Sunday, November 22, 2009

Moscow Police's Shattered Image

MOSCOW’S POLICE: THE CRACKED IMAGE

        In 1998 our team from the International Center for Psychosocial Trauma did a program in Moscow for participants from former USSR countries who were dealing with the psychological trauma of their citizens caused by various conflicts. Because of our interest in law enforcement our director Arshad Husain, Barbara Bauer, a psychologist in private practice who consults with the police, and myself, the author of a book on police stress, were invited to visit the Police Training Academy in Moscow. Besides our contacts at the Academy twelve police psychologists were participants in our six-day seminar on treating victims of trauma. This provided us an opportunity to learn more about crime and police work in Russia.

Russian police's damaged image
        The police in Russia may be in the country's most hated profession. The police psychologists our team of mental health professionals worked with in Moscow felt that the most pressing problem they face is how to upgrade police from the low status they have in the eyes of the public. It was easy for our Russian friends in police work to admit to us that this damaged image was well deserved when the police were an extension of the repressive communist government with powers to search, arrest and interrogate without limits. After all, the police were trained to protect the welfare of the state and not that of the public.
        But it was not only their past repression and terror that make the public leery of the police. Not spoken of openly but admitted by some of my informants is the generous opportunity a police officer has, with a pay of only $160 a month, to add to his income by squeezing bribes from people for various small infractions. These infractions are such things as not carrying one's identification card or committing a minor traffic violation. Police officers are also known to abuse their stop and search power on the street, and we were told that police unfortunately often hassle Africans, Middle Easterners and Asians living in the Russia. Their defense is that these are the people most likely to be dealing drugs.

The Russian Mafia
        The Russian Mafia is very powerful and is involved in most aspects of the economy. Mafia members run the sizable black market and protection rackets, control prostitution, and often take over businesses started by outsiders after they are making a profit. Those who do not cooperate have contracts taken out on their lives and part of the marked increase in murder in Moscow is related to Mafia activities. The police at this time are powerless to do anything about these criminals.
        One point of view, expressed to me by the chief police psychologist from Rostov, is that the Russia Mafia is good for the economy and that if they could be effectively stopped that the economic recovery would stop. He thought the real enemies of the health of the economy are the corrupt state officials who now own businesses and use their position to drive others out. It is the Mafia who are organized to work around these impediments by running an illegal marketplace that keeps prices down and products moving. My informant felt that once the drastic transformation that Russia is now undergoing is over will be the time to unleash the police against the Mafia.

What is being done to improve the police image?
        It may be the most hated profession in Russia but large numbers of young Russians still apply to enter the “militsia” (police force). Two major motivations attract recruits to the profession. First, while the pay is low it is steady. Earning money continues to be a real problem in Russia and many professionals such as teachers and doctors can sometimes go months with no paycheck. There are other financial benefits that make it an attractive occupation: free public transport, free medical services and paid retirement after 20 years of service.
        Second, it is an opportunity to have an interesting career where one can be of help to others. Given the large number of applicants it is expected that by careful screening, availability of psychological counseling and a revision of procedures that high quality officers can be placed on the street. This new, improved police force should be a major step in raising the image of the police.
        Part of the better screening and improved mental health of the police force depends upon the use of practical police psychologists. Rather than take trained psychologists, who are a rarity in Russia, they take police officers and give them a six months intensive training program in psychology and call them practical psychologists. They know something about testing and screening and are learning more about counseling impaired officers and officers who have been exposed to critical incidents. In the U.S. we would consider them highly trained peer helpers.
        Besides the time we spent at the Police Center in Moscow, eight members of the police group asked Dr. Bauer and me to meet with them one of the evenings during the seminar. Some of the officers were from Moscow but the largest number was from Rostov on the Don. They spent three hours firing questions at us. Dr. Bauer was particularly questioned about screening issues and the problems of working with officers impaired by alcohol abuse and critical incident stress.
        In terms of getting a better public image by doing more against organized crime, steps are already being taken to improve their performance by cooperation with the U.S. FBI force against organized crime. An additional indication that the Moscow police are trying to do better is that members of the San Francisco Police Department have been teaching crime-fighting techniques to elite members of the Moscow Police Organized Crime-fighting Regional Department.
        Besides the improvement of their skills as law enforcement personnel the media may be helping repair their damaged image. Russian television had six true crime television shows that did on site reports on the day's or week's major crimes. This exposure to the police (militsia) doing real police work rather than harassing citizens may do much to change the image of police officers.

As a visitor
        How safe did we find Moscow? Very. The Russian Mafia that we hear so much about is very powerful but functions at a level that does not impact the average visitor to Russia. We have been flooded with stories about the dangerousness of the criminals. One source said that there have been over 500 contract killings of top Russian businessmen, bankers, and journalists.
        As a visitor, however, your main concern will be avoiding the gypsy children who function in teams that can quickly cut open your pockets or the belt to your fanny pack and make off quickly. I was told that the police seeing this may not even interfere. Statistically there is very little crime against Americans. Crime against foreigners is mostly against those who are obviously foreign such as Asians and Blacks.
        We enjoyed the warmth shown to by Russians we were helping to train. Their eagerness to share with and learn from us was encouraging. They left us with a sense that we were their colleagues in an important venture. The cracked image of the police can be repaired, but it will take time and will not be fully accomplished until after recovery from the economic disruption of the country.

Saturday, November 21, 2009

Chechnya/Russia Conflict Part 3



The picture done by the artist in our class is of a Chechnya warrior with his leg strapped so that he can not flee from battle.

Chechnya/Russian Conflict Part 3
        In part one I talked about my first experience with the Chechnya/Russian conflict, which centered around my contacts with the Moscow police training academy and two professionals from Chechnya who had worked with Chechnya victims of the conflict. In the second section I talked about some of the experiences of Chechnya survivors of the conflict. In this section I go into detail about our work with the children. Remember in reading this I am reporting what I experienced in 2003).

The Camps of Chechnya
Families fleeing war of Eastern Europe find refuge in Turkish villages.

CHECHEN REFUGEE CAMPS, Istanbul, Turkey - Thirteen of us crowded into the tiny room furnished with a double-bunk bed and two small sofas. The room was about 12 feet by 12 feet with a niche for a kitchen and a closet-like area for a toilet. Our host was living in this one small room, which served three families. I assume someone slept on the floor.
        Of the 150 people in this camp near Istanbul, 60 are children. Before they sought shelter here from the long war for Chechen independence against Russia, this camp was a series of cement structures that the Turks used as open-air picnic areas facing the Bosporus Straits. With no windows or doors on the structures, the living quarters were constructed with the clever use of transparent plastic sheeting and laths.
For the first two years, there was neither running water nor electricity, but nine months before my visit in 2003 both were installed. When our six-member team from the University of Missouri’s International Center for Psychosocial Trauma visited in November, there had been five days of rain. Water was dripping from one of the light fixtures, around which had been taped a plastic catch bag.
        The woman who made the tea had a 5-year-old daughter, Fatima, who smiled once she got over the shock of seeing visitors. The Russians had put the woman’s husband to death by electric chair--one of many extra-legal deaths the refugees told us about. Our translator did not give us the details.
        That evening, we went to Camp 2, which consisted of several large general-purpose rooms, a common cooking area and many small rooms off two hallways. This one lodged 150 people, including very few men but 75 children who had been allowed to stay up late to meet with us.
        As they clamored to have their pictures taken, I thought, "What lovely children." They were full of energy, not frightened of us as outsiders and eager to talk with us despite the language differences. I did not pick up the level of hyper-alertness and tension I had found in other refugee camps I found in places like Bosnia and Kosovo..
        The mothers also wanted to pose for pictures. They told us they felt they had been forgotten by the rest of the world and that anything we could do to call attention to their plight would be welcomed.
        The Chechens in Turkey are a people who officially do not exist. They are not entitled to any aid from the Turkish government or education for their children. These refugees have no official status, which means no resident permit. The Turkish government has taken no steps against them, however, and ignores the fact that they are here. In the first camp, some of the children were in Turkish schools, but no record is kept of them and they are not given diplomas.
        Besides pressure from Russia, another reason the government refuses to offer help is that, if conditions were too good, there would be a massive influx of refugees from those areas.

The Situation
        Our team from the UMC trauma center was led by child psychiatrist Arshad Husain and consisted of Venetta Whitaker and me from UMC and Gail Baker, Andra Ferguson and Rose Procter from Royal Oaks Hospital. The U.S. Institute of Peace provided funds to bring 20 professionals from Ingushetia to Istanbul, and we had eight students from the camps in Istanbul. The Caucasus Foundation provided space and facilities for our training program.
        The professionals who were our students knew little about stress disorders despite the fact that most of them were suffering symptoms of post-traumatic stress. Because of translation problems, we were not always sure how much of what we said was getting through. We were dealing with three major and one minor language, Russian, Turkish, English and Chechen. Despite the language barrier and the fact it was Ramadan, during which everyone fasts during the day, they took an active part in the program.
Training was sometimes pushed to the side because our students had so much they wanted to share with each other and with us about conditions in Ingushetia and Chechnya.

Ingushetia refugee camps
        One of my interviews was with a film director financed by Doctors Without Borders to make documentaries about AIDS and the misuse of drugs.
        "I also work for a" nongovernmental agency "that is suing the Russian government for its violence against human rights," she said. "I direct refugees with problems to the appropriate agencies to get redress."
This woman served as my client for a demonstration. She found it almost impossible to think of a safe place. We eventually created one, but I had to do additional work with her afterward because the exercise brought up so many memories of things she was trying to repress, including her memories of the Russians killing her husband nine years ago.
        Her daughter went back to Grozny and was assaulted in her room one night by men in masks who threatened to kill her. The daughter is now a psychology student who has learned English on her own, and she won’t go back to Grozny. She has tried to get a U.S. visa, but the government fears she will not want to return. My informant felt that Chechnya is losing its best and brightest youths, who are going abroad and won’t be available to help re-establish their country once the Russians leave.
        "My organization keeps track of and makes videos about those who have disappeared," she said. "The Russians do address ‘cleaning,’ where they enter and kill whole families. Often the parents are ‘disappeared’ and children are left parentless. The parents must be gone a year before the children can be officially helped. Our organization helps the widows and educates the children."
        Other students from Ingushetia described the refugee camps there as ragged jerry-built shacks and tents set along muddy roads. There is little education for the children in the refugee camps and no health help from the Russian government. Some Russian churches give food and other supplies. The food is mostly bread and flour. Unemployment is high, and the economic situation is desperate.
        The Ingushetia government is cutting off gas and increasing administrative red tape to pressure Chechen refugees to close the camps. There is little humanitarian aid, but 98 percent of the refugees do not want to return to Chechnya. Many have had their homes destroyed, and there is always fear of people disappearing.
Human Rights Watch investigators report considerable pressure on refugees to leave Ingushetia and return to Chechnya. Pressure includes threats of arrest, withdrawal of food allowances, cutting off heat and electricity to their tents and forced removal. Human Rights Watch says returning people to an active war zone violates the U.N. Guiding Principles on Internal Displacement.

Leader of the movement for independence
        Gen. Aslan Maskhadov, former president of Chechnya and leader of the resistance against Russia, was recently quoted in 2003 as saying, "I would like to state again that we are not international terrorists or fundamentalists. We are Chechens fighting for our national independence. We did not invent the idea of national liberation; we inherited it from our fathers and grandfathers. We are carrying on with what they started centuries ago, when there were no such things as "international terrorism" and "fundamentalism." We simply want to free ourselves from the colonial oppression of a barbaric state, and this is what we are doing."
        The army’s behavior against the Chechens has not gone unobserved in Russia, where human rights groups issued a challenge to Russian President Vladimir Putin. A book released in October (2003) documented hundreds of cases of civilians killed or abducted in Chechnya. The volume is called "People Live Here," a reference to a sign frequently posted by civilians over the rubble of the republic’s capital, Grozny.
Several of the men I interviewed held administrative positions in Chechnya before fleeing the war. They felt there was much support for the Chechen people from European countries, especially France, Germany and Belgium. They believe pressure from Europe will cause the Russians to eventually grant Chechnya independence.

Hope
        The presence of a team of professionals from the United States raised the spirits of both the local refugees and the refugee professionals from Ingushetia. That we would take the time and expense to come to them helped break through some of their sense of isolation.
        Besides recognizing that techniques exist to help them deal with post-traumatic stress reactions, there was the hope that perhaps if these reactions were dealt with in their children, it could help break the cycle of violence that has bedeviled their part of the world.

Chechnya/Russia Conflict Part 2




Chechnya/Russian conflict: part 2
         In part one I talked about my first experience with the Chechnya/Russian conflict, which centered around my contacts with the Moscow police training academy and two professionals from Chechnya who had worked with Chechnya victims of the conflict. In this section I talk about some of the experiences of Chechnya survivors of the conflict. Our team from the University of Missouri International Center for Psychosocial Trauma. We had been turned down for working in a number of other countries before it was decided we would meet with our teachers and doctors in Istanbul, Turkey. Refugees had also settled there and some of them became participants in our training program... The picture was drawn by a Chechnya artist who was in our class. He has me hypnotizing the wolf and asking him to believe that he is Little Red Riding Hood.


Visions of Chechnya
Mental health workers try to help refugees fleeing the Russian province.

A Chechen doctor speaks:
        "In 1995 when Grozny," the capital of Chechnya, "was bombed, I was in my last year in medical school in Volgograd. In two hours I was packed and, with four other Chechen students, I went to defend the city.
"In every city we formed groups of military. All women and children fled to Ingushetia. We didn’t have a leader, so we were not well organized. Then the Russian soldiers came to our village. My father insisted I go back to medical school because, as a doctor, I could be of more help to my people. My brother and father said they would stay and fight to save the village.
        "When I got back to Volgograd, the soldiers arrested me. They wanted to know if I had been fighting. I was able to get documents that said I had been sick for three months. That and my friends all supporting me allowed me to finish medical school.
        When I got back to the university, I faced much hostility. People were always saying, ‘The only good Chechen is a dead Chechen."
        The last statement from the physician, who now lives in Istanbul, was one I was to hear from a number of the seven professionals I interviewed on my trip to Istanbul with the University of Missouri International Center for Psychosocial Trauma.
         Like the doctor, they also worried about being overheard even by fellow Chechens, and when anyone moved close to us, they would fall silent. None of my Chechen interviewees wanted their names used because of the danger to their relatives still in Chechnya or Ingushetia.
        When the doctor first got his degree, he worked in Russia in a hospital. His life was made difficult by constant surveillance. Listening and visual devices were put in his room, and the police frequently hassled him. At that point, he made arrangements to legally move to Turkey.
        "I had a post-traumatic stress disorder when I first came to Turkey," he said. He described nightmares and flashbacks, and he later approached me after a dinner to talk of his tremendous guilt about not staying in Chechnya and fighting the Russians. He feels that he let his people down and that he should have been willing to die. It was of some help for him to be reassured that he will be more valuable to his people as a trained doctor than as a dead, forgotten hero.

The Situation
        Perhaps as many as a quarter of Chechnya’s 1.2 million residents have been killed in the ongoing war with Russia. About half the population has fled the country, but they are living in conditions far short of adequate in housing, food and education for their children.
        My informants said Chechens disappear routinely, particularly young men, and only occasionally are their bodies found. When I brought up torture with one of the women doctors, she said, "That’s too political, I don’t want to talk about it." Later, another informant, willing to go into more detail, indicated the torture of prisoners was common and often the bodies are blown up afterward to destroy evidence of torture.
Villages that might have fighters are destroyed, which leaves nowhere for Chechens to live if they wish to remain in the country. The situation is complicated by an influx of outside terrorists who, in their desire to help fight the Russians, make the situation worse.
        The stories I heard were supported by a United Nations panel’s Nov. 7, 2003 report. It sharply criticized human rights violations in Russia, highlighting the impunity of security forces in Chechnya. The committee said in its report that it was "deeply concerned about continuing substantiated reports of human rights violations in the Chechen Republic, including extra judicial killings, disappearances and torture including rape."

The University of Missouri International
Center for Psychosocial Trauma
         The United States Institute of Peace provided funds several years ago for the UMC International Center for Psychosocial Trauma. Director Arshad Husain, a child psychiatrist at the UMC medical school, had hoped to go to Chechnya to train mental health workers and teachers to work with traumatized children. Given the ongoing fighting in Chechnya, he was told a better place to do training would be the neighboring Russian province of Ingushetia, where 200,000 Chechens have fled during the current conflict. They were living in makeshift refugee camps with few amenities and muddy playgrounds for their children.
         The Russian government refused to grant visas for us to visit. The situation dragged on, and we were told the money we had been granted by the institute would be withdrawn if we did not find some way to use it. A contact in London helped Husain establish a contact in Turkey, where some refugee camps existed in Istanbul. Arrangements could be made to bring a group of 20 teachers and mental health workers from refugee camps in Ingushetia, and eight professionals from the camps in Turkey could join us.
        The arrangement sounded ideal. The center team, which also included educator Venetta Whitaker from UMC and Gail Baker, Andra Ferguson and Rose Procter from Royal Oaks Hospital, would face a minimum of risk. The Chechen professionals would get training plus a break from their present dire living conditions.
When we arrived in Istanbul, we found our training conditions were less than ideal. The large, bare room was cold, and our translator had to be able to speak English, Russian, Turkish and Chechen. Our translator for the first two days had a minimum understanding of English and had stage fright, which prevented him from speaking loudly. The only audio-visual equipment was an overhead projector, and our student body included fewer teachers and mental health workers and more professionals in related areas like administration.
        There were five journalists in the group of 20 visitors from Ingushetia. Why so many journalists? It was difficult for mental health workers and teachers to get permission to leave the area, but Russians are leery of the damage to their image under communism, when they tried to control the media. Now they bend over backward to show they have become democratic and believe in freedom of information and personal rights.
The picture they are trying to project, however, does not conform to reality. Within Chechnya, there are tight restrictions on what reporters can see and report. For example, they are not allowed into the villages destroyed by the Russian army to interview survivors.
        The participants, even those who did not have direct therapeutic contact with traumatized children and adults, said our workshops would help them when they returned to the refugee camps. Even though training conditions were not ideal, we felt we made a difference.

Who are these refugees?
         The southern part of the old Soviet Union was a veritable Babel Tower of languages and ethnic groups in conflict not only with the Soviet Union but with each other over territorial claims and old injustices. The one thing they had in common was their dislike of Russian rule. Some of these areas, like Georgia, became separate countries after the breakup of the Soviet Union, but seven groups remain provinces within Russia, including Chechnya and Ingushetia.
         Both groups have a long history of resisting Russian rule and have been heavily punished for this resistance. When Stalin was conducting his purges in the 1930s, he had the leaders in this area killed. During World War II, many people in the area sided with the Germans, resulting in almost 400,000 of them being deported to Siberia. In 1957, those still alive returned, but by then many who had been left behind had moved with other Caucasians to other countries. Two million of them moved to Turkey.
        The Caucasus Foundation, or Kafkas Vakfi, which supported our visit and provided space for our refugee students and us, was started by Turks who came from the North Caucasus in 1864. Although there are 20 different Caucasian ethnic groups, they feel that they have a common heritage and that Russia is a common enemy. Chechens are one of those groups.
        In 1995, recognizing the difficulties their cultural groups were having in Russia, the Caucasus Foundation re-established relationships with Caucasians in Russia. They wanted to share some of what they had earned but limited their help to those who are suffering from war and were careful that what they did was not seen as military aid.
        Besides giving help to refugees, they were lobbying in Europe to get Russia to stop its attacks on their subject people. They wanted a solution that stops the war. The organization supports Chechnya independence. The foundation doesn’t have the money to give as much help as is needed, but it has become a central resource for those who want to give additional aid and supplies.

Adam’s story
        "The Russians say that the only good Chechen is a dead Chechen, especially if it is a male.
"I went to the University of Grozny and became a mechanical engineer. It was there I learned English.
"I lived in Grozny, but at the beginning of the war, and I moved to my parents’ village. Then the Russians came to our village; they took 28 young people from our village. They just disappeared, and no one knows what happened to them.
        "I had been wounded as a civilian in the last war by planes that came with bombs. If you have wounds, you have a problem because the Russians think you could be a fighter. That was in 2000, and I felt I had to leave. I went to Dagestan and was there for a week, but it was too dangerous. The security people were looking for people who might be fighters. Then I went to Backni, the capital of Azerbaijan, and couldn’t find work. So I came to Turkey. Like most people, I came in on a month visa but didn’t leave when my time was up.
        "I worked illegally for little money, for long hours. Being illegal, I had no rights. When they discovered I was illegal, I lost my job. Then I came to this camp. I have tried to get to France or Belgium where there are other Chechen refugees, but I have had no success. I don’t know what we are to do. It may be many years before the Chechen problem is solved."

Chechnya/Russia Conflict


CHECHNYA

        I’m a retired professor of psychology who after retirement volunteered to work with the University of Missouri, International Center for Psychosocial Trauma. I traveled into trauma zones such as Bosnia and Palestine working with physicians, teachers and mental health workers in treatment skills to use with traumatized children. Rather than individual therapy we focus on techniques that can be used with groups.
        My first personal contact with the problems in Chechnya was during a training program in the trauma psychology in Moscow in 1998. The participants were from a number of former USSR countries and some that had not yet split off.
        One area that wanted independence was Chechnya and a team of Chechen psychologists and psychiatrists who were participants had joined me in discussions outside the classroom and talked freely about conditions in their “country.”
        The following summer Kuri Idrisov, a psychiatrist, and Khapta Akhmedova, a psychologist, joined us on the campus of the University of Missouri for our regular summer training program in Trauma. They did a presentation on post-war psychological problems in Chechnya. Russia and Chechnya went back to war with each other shortly thereafter. Because of their problems with English, I helped Kuri and Khapta translate their presentation. Besides presenting a history of the relationship with Russia, they gave a detailed description of the use of torture by the Russians. I found working on the presentation with colleagues who had treated these victims a harrowing experience.
         About that time the team had been given funds to run a training program for helping professionals in Chechnya, but given the dangers in the area the Russians refused us entry. It was a year later before we could make arrangements to meet with professionals from Chechnya in Istanbul, Turkey.
The first report in this section is background on the Chechnya-Russian conflict, and the later two reports are based on our contacts with the Chechen professionals and refugees in Istanbul.


Chechnya, Russia unable, unwilling to compromise

        In October, 2002, a group of 40 terrorists/freedom fighters seized a crowded Moscow theatre and demanded the withdrawal of Russian forces from Chechnya. After a two-and-a-half-day siege Russian authorities pumped an unnamed chemical agent into the building’s ventilation system and raided it. Forty of the Chechens were killed and 129 of the hostages. Many others were made seriously ill by the gas.
Russian President Putin tried to tie this act in with international terrorism. Chechens I have talked to, on the other hand, see the actions of their people in a different light. Their actions are internal and taken in pursuit of freedom for their “country.” This situation is very different from the external terrorism threat that we in America face and probably more serious in terms of the number of people who will die before it is resolved.
         In 1998, I was on a team of the University of Missouri’s International Center for Psychosocial Trauma working in Moscow and interviewed members of both sides of the conflict. Later, a number of professionals from Chechnya spent some time with us at the University in Columbia during our summer training program. Our team was then invitied to conduct programs for Chechen teachers and mental health workers in the neighboring republic of Ingushetia. This fell through and instead we met with them in Turkey.

Sources of conflict
         Because of its oil resources and its position controlling access to the Black Sea, the province of Chechnya is critical to Russia’s economy. When times are peaceful, the area has operating oil refineries, natural gas and pipeline transit. An independent Chechnya would be damaging not only to Russia, but also to the people who live there.
         Chechens are a Caucasian people who have been abused by Russian governments since the first half of the 19th century. Frequent attempts have been made during the last 200 years to repress Chechens, culminating in Josef Stalin dissolving the republic in 1944 and ruthlessly deporting hundreds of thousands of its leading citizens to Kazakhstan. Unprepared for the move, many died during the first winter.
Thirteen years later, Nikita Khruschev allowed those who were still alive to return home. This kind of treatment added to the anger of the Chechen people.
        With the breakup of the Soviet Union, the resistance to Russian control again broke into the open, and there was the war of 1994-96. Similar to the situation the Russians faced in Afghanistan, warlords fought for control. The war devastated the republic, and more than 80,000 people died, a considerable part of a population of about 1 million. More sinister, however, is the fact that, with the Russians driven out, it became a major training ground for the Russian Mafia, which is now reportedly run by Chechens.

Chechen Mafia
         When I was in Moscow with the International Center for Psychosocial Trauma in 1998, I met with the faculty of the police academy in Moscow. Because of my book, Stress Management for Law Enforcement Officers I was known to the police training academy in Moscow who were using a bootleg version of my book in one of their classes.
         They admitted organized crime was a major problem in Russia. The police felt there was no way they could do much about the leading criminals because the protection of so many people in high places had been bought. If cooperation couldn’t be bought, the resisters were killed. It appeared to be common knowledge that Chechens were in control of organized crime, having done away with the competition.
Through the years, the Russians had either kept competent Chechens out of power or had deposed those who came to power. The only way for an intelligent Chechen to get power was outside the system. Their brightest men seemed to take naturally to the skills required for successful organized crime. The corruption hit a growth spurt during the period of peace after the outbreak of resistance in the mid-1990s. The Chechen Mafia spread its power out over the country. Many moved to Moscow and bought the services of influential people in Moscow. Grozny, the capital of Chechnya, became a center for criminal activity.
        Law and order were nonexistent in the republic, so smuggling became a prime income producer. The Moscow police told me this actually benefited the larger economy because without Chechen organized crime, the economy would have been totally under the control of corrupt government officials and would have ground to a halt. Besides commercial goods like cars, the Mafia also trafficked in narcotics and kidnapped foreigners for ransom.

Kidnapping
        Although there was money to be made in oil and the transportation of products to the Black Sea, the Russians had not allowed these industries to be open to young entrepreneurs who were Chechen. Hostage-taking became a source of income and could almost be considered a cottage industry in Chechnya.
A young mental health worker from Chechnya whom I met in Moscow had been in an apartment with a group that included agency workers from outside the country. The door suddenly slammed open, and masked men with guns rushed in. Her first thought was that this was a training exercise, and it took a few minutes before she appreciated the seriousness of the situation. The men took several of the outsiders to hold for ransom. At the time I talked to her, they had not been returned and she was suffering from a post-traumatic reaction.
        The taking of hostages at the theater in Moscow to put pressure for freedom on the government is a continuation of this kind of guerrilla warfare. Our trauma team has been invited to train Chechnya mental health workers and teachers, but because of the danger of hostage-taking we would not be allowed into the republic. Instead the trainees would come to us in Ingushetia.

The failure of the Russian army
         During the war in the mid-1990s, the Russians sent in troops who were poorly trained, poorly led and in many cases not as well armed as the Chechens. When the Communists pulled out after the disintegration of the Soviet Union, they left a significant number of weapons. When the warlords and the Mafia took over, they were able to arm their troops well. Some weapons such as anti-tank rockets were sophisticated and devastated parts of the Russian army. They bought some of their arms from the Russian soldiers fighting them, who used the money to buy vodka.
        The military tactics used by the Chechens, like those in Afghanistan, bewildered the Russians. Out of frustration, some of the Russian troops engaged in atrocities that turned Chechens who would have supported the government against them.
         A Chechen psychiatrist we worked with reported that many of his clients had been victims of Russian torture. This failure of the Russian army also had a negative effect on the troops. One of the problems our informants in Moscow talked about was the number of post-traumatic stress reactions the returning Russian soldiers were suffering.
        On Oct. 1, 1999, Prime Minister Vladimir Putin of Russia officially declared war on Chechnya. Russia wants to re-establish its control over the Caucasus even if it has to kill every Chechen. A large part of the population, 200,000 people, have fled the fighting and gone to Ingushetia.
        The ordinary Chechen citizen was caught between two forces that showed little evidence of backing off. Both sides were blind to the needs of the other, with Russia being blinder than the Chechens. As a result, freedom fighters/terrorists are likely to plague Russia for some time to come.

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.