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Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity

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Chapter 8
Countertransference in Trauma Clinic: A Transitional
Breach in the Therapists’ Identity
Mayssa’ El Husseini , Sara Skandrani ,
Layla Tarazi Sahab , Elizabetta Dozio and
Marie Rose Moro
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/64842
Provisional chapter
Countertransference in Trauma Clinic: A Transitional Breach
in the Therapists’ Identity
Mayssa’ El Husseini, Sara Skandrani,
Layla Tarazi Sahab, Elizabetta Dozio and
Marie Rose Moro
Additional information is available at the end of the chapter
Abstract
In line with the theoretical elaboration of countertransference in the trauma clinic, this
article addresses the therapist’s relationship to the strangeness of the trauma, as well as
his/her interaction with the cultural dierence of the other, who is in this case, the
traumatized patient. Thirty-one therapists were interviewed about their subjective
experiences, using the methodology of interpretative phenomenological analysis. This
article shows interesting subtleties in countertransference reactions to trauma narratives
and sheds light on processes indicative of trauma transmission. Therapists interviewed
could express experiencing moments of strangeness and inner disquiet; resonance in
the defense mechanisms deployed by therapists and by patients at certain moments of
the therapy; resorting to disregarding cultural interpretations/generalizations to make
sense of an uerly painful situation and put a protective distance with the patients’
culture of origin.
Keywords: countertransference, trauma, humanitarian context, transmission, trans-
cultural psychology
1. Introduction
In line with the theoretical elaboration of countertransference in the trauma clinic, this
article addresses the therapist’s relationship to the strangeness of the trauma, as well as
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
his/her interaction with the cultural dierence of the other, who is in this case, the
traumatized patient. Our objectives are to explore the mechanisms implicated in trauma
transmission through countertransference reactions in therapists working with traumatized
patients and to depict and analyze the processes that could potentially lead to vicarious
traumatization.
1.1. Countertransference and trauma clinic
Countertransference is a concept originally coined by Freud [1], referring to the unconscious
reactions of therapists to their patients’ transference. The classical denition postulates that
the implications of a therapist’s unresolved childhood conicts on their reactions require
examination in order to be controlled [2].
A broader perspective on countertransference suggests a more totalistic denition [3] and
includes the total emotional reactions of the therapist to the patient [4]. Such emotional
reactions relate to a variety of factors, such as the therapist’s life experiences, inherited internal
unknown objects [5], personal psychoanalysis experiences, and theoretical aliations [2] in
interaction with the patient’s transference. Therefore, countertransference reactions are
bidirectional and refer to the inter-subjectivity of the psychotherapeutic dyad of patient and
therapist [6].
In the totalistic perspective of the psychoanalytical theory regarding countertransference, the
laer is an essential tool in helping the analyst beer understand the patient. The analyst is
expected to position himself/herself as a subject of observation and analysis, in order to acquire
the required objectivity [4].
Additionally, Balint examines countertransference reactions in non-psychoanalytical situa-
tions, focusing on the presence of subjectivity in all therapists and its countertransference
mobilization in all types of therapeutic relations [7]. From the same perspective, Devereux [8]
broadens the concept of countertransference to include the social sciences and their impact on
the ndings of research conducted in this domain. Devereux [8] introduces the concept of
cultural countertransference, which is related to the position the therapist adopts towards the
otherness of the patient and to the laer’s cultural codes and perceptions of illness. According
to this perspective, cultural transference and countertransference are also inuenced by
history, politics and geography. Thus, any non-examination of cultural countertransference
will compromise the therapeutic alliance and will enhance the risks of aggressive, aective,
and racist acting-outs [8].
This aspect of countertransference seems to be of particular interest in the therapy of trauma-
tized patients, although it has sparsely been investigated. Over the past two decades, many
studies have investigated the impact of trauma work on therapists who work with trauma
patients through the identication of emotional, cognitive, and physical countertransference
reactions [9–14] and trauma transmission elements [15]. This accumulation of research has led
to innovative concepts such as secondary traumatic stress and compassion fatigue [10],
vicarious traumatization [11], and empathic strain [16].
A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice168
2. Methods
The clinical material in our research was collected through interviews with ten therapists
working with traumatized patients, in a humanitarian intervention context, within which the
therapeutic encounter is mostly short and intense. The encounter can occur between an
expatriate therapist and a patient, or between a foreign therapist and the patient’s community
of aliation. The therapists were recruited through humanitarian institutions that provide
psychological care programs in critical contexts (natural disasters, war zones) or within their
development missions (malnutrition programs in precarious contexts). We have contacted the
heads of psychological programs departments in the humanitarian institutions to explain the
research. We have then sent an email explaining the research objectives, the interview proce-
dure, and the possibility to withdraw their participation at any stage of the research. Therapists
who were interested in participating to the research contacted us by email. All those contacted
met the selection criteria as we had targeted NGO’s providing programs in trauma clinic. We
set an appointment for the interview that would take place at the researcher’s oce or the
participant’s oce, at his/her convenience. In a later stage, the interview analyses were sent
back to the participants to have their validation of the results.
Sex Age Nationality  Years of
experience
Field of
interventions
Countries
of
missions 
Approach  Access to
supervision
Five Men
and 
ve
Women 
Mean= 41.9
Standard
deviation =
12,4 Range:
30–63  
years old
Belgium;
French;
Iranian;
Lebanese
Mean =
10.9
Standard
deviation
= 8 Range:
5–30 years
Six on Natural
disaster (three
earthquakes,
three tsunami);
seven on War
zones (ve civil
war; one invasion;
one
war in a context
of
colonization)
Haiti;
Indonesia;
Lebanon;
Occupied
Territories
of
Palestine
Psychodynamic 
Psychoanalysis
Integrative
Relaxation
Cognitive
Behavioral
Eight referred
to supervision
experience but
none had
access to
supervision on
the time of the
mission
Table 1. Participants’ characteristics.
Our interviews lasted one and a half hours each, were recorded and transcribed, and then
analyzed using the interpretative phenomenological analysis (IPA) methodology [17]. IPA
provides a dynamic approach of the material and privileges a close access to the participants’
experience of the studied phenomenon. The researchers’ conceptions of the phenomenon are
used to make sense of the participants’ personal world through an interpretative activity.
Participants’ characteristics are described in Table 1.
Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity
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169
A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice170
ees would say “ideally,” the therapist should be in a neutral and welcoming listening position
as T.10 explains: “I believe that in my practice the following was essential: how to be able to dissociate
my inner experience of the patient’s narrative from his/her experience, in order to be neutral in my work,
to have a benevolent listening as they say, to be interiorly available for the patient’s account.” In
response to the question about being aected by a certain situation reported by the patient,
some painted a caricature of the aects that could overwhelm the therapist, such as T.9 who
says: “to be aected and say: oh my god, and start crying with the patient? No, no. I don’t believe this
is what the patient came to look for, or that it could be of any help. So if it is a demonstration, then no.
To let yourself get aected by all cases isn’t of any help”; others imagine a pragmatic schema to
protect themselves, such as T.1 “well, I believe that if you are already well protected, it won’t aect
you. You come, you already have your barriers and so you have your stu with you that are solid enough.
You are able to separate things, have empathy with the patient, help her, and then clean yourself up
afterwards, and you are ne.”
In the same interview for instance, we can notice the gap between the theoretical stance and
the lived experience. On that note, T.10 says: “well yes, during that moment, the limit wasn’t clear
anymore. For a while, maybe for a minute, I was myself absorbed by what she was saying. It was as if I
was in the scene, I was looking at the scene from an outside perspective. And really, there was a feeling
of revolt, a feeling of rage. She was sad and I was revolted.” We can also observe this feeling of being
within the scene of the traumatic event in T.1’s narrative, who, while recounting his experience
of the patient’s traumatic event narrative, says: “I saw all the scene happening, I saw all of that, I
was there.”
3.2. Aack of the therapists’ thinking capacity triggering shame, guilt, and change in
worldview
T.1 describes his experience while listening to the trauma narrative of his patient “in this
situation, feelings were all confused. There were my feelings, actually the feelings the patient would give
me, and then the feelings that a therapist is not supposed to have: injustice, the need to stop the therapy,
disgust, the need to vomit, things like that, well, a therapist is not supposed to feel this, but at that
moment, I had them.” He repeats twice that a therapist is not supposed to experience such
feelings, thus, leading us to the issues of shame within the community of peers and guilt
regarding what the professional superego imposes. He continues my stomach was knoed with
the need to vomit, I felt disgusted, I was horried and all. I believe that this is all the countertransference
of the other, and the need for injustice.” Herein, we witness an obvious disorganization of the
narrative that exposes two Freudian slips: the “countertransference of the other” and the “need
for injustice.”
The theme of shame recurs in another sequence—in the frame of a post-trauma therapy group
interview: a young therapist had of her patient, the image of a Minotaur, a devouring monster.
She contemplates the emergence of this image as follows: “I had a feeling of shame, of disgust by
myself, to have had such a feeling that I am not supposed to have. I was a trainee in a learning position,
confronted by something that was very disturbing; I know somehow, from what I have learned during
my studies, that what I feel towards the patient is good, in the sense of a countertransference reaction
that is generally useful working with the patient. But the intensity to that extent was disrupting. In a
Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity
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171
supervision group, I would express this experience in a more intellectualized way, in terms of dehu‐
manization. I wouldn’t have been able to express it as is. I am dealing with an image of an aggressor, to
whom I am supposed to be welcoming. I see the patient as an aggressor, like the Minotaur who is
aggressive, it devours.” The therapist here is deeply disturbed by her discovery of certain cruel
sensations in herself towards this patient and by being prompted into an archaic fantasy of
devouring. T.1 had also referred to “something archaic” that was awaken in him in the situation
he reported.
In this sense, T.9 says: “On the long term, it is inscribed in us (…). Thus, it is repetitive, and indeed,
we are much more sensitive to what happens in the world around us.” This heightened sensitivity is
also reported by T.8 who describes a sense of a widening gap with others once she is back from
her mission, she says: for example, I go to a movie that takes place in a shantytown. The movie
contains lots of scenes happening in the shanty town where I had worked, of which I was an indirect
witness with the children. And in the movie, it is so distant from the reality of the spectators, and I had
this feeling that people around me were not in the reality. They could almost laugh or… well I had cried
as if … I was crying out of shock. (…) It was terrible because the shanty town, at some point, is put on
re, and the shanty town where I was, had been put on re by the authorities in order to empty the terrain
(…) and there were children and families who died there (…). For me, it was serious; it is something
that happens in real life. So, not only was there a whole gap between me and the people in the audience,
but really I felt almost traumatized.” As shown in these illustrations, therapists report a change
in their worldview once they return to their home country in the aftermath of a humanitarian
mission.
3.3. Therapist issues concerning patients’ cultural dierence
In contexts of expatriation and inter-community dierences, therapists tend to highlight the
cultural dierences as a diculty or sometimes as an impediment to the therapy with the
patient. In this sense, T.8 explains “ I am always afraid that they (the target population) see me as a
traditional therapist or a priest or something. In my dream, I had that role in the ceremony.” This
account clearly reveals a fear of self-loss, of depersonalization.
T.9 recounts a situation wherein she was confronted by a mother who—as T.9 puts it—
preferred to let her child die” of malnutrition. T.9 found herself incapable of helping the mother,
or of providing her with therapy: “when it is about a mother who is really ‘closed,’ I don’t understand
the culture she lives in, I don’t know enough to understand this mother, what motivates this mother to
do so. I don’t know how to help her get out of this circle. Therefore, I passed it over.”T.9 refers to culture
without grounding her account in any etiological theory or cultural genealogy. Moreover, she
says: “well, I mean, I can understand that for some mothers who have ve or six children, and who live
in economic situations, in some countries where they cannot nd ways to nurture their children, the
only way would be indeed to have one child who suers malnutrition, as a way to benet from food
program’s help for this child, and then share the food with the others, while leing this one die, because
in all cases he is already malnourished, and thus ‘uninteresting.’ So, in a way, in such situations, mothers
can be violent with these children. Well, I understand her functioning modality. I understand why she
is like this. Nevertheless, what I can’t always do is to nd a way to make her understand that this is a
child, this is a life. Wouldn’t there be other means? Can’t we together nd other means to help feed the
A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice172
others without leing this child die?” So for T.9, this mother had been forced to pick and choose
between her children, as she was unable to feed them all. This functioning would be grounded
in “cultural thing.” To another question in the interview, the same therapist responds: “well…
actually, in general, whether it is within a humanitarian action or not, we arrive with a mandate and a
specic project. Therefore we cannot accept all of the patients who had been traumatized, not when they
do not t our program. Therefore yes, there are persons that we do not accept in the program. And there
are persons whom we accept, because, well, we know it entails other implications.” This statement
highlights another cultural specicity that regards the non-governmental organization’s
culture of implementing programs.
4. Discussion
Our research’s results draw aention to some of the established theoretical concepts that
therapists acquire through their trainings and hold in their background while working in
trauma clinic. Representation of neutrality in psychotherapeutic work refers to the rst
Freudian conceptualization of countertransference (1910) whereby he urges the analyst to have
an aitude analogous to that of a surgeon [1]. Neutrality is to be understood here in the sense
of the imperturbable, as Donnet highlighted in his article “Neutrality and the gap subject-
function” [19]. Nevertheless, while exploring the therapists’ elaborations on specic clinical
situations, theoretical stances seem to fade in favor of the clinical experiences as experienced
hands on. Therefore, we can note particularly intense countertransference reactions that seem
to disrupt the therapist in his/her theoretical assets, consequently unseling his/her profes-
sional identity.
The dread produced by the trauma entails a threat of self-annihilation, hence, mobilizing
defense mechanisms that are immediately operated by the person. These defenses—actualized
in narratives of traumatic experiences—induce a major part of countertransference reactions.
In this sense, actualized defense mechanisms deployed by the patient during the session
underpin the countertransference reactions of the therapist, a sort of countertransference that
is specic to the encounter with trauma.
The fascinating encounter with the unthinkable of the trauma conveys traumatic substance
through infra-verbal channels. This substance is deposited into the therapist’s psychological
system. Yet, as Bion [20] elaborated, this psyche is the means to transform the beta elements
(raw, unthinkable, unlinked sensations) into alpha elements (representable, metabolizable
elements). What happens then, within the therapist’s psyche, when these unidentied
sensations are deposited into him/her through projective identication mechanism, making
him/her share the unedited transgressive experience? We witness then an aack of the thinking
capacity of the therapist. For instance, the slips highlighted in the results seem to underline a
strong resonance with two mechanisms deployed by the patient: one, dissociation, through
the therapist’s concordant identication with the patient’s self; and two, an identication with
the aggressor, in an aempt to escape the helpless state of the patient, through mobilizing
Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity
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173
complementary identication, in the sense that the therapist identied with the object-
aggressor incorporated by the patient.
On one hand, trauma seems to revive the “unshaped substance” of an era associated with
cruelty, which itself could be the origin of the feelings of shame, and the threat of unsubscribing
from the peers community. On the other hand, archaic resurrections of cruelty are hardly
bearable by the therapists, at least in the rst phase. Such archaic resurrections seem to obstruct
the thinking and elaboration capacities of the therapists, even within the framework of
supervision, which is supposed to act as a holding and transforming space for these feelings.
As Heimann stated in [21], such elaboration spaces are supposed to render the analyst capable
of containing feelings within him/her, instead of simply expelling them as the patient would
do, in order to subordinate these feelings to analysis, whereby the therapist functions as a
mirror reection for the patient.
Nevertheless, it would be misleading to believe that the countertransference analysis grants
the analyst the possibility to control his/her inner reactions, as Freud urges [1]. Margaret Lile
[22, 23] formulates the concept of countertransference analysis as an insucient remedy with
inevitable remains unconscious infantile countertransference.
Some of the interviewed therapists, described timidly and with a surprised tone, the resur-
rection of what they qualied as “archaic,” despite the long personal analysis and regular
supervision that they have engaged in. It is signicant to note here that the supervision space
is not always experienced as a room for free and spontaneous expression, but rather, as a space
wherein the therapist is required to intellectualize his/her countertransference experiences.
This brings to mind what Heimann [21] highlighted regarding the diculties that analysts face
to admit their errors and discuss the issue “we all have our private cemetery, but not all graves
have tombstones.”
Another aspect of countertransference which emerges in the interviews, is that related to
cultural issues. In line with Devereux [8] and Nathan’s theories [24], Moro [25] species that
the cultural countertransference emanates from the inner stance of the therapist and inuences
this very stance regarding the patient’s otherness. The stance is underpinned with the thera-
pist’s personal history, as well as the collective, political, geographic, and socioeconomic
history. In contexts of expatriation, therapists sometimes describe a phase of loss of cultural
references and know-how, and nd themselves confronted by a double-layered otherness: the
rst being the trauma, and the other being cultural otherness. The diculty facing trauma
sometimes resorts in disregarding cultural interpretations and making generalizations to make
sense of an uerly painful situation and put a protective distance with the patients’ culture of
origin. At rst level interpretation, the cultural dimension seems to have obstructed the
possibility of engaging in therapy: The therapist was confronted by a dead-end that of cultural
dierence. However, what we observe here is a displacement of the products of traumatic
reality lived by the therapist, for instance the unbearable guilt and violence, and relocating
them to the “stagnant” and “unchangeable” host culture itself, in a defensive move that
consequently maintains security for the therapist, by masking social injustices and deferring
the dread for reality until a further notice. The violent socioeconomic reality—which is
A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice174
probably a source of guilt for non-governmental organization sta (who live in relatively
comfortable conditions in comparison to the context’s reality)—is conated with the violence
of cultural otherness, and probably with the violence of the trauma problematic. Clearly, in
humanitarian contexts, expats often nd themselves obliged to “pick and choose” the patients
they accept in their programs. They too, engage in prioritizing needs/demands, and thus,
operate on basis of selectivity. What we observe here is a displacement mechanism: the
therapist, deployed in a foreign culture, is confronted by a traumatic encounter with trauma-
tized patients, from a target population that is enduring severe socioeconomic precariousness.
Defensively, the therapist assigns to the host culture, the unbearable guilt of having to select
and to prioritize. Thus, the culture becomes the platform within which this violence is
contained and made sense of. The transgressive aspects of the trauma narratives are the most
implicated in the disqualication of the patients’ culture of origin. The transitory disruptions
in the therapists’ beliefs highlight the particularly intense mobilization of countertransference
reactions to trauma. Exploring the disorganization in each therapist’s narrative structure
reects the style of that therapist’s defense mechanisms implicated in countertransference.
This double-layered otherness, trauma and cultural dierence, questions the therapist’s
identity, both, the professional and the human, hence, disrupting their working capacity at
certain times.
5. Conclusion
To conclude, we would like to refer to Françoise Davoine [26]: “the trauma asks the analyst:
who are you?” Trauma calls into question the very identity of the therapist, disturbing his/her
narcissistic assets by evoking questions that concern his/her aliation to the human commun-
ity.
This study reects subtleties in countertransference reactions to trauma narratives and sheds
light on processes indicative of trauma transmission. It also provides corroborative evidence
to previous study ndings in the eld of countertransference to trauma work. The ndings
underline the presence of trauma transmission and depict some of the channels through which
it is conveyed within countertransference reactions. However, this transmission is not static
and does not necessarily obstruct the therapeutic alliance, insofar as the examination of
countertransference reactions helps transform trauma transmission elements into means to
beer understand the therapeutic process.
Moreover, as seen in some therapists’ narratives, the angst triggered by the cultural dierence
complicates the transforming function of the countertransference. What would be the im-
pending future of the trauma residues deposited in the therapist’s psyche? Our results have
shown dierent paths for investigation. Themes of shame and guilt have emerged in therapists’
narratives seemingly arising from the transgressive encounter with the not-to-be-seen aspects
of the trauma, and hence, entailing counteraitudes and reactions that can be hardly shared
with peers. Furthermore, the inscription of un-representable elements of trauma on the
Countertransference in Trauma Clinic: A Transitional Breach in the Therapists’ Identity
http://dx.doi.org/10.5772/64842
175
therapist’s body that can be observed through somatic symptoms experienced by our partici-
pants–therapists while working with their patients on the trauma narrative
Author details
Mayssa’ El Husseini1*, Sara Skandrani2, Layla Tarazi Sahab3, Elizabea Dozio4 and
Marie Rose Moro5
*Address all correspondence to: mayssa.husseini@gmail.com
1 Maison de Solenn Cochin Hospital, CESP, Descartes-Sorbonne University Paris cité, Paris,
France
2 Maison de Solenn Cochin Hospital, Nanterre University, Paris, France
3 Saint Joseph University, Beirut, Lebanon
4 PCPP, Descartes-Sorbonne University Paris cité, Paris, France
5 Maison de Solenn Cochin Hospital, Descartes-Sorbonne University Paris cité, Paris, France
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A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice178
... A second sub-theme linked to perceptions of the uncanny discussed previously concerns what El Husseini et al. (26) referred to in their studies as cultural devaluation. T. 's mother linked her son's traumatic past-an infant who had repeatedly been left alone for several days by his alcoholic parents-to what she called the "Slavic culture. ...
... The difficulty facing trauma results in disregarding cultural interpretations and resorting to generalizations in order to make sense of an utterly painful situation. It also provides a protective distance with the person's culture of origin (26). The parents' accounts show how they are confronted with trauma that cannot be remembered/ elaborated. ...
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... Pearlman and Saakvitne (1995) showed that the absence of counselling to help therapists avoid countertransference increases their vulnerability to vicarious trauma. Traumatic countertransference by therapists is characterized by a range of emotional reactions to trauma survivors, notably identifying with their powerlessness, their distress, and their vulnerability (El Husseini et al., 2016;Gabbard, 2001;Norcross, 2001). According to Courtois (1988), the dynamics of clinical sessions with trauma survivors make therapists more vulnerable to vicarious trauma, especially if the therapist is young (Catherall, 1991) and not receiving adequate supervision (Neumann & Gamble, 1995). ...
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Professionals who work with victims and trauma survivors are continually confronted with the destruction, horror, and losses their clients have experienced and are therefore susceptible to vicarious trauma (as a result of their empathetic engagement with and cumulative exposure to traumas related by patients) and post-traumatic growth (as a multidimensional process that leads to both changes in beliefs, objectives, behaviors, and identity as a consequence to trauma exposure). Although psychologists have long been aware of these two phenomena, they remain under-researched. The present study examined whether professionals who work with trauma survivors are impacted by vicarious trauma and whether they experience post-traumatic growth. We also looked for possible correlations between the two phenomena. Analyses of responses to the ProQOL (vicarious trauma) and PTGI (post-traumatic growth) questionnaires provided by 163 professionals (mostly legal practitioners and psychologists) within a French nationwide victim-support organization showed that they experience both vicarious trauma and post-traumatic growth and that these two phenomena are closely linked. Further research is now needed to confirm and more clearly define these links. Results also showed that profession, professional experience, and specialized training moderate vicarious trauma and post-traumatic growth. These variables must be taken into account when evaluating the two phenomena and when providing support to professionals but also in conception and implementation of training programs and supervision settings.
... These unusual situations dissolved their professional self-confidence, leaving them passive and helpless in the face of this experience. The puzzlement expressed in their answers on the topic of school refusal by youths from transcultural backgrounds might thus mirror the traumatic experience of their encounter with otherness, perhaps recalling the concept of vicarious traumatization (31). Thus, the non-standard practices subsequently developed by some participants for dealing with these situations might be seen as defensive strategies to enable them to again become an active participant, thus recovering their professional identity. ...
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