A Provocative Vocation 

How do professionals cope when their clients are survivors of torture? What inspires them to work with issues that force them to confront the darkest side of humanity? How can they deal with their own reactions to torture and still be helpful to their client? SUE ROXON explores some answers.

 "How on earth do you keep going in this kind of work?" I am asked this question unfailingly at every gathering where I have given a talk or lecture about working at STARTTS. It may be that I am asked this question so often because I am a physiotherapist and I often speak to other physiotherapists, who, like me, received no training, in working with highly traumatised people (although in fact we do it all the time). But this question goes way beyond the practice of physiotherapy. I am beginning to realise that it is one of the most important question I am asked.

I used to attempt to respond to it with an explanation about the way my own personal and family history initially attracted me, and continues to drive me, to work with those people who have been robbed of a place in the world. This growing understanding of my motivations was important to me but I now realise that this is not what other people want to know. They are asking, of course, how they can keep doing this kind of work, and that is precisely the question I will attempt to answer in this article.

How does a worker in this field keep finding the work as enriching as they initially did, while being exposed, even if second-hand, to the horrifying extent of both human vulnerability and human cruelty? How does one identify with one's clients without feeling overwhelmed and becoming defensive? How does one keep hope alive in the face of despair?

My answers to this dilemma have come from my own supervision over six years and from the supervision I have provided to other physiotherapists who have worked at STARTTS. I have noticed similar difficulties and issues arising in all of us as we have struggled to develop our confidence in this area of work for which we have had no prior training, other than our own life experience. It is the discussion of some of these issues that comprise this article. I must emphasise that they are my answers, but I hope they resonate sufficiently with others to be of use.

A common initial reaction to survivors of torture and trauma is one of feeling overwhelmed - by the client's life problems, their symptoms, and the depth of their hopelessness and despair. This may not be a comfortable feeling for professionally trained problem solvers such as ourselves, and can often lead to a compulsive flurry of practical actions, like writing off a batch of referrals (the professional's lifebuoys). A more useful and considerably less stressful initial response, would be a calm examination of our own reactions.

These feelings of being overwhelmed by the client may arise from a combination of factors. The workers may have unrealistic demands of their own role in the relationship. Similarly, the client may place unrealistic demands on the therapist. Such demands, imposed both from within the worker and from the client and indeed their whole community, seem to be particularly strong and stressful on bi-cultural workers working within their own community.

What are these unrealistic expectations on the part of the worker of her own work? Bluntly, the desire to rescue, to save, to take away the effects of the original trauma, as well as the trauma of resettlement, so that the outcome is different. This desire to rescue seems to develop as a result of the worker's inability to tolerate both the client’s and her own pain.

The reaction of the worker to the client's pain is often complicated by her feelings about the trauma and losses in her own life, or in her family or community. Many people who are drawn to this work tend to have a history of trauma, loss and/or displacement and alienation from the dominant culture. This perception of a shared history gives the worker a valuable ability to identify with her clients, as well as a strong motivation to keep working in this area, but it can be source of immense stress and frustration if the worker is unable to clearly differentiate between her own and her client's feelings, and is unconsciously attempting to ease her own or her family's pain through her work with trauma survivors. To learn to differentiate between the client's feelings and one's own is one of the functions of clinical supervision.

The worker's self-imposed demands are likely to be fed by the equally unrealistic and unconscious demands of the client on the worker. They may desire to be saved and returned to their pre-trauma state, for justice to be administered, the effects of the trauma wiped from their lives and their losses restored.

An aspect of feeling overwhelmed by expecting oneself to do the impossible, is a paralysing feeling that there is nothing at all the therapist can do. In my experience, this helplessness is almost invariably fed by the common client behaviour of consciously or unconsciously attempting to convince the therapist that this is indeed true. The client often conveys the impression that the effects of the trauma were so powerful that no improvement in their life is possible and therefore that any professional intervention will be ineffective. This seemingly paradoxical fantasy - that both a miraculous reversal of their fate is possible, and that the destruction they have suffered is too extensive for change to occur - enables the client to avoid facing the true extent of their loss, and the grieving and rage that facing the loss would engender.

Identification and examination of the feelings aroused in the worker by the client, and the worker's expectations of her work are crucial to professional development, and indeed survival, in this field. Only then is it possible for her to develop realistic expectations of her intervention and find satisfaction by working within these boundaries.

What, then, are realistic expectations of a therapeutic intervention? What outcomes can one reasonably hope to achieve, and how can they be achieved? The following points are aspects of my own therapeutic aims and style of working that I have developed and learned to articulate through my six years of work with survivors of torture.

Establishing an environment of safety and a relationship, where trust can develop, is an essential aspect of a therapeutic relationship. It is only within this environment that self-healing can optimally occur. It enables the client to listen, to be heard, to be open to possibilities of new ways of being, and to explore and express themselves, to think the unthinkable and say the unsayable. Exposure to human cruelty can severely hamper an individual's ability to relate intimately. Torture, which invariably occurs in relationships of perverted and highly distorted intimacy, is designed to destroy trust, faith and the ability to relate to others in a loving and meaningful way. Development of a relationship where the client feels safe and supported to explore their lives and feelings is an aim in itself.

Peter Levine, in a taped interview on KGNU radio, describes his shock-trauma therapy as the equivalent of holding a shocked bird in the warmth and security of his hand while it recovers, while resisting the desire to 'do' something with his hands to fix the bird.

One of the ways in which I do this in a physiotherapy context is to hold the client's head and neck in a very supported way, and for long enough for the client to feel that support. If this does indeed feel supportive rather than threatening and intolerable - and it is not something I would do automatically with all clients- it has the immediate effect of enabling chronically tense neck and spinal muscles to stop working so hard, and to reveal to the client new possibilities of movement and spinal coordination, as well relieving the pain of chronic muscle contraction..

The way in which the worker can establish safety and trust will be individual for each work environment, but, as usual, it will always take time and patience.

One major restrictions to forming therapeutic relationships within a health care setting is the economic rationalism of current health care policy which demands immediately measurable standardised outcomes in predictable time frames.

Bearing witness to the injustice and acknowledging the extent of the loss and the destruction the trauma has wrought, is a realistic role for a therapist. It is also an important aspect of the development of a trusting relationship. Acknowledging the extent of destruction in this way often causes consternation amongst physiotherapists who are trained to cheerfully see what is possible to achieve amongst massive destruction. This is of course an invaluable ability, but a client cannot allow him or herself to see what they are capable of while they are aching for their losses to be acknowledged. It is worth conjecturing whether the thirst for acknowledgement by citizens of the host country has increased in the present political climate which is so hostile to refugees.

In order to listen, bear witness, and acknowledge the destructive effects of the trauma, the client's feelings of anger and pain must be accepted. Such acceptance is only possible when the worker can tolerate their own anger and pain of loss. This involves acknowledgement by the worker of the feelings which are inevitably aroused by contact with the client. It also calls for an examination of the way in which the workers own history of loss, grief and alienation affects their arousal, and may be providing them with their motivation to work in this area. It is useful for all workers in this area to ask themselves "Whose pain am I trying to heal? Whose problems am I trying to solve?"

The worker's ability to tolerate her own, and therefore the client's pain, enables the client to learn to tolerate their own pain, albeit in their own way and in their own time. It took three years for a client of mine to stop making jokes about his horrific experiences in a labour camp, to look me in the eye and say quietly "There are some things you don't want to ever think about. You can never forget them but you shouldn't try to recall them, or you won't be able to keep on living". He was telling me that for him there was no peace, either through recalling his experiences or not. I also felt that being able to tell me in a straightforward non-defensive manner that the horror was too great for him to share with any other person was evidence of a greater self-tolerance of his memories.

The premise underlying my work is my belief that a greater degree of peace, of living with consciousness of the past and an improved functioning in life is always possible (though by no means always achieved). The journey to this end will involve mourning and a greater awareness of loss. Not everyone is willing to undertake such a journey, and the form it will take will be unique to, and decided by, each person. The means to living with the past may be through writing or painting, it may be through helping others, it may be through counselling or intensive psychotherapy, it may also consist of involvement in a struggle for social justice and human rights, but the support of another human is of invaluable assistance.

A friend of mine who works with survivors of childhood abuse describes her role with her clients as one of a midwife during a difficult labour, a companion on the journey of a client giving birth to herself. Inherent in the role of midwife are qualities which are equally important in the process of working with trauma survivors. It needs patient, focussed, observant waiting, with appropriate skilled intervention when necessary to facilitate the progress of the labour and ease the pain. Mostly it is the midwife's presence which provides the support needed to guide the labouring woman through the isolation, the fear of the unknown, and the terror of losing control.

So, what keeps one going in this work? I believe it is one's original motivation, embedded in one's history, that remains the driving force in this work. The ability to identify with one's clients can provide patience, compassion and understanding. However it can also be the source of frustration, dissatisfaction and impatience if such identification is not satisfactorily brought to conscious awareness and scrupulously examined on an ongoing basis. This is neatly described in the Gnostics Gospets, quoted in Peter Levy's Waking the Tiger:

If you bring forth that which is within you,

Then that which is within you will be your salvation.

If you do not bring forth that which is within you,

Then that which is within you

Will destroy you

Sue Roxon is a physiotherapist at STARTTS