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Center for Victims of Torture in Guinea, West Africa


* * * * * * * * * * * * * I have organized this presentation more chronologically. I mention challenges as they arose in the timeline of the project, and the tactics ... – PowerPoint PPT presentation

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Title: Center for Victims of Torture in Guinea, West Africa

(No Transcript)
Capacity Building Methods for Providers of Mental
Health Interventions with Trauma Survivors in
Low Resource Countries
  • Center for Victims of Torture
  • (CVT)
  • Minneapolis, Minnesota

David R. Johnson, MD, MPH Linda Nielsen, MSW,
LICSW Pamela Santoso, MPH (cand.) Carol White,
MS, MPH (cand.) Neal Porter, MA, MPPM To heal
the wounds on individuals, their families, and
their communities and to stop torture worldwide.
  • Center for Victims of Torture, 2003

CVT is a hybrid health care human rights
  • I. Target population
  • Survivors of government-sanctioned torture or
    politically-motivated violence
  • II. Human Rights / Advocacy work
  • New Tactics for Human Rights (
  • Public policy work on Torture Victims Relief Act
  • Public policy work on US use of torture
  • Participate in national consortium of torture
    treatment centers
  • III. Local health care and capacity building
  • Two treatment centers in Minnesota using a
    multidisciplinary approach to treating torture
    survivors from over 60 countries
  • Ongoing trainings of local health professionals
  • New Neighbors Hidden Scars networking and
    capacity building project for community
    organizations working with survivors.
  • IV. National Capacity Building
  • Lead capacity building project with local torture
    treatment centers to develop organizational,
    clinical, advocacy and research capacity.

CVT International Projects
International Services International Capacity Building Project Trauma Healing Initiative - Cambodia
Provides direct services, training / capacity building, community sensitization. Builds clinical, organizational, advocacy capacity of foreign torture treatment centers. Develops capacity of government non-governmental service providers, expands resource network
-Sierra Leone -Liberia -Democratic Republic of Congo -Sudan, Ethiopia, Rwanda, Uganda, Kenya, Cameroon, Namibia, S. Africa. -Bangladesh, India, Cambodia, Pakistan -Palestine, others. -Cambodia -Works with multiple in country organizations
Guidelines for International Training in MH
Psychosocial InterventionsFor Trauma Exposed
Populations in Clinical and Community Settings
Weine, S., Danieli, Y., Silove, D., van Ommeren,
M., Fairbank, J., Saul, J.
Values Contextual Challenges Core Curricular Training Elements Monitoring Evaluation
-Respectful -Scientific -Legitimacy of multiple perspectives -Open dialog -Integrating differing perspectives -Culturally sensitive -Entering insecure environments -Needs of all subgroups considered -Integrated with development efforts -Address short long term challenges -Transparent -Uses public health principles -Listening communication skills -Assessment -Interventions to diminish distress -Understand local context -Problem solving strategies -Treat unexplained somatic pain -Ongoing supervision structure -Covers self care -Training include monitoring / eval. -Identify objective w/ needs assess. -Identify process indicators -Indicators to evaluate impact on trainees skills, on services, and on beneficiaries. -Use appropriate approaches -Report / dissem.
Contrast Three Diverse Models of International
Capacity Building
  • Strengths challenges of model
  • Control
  • Scope / beneficiaries
  • Sustainability
  • Effectiveness
  • Evaluation strategies
  • Ethics
  • Project description Target population
  • Model selection process
  • Lessons learned from project implementation

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Center for Victims of Torture International
Services Program
CVT International Services Program Description
  • Countries with large population of highly
    traumatized refugees/returnees Liberia, Sierra
    Leone, Dem. Rep. Congo
  • Qualified expatriate Clinicians provide intensive
    hands on training to national staff -
    Psychosocial Counselors (PSCs)

Current CVT International Services Programs (ISP)
  • Sierra Leone
  • Kono district communities
  • Liberia
  • Monrovia
  • Lofa County
  • Bong County
  • Dem. Republic of Congo
  • Communities in Katanga district (Pweto and

CVT ISP Key Activities
  • I. PSC Training
  • 2. Client Care
  • 3. Community Outreach

Key Activity 1 Training the PSCs
  • CVT Clinicians recruit and train Psychosocial
    Counselors (PSCs) from the refugee community.
  • The PSCs start an intensive training program that
    continues throughout their career with CVT.

Key Activity 1 Training the PSCs
PSCs serve as interpreters and cultural brokers
and help to adapt counseling models to local
  • Initial two-week training
  • Pre- and post-testing
  • First, PSC observes Clinician lead session
  • PSC co-leads, then leads
  • Clinician observes and provides feedback to PSC
  • Ongoing monthly focused 1-3
  • day workshops

Key Activity 2 Client Care
  • Elements of direct mental health services
  • Client identification
  • Intake assessment
  • Group or individual treatment planning
  • Counseling sessions
  • Follow-up client assessments
  • Home and family visits
  • Referrals to other agencies

Key Activity 2 Client Care
  • Small Group Counseling
  • Sessions provide psychoeducation and opportunity
    for trauma processing
  • Sessions average 8-10 weeks, 1.5 hours per week
  • Groups average 6-12 members
  • PSCs participate initially as interpreters, then
    learn how to facilitate groups on their own
  • Individual Counseling
  • For clients unable to attend group sessions due
    to extremity of symptoms or with a great need to
    address problems 11
  • Carried out by expatriate Clinicians until PSCs
    ready to counsel on their own

Counseling hut and PSCs
Key Activity 3 - Community Sensitizations
  • Raise awareness of the prevalence and effects of
  • Help community members know what CVT does to help
  • Help identify potential clients.

Key Activity 3 Community Psychosocial Activities
  • Provide activities such as games, drama, arts and
    crafts, and sports activities provided regularly
  • Engage the community in the healing process,
    promoting positive extra-curricular activities
    for clients.
  • Help identify new clients.

Target Populations- Beneficiaries
  • Survivors of torture and their families in
    refugee settings or communities of return
  • National Staff trained to serve as PSCs
  • Staff at other agencies and community leaders

Model Selection/Context
  • Indigenous capacity in mental health service
    provision is non-existent or destroyed
  • Torture extremely prevalent among target
    population- more than 50
  • Availability of partner agencies nearby to
    provide basic needs, security
  • Need to have enough staff to address high risk of
    vicarious trauma for both expats and local staff

CVT ISP Strengths/Challenges
Strengths of ISP
Hands-on, immediate, continuous clinical supervision and training, allows for long-term professional and documentable skills building
Easier to document improvement in clients
Easier to adapt western therapy models to indigenous culture
Potential to integrate learning back at CVT headquarters
Immediate post-conflict response and treatment but have to balance with security issues
PSCs heal from their own trauma through their work at CVT - Relationships with families and others are improved
Challenges of ISP
Challenge to find qualified expatriate Clinicians and integrate respective skills/interests
Full program means covering all security, financial accountability, human resources, personnel management remotely
Building capacity of national staff to be more independent providers requires 4-5 years minimum
Consistency required in services and training when much is uncertain (funding, political conditions, logistics)
Community acceptance of mental health mission difficult with high material needs of beneficiaries
And its very expensive!
ISP Scope
  • Over the 3 programs in Sierra Leone, DRC and
  • 2,227 clients received direct counseling in 2006
  • 10,714 clients since 1999
  • 1 expatriate clinician required to supervise
    12-15 PSCs
  • 88 PSCs and 6 expatriate clinicians currently
  • Over 250 PSCs trained since 1999
  • 26,671 community members participated in
    sensitization in 2006
  • 1,951 NGO partners, health care, teachers and
    community leaders trained in 2006

ISP Scope
Sierra Leone Kono district communities Admin
office in Freetown
Liberia Lofa County Bong County Monrovia
Dem. Republic of Congo Katanga district (Pweto
and Lubumbashi)
Four to five communities for each site in each
  • Must build skills of entire staff, not just PSCs,
    to ensure long-term sustainability
  • Requires a resource rich and/or diversified
  • donor base to meet the costs
  • Requires clear justification to donors of need
  • development of national staff as mental heath
  • paraprofessionals and of time it requires

  • Better ability to document improvement in clients
    through long-term follow up
  • Widely accepted in communities of operation after
    initial skepticism
  • Good response to services from communities and
    partner agencies

  • Clients-- at 3-month intervals, symptoms social
    support behavioral functioning
  • PSCs--internal trainings and performance
  • External training of partners, health care,
    teachers, religious and community leaders
  • Clinicians--performance

PSC Evaluation
  • Assessed through regular observation,
    supervision, written reports
  • Receive monthly trainings with pre- and
  • Semi-annual performance evaluation
  • Client care
  • Community outreach
  • Training skills
  • Demonstration of ethical conduct
  • Group facilitation skills
  • Learning and listening skills

Lessons Learned
  • Need to make sure there are enough resources
  • Good field management essential
  • Good financial management essential
  • Orientation to CVT organizational culture
  • Not stretch staff too thinly
  • Concentrate staff in minimal number of sites
  • Communities of return more challenging than
    refugee camps
  • Support is crucial

Tired clinicians
Ethical Considerations
  • How to address the issue of ongoing clinical
  • What can we offer our staff in terms of a leave
    behind piece?
  • How to practice as a Human Rights organization
  • Standards of practice (confidentiality, etc)

From Left to right, back row Neal Porter, Jon
Hubbard, Ivan DeKam, Jean-Baptiste Mikulu, Gwen
Vogel, Nelson Kaputo, Cathy Mwaniki, Alieu
Sannoh. Front row from left, Amy Jo Versolato,
Yuvenalis Omagwa, Sharon Gschaider, Linda
Nielsen, Edie Lewison, Michael Kamau Kariuki
(No Transcript)
International Capacity Building ProjectBuilding
capacity of torture treatment centers
  • Pamela Kriege Santoso
  • The Center for Victims of Torture
  • October 31, 2007

Goal of the ICB Project
  • Work with torture treatment centers to strengthen
    their capacities
  • Clinical
  • Organizational
  • Technological
  • Advocacy
  • So better positioned to be sustainable and
    provide effective services

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ContextRole of Torture Treatment Centers
  • About 200 torture treatment centers worldwide
  • Small, isolated, lacking social support
  • Specialized programs can contribute to building
    of knowledge of torture treatment

ContextRole of Torture Treatment Centers
  • Unique role as healers for treatment and advocacy
  • Design interventions that are appropriate for
    local and regional circumstances

  • Torture Treatment and Rehabilitation Partner

Bucharest, Romania Financial management
training leading to update
of internal financial management system
Sofia, Bulgaria Rehabilitation services to
torture survivors from Turkish minority and
establishment of mobile units in Varna and Isperih
Pristine, Kosovo Rehabilitation services,
advocacy, and training of professionals and
students, CBT training for staff
Islamabad, Pakistan Rehabilitation and monitoring
of torture cases in local prisons, training
Ramallah, Palestine New offices in north and
south of West Bank, and evaluation of internal
and external services
Dhaka, Bangladesh Community outreach programs,
torture prevention training for health and law
enforcement professionals, and advocacy work
New Delhi, India Rehabilitation services and
training of health, law, and human rights
Guatemala City, Guatemala Psychosocial monitoring
during mass grave exhumations, and staff
development in technology use and mental health
Khartoum, Sudan
Kono, Sierra Leone CVT provides direct
counseling services and trains local
psychosocial counselors
Phnom Penh, Cambodia Trauma Healing Initiative
(THI) Building clinical and public education
capacity among a network of torture treatment
Yaounde, Cameroon
Addis Ababa, Ethiopia Rehabilitation services and
anti-torture education training
Kampala, Uganda Technology acquisition, public
awareness raising efforts, staff development
trainings, legal services to torture survivors
Nairobi, Kenya Forensic work and monitoring of
prison detainees
Kigali, Rwanda Rehabilitation services, torture
prevention efforts, staff development training
Lima, Peru Clinical and technological skills
training and direct services
Windhoek, Namibia Rehabilitation services and
mobile clinic in northern regions and staff
development training
Cape Town, South Africa Organizational
development, advocacy and lobbying, program
management training
Key Project Activities
  • Organizational assessments
  • Operational sub-grants
  • Technology sub-grants
  • In-country technical assistance from local or
    international consultants
  • Workshops
  • Staff exchanges
  • Database and website development
  • Monitoring and ongoing follow-up coaching

Centro de Atencion Psicosocial (CAPS), Peru
  • The unique aspect of this project is that it
    helps us identify our institutional needs, while
    respecting our own goals and timeframe for the

Examples of Service Delivery enhancement
  • Salaries for clinicians / new staff
  • Community assessments
  • New programs (for children, refugees, prisoners)
  • Mobile clinics
  • Training of other professionals
  • Supervision
  • Training on counseling skills, techniques
  • Workshops
  • Exchanges with other centers

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Evaluation Organizational Matrix
Functional Areas Governance Organizational Operations and Management Systems Human Resources Financial Resources Service Delivery Information Technology External Relations Ratings Emerging Developing Consolidating Sustaining
E. Service Delivery
  • The quality of service delivery is the strongest
    indicator of the success and effectiveness of an
    organization. A viable organization not only
    provides quality services to meet community needs
    but also is able to provide this level of
    excellence over time. Two principle
    activities/outcomes that need to be considered
    are Direct Services to clients and Public

Emerging Developing Consolidating Sustaining
SECTORAL EXPERTISE Organization has limited track record in sector and area of service delivery but some good ideas about how to meet needs of target community/constituencies. It has little operational experience however and no specialization in the sector. Improved targeting and redefined service/technical assistance package. Growing expertise in technical area and ability to access additional expertise in that area when required. Client base well defined and well reached. Efficient delivery of appropriate services. Fee for service and other cost recovery mechanisms being built in to service delivery process. Organization being recognized as having significant expertise in technical area and being invited to contribute to these areas. Organization is able to adapt program and other service delivery capacities to changing needs of constituency and to deliver services to additional communities/ constituencies. Full recognition as experts in technical area and given consultative status in those sectors by government and other multi-sectoral organizations.
IMPACT ASSESSMENT Organization does not systematically monitor or evaluate program/project achievements against projected or planned activities. It does not measure overall impact and has not determined impact indicators or established baseline measures of indicators. Individual projects evaluated to determine if projected activities took place as planned and if specific project objectives were achieved. These objectives may or may not be measurable. The Organization is aware of the issue of program sustainability and is exploring how to measure impact. There are no overall impact indicators selected and no baseline data available or accessed to provide basis of comparison. Measurable indicators of success and impact have been determined. Studies are conducted or accessed which provide baseline measures. This information is regularly re-measured.
Development of a Clinical Matrixfor Torture
Treatment Services
  • Clinical Program Management
  • Clinical Processes
  • Accessibility / physical premises
  • Client intake
  • Clinical records
  • Clinical Training and Experience
  • Staff Clinical Supervision
  • Staff Self-Care
  • Staff performance evaluation
  • Client Services
  • Overall Program Impact / Evaluation
  • Developing Healthcare Pathways for Constituents
  • Individual Client Outcome Measures

2.2 Client Intake 2.2 Client Intake 2.2 Client Intake
Emerging Developing Consolidating Sustaining
2a) Target group not well defined and/or not clear to others.     2a) Target group clearly delineated and specified externally.
2b) Initial client screening process conducted by non-clinician or inexperienced clinician.     2b) Initial client screening process conducted by experienced clinician.
2c) Limited client education about principles of information and treatment confidentiality.     2c) Extensive client education about principles of information and treatment confidentiality.
Strengths of this model
  • Centers already exist no start-up
  • Locally run
  • Partners actively involved in developing training
    and technical assistance plan
  • Can learn from other centers in project
  • Strengthens worldwide movement
  • Holistic approach not just focused on Clinical

Challenges of this model
  • Treatment centers not always where there is need
  • Source of funding may limit partners
  • Lack of trained mental health professionals in
    many developing countries university and other
  • Takes time and funding to improve clinical skills
  • Interest in new techniques while needing basic
  • Loss of staff to higher paying Intl. NGOs
  • Hard for CVT to measure impact on beneficiaries
  • Partners ultimately in control of decisions
  • Risk of dependency on CVT funds

Lessons Learned
  • Strong personal relationships are key
  • Basic counseling skills still needed
  • Must continue to support fundraising and project
    management skills

Partners worldwide doing great work, under
difficult circumstances, with little support
Trauma Healing Initiative Cambodia Building a
culturally appropriate healing
  • Carol White
  • The Center for Victims of Torture
  • Oct. 31, 2007

Project charge
  • To address the high levels of trauma in Cambodia

Poverty Domestic violence Community violence
and exploitation Depression, alcohol abuse,
What model to choose?
  • Direct services with a training component?
  • Training community mental health workers?
  • Professional education?
  • Support a torture treatment/human rights

Project Context
  • Currently one of the poorest countries
  • 80 of population engaged in rural subsistence
  • Trauma is a public health problem.
  • Older generation
  • New levels of violence
  • Rampant government corruption use of violence

Project Context
  • Trafficking gangs practice sexual assault and
    other forms of torture to enforce their control
  • High levels of domestic violence can include
    torture (acid attacks) Adequate mental health
    infrastructure to build local professional
  • Assets
  • At peace for over 15 years
  • Active civil society many NGOs
  • Rapid economic growth
  • Strong family systems
  • A budding mental health infrastructure

A culture of impunity
  • No legitimate war crimes trials have been held
    since Pol Pot times
  • No truth and reconciliation process
  • Former Khmer Rouge KR victims live side by
    side many local officials are former KR
  • Land-grabbing other problems with rule of law
  • After 30 years a tribunal has now been
    authorized, to last 3 years prosecute up to 6
    top leaders, starting in 2007

Exhumed skulls from the killing fields
The model we chose
Trauma Healing Initiative Strategy
  • Training of trainers
  • 2. Community outreach education strategies
  • Training the Network
  • Network model development

Steps in the planning phase
Our first challengeSetting the stage
  • Is it feasible? Do people want it?
  • How can we position the project to get the
    broadest support?
  • Who should lead the effort in Cambodia?

Feasibility assessment
  • Met with 20 organizations
  • 30 key informants
  • Explained project concept

(No Transcript)
Get National Program for Mental Health congruence
  • Dr. Ka Sunbaunet, Director
  • 20 year mental health plan
  • Interest in participating
  • Congruent with plan

Assess relevance to upcoming Khmer Rouge trials
  • Royal Government of Cambodia task force
  • Helen Jarvis, special advisor

Choose implementing partner
  • TPO Cambodia
  • MOU/subgrant
  • scope of work
  • Hire coordinator

And the partner chooses us.
Bring potential core group agency leaders
together for the call
Our next challengeEngaging partners in the
  • Engage individual clinicians
  • Get buy-in from agencies
  • Build knowledge trust in CVT among individuals

Engagement tactics
  • International training events
  • Start regular meetings to share cases decide
    training topics
  • Help review project plan
  • Social time

A core group of clinicians begins to meet monthly
from 9 organizations
  • Trafficking victims
  • Human rights/torture clients
  • Extreme domestic violence/rape clients
  • Government psychiatry
  • University psychology department
  • Childrens mental health
  • Community mental health/training/trauma treatment
  • Khmer Rouge anti-impunity documentation
  • Cambodian returnees from the U.S.

Progress in the implementing phase
The next challenge How to train the Core Group
of Clinicians
Expert trauma training consultant living
in-country for one year
  • In-depth training in psychotherapy(150 hours to
  • Case consultation observation
  • Agency consults as requested
  • Pilot curricula for future maualization

The next challenge How to sustain and deepen the
learning ?
  • Create treatment and training manuals
  • Continue expatriate consultant function as long
    as possible
  • Incent organizational experimentation service
  • Encourage collaboration among partner agencies

Examples of collaboration among partners
  • Department of psychology
  • National Program for Mental Health
  • NGO requests for assistance
  • 5 requests for service enhancement subgrants

By the end of four years, THI hopes to have
  • Trauma treatment and training manuals
  • Piloted public education strategies
  • A core group of multi-disciplinary Cambodian
    clinicians who can train others
  • Piloted innovations in ongoing clinical
    supervision and training
  • A trauma clinic functioning in Phnom Penh that
    cares for torture survivors and serves as a
    training site

By the end of four years, THI plans to have
  • A functioning network of agencies and individuals
    in one urban and one rural area.
  • Ongoing relationships between clinical providers
    serving torture/trauma survivors and human rights
    organizations concerned about prevention of and
    accountability for these abuses.
  • A means of tracking and evaluating the level of
    impact the network is having on reaching and
    serving the target population.

Overall challenges with this model of
  • Low control vs. buy-in low cost
  • Potential for high impact sustainabilitybut
  • High risk for failure
  • How can technology help in low resource/tech
    savvy environment?
  • Is there a tipping point when local agents
    continue to collaborate and train on trauma
    treatment ?

a brighter future for Cambodia !
Guidelines for International Training in MH
Psychosocial InterventionsFor Trauma Exposed
Populations in Clinical and Community Settings
Weine, S., Danieli, Y., Silove, D., van Ommeren,
M., Fairbank, J., Saul, J.
Values Contextual Challenges Core Curricular Training Elements Monitoring Evaluation
-Respectful -Scientific -Legitimacy of multiple perspectives -Open dialog -Integrating differing perspectives -Culturally sensitive -Entering insecure environments -Needs of all subgroups considered -Integrated with development efforts -Address short long term challenges -Transparent -Uses public health principles -Listening communication skills -Assessment -Interventions to diminish distress -Understand local context -Problem solving strategies -Treat unexplained somatic pain -Ongoing supervision structure -Covers self care -Training include monitoring / eval. -Identify objective w/ needs assess. -Identify process indicators -Indicators to evaluate impact on trainees skills, on services, and on beneficiaries. -Use appropriate approaches -Report / dissem.