1. Working with Survivors of Torture Abbey Weiss, PsyD, LP The Center for Victims of Torture Healing in Partnership Project June 8, 2012

2. Objectives  Participants will learn issues and concerns specific to working with survivors of political torture  Participants will learn about a variety of intervention methods  Participants will review and consider how to apply these to specific cases

3. Agenda 8:30am-9:00amIntroduction to “Working with Survivors of Torture.” Background, definitions, unique considerations 9:00am -10:00amEvidenced Based Practices and Beyond Present the model of care at CVT Present various modalities and intervention strategies 10:00am - 10:30 am“In the Consulting Room” – Case #1 10:30am - 10:45amBreak 10:45am - 11:15amSmall group work – Discussion of case examples 11:15am - 11:30am Discussion with the larger group 11:30am -12:00pmSecondary Trauma 12:00pm - 12:15pmNext Steps 12:15pm - 12:30pmQuestions and wrap up

4.  The Center for Victims of Torture  Founded in 1985  Current clinic location CVT Rehabilitative Treatment TrainingResearch Public Policy

5. 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)

6. According to Amnesty International, more than 130 countries worldwide systematically practice torture against their own civilian populations. Amnesty International Report 2004

8. 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...

9. What is the difference? Refugee vs. Asylum Seeker

10. UNITED NATIONS Torture 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

11. …the deliberate and systematic dismantling of a person’s identity and humanity. …the deliberate and systematic dismantling of a person’s identity and humanity. …the attempt to destroy a person’s will to live, and their ability to trust in anyone or anything. …the attempt to destroy a person’s will to live, and their ability to trust in anyone or anything.  Center for Victims of Torture Torture is...

12. è Destroy a sense of community è Eliminate leaders è Create a climate of fear è Produce a culture of apathy è Create a sense of familial disruption  Center for Victims of Torture

13. Forms of torture   Most forms are “low tech”   Beatings   Forced labor   Deprivation   Wrongful imprisonment   Rape

14. Trauma/Torture Events Life threatening Unpredictable Can’t stop Stress is extreme Stress is extreme

15. Emotional or physical reactions are NORMAL.  Center for Victims of Torture

16. NORMAL RESPONSE TO FEAR: Heart beats fast, sweat, get ready to ACT without much THOUGHT because one is trying to survive But…prolonged periods of this can lead to PTSD, or like the alarm never gets shut off

17. Torture, War Trauma and Terrorism affect FIVE basic human needs  The need to feel safe  The need to trust  The need to feel of value (self worth)  The need to feel close to others  The need to feel some control over our lives

18. Common Myths About Survivors of Trauma  Time heals all wounds  Survivors will eventually forget about the past  Bringing up the past only makes it worse  Survivors can bounce back to “normal” once they are removed from war or after a set amount of time  If they look fine on the outside they are fine on the inside

19. Common Diagnoses

20. Post-traumatic Stress Disorder  An adaptive/normal response in a life-threatening situation  A cross-cultural phenomenon  80% of CVT clients meet full criteria for Posttraumatic Stress Disorder  Data from Meta-analysis on Mass Trauma indicate that 65% of trauma survivors suffer with PTSD (SAMHSA, 2001)  People can heal from PTSD

21. Post Traumatic Stress Disorder Symptoms fall in 3 main categories: Re-experiencingAvoidanceHyperarousal

22. Depression  Depressed or irritable mood  Disturbed sleep (too little or too much)  Fatigue or loss of energy  Loss of interest in daily activities  Psychomotor agitation or retardation (moving too much or too slowly)

23. Depression  Difficulty concentrating, thinking, remembering, making decisions  Thoughts of suicide, death  Significant increases or decreases in weight or appetite  Feelings of worthlessness, excessive guilt

24. Depression  70% of CVT Clients meet full criteria for Major Depression  Depressed or irritable mood  Disturbed sleep (too little or too much)  Fatigue or loss of energy  Loss of interest in daily activities  Psychomotor agitation or retardation (moving too much or too slowly)

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

26. Evidenced Based Practice and Beyond  CVT’s model of care  Multi-disciplinary  Theoretical orientation  What experience teaches us

27. Multi-disciplinary  Social Work  Psychotherapy  Individual  Group  Nursing  Medical  Psychiatry  And…

28. Individualized Treatment Plan  There is no ONE methodology used  Each case is unique  Consultation and collaboration allow us to construct the most effective treatment for each person

29. Common practices/interventions:  Group vs. Individual  Cognitive Behavioral  EMDR  Narrative  NET  Other exposure techniques

30. Treatment: Long term vs. Short term

31. Treating Symptoms vs. Treating Persons Treating the FEAR (PTSD) Treating the GRIEF (Depression, grief, mourning

32. Knowing how to intervene  Considering exposure techniques  Considering narrative work  Singular vs. multiple traumas  Developmental considerations  When immigration status matters  Personality factors  When was the trauma?

33. In the consulting room Case #1

34. BREAK

35. Small group work: Discussion of case examples  Work in groups of 3-4  One of three cases  What interventions would you consider?  What questions do you have?  What do you imagine would be this person’s concerns?  What are your thoughts/feelings about working with this person?

36. Discussion with the larger group

37. Secondary Trauma

38. “To much sanity is madness, and the maddest of all is to see life as it is, and not as it should be.” -Miguel de Cervantes

39. 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

40. Stress  What is stress?  Anything that throws your body out of allostatic balance  A demand made upon the adaptive capacities of mind and body  Adverse reaction people have to excessive pressure or demands placed upon them  Humans are unlike animals in that we can create a stress response just by thinking about it  The term “stress” was coined in the 1930s by Hans Selye From Zapolsky, R. (1998). Why zebras don’t get ulcers. New York: W.H. Freeman

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

42. Secondary Trauma Secondary Trauma is a particular type of work stress which comes from working with trauma. It is often more difficult to talk about than general work stress.  Is a normal part of working with survivors  Does not mean we do not like/are not successful at our jobs  It is manageable with the proper tools and support  It is necessary to understand and recognize it in order to avoid burnout

43. “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

44. “Knowing about our own VT is like that unsettling experience of feeling like you’re waking up from a bad dream, and then realizing in a few moments that you’re still asleep, and then waking up again. And again.” Laurie Anne Pearlman “Notes from the Field” from Secondary Traumatic Stress

45. CHANGES YOU MAY OBSERVE OVER TIME  PESSIMISTIC WORLD VIEW  CHALLENGES TO SPIRITUALITY  DIFFICULTY REGULATING AFFECT/EMOTIONS (PTSD & DEPRESSION)  DIFFICULTY SETTING BOUNDARIES  POOR SELF CONCEPT  BODILY SYMPTOMS  Adapted from Pearlman and Saakvitne Trauma and the Therapist

46. CHANGES IN WORLD VIEW  Challenges to perceptions about the world (may not want to believe is true)  Questions about nature of evil  Heightened sensitivity to violence  May lose optimism and hope  Changed hope  May join survivors expectations about the world

47. DIFFICULTY TOLERATING AFFECT/EMOTION  Professionals may experience other’s suffering more intensely  Feelings are much closer to the surface  Impatience with own feelings  Interference with feelings of clients and family and friends

48. “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

49. DIFFICULTY TOLERATING AFFECT/EMOTION  Professionals may become overwhelmed by trauma and lose the capacity to sooth themselves in healthy ways turning to overeating, drinking, spending, working  Feeling like you can’t help everyone can lead to a sense of powerlessness or a sense of inadequacy  Lose the capacity to enjoy outside activities

50. DIFFICULTY MAINTAINING BOUNDARIES If you take on too much you may lose the capacity to make self protective judgements leading to:  loss of empathy and sense of humor  can lead to falling down on the job(missed appointments, impaired judgement)  inability to be introspective

51. CHANGES IN SELF CONCEPT  May blame self for feeling overwhelmed, overworked leading to self-criticism, anxiety  Less energy to attend to the needs of loved ones  Concerns about professional ability

52. ABC’S OF Addressing Secondary Trauma  Awareness  Needs, limits, resources, changes in self  Balance  Among work, play, rest, personal and professional life  Connection  With self/others as antidote to isolation

53. PERSONAL STRATEGIES  Self Care  Exercise, rest, play, nutrition  coping with intrusive traumatic imagery through self-reflection and psychotherapy  Spiritual Renewal  Seek connection, meaning, hope, awareness  Nurture World View  Seek sources that offer perspective

54.  Recognize And Accept Secondary Trauma  Limit Exposure  Attend Empathy/Cynicism  Name Reenactments  Support Groups  Maintain Professional Connections  Professional Education  Supervision & Secondary Trauma Consultation PROFESSIONAL STRATEGIES

55. ORGANIZATIONAL STRATEGIES  Adequate Pay  Time Off, Extended Vacation  Continuing Professional Education  Internal Consultation  Secondary Trauma Training  Control Over Caseload  Predictable Days  Institutional Support  Flexible Organization  Social Activism

56. Next Steps  Clients you already work with  Taking new clients  Consultation  Ongoing training  Other ideas?

57. Questions and Wrap Up

58. A (short) List of Essential Resources:  Judith Herman  John Briere  Viktor Frankl  Pauline Boss  Irvin Yalom

59. 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.

60. Abbey Weiss, PsyD, LP aweiss@cvt.org (612) 436-4832 aweiss@cvt.org

61. Evaluations