levels of Stress and Associated Reactions [edit | edit source]
Self-care is essential; we all need it, as we can all experience stress at work. However, working with people with refugee experience has its unique challenges. There are a number of conditions that rehabilitation professionals develop when they are exposed to high levels of stress. The diagram below demonstrates the conditions that rehabilitation professionals may develop, both positive and negative.
Compassion Fatigue[edit | edit source]
Compassion fatigue refers to an inability to empathise with beneficiaries as they share their experiences, or an unwillingness to bear the pain of difficult stories or provide support. Professionals regularly exposed to the traumatic experiences of the people they service, such as healthcare, emergency and community service workers, are particularly susceptible to developing compassion fatigue. Compassion fatigue is characterised by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to make decisions and care for patients and/or clients. It focuses on cognitive, emotional and behavioural changes occurring when working with victims of trauma.
Compassion fatigue can be the result of a high workload in a clinical setting, especially when the clinician experiences a feeling of helplessness or inability to meet the needs of beneficiaries.
Vicarious or Secondary Trauma [edit | edit source]
This refers to symptoms of trauma which health care workers can begin experiencing as a result of being exposed to stories of traumatic events from survivors. Secondary traumatisation may happen to a worker after a single exposure to a traumatised patient. Symptoms experienced can be the same or similar to those who have suffered the trauma, such as fatigue, hypervigilance, avoidance, numbness and Post Traumatic Stress Disorder type symptoms. Vicarious traumatisation occurs due to cumulative exposure to traumatised patients. This produces mental and cognitive signs and symptoms in regards to the oneself, others, and the surrounding world. Symptoms include:
- Changes in Spirituality
- For example changes in beliefs, causality, and faith, questioning prior beliefs and the meaning and the purpose of life, hopelessness
- Changes in Identity
- For example, changes in the way you think about important identities (e.g. as a friend, family member, or professional)
- Changes in Beliefs Related to Major Psychological Needs
- For example, beliefs regarding safety, control, trust, esteem, and intimacy. These beliefs can influence your thoughts (e.g. worrying about safety issues, mistrust of strangers) and actions (e.g. being more protective of your children)
Most commonly, the onset is gradual as the worker hears more and more stories in a context where they lack support or good self-care practices, Both secondary traumatisation and vicarious traumatisation result in a reduction in motivation to work, work productivity, empathy and an increase in work avoidance.
Burnout[edit | edit source]
Burnout is defined by the WHO (2018) as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterised by three dimensions:
- Feelings of energy depletion or exhaustion
- Increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job
- Reduced professional efficacy
Burnout is characterised by emotional exhaustion, lack of energy or demotivation, 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. 
The table below shows the many symptoms of Burnout.
Causes of Burnout in the Workplace[edit | edit source]
In a workplace context, burnout can be caused by a high workload, inadequate support or resources, organisational and personal conflicts. Interpersonal conflicts, inequality, lack of job satisfaction or recognition can also be contributing factors. Working with the refugee population can be challenging, but it’s also rewarding, inspiring, and energising. You witness their resilience, strength, hope, and their growth during therapy, which fuels you to continue providing support and doing the work of helping.
There are also positive reactions that are associated with working with this population.
Compassion Satisfaction[edit | edit source]
This is the pleasure you derive from being able to do your work, and includes the parts that you experience as being ‘life-giving'. For example, you may feel like it is a pleasure to help others through your work, or you may feel positive about your ability to contribute to the work setting.
Vicarious Resilience (VR)[edit | edit source]
This is the positive impact on personal growth of therapists that results from exposure to both traumatic material and resilience witnessed in survivors. VR manifests itself as personal growth in the areas of self-perception and worldview, spirituality, self-care, trauma work and connection with clients.
The ABC's of Self-Care[edit | edit source]
Understanding how to create self-care is based upon three main principles.
Awareness[edit | edit source]
Awareness is an essential first step in figuring out your responses to what’s happening in your work and your life (the potential risk factors and your own warning signs) and what you can do to take care of yourself in those times. It’s important to check in with yourself on regular bases:
- How You Are Feeling (Emotionally, Physically and Spiritually)?
- Spend some time reflecting on how you’re feeling (physically, emotionally, and spiritually)
- Ask yourself how did you feel when you woke up this morning? How do you feel now? Try exercise like body scans and self-attunement
- Identify The Sources Of Your Stress and How You Are Responding?
- Identify what sort of problems or people do you find it especially easy to empathise with?
- Identify some of the ways that caring about people who have been hurt affects you?
- Identify sources of stress in your life, and which areas of your life need improvement. (A helpful tool here is Wheel of Strife or the Wheel of Life)
- Stay Connected And Present
- When you are working with people with refugee experience it is important to stay connected and present, it will help you observe your body and mind, and be more aware of your actions and reaction.
- List any signs or symptoms that you are experiencing in the Physical, Psychological, Behaviour and relationships, and Worldview or frame of reference (spirituality, identity, and beliefs) areas. (See the table above under sign of stress)
- Think back over the last couple of years. What are your early warning signs? (i.e. the first signals that warn you that you’re struggling in this area)
- Recognise Early The Need To Make the Needed Adjustments To Your Work And Personal Life
- Do you know what you’re doing in your work, and why? (Knowing that your work is making a difference in other people’s lives will remind you that your work has a purpose, a meaning, and a positive impact on people lives)
- How do you measure success in your work? (For example, do you need to accomplish everything on your to do list to feel success? Or do you feel the success when you do your best at any task?)
- What can you control in your work? (Can you make a choice about your work schedule? Structure?) Knowing what you can control and what you can’t will prevent you from putting up energy and focusing on things you can’t change, a helpful tool here is the Circle of Influence:
- What are the costs and rewards of this work, and how are you personally changing? (When you work in a humanitarian field, it is inevitable that you may be changed by your work. Consider what is rewarding about the work you do? What are the risks? Think about why you chose to work in this field? Highlight the differences between then and now.)
- List the ways that you have changed over time because of your work.
Balance[edit | edit source]
It is important to balance your personal needs with the demands of your work; making sure that each work day includes some breaks for meals and physical activity, and that you are taking some time away from work for rest and relaxation, for friends and family, for spiritual renewal. It is also important that you find a balance between caring for others and being cared for. Balance is also about finding a balance within work that will allow you to work in a sustainable way.
List the things that you do to cope with these symptoms - physical, mental and emotional, behaviour and relationships, and at work. What are the activities you do regularly or enjoy doing that can help you cope? Which do you find most helpful to you? And which strategies do you wish you used more regularly? (See self-care strategies table above), a helpful tool here is the Self-Care Wheel.
Connection[edit | edit source]
It is important to keep a connection with people you like and care about. It is about keeping a connection with other people, and with our spiritual selves. It is also important to connect with the community and to a group of people who know each other, share experiences and values, and reach out to one another in good times or in times of need or distress. It is advisable to connect with different communities, for they often provide different types of support.
Self-Care Strategies[edit | edit source]
Assessment Tools[edit | edit source]
The Professional Quality of Life Measure (ProQOL)[edit | edit source]
The ProQOL is the most commonly used measure of the negative and positive effects of helping others who experience suffering and trauma. The ProQOL has sub-scales for compassion satisfaction; burnout and compassion fatigue. The measure has been in use since 1995. Is available in a wide range of translations.
Self-Care Assessment Tool (SCAT)[edit | edit source]
The SCAT is a tool developed by Karen W. Saakvitne and Laurie Anne Pearlman (1996) to provide an overview of effective strategies to maintain self-care in 5 major domains; Physical, Psychological, Emotional, Spiritual, and Workplace and Professional. After completing the full assessment, you can move on to developing a full self-care plan.
Maslach Burnout Toolkit and Maslach Burnout Inventory (MBI)[edit | edit source]
The Original form of the MBI was constructed by Christina Maslach and Susan E. Jackson with the goal to assess an individual’s experience of burnout. The MBI takes between 10-15 minutes to complete and can be administered to individuals or groups. It consists of 22 items pertaining to occupational burnout, and explores three dimensions; Exhaustion, Depersonalisation, and Personal Achievement.
The Work Stress Questionnaire (WSQ)[edit | edit source]
The Work Stress Questionnaire (WSQ) has been developed with the purpose of early identification of individuals at risk of being sick-listed due to work-related stress, and has been used in medical research like the systematic review study on stress among health care professionals.
Tips[edit | edit source]
- Identify your own sources of stress
- Learn your own stress signals, your early warning signs
- Recognise how you deal with stress
- Find healthy ways to manage stress
- Practise self-care strategies regularly e.g.
- Diaphragmatic breathing
- Guided imagery
- Mindfulness exercise
- Progressive muscle relaxation
- Take care of yourself
- Eat a healthy diet
- Live an active life
- Sleep well
- Set work / life boundaries
- Make time for hobbies and leisure activities
- Make time for family and friends
- Connect with or disconnect from
- People e.g if you work mostly with a team try to set some time out as a small break, if you work alone try to connect with other people
- Reach out for support if needed e.g. family members, friends, work colleagues, direct supervisors, counsellors
- Change some of the things that bother you
- Change things you can control e.g. cleaning and organising your desk
- Try something different at work
- Avoid the routine and try to do something in a different way e.g. work on a project with a colleague, conduct a small workshop, learn something new
- Write about your experiences at work
- All About Empowerment by Senior Psychosocial Counsellor, Malak Al-Sarisi at CVT Jordan.
- Find ways to retain or regain perspective during the day
- Practise some exercises to calm your body and ground your mind
- Try some breathing and meditation exercises
- Invest in professional networks and relationships with colleagues
- Share your work experience e.g. case study, some resources, or some non-work experiences with your colleagues.
Resources[edit | edit source]
Signs of Stress[edit | edit source]
More information on signs of stress can be found at:
Organisations[edit | edit source]
References[edit | edit source]
- ↑ Crabb, J. & Cross, S. Impact on Clinicians. In D. Bhugra, T. Craig & K. Bhui, Mental Health of Refuges and Asylum Seekers. Oxford: Oxford University Press. 2010. p.9-21
- ↑ Varvin S. Psychoanalysis with the traumatized patient: Helping to survive extreme experiences and complicated loss. InInternational Forum of Psychoanalysis 2016 Apr 2 (Vol. 25, No. 2, pp. 73-80). Routledge. DOI: 10.1080/0803706X.2014.1001785
- ↑ Tessitore F, Caffieri A, Parola A, Cozzolino M, Margherita G. The Role of Emotion Regulation as a Potential Mediator between Secondary Traumatic Stress, Burnout, and Compassion Satisfaction in Professionals Working in the Forced Migration Field. International Journal of Environmental Research and Public Health. 2023 Jan;20(3):2266.
- ↑ Thomas, L. K. The therapeutic needs of those fleeing persecution and violence, now and in the future. In A. Alayarian (Red.), Resilience, Suffering and Creativity. The Work of the Refugee Therapy Centre. London: Karnac Books. (2007). p. 45-61.
- ↑ 5.0 5.1 PsychCentral. What Self Care Is and What It Isn't. Available from: https://psychcentral.com/blog/what-self-care-is-and-what-it-isnt-2/ [Accessed 30 September 2020]
- ↑ Adapted from “Understanding and Addressing Vicarious Trauma” Module, Headington Institution, 2008
- ↑ Corrado B, Ciardi G, Fortunato L, Servodio Iammarrone C. Burnout syndrome among Italian physiotherapists: A cross-sectional study. European Journal of Physiotherapy. 2019 Oct 2;21(4):240-5. DOI: 10.1080/21679169.2018.1536765
- ↑ World Health Organisation. The role of the pharmacists in self-care and self medication: report of the 4th WHO consultative group on the role of the pharmacist. Geneva, 1998.
- ↑ Harry Mills, Natalie Reiss, and Mark Dombeck, Types of Stressors (Eustress vs. Distress), Harry Mills, Ph.D., Natalie Reiss, Ph.D. and Mark Dombeck, Ph.D. Updated: Jun 30th 2008.
- ↑ Trifunovic N, Jatic Z, Kulenovic AD. Identification of causes of the occupational stress for health providers at different levels of health care. Medical Archives. 2017 Jun;71(3):169.
- ↑ Centre for Studies on Human Stress. Receipes for Stress (CSHS). Available from: http://humanstress.ca/stress/understand-your-stress/sources-of-stress [Accessed 30 September 2020]
- ↑ Headington Institute. We believe those who sacrifice the most deserve the most support. Available form: https://headington-institute.org/home [Accessed 30 September 2020]
- ↑ 13.0 13.1 Harvard Health Publishing. Understanding the stress response - Chronic activation of this survival mechanism impairs health. Available from: https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response [Accessed 30 September 2020]
- ↑ Voulgaropoulou SD, Fauzani F, Pfirrmann J, Vingerhoets C, van Amelsvoort T, Hernaus D. Asymmetric effects of acute stress on cost and benefit learning. Psychoneuroendocrinology. 2022 Apr 1;138:105646.
- ↑ Psychology Tools. Fight or Flights Response. Available from: https://www.psychologytools.com/resource/fight-or-flight-response/ [Accessed 30 September 2020]
- ↑ Tsigos C, Chrousos GP. Physiology of the hypothalamic-pituitary-adrenal axis in health and dysregulation in psychiatric and autoimmune disorders. Endocrinol Metab Clin North Am 1994;23:451-466.
- ↑ McEwen BS. Protective and damaging effects of stress mediators: central role of the brain. Dialogues in clinical neuroscience. 2022 Apr 1.
- ↑ 18.0 18.1 Cocker F, Joss N. Compassion fatigue among healthcare, emergency and community service workers: A systematic review. International journal of environmental research and public health. 2016 Jun;13(6):618.
- ↑ Hernandez-Wolfe, P., Killian, P.K., Engstrom, D. & Gangsei, D. (2015). Vicarious Resilience, Vicarious Trauma, and Awareness of Equity in Trauma Work. Journal of Humanistic Psychology, 55(2):153–172. DOI:10.1177/0022167814534322
- ↑ Day JR, Anderson RA. Compassion Fatigue: An application of the concept to informal caregivers of family members with dementia. Nursing Research and Practice. 2011 Sep 8;2011. Available from: https://www.hindawi.com/journals/nrp/2011/408024/ [Accessed 30 September 2020]
- ↑ Ebren G, Demircioğlu M, Çırakoğlu OC. A neglected aspect of refugee relief works: Secondary and vicarious traumatic stress. Journal of Traumatic Stress. 2022 Jun;35(3):891-900.
- ↑ 22.0 22.1 Headington Institute: 2008, Module 4: Understanding and addressing Vicarious Trauma.
- ↑ 23.0 23.1 World Health Organisation. ICD-11 - International Classification of Diseases 11th Revision; The global standard for diagnostic health information. Available from: https://icd.who.int/en [Accessed 30 September 2020]
- ↑ Pross C. Burnout, vicarious traumatization and its prevention. Torture. 2006;16(1):1-9.
- ↑ Maresca G, Corallo F, Catanese G, Formica C, Lo Buono V. Coping strategies of healthcare professionals with burnout syndrome: a systematic review. Medicina. 2022 Feb 21;58(2):327.
- ↑ Elwood LS, Mott J, Lohr JM, Galovski TE. Secondary trauma symptoms in clinicians: A critical review of the construct, specificity, and implications for trauma-focused treatment. Clinical psychology review. 2011 Feb 1;31(1):25-36.
- ↑ Edelkott N, Engstrom DW, Hernandez-Wolfe P, Gangsei D. Vicarious resilience: Complexities and variations. American Journal of Orthopsychiatry. 2016;86(6):713.
- ↑ Center for Substance Abuse Treatment. Understanding the impact of trauma. InTrauma-Informed Care in Behavioral Health Services 2014. Substance Abuse and Mental Health Services Administration (US).
- ↑ ASCENT. Good Practice Briefing; Self-Care and Professional Resilience. Available from: https://www.wgn.org.uk/sites/default/files/2020-05/Good%20Practice%20Resilience%20Final2020.pdf. [Accessed 30 September 2020]
- ↑ Frantz A, Holmgren K. The Work Stress Questionnaire (WSQ)–reliability and face validity among male workers. BMC public health. 2019 Dec 1;19(1):1580.
- ↑ Cioffredi & Associates Physical Therapy. Learn the Diaphragmatic Breathing Technique. Available from: http://www.youtube.com/watch?v=kgTL5G1ibIo[last accessed 30/09/20]
- ↑ Mark Connelly. Progressive Muscle Relaxation Training. Available from: http://www.youtube.com/watch?v=ihO02wUzgkc[last accessed 30/09/20]