Psychosocial and Psychotherapeutic Approaches to Victims of Torture

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1 Psychosocial and Psychotherapeutic Approaches to Victims of Torture Peter B. Polatin, M.D., M.P.H. Senior Health Advisor International Department Rehabilitation and Research Centre for Torture Victims (RCT) Copenhagen and Washington, D.C.

2 Post torture syndromes PTSD* Anxiety disorders Depression Psychosis Post traumatic personality disorder Insomnia Substance Abuse Chronic pain Somatic disorders Brain Damage/ Organic mental disorders Loss of Function Deconditioning Physical disability Emotional disability

3 Traumatic event Subcortical Memory Amygdala Isolated High Network emotional hypothalamus, hippocampus valency Olfactory & Tactile Stimuli Thalamus Auditory & Visual Stimuli Flashbacks Nightmares Panic attacks Hyperarousability SUBCORTICAL TRAUMATIZATION

4 Cortex Cortex Limbic region Limbic region Brainstem Brainstem NORMAL PTSD Solid colours represent increased functioning and lighter shaded areas represent decreased functioning.

5 Sensory Elements Cognitive Elements Emotional Elements Physiological Elements See road in home village I can t do anything! Helplessness Freezing See bush landscape Smell dead bodies See soldiers With guns This is dangerous! I-ME Fear Tachycardia Hear screaming Rage Hyperventilation See a policeman See media reports Think about event Frustration about asylum process Anger at childrens misbehavior Physical Activity Example of a fear network (from Schauer, Neuner, & Elbert, Narrative Exposure Therqpy)

6 CHRONIC PAIN: impact and co-morbidity

7 Somatization Pain sensitivity Cognitive distortion Catastrophizing Symptom magnification Enforced passivity Psychiatric and Neurocognitive Sequellae

8 CHRONIC STRESS

9 HPA Axis STRESS HYPOTHALAMUS CRH cortisol PITUITARY ACTH ADRENAL CORTEX

10 Health impact of chronic stress Heart disease Diabetes Peptic ulcer disease Compromised immune system Growth problems Impaired memory

11 FUNCTION AFTER TORTURE

12 Impact on ICF defined functions Impaired body functions: Impaired locomotion, e.g. walking Impaired memory and attention Impaired socialization Avoidance Emotional instability Restricted activity and participation Family life Work Civil society Religion/spiritual life

13 THE IMPACT OF TORTURE

14 Effects of Torture on a Society Terror Paranoia Repression Political control/domination Polarization

15 ..on a Victim Anger Fear Anxiety Depression Guilt Paranoia Demoralization Sense of stigma & exclusion

16 Change in Personality? Loss of basic trust Paranoia Loss of belief> skepticism Self defenses Anesthesia Denial Dissociation

Refugees and Triple Traumatization 1. Trauma in home country that causes flight Killings, torture and other violence Persecution and discrimination 2.

17 Refugees and Triple Traumatization 1. Trauma in home country that causes flight Killings, torture and other violence Persecution and discrimination 2. Loss, departure and flight Separation from usual surroundings Dangerous, costly and unpredictable journey 3. Demands and barriers in receiving country Short term: distrust and insecurity Long term: language- and cultural barriers, discrimination, marginalization

18 THE TREATMENT OF TORTURE SURVIVORS

SALUD Decline in health Hypertension Diabetes Chronic pain

sequellae (PTSD, depression, substance abuse, family

) Shame Guilt Demoralization Apathy Paranoia Loss of trust

19 SALUD Decline in health Hypertension Diabetes Chronic pain Brain injury Loss of function SPIRITUAL Psychological sequellae (PTSD, depression, substance abuse, family violence, etc.) Shame Guilt Demoralization Apathy Paranoia Loss of trust TRAUMATIZED INDIVIDUAL Social withdrawal Collapse of family structure Loss of economic capability Loss of social capital SOCIETAL

20 What should be the goals of treatment? -Cure? -Symptom relief? -Social reintegration and empowerment? -Justice and accountability?

21 Optimal Conditions for Trauma Therapy Health+ Safety+ Basic needs+ Motivation+ Medication/drugs +/- Guilt+/-

22 TREATING TORTURE SURVIVORS ( combination therapy ) Primary health care Specialized health care Physical rehabilitation Psychiatric rehabilitation Psychosocial rehabilitation and community based interventions Special populations (children, elderly) Gender sensitivity

23 Rehabilitation: An Interdisciplinary Psychosocial support Medical treatment Model of Care Cognitive behavioral therapy Physical therapy The patient is a member of the treatment team

24 Psycho-social support Basic needs Education about symptoms Self regulatory training Socialization Social services

25 Cognitive-Behavioral Therapy Exposure to traumatic memories>desensitization Cognitive reappraisal overcomes the defenses of numbing, dissociation, fragmentation, and forgetting Transformation by new learning Overcoming pain

26 Socio-Political Aspects Altruism Reconnection with political commitment Social reconciliation

27 Progression of therapies to treat severe emotional traumatization Psycho-social support: food, clothing, shelter, medical care Expressive therapies Art Dance Music Play Other representational approaches Narrative therapies TFCT/TFCP EMDR PET NET TT

28 Goals of Narrative Therapy Transformation of trauma story from an account of shame and humiliation to one about dignity and virtue Relief of emotional distress Catharsis Insight Exposure desensitization Cognitive restructuring Improvement of function

29 ASSISTING THE HEALING PROCESS THERAPIST CORTICAL MEMORY (consciousness) TRUTH AND RECONCILIATION: Justice Reparation COMMUNITY Psycho-education Strategies for panic dissociation CONFRONTATION: Experience the affect TELLING THE TRAUMA STORY Sensitization Rituals Spirituality Empowerment Destigmatization empathy SAFE PLACE trust SUBCORTICAL MEMORY COMMUNITY SUPPORT

30 Cochrane Collaborative Best Practices for PTSD Psychopharmacotherapy (SSRIs) Trauma Focused Cognitive Behavioral Therapy (TFCBT) Eye Movement Desensitization Reprogramming (EMDR) Prolonged Exposure Therapy (PET)

31 Other therapies with positive observational trials Narrative Exposure Therapy (recent small RCT) Testimonial Therapy

32 02/20/10

33 Imaginal exposure: reliving the trauma during the therapy session In vivo exposure: fear and avoidance hierarchy homework of exposure experiences What about clients with multiple traumatic events?

34 02/20/10

35 Autobiographical memory Lifetime periods<> chapters Relationships Occupations Places lived General events<> pages Repeated Single Landmark events Mini-histories Event specific knowledge Hot memories: situationally accessible (reactive to stimuli) Cold memories: verbally accessible (intellectually retrievable)

36 Construction of narrative biography Empathic support of re-experiencing and reprocessing the fear memory (exposure)> chronological re-structure of experience Separate traumatic memory from conditioned emotional response thru detailed narration Testimony created and edited Testimony signed Survivor keeps the narrative

37 Best suited to victims of multiple events of TOV 4-6 sessions Different than PET and TT: All + and emotional moments from birth on Reliving all those moments (sensations, perceptions) Elements of the emotional network assigned specific place and time in the life story

38 EMDR (eye movement desensitization and reprocessing)

39 Isolated Network Hypothesis of why EMDR works Revisualize trauma Adaptive Informational processing Dual attention stimulus Replace adversive qualities with alternate cognitions New associations

40 Testimonial Therapy

41 The 2 Functions of Testimony Objective recording- Evidence, attestation, proof, advocacy Subjective expression- Disapproval, condemnation, protest Catharsis Healing Psychotherapeutic

42 Chile, 1983 Cienfuegos and Monelli: The testimony of political repression as a therapeutic instrument Political/historic>therapeutic Confirm and document a reality that people had experienced Create a document so as to avoid re-traumatization by repetitive telling Provide symptomatic relief by catharsis Integration of the trauma Restore self esteem

43 RCT* Asian Initiative ( ): India,Sri Lanka, Cambodia For victims of torture and organized violence A psycho-legal approach Trainee groups were human rights activists and community workers without prior mental health training a brief therapy intervention re-integration of survivors into the community development context specific manuals (in English, Hindi, Sinhalese, and Cambodian) defined and measured outcomes (M&E) * Rehabilitation and Research Centre for Torture Victims, Copenhagen

44 Asian Model: 4 sessions 1. Session one: Opening the story 2. Session two: Closing the story 3. Session three: Delivery ceremony 4. Session four: Follow up

45 Other essential elements 1. Meditation and Mindfulness integrated 2. Community-based delivery rituals introduced both Western (anger management, classical conditioning) and Eastern (relaxation methods, meditation) elements. cost effective model of psychotherapy which can be done at the victim s doorstep.

46 Results: WHO 5 Total Score Tendency toward higher total scores afer testimonial therapy than before WHO5-sum (grouped) Range is 0 (worst) to 20 (best) Mean pre-tt was 8.6 Mean post-tt was % n pre WHO5-sum grouped (n=84) post WHO5-sum grouped (n=50) feeling worst feeling average feeling best

47 Results- Participation Scale 17 questions Scoring for each item 0- normal 1- no problem 2- small problem 3- medium difficulty 5- a lot of difficulty Range of scores is 0(best)- 85(worst) Pre-TT mean score was Post-TT mean score was Mean values Participation Scale - mean values P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P16 P17 P18 Participation scale questions Pre-mean Post-mean

48 Survivor s Wishes for Use of Testimony 80 % want it published or used for human rights work

49 Conclusions The results clearly demonstrate improvement in wellbeing and participation activities The results cannot confirm any change in anger or any improvement in physical pain Testimonial therapy is a brief therapy that can be used by human rights organizations with and without expertise in mental health More research and refinement of the technique is required

An Experiential Approach to Reliving with Complex Trauma. Dr Jo Billings Berkshire Traumatic Stress Service

An Experiential Approach to Reliving with Complex Trauma Dr Jo Billings Berkshire Traumatic Stress Service A Phase-Based Approach Stabilisation Processing trauma memories Reclaiming life Overview What