Working with Working with Survivors of Survivors of

TortureTortureAbbey Weiss, PsyD, LPAbbey Weiss, PsyD, LPThe Center for Victims of TortureThe Center for Victims of Torture

Healing in Partnership ProjectHealing in Partnership ProjectJune 8, 2012June 8, 2012

ObjectivesObjectives

Participants will learn issues and Participants will learn issues and concerns specific to working with concerns specific to working with survivors of political torturesurvivors of political torture

Participants will learn about a variety of Participants will learn about a variety of intervention methodsintervention methods

Participants will review and consider how Participants will review and consider how to apply these to specific casesto apply these to specific cases

Agenda

8:30am-9:00am Introduction to “Working with Survivors of Torture.”Background, definitions, unique considerations

9:00am -10:00am Evidenced Based Practices and BeyondPresent the model of care at CVTPresent various modalities and intervention strategies

10:00am - 10:30 am “In the Consulting Room” – Case #1 10:30am - 10:45am Break10:45am - 11:15am Small group work – Discussion of case examples11:15am - 11:30am Discussion with the larger group11:30am -12:00pm Secondary Trauma 12:00pm - 12:15pm Next Steps12:15pm - 12:30pm Questions and wrap up

The Center for Victims of TortureThe Center for Victims of Torture Founded in 1985Founded in 1985 Current clinic locationCurrent clinic location

CVT CVT

Rehabilitative TreatmentRehabilitative Treatment

TrainingTraining

ResearchResearch

Public PolicyPublic Policy

Who does the Center Serve? East African, West African, SE Asian, Middle Eastern, European, Central and South American 50% percent male, 50% female Average number of years of formal education:12.9 76% are asylum seekers 68% unable to work at time of intake (no work permit)

According to Amnesty International, more than 130 countries worldwide systematically practice torture against their own civilian populations.

Amnesty International Report 2004

Primary Refugee Arrivals, Minnesota, 2006

Other

6%

FSU

2%Burma

3%

Hmong

4%

Liberia

7%

Ethiopia

9%

Somalia

69%

SomaliaEthiopiaLiberiaHmongBurmaFSUOther

N=5,354

““Other” includes Cambodia, Cameroon, China (also Tibet), Congo, Cuba, Eritrea, Gabon, Guinea, Iran, Kenya, Nepal, Nigeria, Sierra Leone, Sudan, Togo, Vietnam, and Zimbabwe

Refugee Health Program, Minnesota Department of Health

is a person who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country.”

Source: Protecting Refugees: Question and Answers, published by the United Nations High Commission on Refugees (UNHCR) Public Information Section.

A refugee...

Center for Victims of Torture

An asylum seeker...

What is the difference?What is the difference?

Refugee vs. Asylum SeekerRefugee vs. Asylum Seeker

UNITED NATIONSTorture is: Any act by which severe pain or suffering Physical or mental Is intentionally inflicted To obtain information or a confession, to punish, or

to intimidate or coerce Based on discrimination [political, ethnic, religious,

etc.] Inflicted by, at the instigation of, or with the

consent or acquiescence of a public official

… …the deliberate and systematic the deliberate and systematic dismantling of a person’s identity and dismantling of a person’s identity and humanity.humanity.

… …the attempt to destroy a person’s the attempt to destroy a person’s will to live, and their ability to trust will to live, and their ability to trust in anyone or anything.in anyone or anything.

Center for Victims of Torture

Torture is...

Destroy a sense of community

Eliminate leaders

Create a climate of fear

Produce a culture of apathy

Create a sense of familial disruption

Center for Victims of Torture

Forms of tortureForms of torture

Most forms are “low tech” Beatings Forced labor Deprivation Wrongful imprisonment Rape

Trauma/Torture Trauma/Torture EventsEvents

Life threateningLife threatening

UnpredictableUnpredictable

Can’t stopCan’t stop

Stress is extremeStress is extreme

Emotional or physical reactions

are NORMAL.

Center for Victims of Torture

NORMAL RESPONSE TO NORMAL RESPONSE TO FEAR:FEAR:

Heart beats fast, sweat, get ready to ACT Heart beats fast, sweat, get ready to ACT without much THOUGHT because one is without much THOUGHT because one is trying to survivetrying to survive

But…prolonged periods of this can lead to But…prolonged periods of this can lead to PTSD, or like the alarm never gets shut offPTSD, or like the alarm never gets shut off

Torture, War Trauma and Torture, War Trauma and Terrorism affect Terrorism affect FIVEFIVE basic basic human needshuman needs

The need to feel The need to feel safesafe The need toThe need to trust trust The need to feel ofThe need to feel of value value (self worth)(self worth) The need to feel The need to feel close to othersclose to others The need to feelThe need to feel some control some control over our over our

liveslives

Common Myths AboutCommon Myths About Survivors of Trauma Survivors of Trauma

Time heals all woundsTime heals all wounds Survivors will eventually forget about the pastSurvivors will eventually forget about the past Bringing up the past only makes it worseBringing up the past only makes it worse Survivors can bounce back to “normal” once Survivors can bounce back to “normal” once

they are removed from war or after a set they are removed from war or after a set amount of timeamount of time

If they look fine on the outside they are fine on If they look fine on the outside they are fine on the insidethe inside

Common Common DiagnosesDiagnoses

Post-traumatic Stress Post-traumatic Stress DisorderDisorder

An adaptive/normal response in a life-threatening An adaptive/normal response in a life-threatening situationsituation

A cross-cultural phenomenonA cross-cultural phenomenon 80% of CVT clients meet full criteria for Posttraumatic 80% of CVT clients meet full criteria for Posttraumatic

Stress Disorder Stress Disorder Data from Meta-analysis on Mass Trauma indicate that Data from Meta-analysis on Mass Trauma indicate that

65% of trauma survivors suffer with PTSD (SAMHSA, 65% of trauma survivors suffer with PTSD (SAMHSA, 2001)2001)

People can heal from PTSDPeople can heal from PTSD

Post Traumatic Stress Post Traumatic Stress DisorderDisorder

Symptoms fall in 3 main categories:Symptoms fall in 3 main categories:

Re-experiencingRe-experiencing

AvoidanceAvoidance

HyperarousalHyperarousal

DepressionDepression

Depressed or irritable moodDepressed or irritable mood Disturbed sleep (too little or too much)Disturbed sleep (too little or too much) Fatigue or loss of energyFatigue or loss of energy Loss of interest in daily activitiesLoss of interest in daily activities Psychomotor agitation or retardation Psychomotor agitation or retardation

(moving too much or too slowly)(moving too much or too slowly)

DepressionDepression

Difficulty concentrating, thinking, Difficulty concentrating, thinking, remembering, making decisionsremembering, making decisions

Thoughts of suicide, deathThoughts of suicide, death Significant increases or decreases in Significant increases or decreases in

weight or appetiteweight or appetite Feelings of worthlessness, excessive Feelings of worthlessness, excessive

guiltguilt

DepressionDepression

70% of CVT Clients meet full criteria for 70% of CVT Clients meet full criteria for Major DepressionMajor Depression

Depressed or irritable moodDepressed or irritable mood Disturbed sleep (too little or too much)Disturbed sleep (too little or too much) Fatigue or loss of energyFatigue or loss of energy Loss of interest in daily activitiesLoss of interest in daily activities Psychomotor agitation or retardation Psychomotor agitation or retardation

(moving too much or too slowly)(moving too much or too slowly)

These are the clinical These are the clinical names for the ways names for the ways people suffer. It will look people suffer. It will look as varied as the faces in as varied as the faces in this room, as different as this room, as different as each person you meet. each person you meet.

Evidenced Based Practice Evidenced Based Practice and Beyondand Beyond

CVT’s model of careCVT’s model of care Multi-disciplinaryMulti-disciplinary Theoretical orientationTheoretical orientation What experience teaches usWhat experience teaches us

Multi-disciplinaryMulti-disciplinary

Social WorkSocial Work PsychotherapyPsychotherapy

IndividualIndividual GroupGroup

NursingNursing MedicalMedical PsychiatryPsychiatry And…And…

Individualized Treatment Individualized Treatment PlanPlan

There is no ONE methodology usedThere is no ONE methodology used Each case is uniqueEach case is unique Consultation and collaboration allow us Consultation and collaboration allow us

to construct the most effective treatment to construct the most effective treatment for each personfor each person

Common Common practices/interventions:practices/interventions:

Group vs. IndividualGroup vs. Individual Cognitive BehavioralCognitive Behavioral EMDREMDR NarrativeNarrative NET NET Other exposure techniquesOther exposure techniques

Treatment:Treatment:Long term Long term

vs. vs. Short term Short term

Treating Symptoms vs.Treating Symptoms vs.Treating PersonsTreating Persons

Treating the FEAR (PTSD)Treating the FEAR (PTSD)

Treating the GRIEF (Depression, grief, Treating the GRIEF (Depression, grief, mourningmourning

Knowing how to Knowing how to interveneintervene

Considering exposure techniquesConsidering exposure techniques Considering narrative workConsidering narrative work Singular vs. multiple traumasSingular vs. multiple traumas Developmental considerationsDevelopmental considerations When immigration status mattersWhen immigration status matters Personality factorsPersonality factors When was the trauma?When was the trauma?

In the consulting In the consulting roomroom

Case #1Case #1

BREAKBREAK

Small group work:Small group work:Discussion of case examplesDiscussion of case examples

Work in groups of 3-4Work in groups of 3-4 One of three casesOne of three cases

What interventions would you consider?What interventions would you consider? What questions do you have?What questions do you have? What do you imagine would be this person’s What do you imagine would be this person’s

concerns?concerns? What are your thoughts/feelings about What are your thoughts/feelings about

working with this person?working with this person?

Discussion with the Discussion with the larger grouplarger group

Secondary Trauma

““To much sanity is madness, and the To much sanity is madness, and the maddest of all is to see life as it is, and maddest of all is to see life as it is, and

not as it should be.” not as it should be.” -Miguel de -Miguel de

CervantesCervantes

The vast universal suffering feels as thine: Thou must bear the sorrow that thou claimst to heal; The day-bringer must walk in darkest night. He who would save the world must share its pain. If he knows not grief, how shall he find grief’s cure?

-Sri Aurobindo

Stress What is stress? What is stress?

Anything that throws your body out of allostatic Anything that throws your body out of allostatic balancebalance

A demand made upon the adaptive capacities of mind A demand made upon the adaptive capacities of mind and bodyand body

Adverse reaction people have to excessive pressure Adverse reaction people have to excessive pressure or demands placed upon themor demands placed upon them

Humans are unlike animals in that we can create Humans are unlike animals in that we can create a stress response just by thinking about ita stress response just by thinking about it

The term “stress” was coined in the 1930s by The term “stress” was coined in the 1930s by Hans SelyeHans Selye

From Zapolsky, R. (1998). From Zapolsky, R. (1998). Why zebras don’t get ulcers. Why zebras don’t get ulcers. New York: W.H. FreemanNew York: W.H. Freeman

Defining Secondary Defining Secondary TraumatizationTraumatization

““The effect of working with people who have The effect of working with people who have experienced trauma and of being exposed experienced trauma and of being exposed to the difficult stories they share. It is to the difficult stories they share. It is called ‘secondary traumatization’ because called ‘secondary traumatization’ because it is experienced indirectly, through the it is experienced indirectly, through the process of being a witness to another process of being a witness to another person’s trauma.”person’s trauma.”

From Andrea Northwood’s chapter Secondary TraumatizationFrom Andrea Northwood’s chapter Secondary Traumatization

Secondary Trauma Secondary Trauma

Secondary Trauma is a particular type of work Secondary Trauma is a particular type of work stress which comes from working with trauma. stress which comes from working with trauma. It is often more difficult to talk about than It is often more difficult to talk about than general work stress.general work stress.

Is a normal part of working with survivorsIs a normal part of working with survivors Does not mean we do not like/are not Does not mean we do not like/are not

successful at our jobssuccessful at our jobs It is manageable with the proper tools and It is manageable with the proper tools and

supportsupport It is necessary to understand and recognize it It is necessary to understand and recognize it

in order to avoid burnoutin order to avoid burnout

“I.M. described some of the details of the torture he had undergone during his detention in a Latin American country. It was a horrible story, but the most frightening aspect was the way in which he tried to suppress his emotions. The therapist was unable to make I.M.’s fear of being overwhelmed by his own emotions discussable at that moment. His own feelings took him by surprise, particularly the feeling that he had nothing to offer in the face of so much suffering, that he had not experienced anything himself and therefore had no right to speak about such matters. He also felt angry with I.M. for putting him into this uneasy situation.”

-Guus van der Veer, from Counseling and Therapy with Refugees and Victims of Trauma, pp. 136-137

““Knowing about our own VT is like that Knowing about our own VT is like that unsettling experience of feeling like you’re unsettling experience of feeling like you’re waking up from a bad dream, and then waking up from a bad dream, and then realizing in a few moments that you’re still realizing in a few moments that you’re still asleep, and then waking up again. And asleep, and then waking up again. And again.” again.”

Laurie Anne Pearlman “Notes from the Field” from Laurie Anne Pearlman “Notes from the Field” from Secondary Secondary

Traumatic StressTraumatic Stress

CHANGES YOU MAY CHANGES YOU MAY OBSERVE OVER TIMEOBSERVE OVER TIME

PESSIMISTIC WORLD VIEWPESSIMISTIC WORLD VIEW CHALLENGES TO SPIRITUALITYCHALLENGES TO SPIRITUALITY DIFFICULTY REGULATING DIFFICULTY REGULATING

AFFECT/EMOTIONS (PTSD & AFFECT/EMOTIONS (PTSD & DEPRESSION)DEPRESSION)

DIFFICULTY SETTING BOUNDARIESDIFFICULTY SETTING BOUNDARIES POOR SELF CONCEPTPOOR SELF CONCEPT BODILY SYMPTOMSBODILY SYMPTOMS Adapted from Pearlman and Saakvitne Trauma and the TherapistAdapted from Pearlman and Saakvitne Trauma and the Therapist

CHANGES IN WORLD CHANGES IN WORLD VIEWVIEW

Challenges to perceptions about the world Challenges to perceptions about the world (may not want to believe is true)(may not want to believe is true)

Questions about nature of evil Questions about nature of evil Heightened sensitivity to violenceHeightened sensitivity to violence May lose optimism and hopeMay lose optimism and hope Changed hopeChanged hope May join survivors expectations about the May join survivors expectations about the

worldworld

DIFFICULTY TOLERATING DIFFICULTY TOLERATING AFFECT/EMOTIONAFFECT/EMOTION

Professionals may experience other’s Professionals may experience other’s suffering more intenselysuffering more intensely

Feelings are much closer to the surfaceFeelings are much closer to the surface Impatience with own feelingsImpatience with own feelings Interference with feelings of clients and Interference with feelings of clients and

family and friendsfamily and friends

“When a client dissociates from feelings, often the feelings themselves are left with the (professional) while the survivor appears numb or indifferent. The (professional) may be left, both in and after the session, feeling profound anxiety, grief, rage, helplessness, arousal, despair, or powerlessness. Those intense feelings are exhausting when felt for two.”

-Saakvitne & Pearlman

DIFFICULTY TOLERATING DIFFICULTY TOLERATING AFFECT/EMOTIONAFFECT/EMOTION

Professionals may become overwhelmed by Professionals may become overwhelmed by trauma and lose the capacity to sooth trauma and lose the capacity to sooth themselves in healthy ways turning to themselves in healthy ways turning to overeating, drinking, spending, workingovereating, drinking, spending, working

Feeling like you can’t help everyone can lead Feeling like you can’t help everyone can lead to a sense of powerlessness or a sense of to a sense of powerlessness or a sense of inadequacyinadequacy

Lose the capacity to enjoy outside activitiesLose the capacity to enjoy outside activities

DIFFICULTY MAINTAINING DIFFICULTY MAINTAINING BOUNDARIESBOUNDARIES

If you take on too much you may lose the If you take on too much you may lose the capacity to make self protective capacity to make self protective judgements leading to:judgements leading to: loss of empathy and sense of humorloss of empathy and sense of humor can lead to falling down on the job(missed can lead to falling down on the job(missed

appointments, impaired judgement)appointments, impaired judgement) inability to be introspectiveinability to be introspective

CHANGES IN SELF CHANGES IN SELF CONCEPTCONCEPT

May blame self for feeling overwhelmed, May blame self for feeling overwhelmed, overworked leading to self-criticism, overworked leading to self-criticism, anxietyanxiety

Less energy to attend to the needs of Less energy to attend to the needs of loved onesloved ones

Concerns about professional abilityConcerns about professional ability

ABC’S OF Addressing ABC’S OF Addressing Secondary TraumaSecondary Trauma

AwarenessAwareness Needs, limits, resources, changes in selfNeeds, limits, resources, changes in self

Balance Balance Among work, play, rest, personal and Among work, play, rest, personal and

professional lifeprofessional life

Connection Connection With self/others as antidote to isolationWith self/others as antidote to isolation

PERSONAL STRATEGIESPERSONAL STRATEGIES

Self CareSelf Care Exercise, rest, play, nutritionExercise, rest, play, nutrition coping with intrusive traumatic imagery through self-reflection coping with intrusive traumatic imagery through self-reflection

and psychotherapyand psychotherapy

Spiritual RenewalSpiritual Renewal Seek connection, meaning, hope, awarenessSeek connection, meaning, hope, awareness

Nurture World ViewNurture World View Seek sources that offer perspectiveSeek sources that offer perspective

Recognize And Accept Recognize And Accept

Secondary TraumaSecondary Trauma

Limit ExposureLimit Exposure

Attend Attend

Empathy/CynicismEmpathy/Cynicism

Name ReenactmentsName Reenactments

Support GroupsSupport Groups

Maintain Professional Maintain Professional

ConnectionsConnections

Professional Professional

EducationEducation

Supervision & Supervision &

Secondary Trauma Secondary Trauma

ConsultationConsultation

PROFESSIONAL STRATEGIESPROFESSIONAL STRATEGIES

ORGANIZATIONAL STRATEGIESORGANIZATIONAL STRATEGIES

Adequate PayAdequate Pay

Time Off, Extended Time Off, Extended

VacationVacation

Continuing Continuing

Professional EducationProfessional Education

Internal ConsultationInternal Consultation

Secondary Trauma Secondary Trauma

TrainingTraining

Control Over Control Over Caseload Caseload

Predictable DaysPredictable Days

Institutional SupportInstitutional Support

Flexible OrganizationFlexible Organization

Social ActivismSocial Activism

Next StepsNext Steps

Clients you already work withClients you already work with Taking new clientsTaking new clients ConsultationConsultation Ongoing trainingOngoing training Other ideas?Other ideas?

Questions and Wrap UpQuestions and Wrap Up

A (short) List of Essential A (short) List of Essential Resources: Resources:

Judith HermanJudith Herman John BriereJohn Briere Viktor FranklViktor Frankl Pauline BossPauline Boss Irvin YalomIrvin Yalom

Resources

Boss, Pauline (1999). Ambiguous loss: learning to live with unresolved grief. Cambridge, MA: Harvard University Press.

Briere, John, Ph.D. & Scott, Catherine M.D. (2006). Principles of trauma therapy: a guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage Publications, Inc.

Dalenberg, Constance, Ph.D. (2000). Countertransference and the treatment of trauma. Washington, D.C.: American Psychological Association.

Frankl, Viktor ((1959). Man’s search for meaning: an introduction to logotherapy. New York, NY: Simon and Schuster, Inc.

Judith Herman, M.D. (1992). Trauma and recovery: the aftermath of violence – from domestic abuse to political terror. New York, NY: Basic Books.

Stamm, B. Hudnall, Ph. D. Editor. (1995). Secondary traumatic stress: self care issues for clinicians, researchers and educators. Baltimore, MD: The Sidran Press.

Yalom, Irvin (1970). The theory and practice of group psychotherapy. New York, NY: Basic Books.

Abbey Weiss, PsyD, LPAbbey Weiss, PsyD, LPaweiss@cvt.orgaweiss@cvt.org(61(61 2) 436-48322) 436-4832

EvaluationsEvaluations