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Post Traumatic Stress Disorder: Social Work at a Danish Rehabilitation Centre
for Refugees
Margrethe Bennike
Margrethe Bennike is a social worker at the Rehabilitation Centre for Refugees,
rhus, Denmark. This paper was presented at the IFSW/EASW Seminar, 'Culture and
Identity:Social Work in Changing Europe', held at University College, Dublin in
August 1997.
The background of immigration to Denmark
From the fifties through to the mid-seventies, during a period of labour
shortage in Denmark, there was a certain amount of immigration. Immigrants came
from countries such as the former Yugoslavia, Turkey and Pakistan. In the 1950s,
1,600 refugees came from Hungary and in the 1960s there were 2,500 from Poland.
When employment fell during the mid-seventies, immigration was halted, except
for citizens from the Scandinavian and EU countries.
From 1985, the number of refugees increased dramatically over a five-year period
with approximately 26,000 people from Iran, Sri Lanka and the Lebanon as well as
stateless Palestinians. This was a great number of people for a country such as
Denmark and it presented completely new challenges. They also entered the
country at a time when employment was generally low so it was difficult to
integrate so many people into society. Their number alone served to highlight
problems, which many of the previous refugees had probably also experienced.
The rehabilitation centre in rhus
The rehabilitation centre where I work is involved with the most severely
traumatised refugees in our geographical area (the population of rhus County is
approximately 625,000). The centre was opened in 1987 in the wake of the
recognition that there were some people whom the existing institutions were
unable to reach in order to provide them with the help which would enable them
to provide for themselves. About 10%-15% of refugees fell into this category.
The problems they experienced were particularly complex and diverse, and a
variety of kinds of help were needed.
To qualify for entry to the centre, clients must be referred by a social worker.
At present, 67 people attend the centre. In April 1997, eight nationalities were
represented: about 30% Palestinians, 30% Iraqis, 20% Iranians, 8% Bosnians and
the rest from Lebanon, Somalia, Sri Lanka, Afghanistan and Macedonia. The number
of Bosnians is increasing. Educational background varies widely from those with
a university training to those who cannot read or write. Many clients have
serious learning difficulties. A quarter of our clients suffer from a
psychiatric problem; 80% have been exposed to torture and organised violence.
The centre is staffed by psychologists, social advisers, pedagogues, cultural
assistants, physiotherapists, Danish language teachers, a medical adviser,
secretaries and cleaning staff.
Working with post traumatic stress disorder (PSTD)
In this article I will focus on some key areas involved in working with people
from other societies who experience symptoms of post traumatic stress disorder
and who have complex problems which are largely due to war, torture, outrages,
and to their fugitive status.

2. Symptoms of PSTD
PTSD symptoms include:
* difficulty in sleeping;
* nightmares related to the events;
* depressive states;
* a tendency to become startled or afraid at sudden noises or movements;
* a tendency to withdraw from contact with others;
* feelings of irritability (a tendency to become suddenly irritable or angry);
* unstable moods - frequent ups and downs;
* a bad conscience and feelings of guilt;
* a fear of situations which are reminiscent of the events;
* physical tension;
* impaired memory;
* difficulty in concentrating;
and
* loss of basic trust;
* confusion of ego boundaries.
The first twelve symptoms are present no matter what the character of the trauma
may be. However, some types of trauma differ from others because of their
'purpose'. A robbery, an accident, a catastrophe at sea - all mean that the
people involved will feel that they have lost the right to determine their own
lives and to create their own boundaries. In the case of a robbery, the direct
'purpose' of the perpetrator has been to obtain money; in the case of an
accident or catastrophe - the event was unconnected with any definite purpose.
Torture, by contrast, has the direct purpose of obtaining power over the victim,
of breaking down the victim's personality, of robbing the individual of his or
her dignity and personal resources. Torture victims are also rendered incapable
of continuing their resistance and are also isolated from family and friends who
dare not contact them for fear of being imprisoned and tortured themselves. When
people are tortured, their tormentor has power over their bodies and souls and
victims are isolated from their nearest and dearest. Torture is pure malice
directed towards a fellow human being. The victim feels completely alone and
abandoned and this makes it difficult for the person in question to regain any
kind of trust in others or in life as such. This is the reason why I have
included 'loss of trust' and the 'confusion of ego boundaries' as specific
symptoms which require special attention.
The role of the social worker in working with traumatised refugees
Social treatment, as opposed to social counselling, is characterised by a longer
time schedule, more intense contact and entails the implementation of a more
binding plan for solving the problems that the client and the social worker have
agreed upon.
Social treatment is what we offer clients at the rehabilitation centre suffering
from PTSD or chronic states of stress. Social counselling does constitute one
element of social treatment. We must still obtain and organise resources and
ensure that the unmet needs of clients are fulfilled to the greatest possible
extent.
The word social refers to contact with society as a whole in all its aspects -
from relatives and family to social institutions of a private and public
character. The special element in relation to this is that refugees' strategies
for coping with society in general are lacking or have been rendered void in an
overwhelming number of ways.
Treatment therefore contains a passive element. The client, who is the target of

3. the treatment, needs change and has been unable to make this change (or
counselling would be sufficient in itself), so the social worker must play an
active role in this.
Our efforts are concentrated upon those areas in which the lack of adequate
strategies have become a problem to such an extent that they present an obstacle
to integration and rehabilitation.
Social treatment is never primarily directed towards the person's inner world,
but is a process which supports the person's interaction with the external world
and thereby differs from psychotherapeutic treatment.
Social treatment is based on therapeutic principles (such as trust and contact,
a good ability to communicate, the active participation of the client) without
actually being therapy, although the boundary between these two working methods
is fluid.
General goals in treatment
As mentioned, our work is directed towards the problem areas which present an
obstacle to the process of integration and rehabilitation.
This is undertaken by attempting to provide clients with areas of competence
which allow them to act on the basis of a goal in life, to take responsibility
for meeting the demands society makes, to have strategies which allow them to
participate important to take the time to clarify matters thoroughly and to take
things gradually (the stair model where one step at a time is taken).
Methods
Both the therapist and the social worker must have a friendly, open and very
objective attitude towards the client. One of the most important functions in
this respect is to support a mature, rational and self-possessed development in
clients and to avoid developing an overprotective attitude towards them. A
purely compassionate and empathetic attitude is contra-indicated. There must
also be a clear indication that no changes can be brought about if clients do
not make an effort themselves.
Trust and the establishment of boundaries
Because we work with a process of clarification and change, we must work at a
very basic level to establish mutual trust so that we can examine the actual
problems which present obstacles, their character, extent and make up. We must
also be very careful not to repeat the interrogation scenes which may cause
clients to tell us things they do not wish to. We are friendly people in a
system designed to help them and - due to the very nature of the system - may
easily come to 'seduce' clients into saying more than they are really prepared
to say. We have no right to know everything, only what is relevant to the
problems under consideration. We must take care to help clients maintain their
personal boundaries and be willing to establish these boundaries. Trust comes
when clients feel that we are trying to play a completely different role to that
of interrogator.
Breaches of trust and the establishment of boundaries are important themes
throughout the entire treatment and will remain an Achilles' heel for these
clients for the rest of their lives. Clients can be trained to accommodate
greater and greater stress, but in the event of crises - accidents, falling in
love, separation, new jobs - they will still be vulnerable and need supportive
interviews.

4. Repetition / avoidance of repetition of traumatic situations
Besides the experience of being interrogated, many refugees have been in prison
or prison camp. Life in such places has its own particular framework, content
and relations, but there are a number of similarities to the systems the
traumatised refugee may meet in Denmark (see figure 1). One aspect of the
difficulties clients encounter will often be that they relate everything to
their earlier harrowing experiences. So our professional task is to be aware of
the degree to which we may unwittingly repeat traumatic scenes. By this, I do
not mean that we must organise our activities down to the smallest detail to
avoid all possible sensitive areas; we must represent society in a realistic way
and help clients to become desensitised and to recognise the difference between
the past and the present. We must be able to identify situations which are
reminiscent of the cause of the trauma, dare to put them into words and work
with them therapeutically. We must establish a safe place for clients.
Specific goals in practical work
Important headlines in this area are:
* to identify and reduce possible stress factors and to avoid further stress by
removing or reducing the conditions which maintain stress;
* to attempt to re-establish as much basic trust as possible;
* to break the sense of victimisation and avoid re-traumatisation;
* to be aware that we must avoid relations which produce a secondary advance,
such as obtaining the greatest relief by maintaining so many symptoms that
clients can continue to have as much as possible done for them by others.
The treatment process
The first step, thorough delimitation of the most pressing problems, is a
realistic identification, classification and ordering of priorities.
At various stages of the process - very often initially for a long period - the
social worker's role will be to do some 'spring cleaning' among those problems
where it is possible to provide some solutions so as to release clients' energy
to work on the underlying traumas (those in which what has happened cannot be
changed, but where the experience of, and the way of tackling it have a
potential for change), and this is what the psychologist is concerned with.
It is absolutely crucial to spend time - together with the psychologist during
the initial phase - on clarifying which problems the client is experiencing: to
help the process to move from 'everything is wrong' and the expectation of a
catastrophe to separation into smaller, operational units; to establish the
initial priorities with regard to what to work on. To avoid further stress
during this phase, the social worker can either put aside the other problems if
he or she does not consider them an acute obstacle, or take them over - i.e. be
a substitute problem solver.
Stress means that people lose a broad perspective; action and problem solving
become short term, irrationally emotional and impulsive. While some things can
be approached actively, we know from experience that there will often be
'disorganised' areas:
* how are the children? - can we relieve them and their parents by obtaining a
place in a day-care institution, preferably paid for by the state for a period?
* how is the spouse? - should the spouse's social worker be encouraged to get
the person in question to attend language courses, a family club or similar?
* how are things financially? - are there special needs for which we can provide
resources?
* how is the person's health? - does he or she have a good doctor? Have relevant

5. examinations been performed? What is the person's consumption of medicine,
coffee and cigarettes?
With regard to the conditions which cannot be improved, we can prepare a
strategy for the way in which clients can obtain a broader view of matters and
plan measures more appropriately - in the short and long term.
The second step involves suggestions for concrete solutions to the highest
priority problems. Crisis theories, such as those of Rosenberg and Rosenberg
(1989), suggest 'brainstorming' in connection with possible solutions for the
purpose of formulating concrete suggestions which can be carried out in
practice. But I feel that this may be an unreasonable expectation for a refugee
who is as yet unfamiliar with the possible relevant solutions in Denmark. I
believe that during this phase we must use our knowledge to guide and support
clients towards solutions and strategies which appear viable, also in order to
achieve success.
A great deal of 'education' is necessary to become familiar with the social
system when learning problem-solving strategies. This more general introduction
is a suitable area for group teaching.
The third step is to put the suggested solutions into practice, to make sure
something succeeds and to discover why. New problems can then be tackled, and
the social worker will have a less prominent role. Cultural workers, on the
other hand, could experience more pressure as clients may attempt to get them to
take over where the social worker left off and cultural workers may need some
support in saying yes to interpreting, but no to solving clients' problems. The
social worker will now have the role of encouraging clients to find their own
solutions and acting as a safety net when things fail to succeed or something
turns into a fiasco.
Ideally, the situation of clients will now have changed from 'evasive action'
and isolation in response to problems to the desire for some realistic,
concrete, positive goal and the ability to work towards it. They will have
obtained the possibility of choice.
The fourth step is to increase the ability to handle difficult situations which
cannot (immediately) be removed, such as noisy children, illness, chronic pain,
loss of family members, loneliness, etc. I consider these borderline areas
between the psychologist and the social worker where it may be relevant to go
over to a course of therapy.
During the process we will discover new problems and will several times return
to former steps. It is important to make every success achieved visible.
Demands on the social worker
Working with these complex PTSD problems makes great demands on social workers -
both personal and professional. It is a constant challenge to be involved in
establishing boundaries between empathy and excessive sympathy; between our own
readiness to help and openness as opposed to clients' need not to become lost in
the process. It is also challenging to be exposed to doubt as to our
reliability, and to become figures upon whom clients' feelings are transferred
during treatment. We cannot succeed in this without the support of colleagues
and the exchange of difficulties and successes, nor without supervision.
At a professional level, social workers must be able to work systematically, be
able to describe clients as a whole, write good applications and appeals to the
social system, to evaluate a realistic course of rehabilitation and we must be
capable of handling the many, often unreasonable rejections from the authorities
which fail to take the special needs of these PTSD people into account.

6. In the longer term, clients must learn to help themselves more, be able to speak
for themselves, make constructive use of their civil rights, and be financially
independent of the public welfare system. And for those who cannot become
independent, we must struggle to ensure that they receive help over a longer
period to support them in tackling life in Denmark.
Reference
Rosenberg, N. & R. (1989) Angst - Krise og Stress, K›benhavn: Munksgaards
Forlag.
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