Friday, November 20, 2009

Lessons from the Field


TREATING TRAUMA: LESSONS FROM THE FIELD
With Arshad Husain

In the picture I am demonstrating safe place with one of our participants in Pakistan.

        Since 1994 Dr. Arshad Husain, child psychiatrist, University of Missouri-Columbia, has been leading teams from the International Center for Psychosocial Trauma into trauma zones to help victims and professionals deal with the negative psychological consequences of exposure to death and destruction. Since 1996 as a retired professor emeritus of psychology from the University of Missouri-Columbia I have been able to arrange my part-time teaching schedule so that I can travel as a frequent member of the team.
         Essentially the goal has been to train physicians, psychologists, social workers and teachers about ways to help victims of disasters, about ways to train other professionals to help victims, and about ways to help themselves cope with their own Psychological Trauma Stress Reactions as many of them also have been victims.
        The kinds of trauma zones we have worked in have varied from ethnic cleansing in Bosnia, Kosovo and Rwanda, struggle for independence in Palestine and Chechnya, war in Iraq and Afghanistan, and natural disasters in India, Sri Lanka and Indonesia. Our team has learned lessons from each disaster that have been helpful in preparing to work with the next crisis. Whether the disaster is man made or natural, we have learned 10 principles about dealing with traumatized survivors and their helpers that hold true across cultures.
As we discuss these ten lessons, we will also review how our program has evolved.

1. Any team expecting to provide help needs cooperative support at ground zero.
         It is not enough for a competent expert to arrive offering services. Cooperative help at ground zero is needed to bring victims and helpers together in a venue that allows for services or training to be given. An outsider cannot provide his own delivery system.
        One of our team’s failures occurred in Rwanda, where there had been no organization on site to make the necessary arrangements to bring victims and potential therapists together with a training team. This need for on-site, local organization became clear on Husain’s first entry into international trauma work in Sarajevo, Bosnia, in 1994. He arrived knowing that administrators in a position to make arrangements often need to be convinced that an organization offering a service will be providing something of value.
        In Husain’s case he arrived with a specific description of a program of action in hand. First he had to sell the idea of “teachers as therapists” to UNICEF headquarters, then resold it to the staff of the Edhem Mulabdic School in Sarajevo. Not knowing Husain or what he could do, administrators were initially cautious in accepting his training program that he called “teachers as therapists.”
        After a trauma many people want to help, but expect the experts at the site to know how to use whatever skills they bring with them. Many people who want to help do not have a program of action or the necessary expertise that are valuable for a trauma situation. Furthermore, at least in the U.S. more people can be available for tasks than can be used. This occurred after 9/11, (Langewiesche, W., 2002).
        Once the Missouri team had established its value in Bosnia, contacts and arrangements were much easier to make. After 15 years of providing training in the treatment of trauma, Husain has worldwide connections through various organizations such as the World Health Organization, the World Federation of Mental Health, the United States Department of State, and the Red Crescent Society in Muslim countries. These organizations understand the team’s program of action and help Husain make connections in trauma zones where programs are needed.

2. Never enough mental health workers are available to do what is needed.
        On his first trip to Bosnia in 1995, Husain found that thousands of victims with post-traumatic stress reactions had only a limited number of mental health workers available to work with them. Worse, the mental health workers who were available were specialists in mental illness and knew little about post-traumatic stress disorder (PTSD). Although they were aware of the symptoms of victims, they didn’t know how they fit into the diagnosis and that these were expected reactions to horrific or life-threatening events.
         Because there were so few professionals trained in mental health, an approach was needed that would allow a large number of victims to be treated by persons who had not previously been trained in the mental health field. The training program needed to be intense, short and to quickly give the trainees usable treatment skills.
        In Bosnia many teachers had close contact with children and were in a good position to recognize symptoms of PTSD as well as any changes that took place after treatment. In addition they were intelligent people who could be trained in procedures that might prove therapeutic for the children. Although years later it appears obvious, at the time this concept of teachers as therapists was a new one. It was not readily accepted, either by administrators or by the teachers themselves.
        At first teachers complained that doing the various therapeutic activities in their classrooms would take away from their government prepared course outlines requiring them to cover a certain amount of subject matter every week. As the teachers were introduced to some of the consequences of trauma such as concentration problems, hyperactivity and hyper-arousal, they recognized that many of their students would not be able to learn the required materials until after they had practiced some of the therapeutic techniques.
The success with teachers opened the door to other groups. Physicians, psychologists, social workers and nurses also began wanting the same basic training that had been given to teachers. We added additional training to physicians on the use of psychotherapeutic drugs.
        As time went on, we also taught similar techniques to mothers of children in a Bosnian refugee camp for survivors of Srebrenica. For example, Husain demonstrated therapeutic interviewing with a depressed boy. The boy felt he had no future since there were no facilities to do anything, and he wanted to be a soccer player more than anything. Using the boy as an example, the community was shown how to mobilize its meager resources to provide space for the children to play; in so doing the community demonstrated how it valued the children. A later visit found the refugee community with a team playing in the local league.
        In Sri Lanka after the tsunami the team even found that faith healers were a primary source of help for trauma victims, and 26 of them attended one of our training programs.

3. Structured group treatment is effective with children.
        Although some cultural differences exist in how children express their distress, we have been pleased to find that the techniques developed for use with American children also work with traumatized children from other cultures. Research indicates that group mental health activities with traumatized children have a positive impact regardless of cultural background as long as the activities have culturally specific content (Galante and Foa ,1986; Goenjian, Karayan, Pynoos and Minassian, 1997; Yule and Canterbury, 1994).
        For example, Goenjian, et.al. (1997) using a school-based program studied 64 Armenian children, survivors of an earthquake that killed over 25,000 people. On the face of it, the therapy done was minimal. Half of the children received four half-hour group sessions and an average of two one-hour individual sessions over a three-week period. This was done a year-and-a-half after the earthquake when symptoms of PTSD would be expected to have either diminished or to have become chronic.
        Many children, however, continued to have active symptoms of both PTSD and depression despite the passage of time. Although the immediate danger had passed, many problems created by the aftermath of the earthquake remained: displacement of families, lack of adequate housing, insufficient medical or mental health services, and shortages of food. The children were exposed on a daily basis to demolished buildings as reminders of the disaster.

In the therapy sessions with the children, five major areas were covered:
1. Reconstructing and reprocessing their experiences, including excessive guilt
2. Identifying and dealing with traumatic reminders
3. Dealing with change and loss resulting from the disaster
4. Bereavement and grief resolution
5. Identification of missed developmental opportunities.

        The authors came back 18 months later, now three years after the disaster, and found that the treated children had diminished post-traumatic symptoms with no increase in depression. The treated children had improved on all three PTSD symptom categories: intrusive thoughts, hyperarousal and avoidance. The untreated group had worsened symptoms on measures of both PTSD and depression.
The authors concluded that their findings demonstrated the cross-cultural applicability of Western therapeutic approaches in a non-Western culture.
        Our own experience in a variety of trauma zones is consistent with the results of these studies. The teachers and mental health workers we have trained report they can see significant improvement in the behavior of their students/clients after using the techniques we are discussing in this chapter.

4. We found that by giving additional training to our best students that they could then train others.
        It was not long after the program had begun that it was recognized that the Missouri International Center for Psychosocial Trauma did not have the resources financially or in the number of trainers to provide the number of training sessions that were needed for those interested in being trained.
        Husain then developed the idea of taking the most capable participants from our classes abroad and bringing them to the University of Missouri-Columbia campus for a month-long training program. Called Training the Trainers, it was expected that these participants would return to their own countries and educate others in treatment techniques.
        The initial training occurred in 1995, shortly after the Oklahoma City bombing, and included 15 teachers from Oklahoma City as well as 30 teachers and physicians from Sarajevo. This intense course covering a wide variety of topics related to trauma was my introduction to the International Center for Psychosocial Trauma.
        That summer program resulted in the team developing a close relationship with staff from Tuzla, Bosnia. At this point many nongovernmental organizations were working in Sarajevo and only a few in Tuzla. The team at this time diminished their training efforts in Sarajevo and increased them in Tuzla.
        Over time, financial constraints reduced the summer program to a week. Last the post 9/11 visa restrictions based the nation’s fear of terrorists makes it difficult, if not impossible, to bring in professionals from countries such as Iraq and Afghanistan where training is needed. As a result of these restrictions only one of the people invited from Sri Lanka and none invited from Indonesia were able to attend the 2005 summer Training the Trainer program. We find it ironic that one arm of the U.S. State Department supports our program, while another arm’s refusal to grant visas interferes with our mission.

5. Trauma symptoms may vary, but the basic symptoms are similar across types of traumas.
        Initially after a severe trauma event such as an ongoing conflict or a natural disaster that kills thousands, a large percentage of children will have marked symptoms. The most important element is not the type of trauma, but the extent to which the child is exposed to the threat of death, loss, or horrific scenes. Similar observations were made by Goenjian, et.al. (2000).
         Post-traumatic reactions often run as high as 95% as they did in Sarajevo during the war and after Hurricane Andrew among those children who had lost their homes. Because many children are naturally resilient or have protective psychological resources even in a major disaster, after a year the number showing marked symptoms will have shrunk to 30 or 40 percent. Sleep disturbances will be a major problem, with nightmares being frequent. These may involve replays of the incident or, in younger children, may be dreams of monsters.
        Hyper-arousal is common, with the child over-reacting to certain cues varying from situation. In Sarajevo one cue for anxiety was light. Although children usually are likely to be afraid of the dark, children from Sarajevo became frightened during the light because of its association with the terror of snipers. In Sri Lanka and Indonesia the sound of rushing water provoked anxiety, with even the flushing of a toilet causing a child to run out of the room. After the earthquake in India the cue was going into a building, since most of the 80,000 deaths had been caused by falling buildings. Sleeping outside, even in the cold was preferable.
Inability to concentrate, flashbacks, and memory loss for the event were also common. I found my first visit to an orphanage in Tuzla, Bosnia, disturbing and exhausting because the children were so hyperactive and overly alert to the cues around them. As one point I had to get out of the building for a period because my body was mirroring so much of their anxiety.

6. A poor translator is a major handicap.
        With the exception of Pakistan, where English is spoken by most professionals, we are usually working with participants who speak languages we do not understand. This means we must rely on local translators arranged by our hosts. Translators have varied in competence from excellent to questionable.
        On several occasions we have been fortunate to obtain the services of professionals with modern equipment who do instantaneous translations with the use of mikes and earphones. The situations we are concerned about are those where the participants interrupt to correct the translator with, “That’s not what the speaker said.” They then proceed to tell the class what was really said. On several occasions when this has happened, we have been fortunate to have a psychiatrist or teacher among the participants who can assume the responsibility for translation.
        That leaves us to wonder how much of what we say has been understood and communicated. Even with a good translator we can have problems. In Istanbul where we were working with Chechens our translator, after we would give a rather long sound bite, would say just a few words and claim that was the translation. On another occasion we found that a short statement from one of us would result in a long discourse. In that case we found the translator was editorializing, and we asked him to please stop.
One way to compensate is to use translators we can trust to translate our manuals and training materials into the local language ahead of time. The teams’ basic training manual has been translated into six languages: Bosnian, Arabic, Russian, Indonesian, Pushtu and Chechen.
        A recent experience was getting ready to go to Indonesia soon after the tsunami. The Provost at the University of Missouri-Columbia put out a request for translators. Students from Indonesia at the university responded and prepared our training materials in a matter of days.

7. Training materials and training concepts evolve with experience.
        From the beginning we have concentrated on finding treatment techniques or procedures that can be used with groups of victims. At the end of each training program we divide the participants into groups to prepare a feedback session. We use this feedback to evaluate what we are doing and how we can do it better.
        Our programs are highly interactive. Although we use some lecture material, we use less than we did in the beginning. This is because participants keep emphasizing they don’t want much theory; they want practical techniques that they can use now. Our workshops have become lessons in “how to.”
        One format we use is to demonstrate a technique and then have the participants practice it, sometimes in pairs and sometimes in a small group setting. This also has the advantage of allowing them to work in their own language without the intermediate translator. We also ask for feedback on the technique being used to see how it could be improved in their situation.
         Emphasis is also placed on helping the participants find ways to change the content of the exercises to fit their particular culture. For example, training the participants to use the mental imagery of a safe place works in all of the cultures where we have demonstrated it.
        The particular kind of safe place varies from country to country. In the U.S. an individual’s safe place often has a beach scene or other place with water. In Sri Lanka after the tsunami no one used a water scene, instead going to an inland mountain scene. Bosnian clients often used their childhood bedroom as the imaginary safe place.
        The participants appreciate seeing us work with real clients. Husain often demonstrates interviews with traumatized children. Our participants are surprised to see how direct these interviews are and how positively children respond to the opportunity to share their experiences. In some cultures these demonstrations are especially important because the cultural norm is not to talk about what has happened to you, but to forget it. Repression is the defense mechanism of choice.
        We should stress, however, that our primary techniques are not uncovering techniques but rather a full range of activities that deal with a range of symptoms caused by the trauma. Although we believe that discussions of the trauma event and symptoms can be helpful, we also believe that attention must be paid to social networks, self-talk, relaxation techniques and a variety of expressive techniques to work off tension and provide non-verbal ways of dealing with symptoms.
        In a typical program, participants will be introduced to four techniques for helping children relieve tension: progressive relaxation, deep breathing, autogenic suggestion, and safe place imagery. After practicing several of these they are asked to come up with other relaxation techniques that they could use. The most usual are prayer, mediation and listening to music.
        The use of support groups and positive self-talk are demonstrated and practiced. Various experts also demonstrate play therapy and art therapy. In each class there is usually a teacher who has special expertise in art therapy who adds to the class by demonstrating what she is already doing with her students.
        More recently we have been introducing the idea of storytelling as a therapeutic technique. This works naturally with our section on grief and grieving. Over all we have been impressed with how easily some teachers take to these ways of working with traumatized students.
        One of the advantages of storytelling is that like self-talk it encourages resiliency. We try to strike some balance between encouraging the hope that recovery is possible and very probable; but there is no shame that sometimes it takes time for symptoms to diminish, but there are good ways to speed the process. At times some amount of repression and actively moving on is useful.
        Participants do not always welcome new ideas. Dr. Kathy Dewein on a trip to Sri Lanka after the tsunami reported a problem at first with getting participants to see the value of play therapy. The idea that organized play could be therapeutic was a foreign concept to them. With additional demonstrations, such as how to use puppets to converse with the children, they saw how play could be used as part of the treatment package.

8. Formerly hostile groups can work together profitably
        In 1998 a team went to Moscow to train mental health workers from areas in the Caucasus that had been in conflict with each other. The 50 participants were from Georgia, Abkhazia, South Ossetia, Chechnya and Russia. Our biggest concern was that the Chechnyans would have trouble with some of the other participants.
        We mixed up the ethnic groups in small leaderless groups and gave them a series of questions to lead them to discuss mutual problems and interests. To our delight and surprise, within 15 minutes the participants who were previously enemies were talking like old friends.
        In one group, teachers from Georgian communities who had been fighting each other and who had not spoken in six years formed close working relationships. The conflicting parties felt that they related well because they were professionals and their professionalism overrode their differences. Some of the members were already proposing regional meetings to stay in contact with each other. We found a similar phenomenon in Sri Lanka after the tsunami. Tamils, Christians, Hindus, Sinhalese and Muslims were not in the habit of working together and were often hostile to one another. When the team first met with this diverse group, ethnic tensions were evident. Although this was the first time these professionals had come together to work on mutual problems, close relationships developed between the groups as they shared their problems and experiences. Again as we saw in Russia by the end of the program, these former antagonists were making arrangements to continue working together at their home bases.

9. Helpers also have problems dealing with the death and destruction around them.
        My first contact with the team came in 1995, shortly after his retirement, when I and Dr. Barbara Bauer were asked by Husain to prepare a self-care program for the participants in the month-long summer program, “Training the Trainers.” I had been working with stress among law enforcement personnel and burnout among family service workers.
        Techniques were developed to help the teachers and physicians take care of their own responses to trauma and the secondary trauma of working daily with other victims.
        A typical case was one I worked with in Istanbul. The physician said he had tremendous guilt about not staying in Chechnya and fighting the Russians. He felt he had let his people down and that he should have been willing to die. It was of help for him to be reassured that he will be of more value to his people as a trained doctor than as a dead, forgotten hero.
        This problem has been particularly acute among certain professionals. For example, a group of physicians from Iraq who came to a training program in Jordon were extremely demoralized and in a survivor mode. Their attitude was: “How can I survive through this?”
        The ongoing war in Iraq is a terrible time for them and their children, and they had had no hope that things would get better in the near future. It was taking all of their psychological strength to live in the chaos of Iraq. In Bosnia military doctors felt guilt when soldiers they had sent back into battle were killed shortly thereafter.
        Our program on helping the helper is directed at giving the participants some strategies they can use to protect their own mental health. The most common ways to cope are to engage in activities that promote physical health and well-being, such as exercising, sleeping well, and eating healthy foods. These are sometimes difficult to do in a trauma zone.
        The second group of activities involves spiritually oriented activities, such as meditation, being in nature and keeping a journal. Third, we encourage developing pairs or teams to debrief each other and serve as a sounding board for each other’s concerns. Lastly, we have the participants work out a plan of self-care that includes their support group and leisure activities to restore a balance in their lives.
        It has become obvious to us that helpers need active encouragement and permission to take care of their own mental health needs when so many people are making emotional demands upon them.

10. Irrational guilt can interfere with recovery.
         Children often feel responsible and guilty for events that are really beyond their control. These sources of guilt only become apparent when the child is given the opportunity to share. In Bosnia, Husain found children who felt guilt because they believed they could have done more to save a parent’s life, or because they had been angry at the parent shortly before the death, thus feeling they may have willed the parent’s death.
        In one very emotional demonstration Husain interviewed a young woman who felt she should have been the one who died from a sniper attack rather than her father who was walking beside her. Using role playing he helped her to discover that her father would have wanted her to live since she represented his future as well.
        In Sri Lanka and Indonesia it was not uncommon to find people who felt responsible for a death because they could not hold on to others as the force of the water tore them out of their arms.
In a group that Husain ran in Banda Aceh, Indonesia, following the tsunami, one woman, dreamt about a dead friend who asked her to come into the water and join her in death. In that culture it is not unusual for individuals to dream that a dead person is inviting them to cross the barriers to death. This often seems to be the result of survivor guilt, something we have encountered frequently in our workshops. We have found that once uncovered these source of guilt can often be dealt with rationally and logically.
        An idea that works well in one cultural setting may not work well in a different setting. Husain has written in his book, Hope for the Children: Lessons from Bosnia that mental health professionals in Bosnia treating victims of post-traumatic stress often referred to “aggressors,” not Serbs. The intent of the change in words was to break the cycle of ethnic hatred that had haunted the area for hundreds of years. They taught the children not to think in terms of revenge, but in terms of forgiveness. Experience there and elsewhere has shown that focusing on revenge makes it difficult for children to recover from trauma.
        While making a presentation to Palestinian physicians at a conference in Jordan, Husain emphasized that professionals should focus on healing the trauma, which is aided by this forgiveness approach.
This discussion of forgiveness and revenge led to the participants verbally attacking Americans and a complete rejection of the concept. They were not about to consider forgiving either Israelis or Americans. It was clear that what one group was ready to use therapeutically another group was not.


Conclusion
        At times in the beginning it seemed that the problems were so large and the damage so great that we were putting Band-Aids on gaping wounds. With the passage of time and many return trips to some settings, it has become apparent that we have had a ripple effect. Even professionals we have not directly worked with have benefited from being taught some of our techniques by those we have trained. Our handouts have been distributed widely.
        What we are about is summed up by one of Husain’s mottos, “My belief is that, when there is a way to help, one must do it.”
References

Allwood, M.A., Bell-Dolan, D., & Husain, S.A. (2002) Children’s Trauma and Adjustment Reactions to Violent and Nonviolent War Experiences, Journal of the American Academy of Child and Adolescent Psychiatry, 41, 450-457.

Galante, R., & Foa, D. (1986). An epidemiological study of psychic trauma and treatment effectiveness for children after a natural disaster. Journal of the American Academy of Child Psychiatry, 25, 357-363.

Goenjian, A.K., Karayan, I., Pynoos, R.S. & Minassian, D. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154, 536-542.

Goenjian, A.K., Steinberg, A.M., Najarian, L.M., Fairbanks, L.A., Tashjian, M., & Pynoos, R.S. (2000). Prospective Study of Posttraumatic Stress, Anxiety, and Depressive Reactions After Earthquake and Political Violence. The American Journal of Psychiatry, 157, 895-911.

Goldstein, R.D., Wampler, N.S., & Wise, P.H. (1997). War experiences and distress symptoms of Bosnian children. Pediatrics, 100, 873-878.

Husain, S.A. (2005). The Experience of Bosnia-Herzegovina: Psychological Consequences of War Atrocities on Children. In Disasters and Mental Health, John Wiley & Sons.

Husain, S.H., Nair, J., Holcomb, W., Reid, J.C., Vargas, V., & Nair, S.S. (1998). Stress Reactions of Children and Adolescents in War and Siege Conditions. The American Journal of Psychiatry, 155, 1718-1719.

Husain, S.H. (2001) Hope for the Children: Lessons from Bosnia. Columbia Missouri: International Medical and Educational Trust.

Langewiesche, W. (2002). American Ground: Unbuilding the World trade Center. North Port Press: New York.

Russoniello, C.V., (2002). Childhood posttraumatic stress disorder and efforts to cope after Hurricane Floyd. Internet Behavioral Medicine 16 pps.

Sleek, S., (1998) After the storm, children play out fears. APA Monitor, 29, #6 American Psychological Association.

Yule, W., & Canterbury, R. (1994). The treatment of post traumatic stress disorder in children and adolescents. International Review of Psychiatry, 6, 141-151.

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