Journal of Social Development in Africa (1993),82,33-47 Exploring the Effects of Interacting with Survivors of Trauma • GILLIAN STRAKER* ABSTRACT Individuals' reactions to working with survivors of trauma are multiple and diverse. The present paper aims to pinpoint common reactions to trauma work and to elaborate the ways in which these might manifest It outlines experiential exercises aimed at helping workers: • to reexamine their own original reasons for engaging with trauma survivors; and • to identify both their initial and current reactions to such work. Further exercises are outlined that aim at eliciting solutions to the more negative responses which trauma elicits and in promoting and capitalising upon responses at individual and organisational levels. The Effects of Working with Trauma Survivors A well accepted notion in the helping professions is that the degree to which one is in touch with and accepts oneself is a measure of how in touch with and accepting one is able to be of others (Rogers, 1961). This, in turn, influences the degree to which one is able to assist others in the process of coming to terms with themselves and their life situations - which is part of the brief of all those in the helping professions (Gurman & Razin, 1977). This is true even when the primary task of workers and clients may be the resolution of practical problems. The attitude with which workers approach their clients will impact directly upon them (Rogers, 1961). It will affect both their ability and their willingness to enter into joint problem-solving. This is not a one-way process. Clients have a profound influence on the way workers feel and function (Racker, 1968). This is especially true when the clients in question are survivors of massive trauma, such as that involved in armed conflict and war (Comaz-Diaz & Padilla, 1990). Workers entering into the world of trauma survivors are profoundly affected by them, often finding new depth within themselves. They also, however, run the risk of early burnout and even secondary traumatisation. Indeed, interacting • A paper commissioned by SATARI, funded by US Bureau for Refugee Programs. * Professor, School of Psychology, University of the Witswatersrand, Johannesburg, South Africa. 34 Gillian Straker with trauma, even vicariously, has potentially seriousrepercussionsforpsychological well-being (Berah et al, 1984; Raphael, 1986; Taylor & Frazer 1980). Those in the helping professions are not exempt from this. While clearly recognised, these facts are all too often forgotten as work pressures mount. Yet failure to take into account the impact of working with trauma has serious consequences. It makes workers less effective in the professional arena and more susceptible to suffering stress and distress in their personal lives. In turn they are less available emotionally to clients and thus less able to meet their clients' needs. To hear and understand the needs of the other - prerequisites for meeting them - requires emotional availability. Being truly present and open to the other (Binswanger,1963)involvesnotonlytheskilloflisteningattentively and processing information accurately (a skill which can and should be taught and honed), it also requires a particular state of receptivity on the part of the listener (Boss, 1963). At the most superficial level this state of receptivity requires that listeners be sufficiently free from preoccupation with their own issues to hear, not only the overt agendas of the other, but also their more hidden ones. On a deeper level it requires that listeners be centred within themselves, with a clear sense of what they can offer and what they cannot, both in terms of the structures within which they work and their own strengths and limitations. At the deepest level, this capacity for receptivity and for openness to the other presupposes that listeners have integrated the myriad of powerful emotions that working with the survivors of trauma elicit, most particularly the emotions of horror, helplessness, sorrow and anger. It also presupposes that they have not become so blunted by continuous exposure to trauma, by proxy, that they themselves are no longer able to have access to these emotions. These emotions facilitate the identification and empathy crucial to all healing relationships. Given the above, health workers clearly must be able not only to identify their own reactions to interacting with trauma but also to know of ways of dealing with these reactions in practice. Powerful aids to identifying and coming to terms with trauma reactions are knowing and understanding their universality (Agger & Jensen, 1990; Fischman & Ross, 1990). Once it becomes common knowledge that trauma elicits particular reactions, these reactions become easier to own and to integrate as they become more normalised. The intention of this paper, therefore, is to disseminate information concerning common emotions and reactions elicited by working with trauma survivors, including that of early burnout Further, this paper intends to contextualise these reactions within an exploration of the factors informing workers' decisions to enter helping professions in the first place. Exploring the Effects of Interacting with Survivors of Trauma 35 By outlining experiential exercises aimed at helping workers identify for themselves their own journey into the helping profession, and their current status within it, this paper hopes to promote a more personal understanding of the above factors. The specific aim of the exercises is help health workers share their own personal emotional reactions to the work and to elicit their ideas concerning how to deal with these. The exercises are also aimed at promoting self-insight and self-confidence and at providing a much needed space for reflection and relaxation for those who work with survivors of trauma. Trauma workers often need permission and encouragement to use such a space; trauma work by its nature demands continuous action on behalf of others and discourages any focus on the self. Common Reasons for Entering the Helping Professions The reasons individuals enter the helping professions are numerous. For some individuals their decisions have been primarily guided by practical considerations. They may have been given the opportunity to enter this particular field and may have lacked the opportunity to pursue an alternative career. Other individuals' decisions have been primarily guided by more personal considerations. At the conscious level these may include a desire to be helpful, to lead a meaningful life and to make a contribution to society. At an unconscious level they may include identification with the' woundedness' of the other and a desire to make reparation. Whatever the reasons individuals have for entering a particular profession, these reasons impact on their job performance in positive and negative ways. Those, for example, who enter the profession through lack of choice, provided they overcome thekdisappointmentandresentment,maybemorecapableofretainingaconstructive distance from the problems they are called upon to solve, than those who enter for more personal reasons, eg identification with their clients. Those who identify with their clients may be more easily overwhelmed by problems. Equally, however, they may, for the same reason, be more able to sustain involvement and commitment Thus identification is a factor that like any other, will sometimes be helpful in achieving the task at hand and sometimes be counterproductive. All reasons for entering any profession have their pros and cons. What is important is to identify these and to act to enhance the advantageous aspects of each and to reduce the problematic ones. This involves exploring in-depth possible reasons one may have had for joining a helping profession in the first place and becoming involved with trauma survivors in the second place. It involves further 36 Gillian Straker exploration of how thesereasons may have impacted upon one's initial engagement in the work and how this has evolved until the present time. The following group exercise is designed to promote such an exploration. The Tree of Life This exercise invites individuals to explore their current life situation by examining their route to it and their aspirations regarding it (Hope and Timmel, 1984). After introductions and ice-breakers to establish a sense of acceptance of and respect for each group member, every person in the group is invited to draw a tree of life. In this tree, the roots represent the individual's childhood and family of origin and how this has influenced the career choice made; the trunk represents the educational and/orother environmental opportunities and constraints that impinged upon this choice, the branches represent friends and current relationships; the leaves represent the individual's own personality, feelings and emotions; the unripened fruit represents the individual's current feelings concerning their career and their appraisal of their performance and satisfaction in it; the ripened fruit represents where they would like to move to in the future. In giving instructions for this exercise, the group animator should encourage individuals to symbolise the positive and negative aspects of those factors which influenced their career choice. Similarly, the positive and the negative factors affecting their sense of efficacy in their jobs, as well as their sense of satisfaction with them, should be symbolised. Individuals should be given approximately 20 minutes to draw the tree of life; they should then be divided into groups of three to five for approximately one and a half hours to discuss their trees. Approximately one hour should be allocated after this to discuss the experience of this exercise in the larger group. Thus the entire exercise requires approximately three hours to complete. Interacting with Trauma Having explored reasons for entering the helping profession and for choosing to work with trauma survivors, as well as exploring how these affect both job satisfaction and job performance, individuals may be invited to explore in more detail the effects upon themselves of working with trauma. Before outlining group exercises which could facilitate this, the specific effects hJr011™8 W i t h t r a u m a ^ o u t l i n e d in the literature will be summarised, along with the literature pertaining to the reactions of the survivors themselves. In this process it will become clear that workers' reactions to trauma mirror those of the survivors, although the forms in which these reactions manifest themselves may differ. Some ol these effects and consequent reactions to trauma are the following: Exploring the Effects of Interacting with Survivors of Trauma 37 Powerlessness By definition, catastrophic traumas are of a magnitude that overwhelm the individual's capacity to cope effectively in the moment (Raphael 1986). However, the subjective sense of powerlessness and helplessness that this generates at the time of the trauma, rather than dissipating as trauma recedes, frequently becomes pervasive in the post-trauma situation. This leads to a lowered sense of selfefficacy and to generalised feelings of inadequacy and incompetence (James, 1989). These feelings, which are commonly reported by trauma survivors, are equally commonly reported by workers (Fischman, 1991). Among trauma workers, as amongst survivors, a common reaction to these feelings is to deny them and to overcompensate by attempting to be superhuman. In trauma workers this manifests in such activities as working around the clock, taking no time off for friends, family or relaxation, and/or taking untoward risks in the line of duty, while becoming impatient and intolerant of those who do not. This latter manifestation can be particularly dangerous in contexts of continuing traumatic stress, such as that generated by armed conflict and war. In these contexts it is also sometimes difficult to separate out what are necessary from unnecessary risks and what is heroic behaviour from what is reckless. Furthermore, risk-taking behaviour in this context often becomes self-reinforcing, as it is frequently rewarded by fellow workers who do not discriminate necessary from unnecessary risk-taking, or give due recognition to the damage individuals may be inflicting upon themselves and on the fabric of their relationships. The antithesis of this response of denial and its manifestation in heightened activity, is surrender, manifested by passivity and apathy. This response involves giving in to the feelings of helplessness and powerlessness and becoming immobilised by them. In this state the individual feels lethargic and unmotivated, and even those problems that are possible to resolve are experienced to be insurmountable. In regard to both the reaction of denial and surrender, the way out involves recognising that they are both normal and universal reactions occasioned by interacting with trauma. Further, it involves finding ways of empowering the self by defining clearly what may reasonably be achieved within the constraints and opportunities that do exist, as well as setting clear objectives. Pushing against the restraints and attempting to create new opportunities are clearly legitimate activities, but only if the objective is clear and only if this involves a planned strategy that has some chance of success. If this is not the case the possibility that such behaviour may be symptomatic of unresolved feelings of helplessness needs to be probed. A common response to feelings of helplessness is to regress to a child-like position of dependence upon authority, a dependence that breeds anger and resentment and a desire to be oppositional (Raphael, 1986). 38 Gillian Straker Railing against the authorities serves this function, but it is not very effective in bringing about change. This is because it seldom embodies the systematic planning and strategic setting of objectives that effecting change in organisations usually requires. Furthermore, even when it is effective, it seldom pacifies those who are challenging the authority, because the challenge is usually as much an expression of subjective distress as it is an expression of concern about objective problems. Thus resolving objective problems in the external world, while clearly of vital importance, seldom succeeds in resolving individuals' internal dilemmas and conflicts. This requires intervention at a different level. It requires not only recognising the profound feelings of helplessness that trauma engenders, but the entire gamut of conflicting reactions to it. This recognition must encompass not only the negative, but also the positive consequences that may flow from interacting with trauma. One positive consequence concerns the special wisdom, understanding andresilience that exposure to trauma may confer(Silver& Wilson, 1988; Straker, 1992). Negative consequences include profound feelings of anger, sorrow, anxiety and guilt (Abe, 1976; Arvidsohn, 1969; James, 1989; Raphael, 1986). Anger Anger, outrage and horror are normal reactions to any trauma. They are however, particularly intensely felt when the trauma are man-made. These reactions are linked to feelings of betrayal and loss precipitated by the shattering of cherished beliefs. These include a belief in one's own personal invulnerability and in the existence of a benign, well ordered world (Janof-Bulman, 1985). When events conspire to disturb these beliefs, the individuals respond by radically re-ordering their inner thoughts and feelings to accommodate this disturbance. When these events are caused by human intervention, particularly when this is deliberate, a further re-ordering is required to encompassaloss of faith and belief in the goodwill of others. This latter loss of belief is particularly painful because it provokes a sense of disconnectedness from others, cutting across the human need to seek attachment (Catherall, 1991). Attendant upon this sense of disconnectedness is a profound rage, often expressed in a desire for retribution and for revenge. This too cuts across individuals' attachment-seeking behaviour at a time when their desires for nurturance, affection and support are at a peak because of the sense of helplessness which trauma engenders. The individual thus experiences highly conflicted and conflicting emotions that need to be resolved. One resolution involves dividing people into friends from whom nurturance is sought and into foes from whom retribution is sought Exploring the Effects of Interacting with Survivors of Trauma 39 Another response is to become extremely ambivalent towards intimate friends and family members. In this state, feelings of neediness and dependence alternate with feelings of irritation and alienation toward the same person, especially if this person was not subjected to the same level of trauma as the survivor. This is because survivors sense that only those who have experienced the same level of trauma as themselves can understand them (Raphael, 1986). Trauma workers experience similar feelings of anger, disconnectedness and loss of faith as survivors (Moosa, 1992). They too may displace these and may also respond by feeling alienated from those they feel do not understand them or their work, including their friends and families. They may develop a sense of belonging to an in-group of fellow sufferers and/or workers and a sense that those who have not experienced or worked with trauma are part of an out-group. This out-group is then either evangelised and/or denigrated as ignorant and uninformed. There is often a need to make the public aware of the plight of suvivors in the face of catastrophic trauma. The response of evangelising is seen to be a rational response, and indeed it is. However, this should not mask the fact that it may also express less rational responses to the situation, especially if the tendency to evangelise is coupled with a tendency to denigrate. Inthis instance, what is usually being expressed is a loss of belief in humanity and anger about it. This response also represents an attempt to re-connect with the alienated other, but only on certain terms. It symbolises the difficulties workers experience in remaining firmly attached to and in touch with significant others - difficulties created by discontinuities in their view of the world and their view of their place within it, before and after interacting with trauma. It is a signal that the natural disruptions in their inner worlds evoked by interacting with trauma survivors have not been fully integrated and worked through (Catherall, 1991). As in the survivor, so too in the worker, the process of working through reactions totraumaandre-connectingwiththeother is often compounded by a sense of guilt. In the survivor this is directly connected to surviving oneself, while others did not (Lifton, 1973). In workers, this guilt is often connected to a sense of having an undeserved privileged status. Workers thus may feel guilty because, eg they have a family and a home to go to, while the trauma survivor may not. This guilt, if it is not acknowledged and worked through, blocks the ability of both survivors and workers to deal with all the other emotions elicited by trauma. It keeps them stuck in anger and sorrow and puts them at risk for the development of chronic PTSD, depression and psychosomatic ailments. It also makes them vulnerable to feelings of general anxiety and insecurity (McCann & Pearlman, 1990). 40 Gillian Straker Anxiety Anxiety is a concomitant of the heightened physiological arousal with which many trauma survivors live. Because they feel that they can no longer take the world for granted, trauma survivors often live in a state of hyper-vigilance and hyper-arousal, ie they live prepared to meet danger (Eberly et al, 1991). It is this state of hyperarousal that leads to feelings of generalised anxiety which may or may not be channelled into specific fears. This state also leads to sleep disturbances at night, and to intrusive thoughts and heightened reactivity to stimuli in the day. Paradoxically, it is also connected to the emotional bluntedness and numbness which is often apparent in survivors. This reaction, however, is simply the other side of this coin and serves the same protective function as hyper-arousal (Horowitz, 1986). That is, it serves to block strong emotional feelings that may interfere with the individual' s ability toprocess information in a situation of danger and to act accordingly. Once again, these reactions are characteristic not only of trauma survivors but also of those who work with them. Many workers complain of feelings of insecurity and increased anxiety concerning the safety of themselves and their loved ones. They too feel that they can no longer take the world for granted. In order to survive psychologically, most human beings, at least in the Western world, need to believe that the world is a relatively safe and predictable place (Janof-Buhlman, 1985). Further they need to believe that neither their own end nor that of their loved ones, is imminent. Clearly these beliefs are illusions for life is capricious. At no moment is our own continued existence guaranteed; perhaps we would be better off living more consciously with this knowledge. Yet, it is extremely difficult, at least in Western society, to live with this knowledge in the forefront of consciousness (Kubler-Ross, 1969). We own the knowledge intellectually, but by and large we ignore it. We therefore deny emotionally what we may know intellectually. The capacity to split emotion and intellect and live "as if" certain things were not true is destroyed by too immediate a confrontation with trauma. The survivor is confronted directly and the worker indirectly through deep identification with survivors. To regain the capacity to live "as if' life was not unpredictable and "as if one's survival could not immediately be threatened at any moment, paradoxically involves acknowledging fully the opposite. At an emotional level the individual must accept that life is capricious and that the moment of death is never certain, and, in turn, contemplate one's own death and the death of significant others, while simultaneously embracing life. This process must encompass grief and mourning for real losses incurred as a result of trauma as well as mourning for more symbolic losses, including the loss of innocence and the sense of "deathtaintedness" of which survivors frequently complain. Exploring the Effects of Interacting with Survivors of Trauma 41 The term "deathtaintedness" was coined by Robert Lifton (1967) and is connected to his notion of the death imprint When individuals witness the death of others, especially in circumstances where these deaths are multiple and involve mutilation and bodily dismemberment, indelible imprints are left upon the individual's consciousness. This imprint becomes intrusive and the individual has a sense of being immersed in death, of being in death in all its horror and grotesqueness, even in the midst of life. The individual thus feels tainted by death. There is an identification with death and with the dead. This is associated with mourning and grief for the dead and also provokes profound feelings of anxiety and despair. Trauma workers, because their confrontation with death and loss is not as immediate as it is for the survivors, often do not link their own feelings of generalised anxiety and insecurity to their vicarious confrontation with death and loss. Yet, that they are indeed linked is illustrated in the following quotes that reveal a range of reactions experienced by trauma workers: "I'm used to death... but it's usually quiet death in the home...or clinical death in the hospital. It's cleaned up by the nurses beforehand if it's an accident. There was nothing inmy experience that equippedmefor this. The bodies were so mashed; there was blood and guts everywhere ...and so many were dead and some of them were so injured...and it was such a terrible way to die. It seemed so unfair that they were caught and trapped like that by the hand of fate. I could see them alL.just like me or anyone elsc.going off to work in the morning...the same old way for anordinary day, and then this...and life was cut off forever - gone -finished. It just made me realise...well...how it can all end - and then there's nothing. I felt so helpless too, as though there should have been more I could do and there wasn't. I was inadequate to dealwith all that death somehow; itshockedme in a way I wouldn't have thought possible. I dreamt about it for weeks afterwards; I'd wake up in a panic trying to resuscitate someone in my dream...not having the equipment...calling someone to getitforme, andno one coming. I felt bad and guilty, and sometimes the memories of it would flash before my mind". (Granville Rail Disaster worker quoted in Raphael, 1986: 235). "To actually see in flesh and blood a person who had lived through all this terror was moving. One knew from the media what was going on in South Africa's townships, but the reality of it was deeply shocking - one was just 42 Gillian Straker confronted by the horror of it. It was hard afterwards to be withfriends and family who did not share this. It was like having opened a door to a wasteland and having to shutitagain. You had seen it and couldn't go back but you didn' t know how to go forward. It was so vast, I felt overwhelmed. I felt hugely irritatedwith those who live on its brinkanddidri t see it.. It was painful for me just to listen to his experiences. It turned my gut to hear of things that were so inhuman. It made me so angry with the system I wanted to hit back and also guilty about being tainted by it". (South African Detainee Counsellor, 1990). These workers were clearly very in touch with their emotions and how these linked to their exposure to trauma work. It is easy however, in the face of overwhelming emotions, to deny them. When workers are not in touch with how their interactions with trauma impact upon them they often rationalise their anxieties away with reference to such things as escalating crime rates, the state of the world, etc, without being aware of their true origins. If their feelings of anxiety are to be relieved, they need to understand how trauma work elicits these feelings and to understand the meaning their confrontations with death and loss, albeit vicariously, have for them. Failure to acknowledge and/or integrate the emotions elicited by trauma work leads to them being split off and expressing themselves in the myriad forms already mentioned including depression, free-floating anxiety, psychosomatic ailments, and the symptoms usually associated with PTSD. These include sleep disturbances, memory impairment and difficulties in concentration. They also include numbing of responsiveness to the external world and emotional restrictedness. Emotional restrictedness is one of the most difficult to recognise because its onset is often slow and its manifestations are subtle. It resembles burnout which it provokes and by which it in turn is provoked (McCann & Pearlman,1990). Burnout Burnout is a state of chronic fatigue and exhaustion in which the achievement of even minimal goals is felt to be impossible (McCann & Pearlman, 1990). Accompanying this feeling is a desire to withdraw from engagement in the external world and to be less involved with it which is similar to the response of numbing described in relation to trauma survivors. As in this response of numbing to trauma, numbing in response to bumout is also accompanied by a state of heightened emotionality. The individual feels irritable and emotional and often cries or gets angry easily. Exploring the Effects of Interacting with Survivors of Trauma 43 That the symptoms of burnout resemble in many ways those elicited by exposure to trauma is not surprising. Both sets of symptoms result from the individual being overwhelmed by excessive stimulation. In the case of trauma there is usually a single exposure to massive stimulation. In the case of burnout however, this excessive stimulation is usually the result of chronic exposure to enduring problems and difficulties (McCann & Pearlman, 1990). Because of the chronic nature of these problems, the individual must continually marshal all resources to deal with them without time for recovery in between. The symptoms of burnout and exposure to trauma are equally debilitating. They interfere substantially with the individual's ability to function in everyday life; trauma workers are at high risk for both. Trauma workers arecontinuously exposed to problemsneedingurgentsolutions. They are continuously having to marshal all their resources to deal with these under circumstances that, in real terms, often make the problems insurmountable. The frustration, as well as the effort involved in this, predisposes individuals to early burnout. This aspect of the work then interacts with the effects of exposure to the trauma per se, to put workers doubly at risk. Trauma workers therefore need to be alert to andrecognise sooner rather than later, both the symptoms of burnout and vicarious traumatisation in themselves, in their colleagues and in their organisations so that they may take remedial action. Ameliorating Vicarious Traumatisation and Burnout The first step toward ameliorating these problems is of course to recognise them. The second step is to understand them within their contexts as natural and universal responses to particular setsof circumstances. The third step is to take practical steps to alleviate them. In the treatment of trauma survivors the provision of information which normalises symptoms is widely accepted to be a powerful therapeutic tool (Ochberg, 1991; Schwartz & Prout,1991). A similar situation pertains to trauma workers. When workers are initiated into trauma programmes, it is important that they are informed concerning the various signs and symptoms of vicarious traumatisation and burnout outlined above. These may be summarised as follows: 44 Gillian Straker (a) depression (b) anxiety (c) psychosomatic ailments (d) chronic fatigue (e) sleep disturbances (f) survivor guilt (g) memory impairment (h) concentration difficulties (i) heightened emotionality (feelings of rage, distress, irritability) (j) feelings of helplessness (or denial thereof, manifested by attempting the super-human, including taking on the authorities in an inappropriate way and/or taking unnecessary personal risks). Trauma workers should check these signs within themselves regularly and selfconsciously. It is simply not enough to have the knowledge in some recess of the mind, it has to be consciously accessed and examined. Monthly review meetings may give a space to do this and, if the atmosphere is supportive enough, they may also provide a space in which to do this not only for the self but for others. One of the ironies of burnout and of vicarious traumatisation is the more individuals suffer from them, the less able they are to muster the energy required to recognise and deal with them. Thus individuals enter a vicious cycle which often requires outside intervention to break. Frequently the intervention required is not drastic; often simply labelling and commenting upon the individual's response to trauma is sufficient to break the cycle. Peer support groups within organisations providing a regular time for the exploration of these issues in a sustained way, can serve this crucial function. It is equally important for organisations to send workers out on workshops and/ or invite outsiders into the organisations. Organisations themselves when they are involved with trauma work may develop a particular culture in which the abnormal becomes the normal and vice versa. This interferes with their ability to recognise dysfunctional patterns in themselves and in their members. Organisations in this context often develop a "trauma membrane" that is impermeable and serves the same function as emotional numbing in the individual. It cuts out stimulation from the outside world so that the momentous emotions and reactions stimulated by the trauma may be kept within the organisation in the hope of dealing with them there. However, by closing in on itself the organisation facilitates the development of paranoid anxieties and irrational beliefs by cutting off outside reference points of reality. It also limits its own openness to support and help from the outside world and increases its risk of becoming locked into self-fufilling prophesies. Inviting outsiders in or sending workers out to workshops and/or conferences reduces this risk and increases the possibility of the recognition of dysfunction both within individuals and within the organisation itself. Exploring the Effects of Interacting with Survivors of Trauma 45 The following is a description of a group exercise designed for use in a workshop context, aimed at helping individuals explore the signs and symptoms of vicarious traumatisation and burnout in themselves, in their colleagues and in their organisations. Owning Secondary Traumatisation and Burnout Ideally this exercise should follow the tree of life exercise described earlier as this would allow individuals to return to the starting point of their involvement in trauma work, thus bringing a developmental perspective to the current exercise. However, it can be used independently to focus attention on the individuals' current state. To facilitate the group to make of use its own strengths and its own knowledge, the first step is to ask the group, following a brief explanation of the nature of burnout and vicarious traumatisation, to list the signs and symptoms associated with this. Members of the group may draw from what they observe in themselves, their colleagues and their organisation. The group animator writes up all responses; only after a comprehensive exploration of the group's own list should the list generated from the literature be shown for comparison and discussion. There will always be considerable overlap, and this serves to affirm the knowledge and expertise within the group. This section of the exercise requires approximately one to one and a half hours. Following this the group is divided into pairs; each member of the pair is invited to share those aspects of the work that he or she personally has experienced or still experience to be the most traumatic. They are asked to discuss what effects they feel this has had on them and how this has manifested. While each member is sharing this information, the other member of the pair is asked to listen attentively and empathically but without giving advice or attempting to problem solve. Following this mutual sharing, each member of the pair is asked to discuss with the other how they could ameliorate their own difficulties. After discussing this each person is asked to commit him or herself on paper to this solution without identifying themselves. This section of the exercise takes approximately one hour. These slips of paper are then handed to the group animator who reads them to the whole group, thus affording everyone the opportunity to benefit from the ideas of everyone else. This usually requires approximately half an hour. If time is limited, the group may be ended at this point. Ideally, the group should once again be sub-divided and asked to select one of the solutions mentioned in the larger group. They should then be asked to indicate the practical steps they would take to implement this solution in their particular circumstances. This encourages the group to actively use its skills and to mobilise its own resources and thus move 46 Gillian Straker out of the helplessness that both vicarious burnout and traumatisation generate. This section requires approximately one hour. The total time commitment for this exercise is four hours. Thus, a full day would be required for this workshop if this exercise was combined with a tree of life. A combination of both exercises is ideal, for the workshop, in its totality, encompasses many of the elements known to be therapeutic in the treatment of trauma survivors (Schwartz & Prout, 1990). It identifies and labels common reactions to working with trauma. It universalises and normalises them, making them easier to own. It provides a space for more personal and emotional exploration of issues by inviting a focus on what individuals themselves experience as the most traumatic aspect of their work. It allows individuals to be listened to, to be heard, and to feel understood. Furthermore, by combining an exploration of reactions to trauma with an exploration of how the choice to work with trauma was made, a sense of coherence and continuity of personal identity is encouraged, a sense that is frequently disturbed by trauma. It affirms self-efficacy, undermined by trauma and burnout, and it does so by mobilising the group's own existent resources and by providing a space for learning and practising new skills. By focusing attention on solutions and how they may be implemented in the organisations to which individuals will return, it opens the way to contemplating the future and the possibility of productive change. 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