Presentation on theme: "Working with Survivors of Torture Abbey Weiss, PsyD, LP The Center for Victims of Torture Healing in Partnership Project June 8, 2012."— Presentation transcript:
Working with Survivors of Torture Abbey Weiss, PsyD, LP The Center for Victims of Torture Healing in Partnership Project June 8, 2012
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
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
The Center for Victims of Torture Founded in 1985 Current clinic location CVT Rehabilitative Treatment TrainingResearch Public 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
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? Refugee vs. Asylum Seeker
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
…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...
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
Forms of torture Most forms are “low tech” Beatings Forced labor Deprivation Wrongful imprisonment Rape
Trauma/Torture Events Life threatening Unpredictable Can’t stop Stress is extreme Stress is extreme
Emotional or physical reactions are NORMAL. Center for Victims of Torture
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
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
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
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
Post Traumatic Stress Disorder Symptoms fall in 3 main categories: Re-experiencingAvoidanceHyperarousal
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)
Depression Difficulty concentrating, thinking, remembering, making decisions Thoughts of suicide, death Significant increases or decreases in weight or appetite Feelings of worthlessness, excessive guilt
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)
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.
Evidenced Based Practice and Beyond CVT’s model of care Multi-disciplinary Theoretical orientation What experience teaches us
Multi-disciplinary Social Work Psychotherapy Individual Group Nursing Medical Psychiatry And…
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
Common practices/interventions: Group vs. Individual Cognitive Behavioral EMDR Narrative NET Other exposure techniques
Treating Symptoms vs. Treating Persons Treating the FEAR (PTSD) Treating the GRIEF (Depression, grief, mourning
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?
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?
“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
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? 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
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
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
“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 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
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
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
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
“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 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
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
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
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
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
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
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
Next Steps Clients you already work with Taking new clients Consultation Ongoing training Other ideas?
A (short) List of Essential Resources: Judith Herman John Briere Viktor Frankl Pauline Boss Irvin 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.
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