Vicarious resilience and vicarious traumatisation: Experiences of working with refugees and asylum seekers in South Australia

Abstract

The negative psychological impacts of working with traumatised people are well documented and include vicarious traumatisation (VT): the cumulative effect of identifying with clients' trauma stories that negatively impacts on service providers' memory, emotions, thoughts, and worldviews. More recently, the concept of vicarious resilience (VR) has been also identified: the strength, growth, and empowerment experienced by trauma workers as a consequence of their work. VR includes service providers' awareness and appreciation of their clients' capacity to grow, maintaining hope for change, as well as learning from and reassessing personal problems in the light of clients' stories of perseverance, strength, and growth. This study aimed at exploring the experiences of mental health, physical healthcare, and settlement workers caring for refugees and asylum seekers in South Australia. Using a qualitative method (data-based thematic analysis) to collect and analyse 26 semi-structured face-to-face interviews, we identified four prominent and recurring themes emanating from the data: VT, VR, work satisfaction, and cultural flexibility. These findings—among the first to describe both VT and VR in Australians working with refugee people—have important implications for policy, service quality, service providers' wellbeing, and refugee clients' lives.

Keywords

asylum seeker cultural competence mental healthcare qualitative research refugee service provider thematic analysis vicarious resilience vicarious traumatisation

The negative consequences of working with traumatised people, described in terms such as secondary traumatic stress, burnout, empathic stress and compassion fatigue, are well documented (see Figley, 2002; McCann & Pearlman, 1990). A related concept, vicarious traumatisation (VT) has been defined as the cumulative effect of identifying with clients' trauma stories, which can profoundly and negatively impact on service providers' thoughts and emotions, memory systems and schemas, self-esteem, locus of control, sense of safety, and worldviews. Manifestations of VT in people working with refugees can be compared to refugees' reactions to traumatising events such as war, mass killings, torture, rape, and dispossession. VT has been widely researched among carers in diverse fields such as therapists working with survivors of sexual violence and people with AIDS, as well as other professionals—doctors, nurses, social workers, disaster relief workers, and lawyers—caring for a range of trauma clients (Dunkley & Whelan, 2006). According to Dunkley and Whelan (2006), VT is the most appropriate term to describe the consequences of working with clients with traumatic experiences and refers specifically to the impact of trauma work.

Conversely, research on the positive consequences and benefits of trauma work is relatively recent in nature. Vicarious resilience (VR) encompasses the positive consequences of working with trauma survivors and bearing witness to their stories. It includes experiencing personal strength, psychological growth, and empowerment consequent to listening to clients' accounts of resilience, perseverance, and growth (Engstrom, Hernández, & Gangsei, 2008; Hernández, Gangsei, & Engstrom, 2007). VR has been described as the parallel experience, for workers, to trauma survivors' posttraumatic growth (PTG) and “altruism born of suffering” (Arnold, Calhoun, Tedeschi, & Cann, 2005; Staub & Vollhardt, 2008). PTG is the experience of personal growth following exposure to traumatic events, whereas altruism born of suffering is the motivation to reach out and help others as a result of traumatic and other related experiences and psychological reactions (e.g., receiving help from others in times of need, identification with others' suffering).

VR appears to be similar to what has been described as vicarious posttraumatic growth (V-PTG) by Arnold and colleagues (2005) in a study with 21 clinicians working with survivors of diverse traumas, which revealed how participants' lives had been changed in profound and positive ways by their work. More recently, Barrington and Shakespeare-Finch (2013) also identified VT and V-PTG among people working with refugees. The conceptual constructs of VR and V-PTG share many common elements. The main difference between the two concepts appears to be that V-PTG specifically implies growth or improvement over and above workers' pre-work situation, and also the presence of the five components of PTG: namely, increased appreciation for life, more meaningful interpersonal relationships, increased sense of personal strength, changed priorities, and a richer existential and spiritual life (Tedeschi & Calhoun, 2004). In contrast, there is no such implication of growth for VR.

Although still in the early exploratory phase of study, several characteristics of VR have been identified in the literature, including: service providers' awareness and appreciation of their clients' capacity to thrive; reaffirming the value of therapy by maintaining commitment to clients and maintaining hope for change; and including spirituality and community-based interventions in therapy. An important manifestation of VR is when service providers take home life lessons from their clients, reassess their own problems in the light of clients' stories of perseverance, strength and growth, and modify their personal worldviews. VR can also be inferred when service providers take a subjective stance vis-à-vis their clients' predicaments by articulating their personal and professional positions on human rights violations, or by venturing further to take action themselves to mitigate this violence and injustice (Hernández et al., 2007).

VT and VR are not universally experienced, nor are they mutually exclusive: workers reporting VR may also describe experiencing elements of VT similar to how trauma survivors can report both distress and personal growth simultaneously (Arnold et al., 2005). Much more needs to be known about the precise relationship between VT and VR and the different predictors and pathways that may facilitate VR and protect against VT for different service providers. Investigation of VT and VR can potentially contribute to health care workers' welfare and training, to service quality, and ultimately to clients' lives (Hernández, Engstrom, & Gangsei, 2010).

To our knowledge this is the first study to describe VR and VT in a cross-section of Australian service providers working with refugees and asylum seekers, although a recent Australian study reported identifying VT and V-PTG within a single refugee service agency (Barrington & Shakespeare-Finch, 2013). Most research with service providers to refugees has explored the barriers to accessing healthcare or successful resettlement of their clientele (e.g., McKeary & Newbold, 2010). Other studies have focused on the experiences of particular worker categories such as doctors or interpreters (Farley, Askew, & Kay, 2012; Johnson, Ziersch, & Burgess, 2008; Phillips, 2013). Our initial aim was to explore the experiences of three groups of service providers (mental health, healthcare, and resettlement workers) assisting refugees and asylum seekers in South Australia and report the emergent themes we identified.

Background

In 2013, 51.2 million people were displaced worldwide with 16.7 million refugees and 1.1 million asylum seekers (United Nations High Commission for Refugees [UNHCR], 2014). In 2013, Australia accepted approximately 20,000 people under its offshore and onshore refugee programs¹ and about 10 percent of this intake was resettled in the state of South Australia. These new arrivals were from diverse countries including Afghanistan, Bhutan, Burma, Iran, Ethiopia, and several other African, Middle Eastern, and Asian nations (Multicultural SA, n.d.). Migrants to Australia often elect to settle in the large cities (Sydney or Melbourne) which offer more employment and training opportunities and have larger migrant communities (Hugo, 1995). The Australian Government therefore actively encourages settlement in other areas, including South Australia, which has a population of 1.65 million people of whom around 77 percent live in or near the state capital, Adelaide (Australian Bureau of Statistics, 2011).

In Australia, humanitarian entrants (people recognised as refugees according to the UN Refugee Convention of 1951, excluding asylum seekers and others whose immigration status remained undetermined) are eligible for two main programs: the Humanitarian Settlement Services (HSS) and Settlement Grants Program (SGP) (DIAC, 2013). The HSS operates for the initial 6 to 12 months and newcomers are afforded accommodation, an initial food and household package, case management, and assistance to register with social security, Medicare, health services, banks, and schools. After that period and up to 5 years after arrival, less intensive support is offered to eligible persons under the SGP. Newcomers are offered 510 hours of free English language classes and free access to 24-hour telephone translating and interpreting services. Trauma counselling and specialised healthcare services are afforded under separate federal and state level funding arrangements but eligibility is assessed according to stringent criteria.

Australia's policy of mandatorily detaining asylum seekers has been condemned as a violation of international human rights treaty law (Australian Human Rights Commission [AHRC], 2012). Research with asylum seekers has revealed mandatory detention to be a negative socialisation experience that aggravates past trauma (Murray, Davidson, & Schweitzer, 2008). It has also been associated with significantly high rates of suicidal behaviour for men and women (41 and 26 times the national average respectively) and high prevalence rates of psychiatric disorders (e.g., MDD, PTSD, anxiety) (Murray et al., 2008). The negative psychological impact of Australia's harsh asylum seeker policies over the years has been amply documented elsewhere (Newman & Steel, 2008; Silove, Steel, McGorry, & Mohan, 1998; Steel et al., 2006). Although the government's decision to transfer some asylum seekers into the community has been commended on humane grounds (ACHR, 2012), asylum seekers continue to face severe disadvantages, such as: being unable to seek paid employment; little or no access to English classes or vocational training; and income support which is inadequate to maintain basic living standards. The current government's rhetoric of “stopping the boats” and “illegal arrivals” (Hall, 2013), combined with the media blackouts engulfing the subject of asylum seekers, are likely to have further deleterious consequences for people seeking asylum in Australia.

Method

Participants

Study participants were 26 service providers working with refugees and asylum seekers in Adelaide, South Australia. They were women and men who worked in organisations providing services mainly under the SGP, trauma counselling (for both refugees and asylum seekers), or healthcare programs. Participants included doctors, nurses, counsellors, psychologists, managers, project coordinators, and case workers. Their work experience ranged from 1.5 to 30 years with the majority reporting 2–5 years' work experience with refugees. About one-third of participants belonged to visible minority groups including former refugees and recent immigrants. The remaining two-thirds were from mainstream/White Australian society. Their employing agencies were either affiliated with the state health department, or were not-for-profit organisations with or without religious affiliation. We have not provided further details of participant organisations, to ensure participants' and organisations' confidentiality. Table 1 contains a description of participants.

Table 1.

Characteristics of participants (N = 26).

	n	%
Gender
Women	18	69.23
Men	8	30.77
Previous experience working with refugees
Less than 2 years	3	11.54
2–5 years	10	38.46
5–10 years	5	19.23
More than 10 years	6	23.08
Not specified	2	7.69
Profession/current position^a
Doctors	1	3.85
Nurses	3	11.54
Psychologists	2	7.69
Counsellors	9	34.62
Managers	3	11.54
Program officers/coordinators/ case workers	8	30.76
Nature of Organisation^b
Healthcare	5	19.23
Mental health	11	42.31
Settlement	10	38.46
Background
Mainstream	16	61.54
Refugee^c	5	19.23
Recent Immigrant/CaLD^d	5	19.23

Denotes either profession (doctor, nurse, psychologist) or current position (e.g., counsellors included people qualified in social work, nursing or psychology).

Denotes the main service provided by the organisation to which a worker was affiliated and not necessarily the worker's specialisation (e.g., a social worker at a mental healthcare service was considered a “mental healthcare worker”).

“Refugee background” included persons from Asia, Europe, and the Middle East.

“Recent Migrant/CaLD background” included those from Asia, Europe, the Middle East, and South America.

Data collection

The study began after approval by the Ethics Committees of the University of Adelaide and the State Health Department. Participants were offered the option of being interviewed individually or in groups. Apart from two participants, all opted for individual interviews, which were conducted between December 2012 and May 2013. Signed informed consent was obtained from participants before interviews began. Participants were interviewed using a semi-structured interview format comprising several open-ended questions. Interviews lasted about 1–2 hours, were audio-recorded, and were subsequently transcribed. Interview data were supplemented by brochures, reports, and other documentation shared by participants, which were perused for additional information about services offered by organisations and workers' roles, and also to explore “institutional memory”. However systematic analysis was not conducted on these documents and they did not form part of the primary data analysis.

Data analysis

Inductive thematic analysis (Braun & Clarke, 2006, 2013) was used to identify prominent and recurring patterns in the data at a semantic or explicit level of analysis. First, the audiotaped interviews were transcribed orthographically and checked for accuracy. Second, interviews and interview notes were read and re-read to gain familiarity with the data set. Third, interviews were coded and the initial codes generated were searched for overarching themes that were reviewed, defined, and named. Analysis involved moving between the data set, the generated codes, analyses being produced, and relevant theoretical concepts found in the literature. Through this iterative process, several themes and subthemes were identified. Interviews were conducted by the first author who also performed the initial analyses. All authors were involved in producing the final analyses. Participants' identities and their organisational affiliations were altered or concealed to ensure confidentiality.

Interview questions were based on the following topics: personal experiences working with refugee people; challenges faced by clients; strengths and resources of clients; challenges faced by service providers; importance of cultural competency; and recommendations for improvement.

Findings

We identified several major and subordinate themes from analysing participants' interviews. The four identified major themes were: commitment and work satisfaction, cultural awareness and adaptation, vicarious resilience, and vicarious traumatisation. Results of the data analysis including the potential relationships between identified themes and subthemes are depicted in Figure 1.

Figure 1.

Diagram of study findings and the potential relationships between themes and subthemes.

Commitment and work satisfaction

In general, participants indicated enthusiasm, commitment, and work satisfaction despite personal and systemic challenges they encountered. AB, a healthcare worker with more than 25 years of experience working with refugees, represented the sentiments of most of her colleagues by explaining:

It's not a job; you have to be committed and passionate about working in this area and with this client group.

Most participants had been motivated to work with refugees by previous work experiences with diverse cultural groups, in various capacities as doctors, nurses, interpreters, teachers. or volunteers. Nine participants had worked overseas in refugee source or receiving countries—in Africa, the Middle East, or Asia. Several had lived and worked in aboriginal communities in remote parts of Australia. Three participants said they were motivated by empathy and humanitarian concern towards refugees and the dire circumstances of asylum seekers in Australia. Working with refugees was a natural transition for four participants who valued their memories of growing up or living in multicultural European, Middle Eastern, or Asian cities.

Five workers had arrived in Australia as refugees themselves, having become displaced and losing all their possessions during war and conflict, or after prolonged periods in refugee camps. They were sensitised to the challenges faced by their communities, identified with the refugees' struggles, and indicated a desire to lighten the burden of those most vulnerable. One former refugee described how she had been motivated to work at the refugee agency by her personal experiences and her desire to repay to humanity the help she had received in times of need (i.e., altruism born of suffering). Participants' levels of commitment toward their clients and their work satisfaction also appeared to have been strengthened by more experienced workers sharing, guiding, mentoring, and motivating others through supervision and mentoring of trainees, and by teaching workshops and professional development sessions. Shared experiences of mentors and trainers had become integrated into the narratives of lesser-experienced workers as portrayed in several interviews.

Only one participant, CD, indicated less work satisfaction than his colleagues, despite his interview generating the longest transcript of the study. Specifically, he did not appreciate case work as part of his counsellor's workload and he also worried that his clients were too disempowered to benefit from the challenges he posed them as a counsellor—to be assertive, independent, and to take initiative in life. As he somewhat hesitantly explained:

… I don't, I didn't, I haven't had a huge passion for asylum seekers or refugees or anything like that. I didn't come here thinking “I'll fix the world”. I just came here to be a counsellor.

Cultural awareness and adaptation

Changing client profiles

According to participants, the composition of their client caseloads constantly changed depending, in part at least, on global contingencies. This variability required frequently updating their cultural knowledge and adapting to the needs of men and women from diverse ethnic, language, and religious backgrounds; age and education levels; pre-migratory histories; family disruptions; and resettlement experiences.

Cultural differences

Most participants had taken steps to develop their cultural understanding. Resettlement agencies were increasingly employing workers with refugee and other CaLD (culturally and linguistically diverse) experiences to reach into communities and deliver services in culturally appropriate ways. These bicultural workers were encouraged to share their cultural knowledge, with their input on parenting, child rearing practices, and family relationships in their communities often sought by colleagues. Clients were another rich source of cultural knowledge: participants listened to and learned from clients' stories, asked questions, and made clarifications about their cultural practices. Participants also improved their cultural awareness by reading, watching films, and participating in training workshops.

Mental and physical healthcare workers acknowledged that language differences were a barrier to communication during consultations. They utilised interpreters as a source of cultural knowledge but also indicated awareness that they only had indirect access to clients' voices via interpreters' cultural perceptions. Hence, participants described monitoring clients' responses, facial expressions, and bodily postures, and asking for feedback to minimise miscommunication. More experienced participants engaged in training of interpreters, to prevent unprofessional conduct such as prompting clients or rebuking them for culturally unacceptable disclosures. Although several participants emphasised the importance of being sensitive to and accepting of cultural differences, others also noted the significance of self-reflection on their own cultural standing and understanding; as EF explained:

To me, to work transculturally is to be very, very sensitive … that cultures are different … but also to be very sensitive to [my]self as a culturally situated individual … it's not this is mainstream and you're a quaint little culture. I'm a quaint little culture; you're a quaint little culture. They are different. I'm willing to understand the meaning you put on from your cultural perspective. I'm trying to be ultra-sensitive to my cultural understandings … I think cultural awareness starts at home. To be aware of yourself as a culturally bound person.

Other differences

Mental healthcare workers were often aware of their clients' unfamiliarity with, or different understandings of, psychotherapy and counselling. They described the stigma attached to mental illness, necessitating counsellors to afford a “little bit of education” about counselling, and then to navigate around their clients' unfamiliarity until symptoms improved and there was more acceptance. Therapists usually avoided mentioning mental illness and instead focused on physical symptoms (headache, backache, sleeplessness) which seemed more acceptable to clients. Some attempted to draw analogies between the services they offered and the type of support clients would previously have received from community elders or religious leaders. However when clients wanted advice or specific directions consistent with these previous experiences, counsellors had to find a compromise between the client-centred model they adhered to—involving guiding clients to find their own solutions—and their clients' expectations.

Another issue confronting almost all interviewees was clients' inability to keep appointments or to be punctual, because they were overburdened with settlement demands and/or past trauma negatively impacted on their ability to attend to multiple tasks. Participants indicated sensitivity to possible conceptual differences between their understanding of time and that of their clients. They accommodated lateness and missed appointments, gave repeated reminders, and sometimes even expressed disapproval because, as one counsellor explained, tardiness could be a serious disadvantage in Australian society.

Vicarious resilience

Empowering and being empowered

All participants emphasised the importance of establishing independence and confidence in their clients to enable them to overcome initial resettlement difficulties and successfully navigate the Australian system. They described striving to enhance clients' independence and confidence, and the personal satisfaction they experienced when they observed clients gradually gaining in independence and confidence.

Many resettlement, healthcare, and mental health workers reported efforts to counteract the disempowerment of clients and reduce the cultural insensitivity of the local healthcare system. For instance, a female resettlement worker described how she intervened on behalf of a female client who had complained that the staff at her local medical clinic were not utilising the Translating and Interpreting Service (TIS) available at no cost to medical practitioners. Instead, they asked the client to bring her adolescent son to interpret for her, much to her embarrassment. This also inconvenienced her son who had to miss school every time his mother had a doctor's appointment. Hence the resettlement worker visited the clinic, and explained how to utilise TIS. A mental health worker explained how he empowered his clients by prompting them to question their medical practitioners about vital health information, such as precautions during pregnancy or the side effects of medicines that had not been adequately explained or understood. Resettlement staff also consulted specialised health agencies to identify “refugee-friendly” medical practitioners for their clients.

This process of empowering clients and observing them gradually become more independent and confident, overcome “resettlement hurdles”, and move on in life, also in turn empowered service providers as they witnessed the effectiveness and value of their interventions. This rewarding and empowering experience was reported by many participants.

According to mental health workers, advocating on behalf of their clients to address resettlement needs enabled counsellors and therapists to establish safety and trust, and build relationships with their clients, thus laying a vital foundation for subsequent therapy. Mental healthcare workers also described striving to empower their refugee and asylum-seeking clients through innovative group projects such as “theatre of the oppressed”, art therapy, and storytelling. These therapies were typically utilised when one-to-one counselling was less effective with particular clients or groups. For instance MN, a counsellor, explained that certain young men with refugee and asylum-seeking experiences had difficulty engaging with counselling. Hence he and his colleagues started an art class with the help of a professional artist from a similar cultural background to the clients. During art sessions, clients were afforded a variety of materials (crayons, paints, clay) and prompted to create artwork on a particular theme. At the end of each session, the clients, instructor, and counsellors would discuss the significance of the artwork. The outcome of these sessions, MN's appreciation of his clients' capacity to grow, and the reciprocal impact on him was emotionally described by MN in the following extract:

We run an art group for men … we focus on a theme every fortnight and get the guys to draw or paint or do whatever … relevant to that theme. And most themes are around how they resisted and how they survived what they went through … how they see themselves as now than before. And these processes and outcomes are magical. I am beginning to well up. And I think, what you have is this real building of strength that you witness consistently week over week over week. So what you see is their growth … from where they've been to where they're heading. They have this capacity to understand so much more than they did before. And that is a privilege, a total privilege to be able to be involved in that. Yeah, I don't see it in any other way.

Learning from each other

Participants recognised their clients' enormous resilience, strength, and coping in times of adversity (escaping war, surviving in the refugee camp, torture, or other terrible experiences). A mental health worker assisting refugee children expressed her incredulity at her clients' capacity to study, work, and send money back home despite missing family and ongoing acculturation difficulties. Healthcare and mental health workers providing services to women detailed their clients' perseverance amidst a plethora of adverse circumstances—separation from family, grief for missing or killed loved ones, struggle to find housing, ill health, and other problems. OP, a mental health worker, explained how refugees' determination and perseverance was personally motivating to her, as follows:

In my experience people are so resilient … There are terrible situations like … mothers who are longing to be reunited with their sons … lost due to war [and] they don't know what happened to them … And then the suffering of that mother or that father is so intense. But despite that, they wake up the following day, they try to learn English, they try to deal with all these papers (bureaucracy) … they have a million of appointments. How can you not learn from that? How can you not learn from the fact that a person can be so unable to sleep but still cares about the children, still tries for the children to be the best that they can? Sometimes I feel “oh I'm so tired” but then I think [about them].

Some participants explained that because refugees were weighed down with settlement stressors, health problems, cultural bereavement, and language barriers, it was difficult for them to see beyond their current predicament and remind themselves of their incredible journeys of coping and survival. Nonetheless, service providers were inspired by the resilience, personal strength, and perseverance of their clients in the face of seemingly insurmountable obstacles and appeared to learn life lessons by listening to clients' stories. In the following extract OP explains the reciprocal process involved when counselling refugee people, that is, how service providers can learn from their clients, as they simultaneously assist clients to heal from past trauma and resettle into Australian society:

… and sometimes I am so sorry we always see what we can teach them, never what we can learn from them. We [don't] ask what these people have to offer our society … So that's why I see this unique opportunity [of] counselling … that we are able to learn from each other … People must realise how much they will be able to learn.

Mental health and healthcare workers described using a strength-based approach to remind clients of their past resilience and explore potential sources of support (e.g., “what did you do when you were locked up and systematically tortured?”). They strived to understand people's psychological and physical strengths, including their ability to feel love and empathise with their abusers. They utilised the strengths from clients' formative years and upbringing and promoted these cultural coping strategies (prayer, connecting to dead ancestors, religious rituals) to motivate them to move forward. They also taught their clients new coping strategies such as progressive muscle relaxation, visualisation, and mindfulness exercises that could help them overcome ongoing stress.

QR, a counsellor who is also a recent migrant to Australia, described her clients' enormous psychological resources and the potential for others to learn from refugees about survival and problem solving. Referring to the common perception in many host societies that refugees were weak, psychologically damaged and a burden, this participant became emotionally overwhelmed during the interview:

They have gone through things I [can't] even think … how I could survive or how psychologically to go through all that. This is amazing; this is huge. So then we are here in this western country, western culture and then we judge people? … I am not going to swear because we're [on record] … but who the [she swears anyway] are we to even dare to judge people? So you know, they are very strong … and they are very rich inside as well … We can learn so many things from them … There is so much rich knowledge about survival; about humanity; about how to deal with issues and problems.

Reconnecting and bonding

All participants considered establishing relationships with clients to be important. For mental health workers, it was a hallmark of a successful therapeutic relationship and they described spending many months labouring to bond with their clients. Many described the dual benefits of advocacy—both to empower clients and to build vital trust. ST, a mental healthcare worker, described the positive outcome for his client and himself from a successful worker–client relationship, in the following extract:

… I think there is a real growth in me through what I hear. The same way I see them grow once they share their experiences. And that happens with being able to make a connection with someone. You know, feeling … that you have built this trust and now they are in a position to share some of the most intimate tragedies that they have been through … And to witness that resilience or to witness that resistance … this is a privilege for me. And this relationship allows that growth [in both of us].

As aforementioned, when individual therapy was less successful, participants introduced clients to group work—establishing women's and young men's groups, art and theatre therapy to promote socialisation, collective sharing, and problem solving. Group sessions were especially beneficial to those more vulnerable clients who were disconnected from family, isolated from society, and struggling to resettle, as observed by healthcare, mental health, and resettlement workers. Groups were also useful for workers to disseminate information about the availability of vital services (health, mental health, resettlement) as well as for workers and clients to share and benefit from each other's coping resources and strategies. For instance, as UV, a resettlement worker with refugee experiences, explained, she would encourage group members to share their coping strategies (religious rituals, gardening) and she too shared the coping strategies she had utilised when she arrived in Australia. Group interaction also enabled her to ascertain clients' needs and the best ways to assist them.

However, when people were estranged from family, community, and their religious faith, were feeling desperate and hopeless, and nothing else seemed to work, some participants described how they offered themselves as a scaffold for their clients to lean on. KL, a healthcare worker, recalled how she continued to give hope, when participants appeared to have lost all hope and could not see a future in Australia. She did so by sharing the success stories of other refugee communities such as the Vietnamese, who had come to Australia decades ago, had overcome similar challenges, and were holding prominent positions and contributing to Australian society today.²

Vicarious traumatisation

Frustration

Almost all participants shared their frustrations about the difficulties clients encountered when resettling in Australia: difficulty securing private rental accommodation, the seeming arbitrariness and inordinate delays in obtaining public housing, and the insensitivity of the healthcare system (mentioned above). Many expressed their disappointment with what they saw as the unpreparedness of Australia's humanitarian program and its failure to live up to the political rhetoric of multiculturalism, creating systematic barriers for refugees and asylum seekers. Participants reiterated that most refugees required intense settlement support beyond the assistance provided under the HSS program in the first 6–12 months. Mainstream healthcare services followed a general practice model that failed to address clients' unique requirements (e.g., interpreting, diverse understanding, and expression of illness). Mainstream schools were easily overwhelmed by refugee children's plight (e.g., past trauma, family disruptions).

Participants also said that separation from family members and prolonged delay in reunification of families was especially difficult for refugees and asylum seekers, because clients' collective lifestyles and communal identity meant that separation from immediate or extended family led to feeling “as if part of their self was missing”. Many clients were separated or alienated from family, community, and society in Australia, and depended on service providers for vital social contact. Thus, some service providers worried about the weight of responsibility they felt, being the only significant person in their clients' lives: the only person to visit them, inquire after their health, and show that someone cared.

In the following extract, YZ describes a client's desperation to reunite with family, expressing his own frustration at what he considered an unjust and uncaring Australian immigration system. He said:

… worst of all is … the hopelessness people are experiencing … especially when people are experiencing problems that this society creates such as … people who can't sponsor families … for example there is a client whose family is in another country … the son is sick and needs dialysis. He is here, he is sending every bit of money he can … he's trying to sponsor his family but … he does not have the money to sponsor; the program for family reunion is being reduced; governments don't believe that they are suffering …

Almost all participants were aware of the potential negative consequences of working with asylum seekers and refugees. All had access to supervision, counselling, and other supportive services in their workplace and many acknowledged the vital function of supervision and mentoring. Some also described the personal strategies they used to avoid getting emotionally overwhelmed by clients' trauma stories or resettlement distress, such as reducing their caseloads or making a conscious effort not to get emotionally overwhelmed.

Although feelings of frustration and disappointment do not typically amount to VT, nonetheless the cumulative impact of such negative feelings appeared to lead to VT, especially among service providers working with asylum seekers—either in the community or in immigration detention centres.

Identifying with helplessness and hopelessness

Most service providers had worked with both asylum seekers and refugees. They observed that the circumstances of asylum seekers were far bleaker than those of refugees given the multiple causes and consequences of their mental trauma. They spoke at length about the uncertainty and insecurity plaguing their asylum-seeking clients who were often left languishing in detention centres or in the community for an indeterminate period of time. These people were afforded little information about how long it would take for their immigration claims to be determined, and lived in constant fear of being deported. Some participants appeared to identify with the desperation, helplessness, and hopelessness of asylum seekers and became emotionally overwhelmed when discussing their clients' predicaments. According to mental health workers the insecurity and uncertainty surrounding asylum seekers made it impossible to establish the safe environment required for counselling, vitiating meaningful psychological intervention. Hence most counselling was limited to short-term work focusing on symptom management. The following account by AC, a counsellor, represents the helplessness and hopelessness expressed by many other participants regarding what they considered the unacceptable treatment of asylum seekers in Australia:

So I kind of feel that my job is to relieve people's stress and worry and sadness, but the system is increasing that faster than I can help. So … I see people becoming more and more distressed the longer the process goes. And for me I guess it makes me feel a bit helpless; it makes me feel [my] work is not successful … And it's on the news all the time: you go home, you turn on the TV, it's “asylum, asylum, asylum”. So don't get a break from that. So it can be pretty draining.

To reduce work-related stress, AC had reduced her caseload; nonetheless, discussing her clients still appeared to be emotionally overwhelming. Similarly, another mental health worker described how several interpreters working with him had needed compassionate leave because of being “vicariously traumatised”.

BD, a resettlement worker, also expressed feelings of helplessness for her inability to afford more certainty and address the most urgent needs of clients. She recognised the danger of unduly empathising and identifying with her clients to the extent that clients' stories negatively impacted her worldview. In summary, the disempowerment, distress, and helplessness of asylum seekers appeared to have negatively impacted their service providers who had come to connect with their clients and see them as human beings in need of protection and care, as described with some difficulty by BD as follows:

… what they [asylum seekers] want is the visa. And I can't do anything about that … And this thing of wanting to give someone a hug and say “of course come here; come and live in my house”. So … feeling like a heart connection with clients; but not being able to do what they really want … So that definitely; the helplessness is something I have struggled with.

Finally, CE, a senior mental health worker with much experience working with refugees and asylum seekers described how he identified with his clients' difficulties and continued to carry “little scars” left by his clients over the years. An example of identification with clients' problems is highlighted in CE's interview as follows:

… It's much harder … when you got children of your own. [Earlier] people could talk to me about anything. Now … it's not easy … So when a mother says her child died of asthma because she did not know he had asthma … I think “my God, I have a child that age”. The identification with that is so much. So you can defend against that and just not listen, and the person feels that you don't care about the child … I care, I do care. Those are the hardest things I think.

Discussion

The present study explored the experiences of three categories of service providers working with refugees: mental health, physical healthcare, and resettlement workers. Through data analysis we identified two recurring patterns in the data, namely of VR and VT, together with related themes and subthemes (Figure 1).

As aforementioned, VT is the negative psychological impact of working with trauma survivors and identifying with their trauma stories. According to the Constructivist Self-development Theory (McCann & Pearlman, 1990), people construct their own realities through a complex configuration of beliefs, assumptions, and expectations of themselves and of the world. Continuous exposure to stories of despair can disrupt and transform these patterns of thinking. Hence, VT is the cumulative effect of traumatic events as shared by clients and the resultant inner psychological turmoil experienced by service providers.

Several of our findings appear to support this theoretic conceptualisation. Most service providers were familiar with the concept of VT and were concerned that identification with clients' accounts of torture and trauma could change their view of the world as a safe and secure place. Their belief in justice and fair play appeared to give rise to frustration and discontentment at the perceived inadequacy of Australia's humanitarian program, impeding clients' integration into Australian society, exacerbating their current distress, and triggering past traumas. They were disappointed, even incredulous at the cultural insensitivity of some healthcare providers, and the continued application of standard practice models by government and other agencies to people who rarely fit the established script.

In the present study, caring for asylum seekers appeared to be the most emotionally challenging for our participants. People working with asylum seekers seemed negatively impacted by the injustice and inhumane treatment of people who had already suffered so much, and their psychological deterioration over time. The prolonged uncertainty, inadequate services and seeming ineffectiveness of counselling within the asylum seekers' context led to feelings of helplessness. According to Weingarten (2003), trauma workers occupy one of four “witnessing positions” depending on: (i) the extent of their awareness and knowledge of the human rights violations and injustices described by their clients and (ii) their ability or power to take action against the violence. Of these witnessing positions, workers who are aware but feel helpless to do anything about their clients' plight are most at risk of VT—similar to participants working with asylum seekers in the present study.

Nonetheless, participants' narratives also revealed appreciation for the enormous personal resources of the men, women, and children they worked with as well as for clients' unique coping strategies involving family and community—observed to be lacking in more individualist Australian society. Clients' capacity to build relationships, participate and grow during individual or group therapy was remarkable. According to Hernández et al. (2007), emotional reactions of service providers alone do not amount to VR. However, study findings revealed how participants' appreciation and awareness of clients' strengths, resilience, and capacity to grow extended to internalising and benefiting from their clients' positive experiences. Participants also referred to the lessons society could learn from the perseverance, resilience, humanity, love, and trust of clients, and sometimes indicated that they were incorporating these lessons into their personal lives. They also forcefully articulated their subjective positions regarding the perceived injustices faced by their clients in Australia (cf. Engstrom et al., 2008; Hernández, Engstrom, et al., 2010; Hernández, Gangsei, et al., 2007).

Most participants appeared to be utilising a strength-based model to empower clients and thus facilitate successful resettlement and ameliorate acculturation stress (Berry, 1997). Advocating, educating, and assisting with settlement and healthcare needs, they promoted independence and confidence and prevented clients from being disempowered by local bureaucracies. Empowering clients also enabled mental health workers to establish safety and stability for clients, a prerequisite for a successful therapeutic process (Herman, 2001). Witnessing clients' transformations in independence, confidence, and trust enabled mental health workers to experience personal growth themselves, reaffirming the reciprocal effects of therapy (Engstrom et al., 2008).

Participants described a deep awareness of the cultural, religious, and social diversity of their clients. Most interviewees had acquired sensitivity, even appreciation, of culture-based conceptualisations and practices of different people from previous life and work experiences or through guidance and mentoring that inculcated cultural understanding and sensitivity. Cultural competence is defined as the ability of systems, agencies, and service providers to provide care and deliver services to effectively meet the needs of a culturally, socially, and linguistically diverse clientele (see Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Some experts opine that cultural competency can be achieved by ethnocultural matching at institutional, practitioner, and service levels (Kirmayer, 2012). Hence institutions can provide mental health services in community settings, workers of certain ethnicities could be matched with their clients, and clinicians/workers could modify their technique of interaction with clients. Our study indicated that agencies in South Australia and their staff were utilising all three levels of cultural competence.

Although most participants acknowledged the need to be culturally competent, their emphases varied. Some interviewees considered cultural awareness and knowledge as an essential prerequisite to working with refugees. To others basic human decency, openness to differences, and a willingness to learn from clients were the overriding requirement. Several workers of all three categories also indicated reflexivity about their cultural and social positioning vis-à-vis their clients. Conversely, the lack of cultural competence or safety in the wider Australian context together with the insensitivity and non-reflexivity of service providers such as medical practitioners appeared to be of concern to participants (cf. Renzaho, 2008). In our study cultural competence/safety and reflexivity appeared to be a prerequisite to participants' experiences of VT and VR together with commitment and work satisfaction (Figure 1). Conversely, lack of cultural competency/safety may have also led to VT, although study findings did not support this contention.

In Simich and Andermann's recent book on refugee resilience, Vasilevska (2014) referred to four principles of incorporating ecological factors into resilience, namely: decentrality, complexity, atypicality, and cultural relativity (Ungar, 2011, as cited in Vasilevska, 2014), to demonstrate how Canadian settlement workers promoted resilience in refugees. Similarly, our participants recognised the importance of environmental factors such as assisting clients to secure settlement needs (e.g., housing, food, legal assistance) in appreciation of the interconnectedness of various needs and their impact on clients' psychosocial wellbeing (complexity). Most participants adhered to a client-centred approach that focused on individual clients' needs, recognising that a protective factor for one client (e.g., religious belief, community contact) may not be so for another (atypicality). Participants were also endeavouring to be culturally flexible and reflective in their work, lending support to the principles of “cultural relativity”. Striving to promote clients' resilience and coping and observing clients' growth enhanced participants' resilience within the reciprocal worker–client relationship described by study participants.

Study limitations

There were several limitations to the study. First, participants' attempts to portray themselves and their work in a positive light in a university research interview cannot be discounted. However, this potential bias was to a large extent mitigated because no direct questions regarding VT and VR were put to participants. Instead, VR and VT were identified as emerging themes of the interview data. Adopting an informal interview strategy that prompted elaboration and discussion was an additional safeguard.

Second, the interviewer's obvious CaLD status (the first author is a recent migrant to Australia from South Asia), could have prompted participants to be more vociferous in expressing their disappointment and frustration at Australia's treatment of refugees and asylum seekers. Despite this, we suggest that any additional information provided by participants strengthened study findings by elaborating the possible reasons for VR and VT. Third, although we identified the positive and negative consequences of working with trauma clients as VR and VT, we cannot deny that other researchers might use similar but different concepts to identify comparable study findings (e.g., V-PTG). Fourth, interview procedure slightly varied across participants in that when given the choice, two service providers opted to be interviewed together. However the analysis did not reveal any differences between their interviews and that of the others. We also found no noticeable differences between the three categories of workers regarding the identified themes—either because of our small sample size, or perhaps because although participants' organisations could be broadly delineated as “healthcare”, “mental health”, and “resettlement”, this did not totally correspond to workers' professional disciplines (Table 1).

Finally, the exploratory and cross-sectional nature of the study and purposive sampling precluded us from making causal linkages within study findings. Nonetheless, the elaborate data shared and collected and the insights into VT and VR, cultural flexibility, and work satisfaction undoubtedly add to the literature on refugees and their service providers. Future researchers could focus on identifying the moderators and mediators of VT and VR, and the different pathways to VR and VT, as well as exploring the link between these concepts and cultural competence/safety.

Implications

The study findings have implications for policy and practice. Emphasising the rewards of working with refugees can enhance the motivation of existing workers and encourage others to enter the field. Such a positive focus can also minimise the negative consequences of trauma work, safeguard workers' welfare, and enhance the quality of services provided. Training, supervision, and mentoring programs can raise awareness about VR and prompt workers to share their positive work experiences with each other. Various elements of VR can also be incorporated into training and mentoring programs to enhance the usefulness of such programs (Hernández et al., 2010).

A continuing focus on the risks of VT as well as mechanisms to prevent or address the negative impact of VT (e.g., reducing caseloads) is also essential. In this context, the study highlights the importance of continuous supervision and mentoring for workers caring for refugees and asylum seekers in Australia. The efficacy and adequacy of these programs need to be frequently evaluated and updated considering the volatile nature of the work involved. Because cultural flexibility can be a pre-requisite for this type of work, the importance of reflexivity of one's own cultural standing needs to be emphasised in training and mentoring programs for persons working with refugees and other immigrants. Future research could explore the potential differences in VR and VT between workers with different professional disciplines and/or different personal backgrounds (e.g., refugee or migration experiences), utilising larger samples of service providers. Future research could also explore VT as experienced by workers in different resettlement countries (cf. Australia, Canada, UK) with varying policies, regulations, and laws pertaining to the entitlements of refugees and asylum seekers. Finally, our study contains an important message for the Australian government: harsh and inhumane immigration policies have dire consequences, even beyond the psychological and physical wellbeing of refugees and asylum seekers. Our study indicates that such policies, regulations, and laws also take a psychological toll on workers providing healthcare, mental health, and resettlement services to refugees and asylum seekers.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Notes

Teresa Puvimanasinghe, BA Hons, Attorney at Law (Sri Lanka), PhD, recently completed her doctoral studies at the School of Psychology, University of Adelaide. She worked as a human rights lawyer and advocate in Sri Lanka and Hong Kong. She is the editor/co-editor of books such as: An Exceptional Collapse of the Rule of Law: Told through Stories by Families of the Disappeared in Sri Lanka and An X-Ray of the Sri Lankan Policing System and Torture of the Poor. She currently works as Research Assistant at the University of South Australia and Counsellor to survivors of torture and trauma at STTARS, Adelaide, South Australia.

Linley Denson, MPsych, PhD, is a Fellow of the Australian Psychological Society and a Senior Lecturer in the School of Psychology at the University of Adelaide, where she coordinates the Clinical Psychology program. Utilising qualitative and quantitative methods, her research focuses on psychological and developmental aspects of intergenerational family care, health and lifestyle decision-making, and mental health service utilisation.

Martha Augoustinos, BA Hons, PhD, is the Director of the Social and Organisational Unit and a Professor of psychology in the School of Psychology at the University of Adelaide. Dr Augoustinos’ research interests are in social psychology and discourse. Her published works focus on racial discourse, and more recently on majority group representations of asylum seekers and refugees. She is co-author of Social Cognition: An Integrated Introduction with Iain Walker and Ngaire Donaghue (2014, Sage).

Daya Somasundaram, BA, MBBS, MD, FRANZCP, FRCPsych, FSLCP, is a senior professor of psychiatry in the Faculty of Medicine at the University of Jaffna, Sri Lanka and Clinical Associate Professor, Discipline of Psychiatry, University of Adelaide and Consultant Psychiatrist, Jaffna and STTARS, Adelaide and South Eastern Community Mental Health Services, Mt. Gambier, South Australia. Apart from teaching and training a variety of health staff and community level workers, his research and publications have concentrated on the psychological effects and treatment of disasters, both manmade wars and natural tsunami. His book, Scarred Minds, described the psychological effects of war on individuals, while Scarred Communities describes psychosocial consequences of disasters.

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