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Working with Survivors of Torture

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Working with Survivors of Torture Abbey Weiss, PsyD, LP The Center for Victims of Torture Healing in Partnership Project June 8, 2012 – PowerPoint PPT presentation

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Title: Working with Survivors of Torture


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 830am-900am Introduction to
Working with Survivors of Torture. Background
, definitions, unique considerations 900am
-1000am Evidenced Based Practices and
Beyond Present the model of care at
CVT Present various modalities and
intervention strategies 1000am - 1030 am In
the Consulting Room Case 1 1030am -
1045am Break 1045am - 1115am Small group
work Discussion of case examples 1115am -
1130am Discussion with the larger
group 1130am -1200pm Secondary Trauma
1200pm - 1215pm Next Steps 1215pm -
1230pm Questions and wrap up
4
  • The Center for Victims of Torture
  • Founded in 1985
  • Current clinic location
  • CVT
  • Rehabilitative Treatment
  • Training
  • Research
  • 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
    education12.9
  • 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
7
(No Transcript)
8
A refugee...
An asylum seeker...
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.
  • Center for Victims of Torture

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
Torture is...
  • the deliberate and systematic dismantling
    of a persons identity and humanity.
  • the attempt to destroy a persons will to
    live, and their ability to trust in anyone or
    anything.
  • Center for Victims of Torture

12
Purpose of Torture
  • 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

13
Forms of torture
  • Most forms are low tech
  • Beatings
  • Forced labor
  • Deprivation
  • Wrongful imprisonment
  • Rape

14
Trauma/Torture Events
  • Life threatening
  • Unpredictable
  • Cant stop
  • 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
  • Butprolonged 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-experiencing
  • Avoidance
  • Hyperarousal

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
  • CVTs 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
TreatmentLong 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 workDiscussion 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 persons
    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 griefs
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 dont 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 persons trauma.
  • From Andrea Northwoods 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 youre waking up from
    a bad dream, and then realizing in a few moments
    that youre 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 others 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 cant 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
ABCS 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
PROFESSIONAL STRATEGIES
  • Recognize And Accept Secondary Trauma
  • Limit Exposure
  • Attend Empathy/Cynicism
  • Name Reenactments
  • Support Groups
  • Maintain Professional Connections
  • Professional Education
  • Supervision Secondary Trauma Consultation

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

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). Mans 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, LPaweiss_at_cvt.org(61 2)
436-4832
61
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