Working with Traumatized Clients
in Prisons and Detention
Centers: Barriers and Strategies
for Advocates
Kate Porterfield, Ph.D.
212-562-8719
Bellevue/NYU Program for Survivors of
Torture
[email protected]
Goals of this session
• Provide overview of effects of torture and
interpersonal trauma on humans
• Understand barriers that advocates face
when working with a traumatized individual
• Gain strategies for working with
traumatized clients
Cases
• Case 1: 52 year old male, imprisoned since 35, with no
possibility of parole. African-american, Diabetic, history of
childhood abuse by father. No family contact except one
daughter who writes letters sporadically.
• Case 2: 30 year old Liberian male in an immigration detention
center, awaiting deportation. History of imprisonment in
Liberia and possible history of torture. Wife and two children
are in Liberia in a refugee camp, but he has had no contact
with them since leaving Liberia three years earlier.
Cases, contd.
• Case 3: 25 year old Pakistani female, held in pre-trial
detention on charges of material support for terrorism, after
assisting a family member who went to Pakistan for alleged
terrorist activities. Has been unwilling to speak to lawyers.
• Case 4: 35 year-old male, held on death row, awaiting
appeals. White, convicted of murder in the context of hate
crime, member of a white supremacy group in jail. History of
childhood abuse, question of mental retardation.
What is trauma and what does it
do to us?
• Event outside normal range of
experiences (life-threatening, threat to
bodily integrity) that results in…
• Experience of terror, horror.
• “Man-made” trauma (torture, abuse, war)
vs. Natural disasters
What is Torture?*
• Severe pain or suffering (physical or mental)
• Intentionally inflicted
• For a purpose: eg. to obtain information or confession;
as punishment for a suspected act; or for purposes of
humiliation, intimidation and coercion
• Inflicted by or at the acquiescence of public officials
*UN Convention against torture and other cruel, inhuman or degrading treatment or
punishment
Occurrence of Torture
Studies show torture among refugee populations
varies from 5% to 35%.
(Baker, 1992; Jacobsen & Vesti, 1990 )
Torture and ill-treatment are widespread
in 111 countries worldwide.
(Amnesty International Report , 2009)
It is estimated that 400,000 Survivors of Torture live in
the U.S.
(Center for Victims of Torture, report to the DJJ Office of Victims of Crime, 1998)
Sitting with a severely traumatized
client
• Must understand that the traumatic history
is in the room and playing a part in the
client’s perceptions/interactions with you
• The more you understand the effects of
long-term trauma, the more you can
recognize and address barriers that exist
in your interaction
TRAUMA: UNDERSTAND THE
PHENOMENA BEFORE THE DIAGNOSIS
Post Traumatic
Stress Disorder
Depression
TERROR
LOSS/
POWERLESSNESS
PTSD – A disorder of memory and
arousal
• Amygdala and hippocampusinvolved in:
1. registering danger (“fight or
flight”) and
2. formation of memories
• Fear Network (cognitive,
sensory, physiological,
emotional experiences) is
established with “faulty”
connections –arousal linked to
memory
Perceptions
are stored
in highly
aroused stateFEAR NETWORK
Network
is reactivated
by triggers—
EXTREME
DISCOMFORT
Individual
expends great energy
avoiding reminders
Posttraumatic Stress Disorder
(PTSD)
•
•
•
Reexperiencing: intrusive thoughts and
images, flashbacks, nightmares
Hyperarousal: poor sleep, irritability,
startle response, poor concentration
Avoidance: numbing, emotional
constriction, avoiding reminders of the
trauma
QuickTime™ and a
decompressor
are needed to see this picture.
Complex Trauma
• Often seen in those with early and chronic
trauma; Can come out of extensive adult trauma
• In 2006, almost 500,000 substantiated cases of
abuse/neglect of a child under 7, 83% were
abused by parent or primary caretaker
• Almost half were reported abused or neglected
again within 5 years
•
(American Academy of Experts in Traumatic Stress:
www.aaets.org/article174.htm)
Complex Trauma impacts multiple aspects of a
human’s functioning--i.e. the whole system
• Alterations in:
– Regulation of affect and impulses
– Attention or consciousness
– Self-perception
– Relations to others
– Body functioning and integrity (somatization)
– Systems of meaning
(Roth et al., (1997-full citation at end)
What does it feel like to be with
someone with Complex PTSD?
And what can you do to do good,
effective work?
General Principles
• Recounting the events of abuse is extremely
stressful and potentially retraumatizing for the
victim.
• Listening to accounts of torture/trauma can be
very stressful for the interviewer as well.
(Vicarious traumatization.)
• Establishing a rapport and eliciting a thorough
and complete history takes time.
General Principles (cont.’d)
• There is variability in:
– the degree of physical and psychological signs,
symptoms or consequences which a torture victim
will manifest.
– the manner in which trauma/torture victims conduct
themselves in interviews and in recounting the
events of their abuse.
– the amount and detail of information which an
individual will recall with regards to the events of the
trauma.
When working with a
traumatized individual
• Anticipate barriers
• Create strategies for addressing those
barriers
• Set realistic goals for yourself and for the
client
• Be aware of and attentive to your own
reactions
Potential Barriers to Effective
Communication
• Environmental barriers
• Lack of privacy or a comfortable setting
• Inadequate time
• Reminders in the room
• Physical Barriers
• Pain, fatigue, sensory deficits
• Sociocultural Barriers
• Gender issues, interpreters, reaction to authority,
Psychological barriers to communication for a
traumatized person
• Disruptions in memory, concentration and
cognitive abilities
• Impairment in reality testing
• Interpersonal discomfort/distortion
• Avoidance of conversations about trauma
• Detachment from emotional responses
• Increased anxiety when remembering
• Narrative inconsistencies
• Shame when recounting
Communication Strategies
• Help client anticipate: Lay out the time
frame/structure of the interview; tasks, goals,
and why you are asking about what you are
asking about
• Allow time to build rapport, trust
• Talk about talking
• Invite questions
• Normalize reactions: “Many people feel…”
• Provide closure: Discuss experience of interview
at the end and anticipate the next step if
possible
Types of client “problems”
The withdrawn client
• Strategy: Try to gently engage by normalizing
and providing a feeling of control:
“Sometimes people have a hard time answering
these questions. I know that you have been
asked a lot of questions and that you are
probably concerned about answering any more.
Is there something that you would like me to
know before I ask you some of my more specific
questions?”
Strategy: Return to education about why you
are asking detailed questions about
particular issues:
• “We really need to convey to the court
what you have been through and how
much you have suffered. Often times
these are the most difficult things to
discuss, but they can be the most
important things for the Court to
understand in order to know the truth
about how you were treated.”
Strategy: Return to the reason for the question and
how it can be helpful to the client:
• “One thing that is difficult about our legal
system is its adversarial nature, which
means that it is the job of the lawyer on
the other side to try to argue with or
challenge your story. This means that we
have to anticipate these challenges and
address them ourselves so that we are
prepared.”
The “flooding” client
• What is flooding?
--An overload of information/expression
--Content/facts
--Emotions
--Often feels hard to stop or contain
Strategy: Try to contain, both by providing more
structure in the interview, suggesting short breaks,
and explaining why you need to focus on certain
issues
• “I can understand how important it is for
you to make sure I understand what you
are telling me. I want to hear the things
that are important to you. I also have some
specific things I want to hear about today,
so I’d like to make time to talk about those
things.”
Strategy: End the interview if
necessary:
– Client is unable to contain emotions at all
– Client is incoherent, even after attempts to
ask more basic questions
– Client becomes aggressive, overtly hostile
The hopeless client
• Strategy: Reflect back what you see and
empathize
“I can see that you don’t believe it’s worth it
to try to do anything to fight for your case. I
know that I am not in your position and
can’t imagine how you feel. But I really
understand that you are telling me you
cannot fight this situation anymore.”
Strategy: Share your
commitment
• “Even though I hear what you are saying
about not wanting to fight anymore, I want
to explain my position and my beliefs. I
believe that you and your case are worth
fighting for. I’d like to tell you why…”
Strategy: Make small work
commitments together
• “I know you are saying you don’t want to
keep up this fight forever. How about if we
agree to keep working for the next month
and see how you feel after that?”
HUMANIZE
• THE SINGLE MOST EFFECTIVE
“STRATEGY” WITH A TRAUMATIZED
PERSON
• How?
– Genuineness
– REAL Listening
– Self-disclosure (CAREFULLY)
– Transparent expressions of desire to
understand and assist
Other interview challenges
• Delivering bad news
– Be direct
– Do not try to “spin it” right away
– Share your reaction if appropriate but it is not about
“you”
– Ask for reaction/Reflect back what you hear
– Recognize that it takes time to deal with bad news
• Ending your work with a client
– Use above principles
– Do not avoid
– Be genuine
Self-care for the evaluator
Vicarious traumatization
• Can occur in those who work with survivors of
severe trauma
• Can be a normal reaction to hearing very vivid,
distressing narratives.
• Manifests itself in distress and symptoms of
PTSD (e.g., nightmares, irritability, anger).
• Feelings of demoralization and depression are
also frequent.
• Can feel like you are a victim/perpetrator
Strategy: managing boundaries
• Clarifying the limits of your role with your
clients
• Clarifying what you CAN do for your client
• Tolerating feelings of guilt and
helplessness
• Recognizing fantasies of rescue and
omnipotence
Strategy: Attending to and
processing team dynamics
•
•
Recognizing team members’ different
ways of coping with the stress (e.g.-the
staff member who “gives extra”, the staff
member who withdraws, the staff
member who rants).
Building time for team to process
experiences together.
Sources
• Robins, et. al., (2005) Psychiatric problems of detainees under
the Anti-Terrorism Crime and Security Act 2001, The Psychiatrist
(2005) 29: 407-409.
• Cook, A., Blaustein, M., Spinazolla, J., van der Kolk, B. (2003).
Complex trauma in children and adolescents. White paper from the
national child traumatic stress network complex trauma task force.
Los Angeles, CA: National Center for Child Traumatic Stress
• Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al. (2005).
Complex trauma in children and adolescents. Psychiatric Annals,
35:5, 390-398.
• Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel,
F.S. (1997). Complex PTSD in victims exposed to sexual and
physical abuse: Results from the DSM-IV Field Trial for
Posttraumatic Stress Disorder. Journal of Traumatic Stress 10, 539556.
Sources (contd.)
•
“Leave No Marks: Enhanced InterrogationTechniques and the
Risk of Criminality.” Physicians for Human Rights/Human Rights
First. Available at: www.phrusa.org
• Scott Allen, M.D. Center for Prisoner Health and Human Rights,
The Warren Alpert Medical School, Brown University
Extra slides follow on Complex
Trauma
Complex Trauma impacts multiple aspects of a
child’s functioning--i.e. the whole system
• Attachment-boundary problems, mistrust,
isolation, difficulty attuning to others or enlisting
others as allies
• Biology-sensorimotor problems,
coordination/balance problems, somatization
• Emotional regulation- high intensity emotions,
pervasive negative feelings, emptiness,
oscillation between over-expression and overinhibition of emotions
(American Academy of Experts in Traumatic Stress:
www.aaets.org/article174.htm)
Complex Trauma impacts multiple aspects of a
child’s functioning--i.e. the whole system (contd)
• Dissociation-alterations in consciousness, amnesia,
multiple states of consciousness
• Behavior/Impulse control- poor control; self-destructive
behavior, aggression, sleep/eating disturbance,
substance abuse; difficulty with rules; repetition
• Cognition- attention, concentration, executive
functioning/planning, impairment in language,
visuospatial, acoustic processing
• Self-Concept- fragmented sense of self, poor selfesteem, shame/guilt, poor sense of separateness, body
image
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Interviewing Survivors of Torture In a Legal Context: Barriers and