Special Report

17 December 2001 | Special Report No. 79

Judy Barsalou
Training to Help Traumatized Populations

Summary

Defining Trauma

While the approaches used by trauma specialists vary, workshop participants employed similar language to describe the problems they address. According to Dr. Syed Arshad Husain of the University of Missouri, post-traumatic stress disorder (PTSD), as this form of psychological distress is commonly known, involves the development of characteristic symptoms following a psychologically distressing event that is outside the range of normal human experience. Such events may involve a threat to one's life, harm to one's self or family members, the sudden death of family members or destruction of one's home, or the witnessing of violent injury or death. Traumatic events become internalized in the minds of victims and are relived by them long after the events are over.

PTSD symptoms, according to Dr. Husain, are generally divided into three groups. "Re-experiencing symptoms" include disturbing recollections, distressing dreams, flashbacks, and intense distress. "Avoidant symptoms" involve an effort to avoid thoughts or feelings about the traumatic event, avoidance of activities related to the event, inability to recall the event, diminished interest in significant activities, detachment or estrangement from others, and a foreshortened sense of the future. "Hyper-arousal symptoms" include difficulty in falling or staying asleep, irritability, difficulty concentrating, hyper-vigilance, exaggerated startle response, and psychological reactions to events that symbolize or resemble the traumatic event. Traumatic experience may also be translated into physical disorders, such as nausea, headaches, and backaches, as well as cause severe learning difficulties.

Dr. Vamik Volkan, director of the Center for the Study of Mind and Human Interaction at the University of Virginia, makes a distinction between individual traumas and those shared by large numbers of victims. The latter include natural traumas (such as earthquakes), human-induced traumas (such as the meltdown of a nuclear power plant), symbolic losses (such as the death of a revered leader), revolutions that profoundly change the established order, and deliberate injuries inflicted by an enemy group (often during armed conflict). These different types of traumas may be difficult to disentangle. The injurious effects of a natural trauma, such as an earthquake, for example, may be compounded by further traumas linked to human errors, such as the destruction of buildings that do not comply with earthquake building codes, or inadequate response to earthquake victims from government officials and humanitarian relief workers.

Massive traumas may create changes on three different levels, according to Dr. Volkan. They may result in various forms of PTSD in individual victims, may cause new social and political processes on a broader social level, and may result in altered behavior transmitted from one generation to another.

In events where the trauma is shared broadly within a society, but the backbone of that society is not broken, "psychosocial regeneration" may result. As an example of this, Dr. Volkan described a village in Wales that experienced an extraordinarily high birthrate in the wake of the loss of a number of village children from a landslide. In such cases, psychosocial regeneration is marked by the ability of victims to eventually perform two tasks. They regain basic trust in the order of things, and, during a period that often lasts one-to-two years, they undergo a psychophysiological mourning process that must be experienced before forgiveness is possible.

Trauma Caused by Ethnic Conflict

Traumas resulting from natural disasters may sometimes be distinguished from those caused by ethnic conflict (a form of human-generated trauma) by an important difference: The damaging effects of the latter can produce profound changes in social and political processes that affect not only the generation that directly experienced the trauma but also subsequent generations. Dr. Volkan described such changes as "psychobiological degeneration."

Among the symptoms of psychobiological degeneration in deeply traumatized societies are the loss of basic trust in the order of things, difficulty in mourning, and difficulty in reversing a sense of helplessness and humiliation. Terrifying new social patterns, such as aggression, domestic violence, prostitution, rape, kidnapping, youth gangs, and organized criminality tend to increase. Morality becomes more "flexible" in such settings, and some individuals increasingly rely on "magical thinking," such as belief in spells against illness. The breakdown of societies involved in serious ethnic conflict is also often accompanied by human destruction of the natural environment.

Shared traumas caused by a common enemy, according to Dr. Volkan, increase the sense of large-group identity or "we-ness," and the perception of larger distance between "us and them." The greater the stress experienced by the group, the harder group members cling to their group identity, to the point where the thought of losing that identity may become more horrible than facing death. Unlike trauma caused by natural disasters, trauma caused by the activities of an enemy also creates a sense of shame, humiliation, and helplessness among the victims for whom the traumatic event in question may be so devastating that previous personal strengths cannot withstand the stress.

Victims may also become preoccupied with borders and boundaries of all sorts that separate them from their real and imagined enemies, and they may adopt minor differences in their behavior or dress to subtly but clearly mark their separateness from the enemy. As an example of the latter, Dr. Volkan cited Turkish and Greek farmers in Cyprus who can be distinguished by the differently colored belt sashes that they wear (red for Turks and blue for Greeks) and by their different choice of cigarette brands (respectively characterized by their distinctive red and blue boxes). In addition, purification rituals of various types may become obligatory in traumatized societies. After experiencing trauma, victims may ask themselves, "Who am I now?" and shed the identities that they shared with the perpetrators of the trauma. Examples of purification processes include removal of bodies in cemeteries belonging to the "other," and changes in language to produce greater differences, for example, between Croatian and Serbian. Ethnic cleansing of territory is the most malignant form of purification.

Traumatized societies sometimes engage in historical images and fantasies that may bear little relation to reality. These shared images become what Dr. Volkan described as "chosen traumas." By helping to mark group identities, and through leader-follower interaction, chosen traumas can be reactivated over time to provide the fuel for war. President Slobodan Milosevic of Yugoslavia, for example, reactivated a chosen trauma when he disinterred the body of Prince Lazar, killed in the Battle of Kosovo in 1389, and ceremoniously buried the body in one Serbian village after another, revitalizing the mourning process as though Prince Lazar's death had occurred yesterday. The renewed sense of threat and entitlement to seek revenge helps to magnify large group conflicts and mobilize large-group activities, sometimes leading to the infliction of new traumas.

In societies traumatized by ethnic conflict, younger generations are often asked, consciously or unconsciously, to perpetuate a certain mental representation of the historical event and to maintain large-group ethnic markers. In these ways, through their chosen traumas, enemies become bound together through hate. In order to be effective, those who seek to help the traumatized must be familiar with the complete historical, social, and psychological contexts in which the traumas occurred.

Goals for Trauma Training

Dr. Paula Gutlove of the Institute for Resource and Security Studies in Cambridge, Mass., outlined principles and goals for trauma recovery training based on the lessons learned in the work that she has been doing with psychiatrists and psychologists in the former Yugoslavia. She highlighted four general principles for trauma assistance interventions, as follows:

• Those working with traumatized populations must understand that most post-traumatic reactions are normal reactions to abnormal events.
• The healing of traumatized individuals cannot take place within a social vacuum, and it is often part of an ongoing social process. By helping others, traumatized individuals can help themselves.
• Where international professionals are active in zones of conflict, they should seek to establish cooperative, mutual partnerships with local professionals, where they come together to both teach and learn from each other. They should be prepared to make a long-term commitment to those relationships and to their work in the conflict area.
• Trauma recovery is a long-term, evolving process, requiring periodic assessment of the needs of the community and the caregivers, and the adjustment of approaches and techniques accordingly.

Dr. Gutlove continued with an overview of the healing goals of psychosocial assistance work. At the individual level, these goals reflect the need to help traumatized individuals move through the following stages (as articulated by Judith Herman in Trauma and Recovery, New York: Basic Books, 1997):

• Safety--evolving from a state of feeling vulnerable to unpredictable danger to a state of feeling reliably secure. This process is aided by providing a safe space for people to start rebuilding their lives.
• Acknowledgment--moving from a sense of disassociated trauma to acknowledged memory of the traumatic event(s). Recounting experiences enables victims to seek acknowledgment of wrongs committed and to mourn their losses, and also enables perpetrators to apologize for transgressions.
• Reconnection--overcoming feelings of isolation and stigmatism by reconstructing meaningful social connections.

Based on her work in the former Yugoslavia, in which trauma recovery is embedded in a process of both individual and community healing, Dr. Gutlove pointed out three additional goals that involve healing at the community level:

• Social reconstruction--rebuilding the social infrastructure, including reintegration, resettlement, retraining, and physical and psychological care.
• Volunteer action--empowering individuals and groups to help each other through unpaid, volunteer public service and social reconstruction activities.
• Helping the helpers--assisting the professionals and laypersons who are helping people and communities to address the secondary trauma or stress they experience as a result of their therapeutic interventions with trauma victims and perpetrators.

As the above goals imply, no single approach to traumatized populations will suffice. Traumatized communities are best served by interdisciplinary teams that can address the need to rebuild identities and relationships on the personal level, reconstruct communities at the physical and social levels, and manage complex relations among different ethnic groups. In other words, teams of professionals working in conflict zones need to possess skills in trauma intervention, social reconstruction, and conflict resolution. A major challenge facing the conflict resolution field is the training of workers who can address these multivariate needs.

Training for Trauma Relief

Anne Anderson, Leila Dan, and Tamra Pearson D'Estree described "A Training Curriculum in Trauma Relief" prepared by an interdisciplinary team of which they were members and organized jointly by the American and Canadian Psychological Associations and by Psychologists for Social Responsibility. The curriculum is designed for graduate-level training of psychologists and related professionals involved in trauma intervention and conflict resolution activities in zones of conflict, and is available free of charge at two websites: http://www.psysr.com and http://cpa.ca/epw/epw.

The three speakers noted that training programs for trauma professionals must acknowledge a number of challenges:

• Cultural, including sensitivity to cultural and language differences, and understanding of local power structures.
• Ethical/strategic, including an appreciation of the purposes served by, and the possible negative effects of, intervention. Workers need to take care not to "medicalize" political problems (such as human rights violations), or to create a victim mentality among those whose needs are being addressed. Programs should also be planned and implemented with full local participation, and with the goals of building local capacity and ownership and long-term sustainability.
• Methodological, including programs designed to reflect local needs and customs and to be capable of adapting to changing circumstances. Professionals working with traumatized populations should perceive their roles as change agents, and not merely as service providers.
• Systemic, including the importance of understanding the broader social and political context in which their work is carried out. Problems often need to be addressed at multiple levels if lasting change is to be achieved.
• Personal/operational, including an understanding of their own values, abilities, and goals. Trauma professionals must be aware of the personal stresses and secondary trauma that may result from working in conflict zones, and the importance of maintaining their own impartiality when intervening in conflicts.

Designing Training Curricula

Educational programs that train professionals working with traumatized populations must be carefully structured if they are to build skills to master the challenges and meet the goals described above. First of all they need to be learner-centered, where the learner has a strong sense of his or her own capacities and competencies and develops a sensitivity to the cultures of others. Such programs should also be highly participatory, involving active-learning techniques and problem-solving exercises. Education programs also need to incorporate case-based approaches to learning in which the views of opposing professionals are sought on specific topics to enable the learner to contend with diverse perspectives. Because no individual alone will be capable of addressing the multivariate needs of traumatized communities, pedagogical approaches should also emphasize team-based strategies in which the individual learns to work closely with others possessing diverse skills.

Educational programs that are experiential by advancing training through internship placements are highly desirable. According to Tamra Pearson D'Estree of George Mason University, trainees may benefit most if organized in groups of two and given responsibilities designed not to stretch them beyond their capacities. They must also be carefully supervised by advanced professionals.

Training Programs in Action

Workshop participants shared information about programs they have implemented around the world:John Hubbard of the Center for Victims of Torture (CVT) in Minneapolis described a CVT peer counseling training program based on experiential learning involving refugees in camps in Guinea. Trainees selected from the ranks of refugees--through tests assessing their conflict solving and other abilities--completed an intensive two-week overview course. Thereafter, the trainees participated in a series of ten-week group counseling sessions for traumatized refugees in the camps. Initially, the trainees merely served as interpreters and observed the advanced professionals running the sessions. At the end of each day's session, the trainees and trainers analyzed the session and planned future sessions. With time, trainees co-facilitated group sessions and eventually assumed full responsibility for leading them. Their training was enriched by intensive two-day workshops on specific skills, such as active listening.

While it makes sense to target trauma training at health care, development, and conflict resolution professionals from the zone of conflict in question, the reality is that there may be few such trained professionals. As an alternative, training programs organized by Dr. Syed Arshad Husain and his colleagues at the University of Missouri have trained local school teachers as therapists. In programs ranging from Kosovo to Ingushetia and beyond, Dr. Husain and his interdisciplinary team have found teachers to be highly receptive learners of the therapeutic techniques they offer.

Bobbie Houser and Phillippe Dupont of Training Workshops International (TWI) for the Children in Springfield, Va., have also provided trauma training for individuals with little or no prior professional experience in related fields. They started by mounting educational programs for traumatized children in Bosnian orphanages. With time, they refocused their efforts to provide training for the children's care providers, and, eventually, the childrens' teachers. When it became clear that the caregivers and teachers themselves needed help to deal directly with their own traumas before they could be fully effective in helping the children, TWI for the Children redirected some of their focus from the needs of the children to the needs of the adults working with them.

Lakshmi Ramarajan of Opportunities Industrialization Centers (OIC) International in Philadelphia described a workshop organized by OIC in Sierra Leone for local teachers, healthcare providers, workers for non-governmental organizations (NGOs), government officials, and community leaders. The workshop focused largely on helping participants recognize the signs of trauma and understand its impact on behavior. It also provided them with preliminary tools to address the needs of their clients, but the OIC organizers recognized that more extended training and follow-up are needed to enable the workshop participants to gain all the necessary skills.

Along with his colleagues at the Center for the Study of Mind and Human Interaction at the University of Virginia, Dr. Vamik Volkan has returned a number of times over the years to work with healthcare professionals in Georgia and the breakaway territory of South Ossetia. The center's four-pronged approach has included: (1) working intensively with a small group of indigenous helpers from both sides to deal with their own trauma and provide services to others; (2) organizing workshops and lectures for Ministry of Health Officials, NGO leaders, postgraduate students, and others about the causes and effects of trauma; (3) providing professional guidance by observing and supervising the work of the healthcare professionals grappling with traumatized clients; and (4) preparing materials about trauma for the Georgian mass media. In working with healthcare providers, Dr. Volkan and his colleagues have addressed the psychological obstacles they have encountered both personally and professionally among their clients, and have explored these providers' motivations for, and fears about, working in this difficult field. In an effort to establish lasting professional relationships between two groups of health workers across enemy lines, the program has helped participants understand a basic operating principle: Their interactions must respect the needs of the two opposing groups to maintain their separate identities, as well as an "unambiguous psychological border" between them.

Paula Gutlove of the Institute for Resource and Security Studies in Cambridge, Mass., described building a network of more than 200 physicians, psychologists, nurses, and teachers from throughout the former Yugoslavia to identify and apply healing principles and strategies for psycho-social assistance to trauma victims. She then focused on a set of programs in Gracanica, Bosnia, which is one of twelve "nodes" in the former Yugoslavia connected to this network of professionals. Activities in Gracanica started modestly with the training of an ethnically mixed group of twelve townspeople who established two support groups that met in a basement in the town, one for sexually abused women and the other for the mothers of disabled children. As more townspeople became involved, new groups were organized, including a sexual education discussion group (which became a teen support group), an elder-care program, a day-care center, and teenager-led sports teams. The rehabilitation of the dilapidated basement by soldiers and youth from the town gradually expanded to the refurbishment of school and other community buildings in outlying areas. In short, within the space of two years, this war-traumatized community helped rebuild itself and other communities by mobilizing thousands of local volunteers. In so doing, the community moved towards significant recovery from the war trauma it had suffered.

Lessons Learned

Several essential themes emerged from the workshop discussions:

• Individuals and groups suffering from the trauma of armed conflict have psychological needs that need to be addressed at the individual, community, and national levels. Professionals working in different fields--psychiatry, psychology, community development, education, and conflict resolution--all have different skills and strengths to offer to trauma victims.
• Training programs that involve integrated approaches to needs, reflect a sophisticated understanding of the social, economic, and political forces that led to conflict in the first place, and account for power dynamics in the community are likely to be the most successful.
• Many zones of conflict have relatively small numbers of trained psychological professionals. Accordingly, training programs must often focus instead on training educators, NGO professionals, community leaders, and others.
• Local professionals working with trauma victims almost always have personally experienced trauma, or may suffer from the secondary effects of working with the traumatized. Programs designed to train local trainers must take into account the need first to help the trainers deal with their own trauma.
• Sustained approaches to trauma are far more likely to have lasting positive effects than programs organized on a one-time basis. Groups involved in transferring skills to trainers working with the traumatized must be committed to maintaining contact with, and support for, the trainers over a long period of time.

About the Report

A diverse group of United States Institute of Peace grantees specializing in trauma training in zones of conflict met at Airlie House in Warrenton, Va., in August 2001. Joining them for the two-day workshop were additional trauma training experts, other professionals (including a number of military chaplains) who have worked with trauma victims, and Institute staff.

The primary purpose of the workshop was to share training approaches and perspectives on trauma relief, as well as to establish better communication among experts working in the field. Several Institute grantees made presentations describing their work in the Balkans, the Caucuses, and Africa, while another grantee outlined a training curriculum in trauma relief.

This report was written by Judy Barsalou, director of the USIP's Grant Program.

The views expressed in this report do not necessarily reflect those of the United States Institute of Peace, which does not advocate specific policies.

Of Related Interest

• Trauma and Transitional Justice in Divided Societies
• Healing the Holy Land: Interreligious Peacebuilding in Israel/Palestine
• Trauma and Conflict Web Links: Web Links

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