1Providing CulturallyAppropriate Services toRefugee Survivors ofTorture & TraumaChris LobsingerClinical Social Worker&Greg...
2Chris LobsingerSocial worker/ Priviate practiceIndividul, Couple and Family Therapy07 33673367lobsinger@bigpond.comwww.us...
3Material for this workshop isderived from The Need forUnderstanding (© 2002,QPASTT & QTMHC), written &researched by Chris...
4ContentsThis workshop cover theassessment care of migrantsas well as refugee survivorsof torture and trauma.The refugee e...
5Exercise 1: Warm-upAs a large group:Take it in turns to sharewith the group who youare, where you work andyour interest i...
6Exercise 2: Defining traumaIn groups of two or three,come up with a definition ofTRAUMAHave one of your groupmembers act ...
7Definition of traumaDictionary definitiontrauma, n., pl. -mata -mas 1.Pathol. A bodily injury. 2.Psychol. A startling exp...
8Exercise 3: Defining tortureIn the same groups of two - threeas you were in during the lastexercise, take five minutes to...
9Definitions of torture“A systematically programmed intentionaland calculated activity which results inphysical and psycho...
10Forms of tortureBeatings to the body and head- Falanga: the beating of the soles of the feet withinstruments of wood or ...
11Organised violence as stateterrorismSystematic state terrorism (SST) is the most perniciouskind of terrorism, as its tar...
12The economy of tortureDefinitions of torture emphasise the intentionality ofthose who conduct it. Their ultimate goal is...
13Key messagesTorture is routinely practiced inover 100 countries in the worldtoday.Torture is about the control of:- Indi...
14Refugee experience“Arriving in a new country asa refugee is like arriving as anew born baby. We comewithout clothes, wit...
15The difference betweenrefugees and migrantsOn the whiteboard, two headings:Migrants RefugeesExperience…… Experience…….As...
16Refugees and migrants.What’s the difference?MIGRANTS REFUGEES Choose their new countrycarefully and find out allthey ca...
17Impacts to considerSavdie, T. & Carey, L. (1999) Families in cultural transition.STARTTS: NSW.
18Life events, stressand refugee statusThe following conditions represent risk factors for psychologicaldisorders among re...
19Culture shockThe term culture shock refers to emotionswhich can occur in people who find themselvesin a strange cultural...
20Overcoming culture shock1. The first phase is one of euphoria: everything inthe new situation is beautiful and impressiv...
21Key messagesMigrants hope to improve theirlives by migrating, and havetime to plan and prepare.Refugees often have no ch...
22Exercise 5: Responses totrauma victimsIn groups of two or three, each person reflects upona situation in which a past pa...
23Positive responsesSympathy/empathy offered.Material assistance offered.Moral and social supportoffered.Government and ot...
24Blaming the victim,a common response“Family members and other sources of social support can beso horrified at being remi...
25Key messagesTorture and trauma are harmful toexperience, to witness or simply hearabout.Feelings of compassion, anger an...
26Exercise 6: The effects oftorture and traumaIn the large group, brainstorm asmany answers as possible to thequestion:“Wh...
27Psychiatric disordersassociated with the refugeeexperienceAdjustment DisorderDistress and disturbance interfering with s...
28Stress or PTSD“What distinguishes people whodevelop PTSD from people whoare merely temporarily stressed,is that they sta...
29Effects of torture on theindividual1. PSYCHOSOMATICPains, headachesNervousnessInsomniaNightmares, panicTremors, weakness...
30Four key components of thetrauma reactionCHRONIC FEAR, LOSS OFCONTROL, HELPLESSNESSDISCONNECTION FROMSIGNIFICANT ATTACHM...
31Key messages1. There are four key components oftrauma reaction: chronic fear, loss of control,helplessness; disconnect...
32Exercise 8: The impact oftrauma on the family1. In groups of two or three share oneexperience about a family who suffere...
33The impact of trauma on thefamilyOften several members of a family have beenvictims of, or witnesses to, torture and tra...
34Exercise 9: The impact oftrauma on childrenIn a large group, brainstorm answersto the question:“What signs and symptoms ...
35Pre-school agesigns and symptomsThumb-sucking (after having stopped)Bed-wetting (after having stopped)Afraid of being le...
36Symptoms criteria of PTSD inchildren1. Child experiences unusual event(s) that would be markedlydistressing to almost an...
37How war affects childrenTHE BETRAYALLet down by adults/parentsThe collapse of societyThe fall of the world orderTHE LOSS...
38Refugee experience“Arriving in a new country asa refugee is like arriving as anew born baby. We comewithout clothes, wit...
39Exercise 1: Keys toassessmentIn the large group, watch the video ‘Eye of theNeedle’.While you are viewing, keep in mind ...
40Gus van der Veer’s List1. The therapist’s first impression of the refugee.2. Complaints and statements about problematic...
41Key messagesWhen makingassessments, be curiousand attentive.Organise your thoughts, notthe client’s thoughts.Avoid the r...
42Exercise 3: Use of culturalinformationIn groups of two or three come upwith at least one example of eachsituation:A situ...
43Flexible use of technique“Everyone who seeks assistancefor mental problems wants to betreated by an expert whom he canco...
44Cultural formulation1. Cultural identity• Cultural reference group(s)• Language• Cultural factors in development• Involv...
45Questions to elicit the client’sexplanatory modelWhat do you think has caused your problem?Why do you think it started w...
46Minimising bias duringassessment1. The practitioner should examine his or her ownbias and prejudice before engaging in t...
47Barriers to cross-culturalcommunication1. Language difficulties - this may mean- Lack of vocabulary- Lack of idiomatic e...
48Key messagesStereotypes are natural - butinadequate sources of informationabout a client.Information about a mental heal...
49Some general assessment toolsGlobal Assessment of Functioning (G.A.F) ScaleSocial and Occupational Functioning Assessmen...
50Global Assessment ofFunctioning (G.A.F) Scale(DSM-IV p. 32)Consider psychological, social and occupational functioning o...
51Social and OccupationalFunctioning Assessment Scale(S.O.F.A.S) (DSM-IV p. 32)Consider social and occupational functionin...
52Harvard TraumaQuestionnaire(Focus on PTSD and its features)“The Harvard Trauma Questionnaire (Mollica, Wyshak &Lavelle, ...
53Assessment of childrenFrom the health assessment of adults and their history ofpersecution you will know if children hav...
54Key messagesRegard all instruments as apartial tool only, not as theentire assessment.Beware of the temptation toover-re...
55Carlson’s Framework of theeffects of traumaTraumatic eventsPerception of event as negativeSuddennessLack of controlCore ...
56The core points of PTSDtreatment“….the core problem in PTSD consists of afailure to integrate an upsetting experienceint...
57Exercise 6: Vulnerability toPTSDIn small groups discuss thequestion:“Why do some peopleappear to be morevulnerable to PT...
58Vulnerability to PTSD1. Genetic constitutional vulnerability topsychiatric illness.2. Adverse or traumatic experience in...
59Controlled exposure in a safecontext1. “The person must attend to trauma-related information in a manner thatwill activa...
60Key messagesThe core problem ofPTSD is that of failure tointegrate an overwhelmingexperience into memory.The core treatm...
61Overview of three stages ofrehabilitationSTAGE I - SAFETYRegaining control and putting order into daily existencepersona...
62Judith Herman’s three stagesof rehabilitationStage I SafetyThis stage emphasises the re-establishmentof a person’s sense...
63Exercise 7: Staged recoveryIn the large group, using the whiteboard write up inthree columns, J. Herman’s stages.Brainst...
64Some treatment methods“Alphabet therapies”E.M.D.R or Eye Movement Desensitisation and ReprocessingT.I.R Traumatic Incide...
65Group work1. Stabilise psychological andphysiological reactions.2. Explore and validate the experience.3. People underst...
66Group work purposesEducationalGroupsTherapeuticGroupsSupportGroupsOne Two ThreeTherapeutictaskSafety Remembrance& mourni...
67Universal components ofeffective intervention1. Intervene immediately or promptly after thetraumatic event.2. Focus on p...
68Key messagesWork with refugee survivors of tortureand trauma can be thought of ashaving stages:1. Safety2. Remembrance &...
69Exercise 8: Culture providesAs a large group take a few minutesto consider the following questions.Record your answers o...
70Culture provides security andprotection from traumaSocial supportValuesNormsShared expectationsRelationship with the spi...
71Key messagesCulture acts as a protector,part of an integratedsystem of the individual.Culture is a double-edgedsword. Be...
72The relationship in treatment“Emotional attachment isprobably the primaryprotection against feelings ofhelplessness andm...
73What is culture?Is much broader than just ethnicity and includes:- Age- Gender- Place of residence- Status (educational,...
74Exercise 9: Cross-culturalcompetenceBreak up into groups of two anddiscuss the question:“What qualities should aperson h...
75Characteristics of interculturalcompetence (Hammer 1989)Flexibility towards ideas of others.Respect towards others.Liste...
76Key messagesRelationship is an important factor in:- protecting people from the effectsof traumatic experience;- helping...
77Case vignettesFEMIFemi was a teacher in a West African country, who was politically active on behalf of his tribal group...
78Strategies for healthprofessionals1RESTORE:CONTROLSAFETYREDUCING FEAR ANDANXIETY Restoring health through screening and...
79Summary of generalframeworksFOUR KEY COMPONENTS OF TRAUMAREACTION1. Chronic fear of loss of control/helplessness2. Disco...
80Exercise 12: EmotionalresponsesIn groups of two or three discussthe following question:“What do you think theemotional r...
81Emotional response ofworkers1. Helplessness2. Guilt3. Anger4. Dread and horror5. Idealisation6. Personal vulnerability7....
82Modes of empathic strain incounter-transference reactions(CTRs)Reactive style of therapistTYPE OF REACTION(UNIVERSAL, OB...
83Vicarious traumatisationThe transformation of the person’s innerexperience resulting from empathic exposure to theclient...
84Exercise 13: Risk factorsBrainstorm in the large group:“What might be some riskfactors for developingvicarioustraumatisa...
85Risk factors for vicarioustraumatisationToo high demands from self.Too high demands from others and thesituation.Lack of...
86Contributing factors ofvicarious traumatisationCharacteristics of work- Clients with traumatic histories- Clients who ar...
87Exercise 14: Strategies toreduce risk of vicarioustraumatisationBrainstorm answers to thefollowing question:“What strate...
88Reducing the risk of vicarioustraumatisationPERSONAL STRATEGIESMaintain a personal lifeUse personal lifeIdentify healing...
89Where to from here?Invite the group to discuss any closing house-keeping.Allow them to have time to explore any futuredi...
90“History, despite itswrenching pain, cannotbe unlived, but if facedwith courage, need not belived again”.Maya Angelou
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Providingculturllyweb

  1. 1. 1Providing CulturallyAppropriate Services toRefugee Survivors ofTorture & TraumaChris LobsingerClinical Social Worker&Greg TurnerCommunity Psychologist
  2. 2. 2Chris LobsingerSocial worker/ Priviate practiceIndividul, Couple and Family Therapy07 33673367lobsinger@bigpond.comwww.users.com.bigpond/lobsinger/rGreg TurnerCommunity PsychologistDirector, Global CommunityConsultingEducation & DevelopmentCoordinator, Qld. Transcultural MentalHealth Centreglobalcommunity@powerup.com.au
  3. 3. 3Material for this workshop isderived from The Need forUnderstanding (© 2002,QPASTT & QTMHC), written &researched by Chris Lobsinger.We would like to acknowledgeand thank the QueenslandProgram of Assistance toSurvivors of Torture & Trauma(QPASTT) and the QueenslandTranscultural Mental HealthCentre (QTMHC) for givingpermission to utilise this material.
  4. 4. 4ContentsThis workshop cover theassessment care of migrantsas well as refugee survivorsof torture and trauma.The refugee experienceTraumaTortureCulture shockResponse to victimsPsychiatric DisordersImpact on familiesVicarious trauma
  5. 5. 5Exercise 1: Warm-upAs a large group:Take it in turns to sharewith the group who youare, where you work andyour interest in today’sprogram.
  6. 6. 6Exercise 2: Defining traumaIn groups of two or three,come up with a definition ofTRAUMAHave one of your groupmembers act as a scribe andwrite down your group’sideas.After five minutes each groupwill take turns sharing theirdefinition and ideas with thelarger group.
  7. 7. 7Definition of traumaDictionary definitiontrauma, n., pl. -mata -mas 1.Pathol. A bodily injury. 2.Psychol. A startling experiencewhich has a lasting effect onmental life; a shock. - traumatic,adj. The Macquarie DictionaryNew Budget Edition (1985).Working definitiontrauma: an inescapablystressful event that overwhelmspeople’s existing copingmechanisms.
  8. 8. 8Exercise 3: Defining tortureIn the same groups of two - threeas you were in during the lastexercise, take five minutes tocome up with a definition ofTORTUREHave one of your groupmembers act as a scribe andwrite down your group’s ideas.After five minutes, each groupwill take turns sharing theirdefinition and ideas with thelarger group.
  9. 9. 9Definitions of torture“A systematically programmed intentionaland calculated activity which results inphysical and psychological suffering andwhich inflicts a violent attack on personalintegrity”.Bustos, E. (1990) Dealing with the unbearable. Reactionsof therapist and therapeutic institutions working withsurvivors of torture. In Suedfeld, P. (Ed.), Psychology andtorture. Hemisphere Publications: New York.“Extreme and deliberate form of violenceinflicted upon a victim who experiences itconsciously and who has no control over itsform or duration. It produces pain andmental or psychological stress and isintended to destroy the victim’s will in anattempt to perpetuate a determined order ofpower relationship”.Bendfeldt-Zachrisson, F. (1985) State (political torture):some general, psychological and particular aspects. InInternational Journal of Health Services 15(2), p. 339-349.
  10. 10. 10Forms of tortureBeatings to the body and head- Falanga: the beating of the soles of the feet withinstruments of wood or metalBeing forced to maintain crippling positions for longperiodsBurningElectric shocksForced to watch loved ones being raped, killed orbrutalisedIsolation and solitary detentionMutilation- All parts of body- Teeth: drilling, extractionNear-fatal drowning or suffocationOther forms of violent abuse used variably andunpredictablySensory and sleep deprivationSexual violence and rape (of men, women and children)Sham executionsStarvation and exposure to heat and coldStrapping, binding the victim with ropes, straps, etc.Suspension- By arms- By knees using a stick in hollow of kneesUse of mind-altering drugs
  11. 11. 11Organised violence as stateterrorismSystematic state terrorism (SST) is the most perniciouskind of terrorism, as its target is the wholepopulation, carried out by the forces of state andcondoned by the government.Systematic state terrorism includes:EXTRAORDINARYEVENTS Mass executions Disappearances Spectacular raids Torture"ORDINARY EVENTS" Systematic harassing Pressuring Labelling Moral discreditingSST has pathological consequences for individuals, butalso has important collective consequences resulting in apopulation terrorised by an internalised fear, with noalternative but to comply with the imposed politicaloptions.Martin-Baro, I., Aron, A. & Corne, S. (1994) Writings for a liberationpsychology. Harvard University Press.
  12. 12. 12The economy of tortureDefinitions of torture emphasise the intentionality ofthose who conduct it. Their ultimate goal is not theinfliction of pain on the individual, but the cumulativeeffects of pain, unpredictably and intentionallyinflicted. Primary among the responses of thetortured individuals are the loss of self-esteem,autonomy and a sense of meaning, anxiety,depression and dissociation.When such an individual is returned to his or hercommunity, a ripple effect is seen in the lives ofothers with no direct experience of torture. Thecommunity takes on the fears and insecurities theysee in the damaged individual, and suffer similarlosses of self-esteem, autonomy and meaning.Beyond this, the successful torturer ensures his/herinternalisation in the victim, who thereafter tortureshimself or herself from within, even in the absence ofthe torturer.These, then, are the economies of scale of torture.Helen Pavlin (1998), QPASTT
  13. 13. 13Key messagesTorture is routinely practiced inover 100 countries in the worldtoday.Torture is about the control of:- Individuals- Communities- NationsTorture and human rightsviolations are inextricably linked,one is not possible without theother.Trauma is fundamentally theoverwhelming of the individual’scoping mechanisms, and tortureis a method for achieving this.
  14. 14. 14Refugee experience“Arriving in a new country asa refugee is like arriving as anew born baby. We comewithout clothes, withoutbaggage. We come withoutknowledge about the world inwhich we find ourselves,without the language to findout. We are totallydependent on the good will ofthose around us to ensurethat we survive, and also forthe quality of that survival”.Pittaway, E. (1991) Refugee women - still at risk in Australia.AGPS: Canberra. (p. 1)
  15. 15. 15The difference betweenrefugees and migrantsOn the whiteboard, two headings:Migrants RefugeesExperience…… Experience…….As a large group, brainstorm thedifferences between the two experiences.
  16. 16. 16Refugees and migrants.What’s the difference?MIGRANTS REFUGEES Choose their new countrycarefully and find out allthey can about it beforethey leave. Take the quickest way outof their country, often notknowing where they willfinish up. Plan their move carefullyin advance. Leave hastily, often toescape from midnight raidsand soldiers with guns. Take time to get theirpassport and visa ready. Leave secretly, often notdaring to advertise theirintention of leaving byarranging travel documents. Pack all their belongingsup and organise foreverything to be sent totheir new home. Leave with whatever theycan carry, often no morethan the clothes on theirbacks. Say goodbye to friendsand family. Often cannot tell anyonethat they are leaving forfear that friends or familywill be tortured to revealthe information. Leave a forwardingaddress. Often dare not get in touchwith anyone in case theyare suspected of having thesame beliefs and tortured orheld to ransom. Can go home if thingsdont work out in their newcountry. Will probably never be ableto go home.
  17. 17. 17Impacts to considerSavdie, T. & Carey, L. (1999) Families in cultural transition.STARTTS: NSW.
  18. 18. 18Life events, stressand refugee statusThe following conditions represent risk factors for psychologicaldisorders among refugees:1. Stress-provoking conditions and events leading up to thedecision to migrate or flee.2. Conditions associated with the actual flight (eg. loss offamily, possessions left behind, dangers on the journey).3. Conditions on arrival in a host community (see below).4. Further migrations and resettlement, although the initialmove is usually the most stressful.The conditions of settlement in a host community can alsoproduce possible risk or stress factors, including the following:1. Differences between the culture of the refugee and the hostculture; migration within one’s own country may be lessstressful.2. Status loss, loss of possessions, loss of employment, and soon.3. Lack of family or other social support.4. Difficult living conditions, for example, in camps, due toresettlement schemes, poverty and violence.5. Continued worries concerning family members left behind orotherwise separated.6. Discrimination by the host community against the refugees.Orley, J. (1994) Psychological disorders among refugees: some clinical andepidemiological considerations. In Marsella, A., Bornemann, T., Ekblad, S. &Orley, J. (Eds.), Amidst peril and pain: the mental health and well-being of theworld’s refugees. American Psychological Association: Washington DC.
  19. 19. 19Culture shockThe term culture shock refers to emotionswhich can occur in people who find themselvesin a strange cultural environment.1. The loss of love and respect, as this wasexperienced in the relationship with friends andfamily.2. The loss of social status, which may or maynot be accompanied by discrimination.3. The loss of a familiar social environment,with its mutual obligations and dependencieswhich gave meaning to life.“As a result of the loss of familiar culturalbacking, the ability to integrate newexperiences is reduced: familiar frames ofreference cannot be applied to the flood of newexperiences and impressions”.Coelho, G. (1982) in Nann, R. (Ed.), Uprooting and surviving.Reidel Publishing Co: Dordrecht. Cited in van der Veer, G. (Ed.),Counselling and therapy with refugees and victims of trauma:psychological problems of victims of war, torture and repression.John Wiley & Sons: Europe. (p. 101-107)
  20. 20. 20Overcoming culture shock1. The first phase is one of euphoria: everything inthe new situation is beautiful and impressive, orchallenging and mysterious. One could add thatrefugees also experience relief because they are freefrom persecution.2. Then there is a second phase of disappointmentand related anger. The society in which the refugeefinds himself turns out not to be so ideal and in somerespects it is inaccessible. In exile the refugee is alsoconfronted with injustice, violence, bureaucracy,human error and indifference toward the misery oftheir fellow men, and so on. In this phase, somerefugees strongly accentuate their cultural roots, eg.he starts to play the traditional music of his country,while previously he considered the music as boring orprimitive. (cf. Garza-Guerrero, 1974).3. Finally, there is a phase of adaptation, when therefugee starts to learn the language, build up asupporting social network and establishes emotionalrelationships, without denying their own culturalheritage.Coelho, G. (1982) in Nann, R. (Ed.), Uprooting and surviving. Reidel PublishingCo: Dordrecht. Cited in van der Veer, G. (Ed.), Counselling and therapy withrefugees and victims of trauma: psychological problems of victims of war,torture and repression. John Wiley & Sons: Europe. (p. 101-107)
  21. 21. 21Key messagesMigrants hope to improve theirlives by migrating, and havetime to plan and prepare.Refugees often have no choiceand must leave to survive.Return to their country of originwould result in imprisonment,torture, death or persecution.Migration is inherently stressful.Culture shock is commonamong all migrants and isgenerally worse in refugees.The core experience of refugeesurvivors of torture and traumais that of the profounddiscontinuity in almost all areasof their lives.
  22. 22. 22Exercise 5: Responses totrauma victimsIn groups of two or three, each person reflects upona situation in which a past patient/client wastraumatised.** Please do not use yourself or the experienceof someone close to you as an exampleHave one person in the group act as a scribe andwrite down the group’s answers to the followingquestions:In what positive ways did peoplerespond to the traumatised person?In what negative ways did peoplerespond to the traumatised person?After 8-10 minutes, each group will share theiranswers with the large group.
  23. 23. 23Positive responsesSympathy/empathy offered.Material assistance offered.Moral and social supportoffered.Government and other groupsdevelop programs and policy toaid victims of trauma.Legal and medical professionsvalidate the trauma victimssuffer.
  24. 24. 24Blaming the victim,a common response“Family members and other sources of social support can beso horrified at being reminded of the fact that they too can bestruck by tragedies beyond their control that they startshunning the victims and blame them for what has happened- a phenomenon that has been called ‘the second injury’”.Symonds, M. (1982) Victims response to terror: understanding andtreatment. In Ochberg, F. & Soskis, D. (Eds.), Victims of terrorism.Westview Press: Boulder CO. (p. 95-103)“Society’s reaction to traumatised people are rarely theresults of objective and rational assessments. Rather, theyare primarily the results of conservative impulses in theservice of maintaining the belief that they world is essentiallyjust, that good people are in charge of their lives and that badthings only happen to bad people. Although people arecapable of profound bursts of spontaneous generosity tovictims of acute trauma, the continued presence of thevictims as victims constitutes an insult to the belief (at least inthe western world) that human beings are essentially mastersof their fate. Victims are the members of society whoseproblems represent the memory of suffering, rage and pain ina world that longs to forget. (p. 29)Individuals and even entire cultures build up elaboratedefenses in order to keep these stark realities out ofconscious awareness”. (p. 43)Van der Kolk, B., McFarlane, A. & Weisaeth, L. (1996) Traumatic stress: theeffects of overwhelming experience on mind, body and society. GuildfordPress: New York.
  25. 25. 25Key messagesTorture and trauma are harmful toexperience, to witness or simply hearabout.Feelings of compassion, anger andrepulsion are normal for thoseworking with survivors of trauma.Positive responses to survivors arealso common but can beovershadowed by the inherentrepulsiveness of the trauma itself.Blaming the victim of trauma iscommon even among professionalswho have experience working withtraumatised people.
  26. 26. 26Exercise 6: The effects oftorture and traumaIn the large group, brainstorm asmany answers as possible to thequestion:“What are the effects oftorture and trauma?”
  27. 27. 27Psychiatric disordersassociated with the refugeeexperienceAdjustment DisorderDistress and disturbance interfering with social functioningand performance which occurs in a period of adaptation tosignificant life changes or to the consequences of a stressfullife event.Acute Stress Reactions (Acute Stress Disorder DSM-IV)Severe, transient, short livedRelated to an overwhelming trauma incidentLasts hours, two - three daysSymptoms include arousal, avoidance of stress evokingstimuli and dissociationPost Traumatic Stress DisorderA delayed protracted response to a stressful event(memory phobia)Symptoms include arousal, avoidance of stimuli andmemory, dissociation and re-enactmentEnduring Personality ChangesAs a result of a catastrophic event, concentration camp,torture or disasters.Orley, J. (1994) Psychological disorders among refugees: some clinical andepidemiological considerations. In Marsella, A., Bornemann, T., Ekblad, S.& Orley, J. (Eds.), Amidst peril and pain: the mental health and well-being ofthe world’s refugees. American Psychological Association: Washington DC.
  28. 28. 28Stress or PTSD“What distinguishes people whodevelop PTSD from people whoare merely temporarily stressed,is that they start organising theirlives around the trauma”.“It is the persistence of intrusiveand distressing recollections andnot the direct experience of thetraumatic event itself, that is theactual driver of the biological andpsychological dimensions ofPTSD”.Van der Kolk, B., McFarlane, A. & Weisaeth, L. (Eds.) (1996)Traumatic stress: the effects of overwhelming experience on mind,body and society. Guildford Press: New York.
  29. 29. 29Effects of torture on theindividual1. PSYCHOSOMATICPains, headachesNervousnessInsomniaNightmares, panicTremors, weakness, fainting, sweating, diarrhoea2. BEHAVIOURAL AND PERSONALITY CHANGESWithdrawal, irritability, aggressiveness, impulsivenessSuicide attemptsSexual dysfunction (severe)3. AFFECTIVEDepression, frequent cryingFearAnxiety4. MENTAL FUNCTIONConfusion, disorientationMemory disturbanceLoss of concentration, attention blocking5. PHYSICAL DAMAGEScars, burnsFracturesDeafnessWeight lossOther (teeth broken, tendons torn, rashes)Reid, J. & Strong, T. (1987) The health care needs of victims of torture. NSWDepartment of Health: NSW.Cunningham, M., Becker, R. & Aroche, J. (1995) Eye of the needle trainers kit.STARTTS: Sydney.
  30. 30. 30Four key components of thetrauma reactionCHRONIC FEAR, LOSS OFCONTROL, HELPLESSNESSDISCONNECTION FROMSIGNIFICANT ATTACHMENTSSHATTERED COREASSUMPTIONS OF MEANINGGUILT, SHAME ANDHUMILIATIONKaplan, I., Victorian Foundation for Survivors of Torture (1998).
  31. 31. 31Key messages1. There are four key components oftrauma reaction: chronic fear, loss of control,helplessness; disconnection from significantattachments; shattered core assumptions ofmeaning; guilt, shame and humiliation.2. PTSD overlaps affective,somatoform, dissociative and anxietydisorders.3. What distinguishes people who havePTSD from people who are stressedis that they start organising their livesaround the traumatic memory.
  32. 32. 32Exercise 8: The impact oftrauma on the family1. In groups of two or three share oneexperience about a family who suffered atraumatic event.2. Remember to protect confidentiality and notto draw on your personal or family history forthis exercise.3. After everyone has shared in the smallgroups, the large group then brainstormstheir ideas about the following question:“What are the impact oftorture and forced migrationon families?”
  33. 33. 33The impact of trauma on thefamilyOften several members of a family have beenvictims of, or witnesses to, torture and trauma.The impact of torture and trauma interacts with thedemands of settlement to produce many changesin the family system.1. Roles within the family are commonly drasticallyaltered. The father may no longer be thebreadwinner.2. Patterns of responsibility shift. Children may carrythe burden of communicating with institutions andservice providers in the new country. They mayalso carry primary responsibility for caring foryounger children and parents.3. The exposure to new values can producegenerational conflict. Parents and children usuallyadapt at different rates and to a different extent.4. Parents may lose their protective and nurturingroles due to current dysfunction and changes toparents’ reduced capacity for intimacy.5. Extreme disturbances in the form of violence,suicidal behaviour and psychotic breakdownconstitute new traumatic events for the family.6. Loss of employment, financial and social statusadd enormous burdens.
  34. 34. 34Exercise 9: The impact oftrauma on childrenIn a large group, brainstorm answersto the question:“What signs and symptoms mightbe evident in children aged 1-5years who have experiencedtraumatic stress?”Write down all the answers on thewhiteboard.Discuss.
  35. 35. 35Pre-school agesigns and symptomsThumb-sucking (after having stopped)Bed-wetting (after having stopped)Afraid of being left alone (separationanxiety)Seems afraid of strangersIrritabilityConfusionClinging to parents, loss ofindependenceImmobilityNervous ticsSpeech disorders (eg. stuttering,selective mutism)Nightmares and disturbed sleepSavdie, T. & Carey, L. (1996) Families in cultural transition.STARTTS: Sydney.
  36. 36. 36Symptoms criteria of PTSD inchildren1. Child experiences unusual event(s) that would be markedlydistressing to almost anyone.A. Directly experiences eventsB. Vicariously experiences eventsi. Personally witnesses eventsii. Events experienced and conveyed by significantothers2. Re-experiencing phenomenaA. Intrusive recollections/imagesB. Traumatic dreamsC. Repetitive playD. Re-enactment behaviourE. Distress at traumatic reminders3. Psychological numbness/avoidanceA. Avoidance of thoughts, feelings, locations, situationsB. Reduced interest in usual activitiesC. Feelings of being alone/detached/estrangedD. Restricted emotional rangeE. Memory disturbanceF. Loss of acquired skillsG. Change of orientation towards the future4. Increased state of arousalA. Sleep disturbanceB. Irritability/angerC. Difficulty concentratingD. HypervigilanceE. Exaggerated startle responseF. Automatic response to traumatic remindersMarsella, A. et al. (Eds.) (1996) Ethnocultural aspects of post-traumatic stressdisorders: issues, research and clinical applications. AmericanPsychological Association: Washington DC. (p. 393)
  37. 37. 37How war affects childrenTHE BETRAYALLet down by adults/parentsThe collapse of societyThe fall of the world orderTHE LOSSLoss of close relativesFriends, teachers, othersLoss of home, culture, nationTHE TRAUMAThe distorted mindIntrusive memoriesTrying to avoidIncreased arousalReduced responsivityRaundelen, M. (1997) Centre for Crisis Psychology, Bergen, Norway- Brisbane presentation.
  38. 38. 38Refugee experience“Arriving in a new country asa refugee is like arriving as anew born baby. We comewithout clothes, withoutbaggage. We come withoutknowledge about the world inwhich we find ourselves,without the language to findout. We are totallydependent on the good willof those around us to ensurethat we survive, and also forthe quality of that survival”.Pittaway, E. (1991) Refugee women - still at risk in Australia.AGPS: Canberra. (p. 1)
  39. 39. 39Exercise 1: Keys toassessmentIn the large group, watch the video ‘Eye of theNeedle’.While you are viewing, keep in mind the keyareas of assessment below.ASSESSMENT OF TORTURE AND TRAUMASURVIVORSKEY AREASPresenting problems/complaintsCurrent life situationCultural formulationCurrent health statusPrevious functioningTrauma history- Torture- Migration- Organised violence/oppression- RacismCurrent functioning
  40. 40. 40Gus van der Veer’s List1. The therapist’s first impression of the refugee.2. Complaints and statements about problematic behaviour, the concretesituations in which both these complaints and this problematicbehaviour manifest themselves, and factors or conditions that makethe disturbing effect of the complaints or problematic behaviour moreor less severe.3. Information about aspects of the psychological functioning of therefugee which are not problematic, but adequate or even charming, orenvironmental factors that suggest points of application forprofessional help, like the availability of a social network, such as afamily or a compatriot community which can provide emotional support(Boman & Edwards, 1984; Figley, 1985; Wren, 1986).4. Information about the way in which both the refugee and people in hisor her social environment experience his or her problem, and theirideas about what caused or provoked the complaints or problematicbehaviour.5. Information about traumatic experiences that the refugee may haveundergone.6. Information about the course of the refugee’s personalitydevelopment, and the level of his or her development in variousdimensions.7. Information about the political field or forces to which the refugee issubject, and other environmental factors that are burdening him or her,such as uncertainty about legal status, having to live in aneighbourhood with a high incidence of delinquency, worries aboutrelatives who have remained behind, and so on.8. Signals that indicate the possible presence of psychiatric symptoms,like disturbances in perception and reasoning and so on.9. Statements about the kind of help the refugee asks for or explicitlyrejects, in relation to experiences he or she possibly had with otherhelping professionals.* This information has to be evaluated against the refugee’scultural background of course.Van der Veer, G. (1992) Counselling and therapy with refugees and victims oftrauma: psychological problems of victims of war, torture and repression.
  41. 41. 41Key messagesWhen makingassessments, be curiousand attentive.Organise your thoughts, notthe client’s thoughts.Avoid the risk of beingperceived as theinterrogator.Increase the likelihood thatyou will be perceived as asafe presence.
  42. 42. 42Exercise 3: Use of culturalinformationIn groups of two or three come upwith at least one example of eachsituation:A situation where there was……..1. A misunderstanding of a client’sculture which led to less thanappropriate treatment.2. A misunderstanding of a client’sculture based on a generalisationwhich turned out not to be the case.3. Consideration of the client’s culturewhich resulted in appropriatetreatment interventions.
  43. 43. 43Flexible use of technique“Everyone who seeks assistancefor mental problems wants to betreated by an expert whom he canconsider as trustworthy (cf.Pederson, 1981). But the criteriaby which someone is consideredas an expert and as trustworthyare not the same in all cultures.The same goes for specifictherapeutic techniques: what isconsidered as useful and crediblein one culture, may be thought ofas stupid or immoral in a secondculture. The therapist has to beattentive to these differences, andflexible in the use of techniques”.Van der Veer, G. (1992) Counselling and therapy with refugees andvictims of trauma: psychological problems of victims of war, tortureand repression. John Wiley & Sons: Europe. (p. 101)
  44. 44. 44Cultural formulation1. Cultural identity• Cultural reference group(s)• Language• Cultural factors in development• Involvement with culture of origin• Involvement with host culture2. Cultural explanations of distress• Predominant idioms of distress and local illnesscategories• Meaning and severity of symptoms in relation tocultural norms• Perceived causes and explanatory models• Help-seeking experiences and plans3. Cultural factors related to psychosocial environment andlevel of functioning• Social stressors (eg. migration itself)• Social supports• Levels of functioning and disability4. Cultural elements of the clinician-client relationship• Use of interpreters• Attendance of family or cultural members• Culture-bound behaviour, manner, rituals, dress andattitudes5. Overall cultural assessmentAcknowledgments to the Qld Transcultural Mental Health Centre for adaptingthis from the DSM-IV
  45. 45. 45Questions to elicit the client’sexplanatory modelWhat do you think has caused your problem?Why do you think it started when it did?What do you think your sickness (or injury) doesto you? How does it work?How severe is your sickness (or injury)? Will ithave a long or short course?What kind of treatment do you think you shouldreceive?What are the most important results you hope toreceive from this treatment?What are the chief problems your sickness (orinjury) has caused for you?What do you fear most about your sickness (orinjury)?Qld Transcultural Mental Health Centre (2002) Managing culturaldiversity mental heath. Brisbane.
  46. 46. 46Minimising bias duringassessment1. The practitioner should examine his or her ownbias and prejudice before engaging in theevaluation of clients who do not share thepractitioner’s race and ethnicity.2. The practitioner should be aware of the potentialeffects of racism.3. The practitioner should include an evaluation ofsocioeconomic variables and use them.4. The practitioner should try to reduce thesociocultural gap between the client and himself orherself.5. The practitioner should include an evaluation ofculturally related syndromes.6. The practitioner should ask culturally appropriatequestions.7. The practitioner should consult paraprofessionalsand folk healers within the particular multiculturalgroup.8. The practitioner should avoid the mental statusexamination.9. The practitioner should try to use the least biasedassessment strategies first, then consider the mostbiased strategies under special circumstances.
  47. 47. 47Barriers to cross-culturalcommunication1. Language difficulties - this may mean- Lack of vocabulary- Lack of idiomatic expressions- Different intonation and emphasis- Choice of vocabulary and phrasing2. Non-verbal communication differences - these non-spoken clues or body language can impedecommunication, even if the words used are beingunderstood - high and low context styles ofcommunication.3. Preconceptions and stereotypes - based onassumptions and value judgements can lead todiscrimination and racist behaviour - everyone’sshorthand understanding of the world needs to bechecked out and understood in context.4. Evaluate behaviour - cross-cultural conflict can stilloccur when one person can recognise the culturalpatterns/context of the other person, but evaluates theirbehaviour as good or bad against their own cultural setsof values.5. Stress and lack of time - building trust and relationshipsis time consuming.6. Not using adequate interpreters or interpreters in aprofessional manner.7. Not knowing the context - eg. is the person a migrant,refugee or indigenous person, how long have they beenin Australia, etc.8. Always use professional interpreters.Rossi, D. QPASTT, 1999
  48. 48. 48Key messagesStereotypes are natural - butinadequate sources of informationabout a client.Information about a mental healthclient should, if at all possible, beobtained from a range of sources:family, friends, medical practitioners,bicultural mental health workers, aswell as the client himself/herself -through an interpreter if necessary.Finding out what people believe tobe the cause of the illness and how itmight be treated can inform thehealth professional about how to bemost helpful to the client.Qld Transcultural Mental Health Centre. (2002) Managing culturaldiversity in mental health. Brisbane.
  49. 49. 49Some general assessment toolsGlobal Assessment of Functioning (G.A.F) ScaleSocial and Occupational Functioning AssessmentScale (S.O.F.A.S)Harvard Trauma QuestionnaireHopkins Symptom Checklist 25Children’s Assessment ProformaThe tools shown are used by QPASTT to undertakemore rigorous and in-depth assessment for clinicaland advocacy purposes.None of the instruments included here can or shouldbe used in an exclusive manner.Use of any of these instruments outside a therapeuticcontext, and without a therapeutic intent and withouta therapeutic alliance, is not appropriate. Theinstruments included are at most adjunctive tocounselling or psychosocial reports, and/or as part ofthe semi-structured interview process.
  50. 50. 50Global Assessment ofFunctioning (G.A.F) Scale(DSM-IV p. 32)Consider psychological, social and occupational functioning on a hypothetical continuum ofmental health illness. Do not include impairment in functioning due to physical (orenvironmental) limitations.Code Note: use intermediate codes when appropriate, eg. 45, 68, 72)100-91Superior functioning in a wide range of activities, life’s problems never seem to get out ofhand, is sought out by others because of his or her many positive qualities. No symptoms.90-81 Absence of minimal symptoms (eg. mild anxiety before an exam). Good functioning in allareas, interested and involved in a wide range of activities, socially effective, generallysatisfied with life, no more than every day problems or concerns (eg. an occasionalargument with family members).80-71 If symptoms are present, they are transient and expectable reactions to psychosocialstressors (eg. difficulty concentrating after family argument); no more than slightimpairment in social, occupational or school functioning (eg. temporarily fallingbehind in school work).70-61 Some mild symptoms (eg. depressed, mood and mild insomnia) OR some difficulty in social,occupational or school functioning (eg. occasional truancy or theft within the household), butgenerally functioning pretty well, has some meaningful interpersonal relationships.60-51 Moderate symptoms (eg. flat affect and circumstantial speech, occasional panic attacks) ORmoderate difficulty in social, occupational or school functioning (eg. few friends, conflicts withpeers or co-workers).50-41 Serious symptoms (eg. suicidal ideation, severe obsessional rituals, frequent shoplifting) ORany serious impairment in social, occupational or school functioning (eg. no friends, unable tokeep a job).40-31 Some impairment in reality testing or communications (eg. speech is at times illogical, obscureor irrelevant) OR major impairment in several areas such as work or school, family relations,judgement, thinking or mood (eg. depressed man avoids sirens, neglects family and is unableto work; child frequently beats up younger children, is defiant at home and is failing at school).30-21 Behaviour is considerably influenced by delusions or hallucinations OR serious impairment incommunication or judgment (eg. sometimes incoherent, acts grossly inappropriately, suicidalpreoccupation) OR inability to function in almost all areas (eg. stays in bed all day; no job,home or friends).20-11 Some danger of hurting self or others (eg. suicide attempts without clear expectation of death;frequently violent; maniac excitement) OR occasionally fails to maintain minimal personalhygiene (eg. smears faeces) OR gross impairment in communication (eg. largely incoherent ormute).10-0 Persistent danger of severely hurting self or others (eg. recurrent violence) OR persistentinability to maintain minimal personal hygiene OR serious suicidal act with clear expectation ofdeath.0 Inadequate informationClient Name: ……………………………………………………………………………………..……………....Date Scored: ……………………...… Score: …….…… Scorer’s Name: ...………………….....………………Date Scored: …………………...…… Score: …….…… Scorer’s Name: ……………………...………………
  51. 51. 51Social and OccupationalFunctioning Assessment Scale(S.O.F.A.S) (DSM-IV p. 32)Consider social and occupational functioning on a continuum from excellentfunctioning to grossly impaired functioning. Include impairments in functioning due tophysical limitations, as well as those due to mental impairments. To be counted,impairment must be a direct consequence of mental health physical health problems;the effects of lack of opportunity and other environmental limitations are not to beconsidered.Code Note: use intermediate codes when appropriate, eg. 45, 68,72)100-91 Superior functioning in a wide range of activities.90-81 Good functioning in all areas, occupationally and sociallyeffective.80-71 No more than slight impairment in social, occupational orschool functioning (eg. infrequent interpersonal conflict,temporarily falling behind in school work).70-61 Some difficulty in social, occupational or school functioning,but generally functioning well, has some meaningfulinterpersonal relationships.60-51 Moderate difficulty in social, occupational or schoolfunctioning (eg. few friends, conflicts with peers or co-workers).50-41 Serious impairment in social, occupational or schoolfunctioning (eg. no friends, unable to keep a job).40-31 Major impairment in several areas such as work or school,family relations (eg. depressed man avoids friends, neglectsfamily and is unable to work; child frequently beats up youngerchildren, is defiant at home and is failing at school).30-21 Inability to function in almost all areas (eg. stays in bed allday; no job, home or friends).20-11 Occasionally fails to maintain minimal personal hygiene;unable to function independently.10-0 Persistent inability to maintain minimal personal hygiene. Unable to functionwithout harming self or others or without considerableexternal support (eg. nursing care and supervision).0 Inadequate informationClient Name: …………………………………………………………………………..……………....Date Scored: ……………………...… Score: …….…… Scorer’s Name: …...…….....………………Date Scored: …………………...…… Score: …….…… Scorer’s Name: …………...
  52. 52. 52Harvard TraumaQuestionnaire(Focus on PTSD and its features)“The Harvard Trauma Questionnaire (Mollica, Wyshak &Lavelle, 1987; Mollica & Caspi-Yavin, 1991) is a guidedinterview that begins by assessing 17 trauma experiencesspecific to Indochinese refugees. The second interviewsection includes an open-ended question about therefugee’s perceived worst experiences, so that salientaspects of the stressor can be delineated. The thirdsection elicits 30 symptoms related to torture and trauma,16 of which overlap the DSM-III-R criteria. One strength ofthe measure is that it is available in English and threeIndochinese languages. Perhaps more important is that itrepresents an effort to assess trauma exposure andsymptoms cross-culturally, a task few investigators haveundertaken to date”.Newman, E., Kaloupek, D. & Keane, T. (1996) Assessment ofposttraumatic stress disorder in clinical and research settings. Invan der Kolk, B., McFarlane, A. & Weisaeth, L., Traumatic stress:the effects of overwhelming experience on mind, body and society.The Guildford Press: New York. (p. 263)Hopkins Symptom Checklist 25(Focus on anxiety and depression)This instrument includes 25 questions, 10 regardinganxiety and 15 regarding depression.It was developed by Mollica in 1986 in co-operation withthe U.S. Office of Refugee Resettlement.
  53. 53. 53Assessment of childrenFrom the health assessment of adults and their history ofpersecution you will know if children have been exposed totrauma and what level of insight parents have. Some questionsare:How have the children been?Has each child got any health problems?Have you noticed any changes in your child’s behaviour sincethe troubles/war began?How do you think they coped with…….?By this time, if little information has been elicited and there isevidence of exposure to traumatic circumstances, askHow have they been sleeping?Any nightmares?Have you noticed if they’re forgetful?Do they misbehave in ways they didn’t before?Do they enjoy things?Have they made friends?Do they get sad?How are they doing at school?Link these questions to information provision by saying “I’veasked you lots of questions about the children and this isbecause we know that children are affected by havingexperienced or witnessed terrible things”.It is difficult for some parents to bear the burden of childrenbeing traumatised and one should not shatter their defences.Dr Ida Kaplan, The Victorian Foundation for Survivors of Torture Inc, 1998.
  54. 54. 54Key messagesRegard all instruments as apartial tool only, not as theentire assessment.Beware of the temptation toover-rely on any instrument.Cross-cultural assessment ispossibly best done in a semi-structured interview style.Self administered tests are notconsidered as appropriate asclinically administered semi-structured interviews.
  55. 55. 55Carlson’s Framework of theeffects of traumaTraumatic eventsPerception of event as negativeSuddennessLack of controlCore responsesRe-experiencingAvoidanceSecondary responses (results of the socialenvironment) Depression Aggressiveness Poor self esteem(result of core responses)Associated responses Identity disturbances Relationship problems Guilt Shame
  56. 56. 56The core points of PTSDtreatment“….the core problem in PTSD consists of afailure to integrate an upsetting experienceinto autobiographical memory….”“….traumatic memories need to become likememories of everyday experience; that is,they need to be modified and transformedby being placed in their proper context andreconstructed into a meaningful narrative”.“…treatment consists of finding ways inwhich people can acknowledge the reality ofwhat has happened without having to re-experience the trauma all over again”.“Talking about the trauma is rarely if everenough; trauma survivors need to takeaction that symbolises triumph overhelplessness and despair”.Van der Kolk, B., McFarlane, A. & Weisaeth, L. (Eds.) (1996)Traumatic stress: the effects of overwhelming experience on mind,body and society. The Guildford Press: New York.
  57. 57. 57Exercise 6: Vulnerability toPTSDIn small groups discuss thequestion:“Why do some peopleappear to be morevulnerable to PTSD thanothers?”
  58. 58. 58Vulnerability to PTSD1. Genetic constitutional vulnerability topsychiatric illness.2. Adverse or traumatic experience inchildhood.3. Certain personality characteristics (such asthose found in antisocial, dependent,paranoid and borderline patients).4. Recent life stresses or changes.5. Compromised or inadequate support system.6. Recent heavy alcohol use.7. A perception that the locus of control isexternal rather than internal.Davidson, J. & Foa, E. (Eds.) (1993) Epilogue. In Posttraumaticstress disorder. DSM-IV and beyond. American PsychologicalPress: Washington DC. (p. 229-235)
  59. 59. 59Controlled exposure in a safecontext1. “The person must attend to trauma-related information in a manner thatwill activate his or her owntraumatic memories.2. In order for the person to form anew, non-traumatic structure,trauma-discrepant information mustbe provided.3. The most important newinformation is probably the fact thatthe patient is unable to confront thetraumatic memory with a trustedtherapist in a safe environment(van der Hart & Spiegel, 1993)”.Van der Kolk, B., McFarlane, A. & Weisaeth, L. (1996) Traumaticstress: the effects of overwhelming experience on mind, bodyand society. The Guildford Press: New York.
  60. 60. 60Key messagesThe core problem ofPTSD is that of failure tointegrate an overwhelmingexperience into memory.The core treatmentprinciple compatible with anumber of treatments isthat of controlled exposureto the traumatic memory,within a safe context.PTSD is a biological,psychological andsociological phenomena.
  61. 61. 61Overview of three stages ofrehabilitationSTAGE I - SAFETYRegaining control and putting order into daily existencepersonal safetyi. Re-establishment of bodily integrityii. Safety in life and homeiii. Safety in broader community/countryEstablishment of safety networksi. Identity personal strengthsii. Develop patterns of control and routine in daily lifeiii. Establish personal support systems and networksiv. Identify secure placesSTAGE II - REMEMBRANCE AND MOURNINGSharing the trauma and learning to grievei. A decision to rememberii. Maintenance of safety and healthiii. Sharing the traumatic experienceiv. Grief and mourningv. The integration of affect, memory and cognitionSTAGE III - INTEGRATIONBuilding a future with meaningi. Helping the survivor to claim his or her worldii. Reconnecting with othersTRANSACT (1996). Companions in the search: multidisciplinary guide to assistin the rehabilitation of clients who have experienced torture and traumabefore settling in Australia. TRANSACT: Canberra.
  62. 62. 62Judith Herman’s three stagesof rehabilitationStage I SafetyThis stage emphasises the re-establishmentof a person’s sense of safety and bodilyintegrity.Stage II Remembrance &mourningIn this stage the client focuses on the retellingand mourning of their traumatic experience/s.Stage III IntegrationIn the integration stage the client workstowards being able to re-establishrelationships and interact with the worldagain.Herman, J. (1992) Trauma and recovery: the aftermath of violencefrom domestic abuse to political terror. Basic Books: New York.
  63. 63. 63Exercise 7: Staged recoveryIn the large group, using the whiteboard write up inthree columns, J. Herman’s stages.Brainstorm possible strategies for achieving eachstage and list them under the heading.Stage ISafetyStage IIRemembrance& MourningStage IIIIntegration
  64. 64. 64Some treatment methods“Alphabet therapies”E.M.D.R or Eye Movement Desensitisation and ReprocessingT.I.R Traumatic Incident ReductionV.K.D Visual Kinesthetic DissociationT.F.T Thought Field TherapyArt therapyCognitive behavioural therapiesExposure therapyAnxiety management therapyDirect therapeutic exposure techniquesCounting methodFloodingImageryImplosiveSystematic desensitisation (exposure therapy) as in CBT aboveTestimony methodGroup therapiesCouple therapyFamily therapyPsychodynamic approachesInsight therapy (IRCT Denmark)PsychoanalysisPsychodynamic oriented psychiatryPharmacotherapyOthersHomeopathyMassageSand playYogaMeditationWorking cross-culturally requires a flexible technique
  65. 65. 65Group work1. Stabilise psychological andphysiological reactions.2. Explore and validate the experience.3. People understand the effects of pastexperience.4. People learn new ways of coping.5. People rebuild meaningfulconnections.*Adapted from: van der Kolk, B., McFarlane, A. & Weisaeth, L.(1996) Traumatic stress: the effects of overwhelmingexperience on mind, body and society. The Guildford Press:New York.
  66. 66. 66Group work purposesEducationalGroupsTherapeuticGroupsSupportGroupsOne Two ThreeTherapeutictaskSafety Remembrance& mourningReconnectionTimeorientationPresent Past Present, futureFocus Self-care Trauma InterpersonalrelationshipsMembership Homogeneous Homogenous HeterogeneousBoundaries Flexible,inclusiveClosed Stable, slowturnoverCohesion Moderate Very high HighConflicttoleranceLow Low HighTime limit Open-ended orrepeatingFixed limit Open-endedStructure Didactic Goal-directed UnstructuredExample Twelve-stepprogramSurvivorgroupInterpersonalpsychotherapygroupHerman, J. (1992) Trauma and recovery: the aftermath of violence fromdomestic abuse to political terror. Basic Books: New York. (p. 218)
  67. 67. 67Universal components ofeffective intervention1. Intervene immediately or promptly after thetraumatic event.2. Focus on presenting complaints or currentdistress.3. Use specific and possibly directive techniques.4. Deal with any guilt and self-blame early anddirectly.5. Experience and communicate empathy readily.6. Strengthen the client’s sense of competence,autonomy and self-worth.7. Help clients make sense of the traumatic event inthe context of their lives (including culture).8. Deal with any object losses early and directly.Draguns, J. (1996) Ethnocultural considerations in the treatment ofPTSD: therapy and service delivery. In Marsella, A., Friedman,M., Gerrity, E. & Scurfield, R., Ethnocultural aspects of post-traumatic stress disorders: issues, research and clinicalapplications. American Psychological Association: WashingtonDC. (Chapter 18, p. 459-479)
  68. 68. 68Key messagesWork with refugee survivors of tortureand trauma can be thought of ashaving stages:1. Safety2. Remembrance & mourning3. IntegrationThere are a number of treatmentmodels and approaches which can beused to achieve the goals of eachstage.No one method has yet proven to bethe definitive method with refugeesurvivors of torture and trauma.
  69. 69. 69Exercise 8: Culture providesAs a large group take a few minutesto consider the following questions.Record your answers on thewhiteboard.“What does a person’sculture provide forthem?”
  70. 70. 70Culture provides security andprotection from traumaSocial supportValuesNormsShared expectationsRelationship with the spiritualRelationship with meaningMaterialistically as a healthmaintenance systemMarsella, A., Friedman, M., Gerrity, E. & Scurfield, R. (1996)Ethnocultural aspects of post-traumatic stress disorders: issues,research and clinical applications. American PsychologicalAssociation: Washington DC.
  71. 71. 71Key messagesCulture acts as a protector,part of an integratedsystem of the individual.Culture is a double-edgedsword. Because of humanbeings’ dependence on it,its loss becomes traumatic.De Vries, M. (1996) Trauma in cultural perspective. In van der Kolk,B., et al., Traumatic stress: the effects of overwhelmingexperience on mind, body and society. The Guildford Press:New York.
  72. 72. 72The relationship in treatment“Emotional attachment isprobably the primaryprotection against feelings ofhelplessness andmeaninglessness; it isessential for biologicalsurvival in children, andwithout it existential meaningis unthinkable in adults”.De Vries, M. (1996) Trauma in cultural perspective. In van der Kolk,B., et al., Traumatic stress: the effects of overwhelming experienceon mind, body and society. The Guildford Press: New York.
  73. 73. 73What is culture?Is much broader than just ethnicity and includes:- Age- Gender- Place of residence- Status (educational, economic, etc.)- Affiliation (formal/informal)- Nationality- Ethnicity- Language- ReligionIs learnt not innate.Is changing and dynamic.Is complex and no one can hope to learn everyaspect of culture.“There may well come a time when we will nolonger speak of cross-cultural psychology as such.The basic premise of this field - that to understandhuman behaviour, we must study it in it’ssociocultural context - may become so widelyaccepted that all psychology will be inherentlycultural”.Paul Pederson, p. 352.
  74. 74. 74Exercise 9: Cross-culturalcompetenceBreak up into groups of two anddiscuss the question:“What qualities should aperson have to be cross-culturally effective?”
  75. 75. 75Characteristics of interculturalcompetence (Hammer 1989)Flexibility towards ideas of others.Respect towards others.Listening & accurate perception of theneeds of others.Trust.Friendliness & cooperation with others.Calm & self control when confronted byobstacles.Sensitivity to cultural differences.Tolerance for ambiguity.Interaction management skills (negotiatingskills).
  76. 76. 76Key messagesRelationship is an important factor in:- protecting people from the effectsof traumatic experience;- helping people to come to termswith traumatic experience.The extent and quality of theclient’s/patient’s holding environment(relationship) is an importantconsideration and predictor ofoutcome.The counsellor/helper is likely to bemore helpful and successful ifintercultural competencies arepursued by the professional.
  77. 77. 77Case vignettesFEMIFemi was a teacher in a West African country, who was politically active on behalf of his tribal group.He experienced discrimination, harassment and victimisation from a very young age. On one of hismissions, he was targeted, gagged, blind-folded and taken away in the middle of the night. He wasthen confined without water, food or toilet and beaten, ending up in a cell with 100 people.As a student, he spent one and a half years in a refugee camp in Austria. Currently, he has been inAustralia for a similar length of time as an asylum seeker. For three years, he had virtually nocontact with any family members, even with his defacto wife and child, as he considered this was toodangerous. His parents remain in their village and his siblings are scattered.At first, as his English was limited, work was begun using an interpreter who spoke his locallanguage, but issues of trust in the small, divided community lead to problems. More recently,interpersonal work has proceeded primarily through the medium of art, which has provided a newavenue of expression for him.MOHAMMED AND NAVAHMohammed and Navah are a refugee couple from Iran who arrived in Australia recently with theirthree young children after spending two years in grim conditions in Turkey following the destructionof their home. The trip to Turkey itself was horrific, with conditions so bad that one young mother inthe group of travelling refugees placed her baby in the sea, rather than subject it to furtherdeprivation.It is clear now that Mohammed was politically active, but his way of protecting his family was torefrain from mentioning or explaining anything that he did. Thus, one day, he just disappeared, andone day, much later, he reappeared. He has not yet talked in detail of his prison experience, exceptthat it was underground and he slept on wet concrete.In Australia he was inpatient with himself, for not being quicker to master English and findemployment. He was impatient and grumpy - ‘a different person’ - with his family. He was impatientand resistant with his therapist.A patient, accepting approach, moving gradually into basic western family therapy techniques hashelped this couple start to move forward and leave some of their trauma behind. The beauty ofmusic has helped break the pattern too.MARIJANAMarijana is a 6 year old girl from Former Yugoslavia who arrived in Australia with her grandmotherearlier this year to live with her uncle and aunt who sponsored them, having been in Australia forsome years.She was an only child who last year became an orphan, her parents being killed six weeks apart.She never saw her mother’s body, though her father tried to explain that she had been killed. Shewas found beside her father’s body after he had been shot, and was trying to wake him up.In Australia, she and her grandmother continue to be close, and she can hardly wait each day untilher grandma picks her up from school. Her English remains limited, and she appears shy aboutaccepting friendly overtures from other children. She is serious. It is not known whether she hasnightmares. She sleeps well if a story is read to her, but sweats heavily in her pyjamas each night.
  78. 78. 78Strategies for healthprofessionals1RESTORE:CONTROLSAFETYREDUCING FEAR ANDANXIETY Restoring health through screening andtreatment. Establish patients previous experience withhealth professionals to anticipate concerns. Explain procedures. Give choice about proceeding withinvestigations. Provide information about diagnosis, prognosis. Provide opportunity for patient to ask questions. Use an interpreter. Expect anxiety in patients. Medication for anxiety and symptoms of PTSD(GPs). Making referrals for counselling and otherservices.2RESTORE:ATTACHMENTCONNECTIONSOVERCOMING GRIEFAND LOSS Respectful treatment conveys possibility ofmeaningful relationship. Expecting grief in patients. Medication for depression (GPs).3RESTORE:IDENTITYMEANINGPURPOSE Respectful treatment and genuine concern. Acknowledgment of difficulties. Expecting distrust, withdrawal, anger, demandingbehaviour and accommodating emotionalreactions. Knowledge of human rights violations andeffects.4RESTORE:DIGNITYVALUE Respectful treatment and genuine concern. Anticipation of reluctance to self-disclose. Respect for privacy. Expecting fear regarding invasive procedures.Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered lives training guide.Victorian Foundation for Survivors of Torture Inc: Victoria. (p. 169)
  79. 79. 79Summary of generalframeworksFOUR KEY COMPONENTS OF TRAUMAREACTION1. Chronic fear of loss of control/helplessness2. Disconnection from significant other3. Shattered core assumptions of meaning4. Guilt, shame and humiliationPHASES OF TREATMENT1. Safety2. Remembrance and mourning3. IntegrationNECESSARY ELEMENTS TO INCLUDE• Social injustice critique• Cultural appropriateness and sensitivity• Therapeutic relationship
  80. 80. 80Exercise 12: EmotionalresponsesIn groups of two or three discussthe following question:“What do you think theemotional responses ofa person working withsurvivors of torture andtrauma would be?”
  81. 81. 81Emotional response ofworkers1. Helplessness2. Guilt3. Anger4. Dread and horror5. Idealisation6. Personal vulnerability7. Avoidance reactions8. FulfilmentSpecial thanks to the Victorian Foundation forSurvivors of Torture Inc.Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shatteredlives training guide. Victorian Foundation for Survivors ofTorture Inc: Victoria. (p. 148-152)
  82. 82. 82Modes of empathic strain incounter-transference reactions(CTRs)Reactive style of therapistTYPE OF REACTION(UNIVERSAL, OBJECTIVE, INDIGENOUS REACTIONS)NormativeEmpathic DisequilibriumUncertaintyVulnerabilityUnmodulated AffectEmpathic WithdrawalBlank Screen FaçadeIntellectualisationMisperception of DynamicsType II CTR(Over-identification)Type I CTR(Avoidance)Empathic EnmeshmentLoss of BoundariesOver-involvementReciprocal DependencyEmpathic RepressionWithdrawalDenialDistancingPersonalised(PARTICULAR, SUBJECTIVE, IDIOSYNCRATIC REACTIONS)Wilson, J. & Lindy, J. (1994) Countertransference in the treatment of PTSD. The GuildfordPress: New York. (p. 15)
  83. 83. 83Vicarious traumatisationThe transformation of the person’s innerexperience resulting from empathic exposure to theclient’s material (Pearlman, Saakvitne 1995)Occupational hazardEffects are cumulative and permanentVicarious traumatisation is a response to theeffects of traumatic exposure on our clients.EFFECTSIncludes changes in the person’s:Sense of identityRelationships with self/others/worldBeliefs about self/others/worldTolerance of feelingsPsychological needsMemory and imagery changes (vulnerable to PTSDsymptomatology)Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists.In Figley, C. (Ed.), Compassion fatigue: secondary traumaticstress disorders in those who treat the traumatized. Brunner-Routledge: New York.
  84. 84. 84Exercise 13: Risk factorsBrainstorm in the large group:“What might be some riskfactors for developingvicarioustraumatisation?”
  85. 85. 85Risk factors for vicarioustraumatisationToo high demands from self.Too high demands from others and thesituation.Lack of resources, personnel and time.Lack of control over the situation.Lack of support from leaders, organisations,colleagues.Unrealistic expectations.Lack of acceptance and acknowledgment.Smith, B., Agger, I., Danieli, Y. & Weisaeth, L. (1996) Healthactivities across populations: emotional responses ofinternational humanitarian aid workers. In Danieli, Y. et al.(Eds.), International responses to traumatic stress:humanitarian, human rights, justice, peace and developmentcontributions, collaborative actions and future initiatives.Baywood Publishing: New York.
  86. 86. 86Contributing factors ofvicarious traumatisationCharacteristics of work- Clients with traumatic histories- Clients who are continually exposed todanger- Clients who are difficult to understandCharacteristics of the worker- Vulnerabilities- Experience of personal trauma- Ideas, values- Ability to attend to their own care needsCharacteristics of society- Society’s tolerance of abuse- Society’s attitude towards violence andsocial justice eg. misogynist, racist andhetero-sexist and victim-blaming contexts.Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists.In Figley, C. (Ed.), Compassion fatigue: secondary traumaticstress disorders in those who treat the traumatized. Brunner-Routledge: New York.
  87. 87. 87Exercise 14: Strategies toreduce risk of vicarioustraumatisationBrainstorm answers to thefollowing question:“What strategies and/ortechniques have you, orcould you use, to reducethe risk of vicarioustraumatisation?”
  88. 88. 88Reducing the risk of vicarioustraumatisationPERSONAL STRATEGIESMaintain a personal lifeUse personal lifeIdentify healing activitiesAttend to your spiritual needsPROFESSIONAL STRATEGIESArrange supervisionDevelop professional connectionDevelop a balanced work lifeRemain aware of your goalsORGANISATIONAL STRATEGIESAttend to physical settingArrange for adequate resourcesCreate an atmosphere of respectDevelop adjunctive servicesPearlman, L. & Saakvitne, K. (1995) Treating traumatisedtherapists. In Figley, C. (Ed.), Compassion fatigue: secondarytraumatic stress disorders in those who treat the traumatized.Brunner-Routledge: New York.
  89. 89. 89Where to from here?Invite the group to discuss any closing house-keeping.Allow them to have time to explore any futuredirections they may wish to pursue as a group ofworkers.ExamplesMore training?Regular case discussion?A literature review group?A peer support group?
  90. 90. 90“History, despite itswrenching pain, cannotbe unlived, but if facedwith courage, need not belived again”.Maya Angelou

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