Working with
Survivors of Torture
Abbey Weiss, PsyD, LP
The Center for Victims of Torture
Healing in Partnership Project
June 8, 2012
Objectives
 Participants will learn issues and
concerns specific to working with
survivors of political torture
 Participants will learn about a variety of
intervention methods
 Participants will review and consider how
to apply these to specific cases
Agenda
8:30am-9:00am
9:00am -10:00am
10:00am - 10:30 am
10:30am - 10:45am
10:45am - 11:15am
11:15am - 11:30am
11:30am -12:00pm
12:00pm - 12:15pm
12:15pm - 12:30pm
Introduction to “Working with Survivors of Torture.”
Background, definitions, unique considerations
Evidenced Based Practices and Beyond
Present the model of care at CVT
Present various modalities and intervention strategies
“In the Consulting Room” – Case #1
Break
Small group work – Discussion of case examples
Discussion with the larger group
Secondary Trauma
Next Steps
Questions and wrap up
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The Center for Victims of Torture
Founded in 1985
Current clinic location
CVT
Rehabilitative Treatment
Training
Research
Public Policy
Who does the Center Serve?
 East African, West African, SE Asian,
Middle Eastern, European, Central and
South American
 50% percent male, 50% female
 Average number of years of formal
education:12.9
 76% are asylum seekers
 68% unable to work at time of intake (no
work permit)
According to Amnesty International, more
than 130 countries worldwide
systematically practice torture against their
own civilian populations.
Amnesty International Report 2004
Primary Refugee Arrivals, Minnesota, 2006
Hmong
Burma
4%
3%
FSU
2%
Liberia
Other
7%
6%
Ethiopia
9%
Somalia
Somalia
Ethiopia
Liberia
Hmong
Burma
FSU
Other
N=5,354
69%
““Other” includes Cambodia, Cameroon, China (also Tibet), Congo, Cuba, Eritrea, Gabon, Guinea, Iran, Kenya, Nepal,
Nigeria, Sierra Leone, Sudan, Togo, Vietnam, and Zimbabwe
Refugee Health Program, Minnesota Department of Health
A refugee...
An asylum seeker...
is a person who “owing to a well-founded fear
of being persecuted for reasons of race,
religion, nationality, membership in a particular
social group, or political opinion, is outside the
country of his nationality, and is unable to or,
owing to such fear, is unwilling to avail himself
of the protection of that country.”
Source: Protecting Refugees: Question and Answers, published by the United
Nations High Commission on Refugees (UNHCR) Public Information Section.
 Center for Victims of Torture
What is the difference?
Refugee vs. Asylum Seeker
UNITED NATIONS
Torture is:
 Any act by which severe pain or suffering
 Physical or mental
 Is intentionally inflicted
 To obtain information or a confession, to punish,
or to intimidate or coerce
 Based on discrimination [political, ethnic,
religious, etc.]
 Inflicted by, at the instigation of, or with the
consent or acquiescence of a public official
Torture is...
…the deliberate and systematic
dismantling of a person’s identity and
humanity.
…the attempt to destroy a person’s
will to live, and their ability to trust
in anyone or anything.
 Center for Victims of Torture
 Destroy a sense of community
 Eliminate leaders
 Create a climate of fear
 Produce a culture of apathy
 Create a sense of familial disruption
 Center for Victims of Torture
Forms of torture
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Most forms are “low tech”
Beatings
Forced labor
Deprivation
Wrongful imprisonment
Rape
Trauma/Torture Events
Life threatening
Unpredictable
Can’t stop
Stress is extreme
Emotional or physical
reactions
are NORMAL.
 Center for Victims of Torture
NORMAL RESPONSE
TO FEAR:
Heart beats fast, sweat, get ready to ACT
without much THOUGHT because one is
trying to survive
But…prolonged periods of this can lead to
PTSD, or like the alarm never gets shut off
Torture, War Trauma and
Terrorism affect FIVE basic
human needs
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The need to feel safe
The need to trust
The need to feel of value (self worth)
The need to feel close to others
The need to feel some control over our
lives
Common Myths About
Survivors of Trauma
 Time heals all wounds
 Survivors will eventually forget about the past
 Bringing up the past only makes it worse
 Survivors can bounce back to “normal” once
they are removed from war or after a set
amount of time
 If they look fine on the outside they are fine
on the inside
Common Diagnoses
Post-traumatic Stress
Disorder
 An adaptive/normal response in a life-threatening
situation
 A cross-cultural phenomenon
 80% of CVT clients meet full criteria for Posttraumatic
Stress Disorder
 Data from Meta-analysis on Mass Trauma indicate that
65% of trauma survivors suffer with PTSD (SAMHSA,
2001)
 People can heal from PTSD
Post Traumatic Stress
Disorder
Symptoms fall in 3 main categories:
Re-experiencing
Avoidance
Hyperarousal
Depression
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Depressed or irritable mood
Disturbed sleep (too little or too much)
Fatigue or loss of energy
Loss of interest in daily activities
Psychomotor agitation or retardation
(moving too much or too slowly)
Depression
 Difficulty concentrating, thinking,
remembering, making decisions
 Thoughts of suicide, death
 Significant increases or decreases in
weight or appetite
 Feelings of worthlessness, excessive
guilt
Depression
 70% of CVT Clients meet full criteria for
Major Depression
 Depressed or irritable mood
 Disturbed sleep (too little or too much)
 Fatigue or loss of energy
 Loss of interest in daily activities
 Psychomotor agitation or retardation
(moving too much or too slowly)
These are the clinical
names for the ways
people suffer. It will look
as varied as the faces in
this room, as different as
each person you meet.
Evidenced Based Practice
and Beyond
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CVT’s model of care
Multi-disciplinary
Theoretical orientation
What experience teaches us
Multi-disciplinary
 Social Work
 Psychotherapy
 Individual
 Group
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Nursing
Medical
Psychiatry
And…
Individualized Treatment
Plan
 There is no ONE methodology used
 Each case is unique
 Consultation and collaboration allow us
to construct the most effective treatment
for each person
Common
practices/interventions:
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Group vs. Individual
Cognitive Behavioral
EMDR
Narrative
NET
Other exposure techniques
Treatment:
Long term
vs.
Short term
Treating Symptoms vs.
Treating Persons
Treating the FEAR (PTSD)
Treating the GRIEF (Depression, grief,
mourning
Knowing how to intervene
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Considering exposure techniques
Considering narrative work
Singular vs. multiple traumas
Developmental considerations
When immigration status matters
Personality factors
When was the trauma?
In the consulting room
Case #1
BREAK
Small group work:
Discussion of case examples
 Work in groups of 3-4
 One of three cases
 What interventions would you consider?
 What questions do you have?
 What do you imagine would be this person’s
concerns?
 What are your thoughts/feelings about
working with this person?
Discussion with the larger
group
Secondary
Trauma
“To much sanity is madness, and the
maddest of all is to see life as it is, and
not as it should be.”
-Miguel de Cervantes
The vast universal suffering feels as
thine: Thou must bear the sorrow
that thou claimst to heal; The daybringer must walk in darkest night.
He who would save the world must
share its pain. If he knows not grief,
how shall he find grief’s cure?
-Sri Aurobindo
Stress
 What is stress?
 Anything that throws your body out of allostatic
balance
 A demand made upon the adaptive capacities of mind
and body
 Adverse reaction people have to excessive pressure
or demands placed upon them
 Humans are unlike animals in that we can create
a stress response just by thinking about it
 The term “stress” was coined in the 1930s by
Hans Selye
From Zapolsky, R. (1998). Why zebras don’t get ulcers. New York: W.H. Freeman
Defining Secondary
Traumatization
“The effect of working with people who have
experienced trauma and of being exposed
to the difficult stories they share. It is
called ‘secondary traumatization’ because
it is experienced indirectly, through the
process of being a witness to another
person’s trauma.”
From Andrea Northwood’s chapter Secondary Traumatization
Secondary Trauma
Secondary Trauma is a particular type of work
stress which comes from working with trauma.
It is often more difficult to talk about than
general work stress.
 Is a normal part of working with survivors
 Does not mean we do not like/are not
successful at our jobs
 It is manageable with the proper tools and
support
 It is necessary to understand and recognize it
in order to avoid burnout
“I.M. described some of the details of the torture he had
undergone during his detention in a Latin American
country. It was a horrible story, but the most frightening
aspect was the way in which he tried to suppress his
emotions. The therapist was unable to make I.M.’s fear
of being overwhelmed by his own emotions discussable at
that moment. His own feelings took him by surprise,
particularly the feeling that he had nothing to offer in the
face of so much suffering, that he had not experienced
anything himself and therefore had no right to speak
about such matters. He also felt angry with I.M. for
putting him into this uneasy situation.”
-Guus van der Veer, from Counseling and Therapy with
Refugees and Victims of Trauma, pp. 136-137
“Knowing about our own VT is like that
unsettling experience of feeling like
you’re waking up from a bad dream, and
then realizing in a few moments that
you’re still asleep, and then waking up
again. And again.”
Laurie Anne Pearlman “Notes from the Field” from
Secondary Traumatic Stress
CHANGES YOU MAY
OBSERVE OVER TIME
 PESSIMISTIC WORLD VIEW
 CHALLENGES TO SPIRITUALITY
 DIFFICULTY REGULATING
AFFECT/EMOTIONS (PTSD &
DEPRESSION)
 DIFFICULTY SETTING BOUNDARIES
 POOR SELF CONCEPT
 BODILY SYMPTOMS
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Adapted from Pearlman and Saakvitne Trauma and the Therapist
CHANGES IN WORLD VIEW
 Challenges to perceptions about the world
(may not want to believe is true)
 Questions about nature of evil
 Heightened sensitivity to violence
 May lose optimism and hope
 Changed hope
 May join survivors expectations about the
world
DIFFICULTY TOLERATING
AFFECT/EMOTION
 Professionals may experience other’s
suffering more intensely
 Feelings are much closer to the surface
 Impatience with own feelings
 Interference with feelings of clients and
family and friends
“When a client dissociates from feelings,
often the feelings themselves are left with
the (professional) while the survivor
appears numb or indifferent. The
(professional) may be left, both in and after
the session, feeling profound anxiety, grief,
rage, helplessness, arousal, despair, or
powerlessness. Those intense feelings are
exhausting when felt for two.”
-Saakvitne & Pearlman
DIFFICULTY TOLERATING
AFFECT/EMOTION
 Professionals may become overwhelmed by
trauma and lose the capacity to sooth
themselves in healthy ways turning to
overeating, drinking, spending, working
 Feeling like you can’t help everyone can lead
to a sense of powerlessness or a sense of
inadequacy
 Lose the capacity to enjoy outside activities
DIFFICULTY MAINTAINING
BOUNDARIES
If you take on too much you may lose the
capacity to make self protective
judgements leading to:
 loss of empathy and sense of humor
 can lead to falling down on the job(missed
appointments, impaired judgement)
 inability to be introspective
CHANGES IN SELF
CONCEPT
 May blame self for feeling overwhelmed,
overworked leading to self-criticism,
anxiety
 Less energy to attend to the needs of
loved ones
 Concerns about professional ability
ABC’S OF Addressing
Secondary Trauma
 Awareness
 Needs, limits, resources, changes in self
 Balance
 Among work, play, rest, personal and
professional life
 Connection
 With self/others as antidote to isolation
PERSONAL STRATEGIES
 Self Care
 Exercise, rest, play, nutrition
 coping with intrusive traumatic imagery through self-reflection
and psychotherapy
 Spiritual Renewal
 Seek connection, meaning, hope, awareness
 Nurture World View
 Seek sources that offer perspective
PROFESSIONAL STRATEGIES
 Recognize And
 Maintain
Accept Secondary
Professional
Trauma
Connections
 Limit Exposure
 Attend
Empathy/Cynicism
 Professional
Education
 Supervision &
 Name Reenactments
Secondary Trauma
 Support Groups
Consultation
ORGANIZATIONAL STRATEGIES
 Adequate Pay
 Time Off, Extended
Vacation
 Control Over
Caseload
 Predictable Days
 Continuing
 Institutional Support
Professional Education
 Flexible Organization
 Internal Consultation
 Social Activism
 Secondary Trauma
Training
Next Steps
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Clients you already work with
Taking new clients
Consultation
Ongoing training
Other ideas?
Questions and Wrap Up
A (short) List of Essential
Resources:
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Judith Herman
John Briere
Viktor Frankl
Pauline Boss
Irvin Yalom
Resources
Boss, Pauline (1999). Ambiguous loss: learning to live with unresolved grief.
Cambridge, MA: Harvard University Press.
Briere, John, Ph.D. & Scott, Catherine M.D. (2006). Principles of trauma
therapy: a guide to symptoms, evaluation, and treatment. Thousand Oaks,
CA: Sage Publications, Inc.
Dalenberg, Constance, Ph.D. (2000). Countertransference and the
treatment of trauma. Washington, D.C.: American Psychological Association.
Frankl, Viktor ((1959). Man’s search for meaning: an introduction to
logotherapy. New York, NY: Simon and Schuster, Inc.
Judith Herman, M.D. (1992). Trauma and recovery: the aftermath of violence
– from domestic abuse to political terror. New York, NY: Basic Books.
Stamm, B. Hudnall, Ph. D. Editor. (1995). Secondary traumatic stress: self
care issues for clinicians, researchers and educators. Baltimore, MD: The
Sidran Press.
Yalom, Irvin (1970). The theory and practice of group psychotherapy. New
York, NY: Basic Books.
Abbey Weiss, PsyD, LP
aweiss@cvt.org
(612) 436-4832
Evaluations