When Society is the Victim: The Catastrophic Trauma Recovery Project

Psychological and emotional injuries may be the most enduring effects of war, yet historically, they may be the least addressed in terms of rebuilding a society and preventing future violence. Perhaps there is a relationship here. Large-scale recovery efforts commonly have focused on more visible needs like food, shelter, clothing, and physical health, as well as economic aid. Psychological trauma has been overlooked or minimized and never truly resolved, leading to its becoming part of the psyche of a society that extends into future generations.

In recent world conflicts, terrorism has often been purposely utilized against civilians as a means of attacking the self-esteem and morale of “the enemy,” as well as simple retribution. Ironically, perpetrators have frequently justified these actions based on past unresolved emotional wounds of their own.

This psychological paradox of victims becoming perpetrators has long been examined in the field of psychotherapy relative to individuals, yet the parallel transformation on the societal level has been studied far less. For in-depth healing to occur on both levels, actions must be judged separately by their universal quality of being humane or not, rather than by the identity of who does them. When two societies in conflict each carry the deeply rooted identity of “victim,” there is the greatest danger of blind, brutal treatment toward a dehumanized and demonized “other.” Conversely, such inhumane actions against members of a society can further validate that society’s demonized view of the perpetrators. The cycle of violence contributes to the cycle of trauma.

Whether in the Balkans, the Middle East, or elsewhere, in modern times or the past, regardless of the original motivation of conflict, unresolved communal psychological wounds are one of the most — if not the most — powerful fuels of war and violent conflicts. The underlying insecurity and pervasive distrust, both on the part of individuals and groups, only intensify and validate fear of “the other” and contribute to dehumanizing stereotypes. Lack of understanding of these wounds can account for the seemingly incomprehensible dynamics of a conflict when viewed from afar.

Efforts at maintaining peace and avoiding war are seriously handicapped if they do not address such current and historical wounds, and create the means to prevent future traumas.

Treating large civilian populations experiencing catastrophic psychological trauma at all levels of a society due to war and violence poses unique challenges not typically focused on in the therapeutic literature or conventional clinical practice. When the society is one where human services are seriously underdeveloped or absent, and where the integrity of the existing social support system itself is critically compromised, this challenge can become overwhelming.

What is needed are new models oriented toward treating large populations. These models must incorporate an integrated flow of services and supports designed to respond to both immediate and long-term effects of trauma. They should instill in the local community the capacity to provide and expand these services on an ongoing basis. It is imperative that any model also be sensitive to the cultural context of both the trauma experience and treatment. Thus, in addition to adaptations of standard mental health treatment methods, it is important to enlist traditional aspects of the society itself, such as its cultural and spiritual resources (Olweean & Friedman, 1997).

Beginning in 1999 and during the recent Balkan conflicts, a series of special roundtables on the Balkans were held at the Annual International Conference on Conflict Resolution (ICR) in St. Petersburg, Russia, sponsored by Common Bond Institute of the USA and Harmony Institute for Psychotherapy and Counseling of Russia. Representatives of non-governmental (NGO) relief and conflict resolution organizations from Albania, Serbia, Kosovo, Bosnia, and Croatia participated. The first such roundtable occurred the afternoon of the bombing of the Chinese compound in Belgrade. What was striking about these dialogues was the consensus that the most urgent and neglected need throughout all societies in the region was for healing from pervasive psychological trauma. Additionally striking was that all participants agreed this trauma was linked to not only recent but also past occurrences of violence, terror, and loss, many dating back generations, and some going back for centuries. In subsequent discussions with key participants from each of these Balkan countries, trauma recovery needs were continually accented as the single most threat to future peace and reconciliation in the region.

Although in 1999 the United Nations Inter-Agency Needs Assessment Mission had also assessed this need to be widespread and relatively unattended to, there was little in the way of adequate direct services or local training being provided in trauma treatment (United Nations Security Council, 1999). It can be reasoned that at least part of this lack of action has been due to an absence of workable models for undertaking such an immense task.

In response to requests for such new models, and in cooperation with local Balkan NGOs and an international network of training organizations, Common Bond Institute developed the Catastrophic Trauma Recovery (CTR) Project. The purpose was to design an intensive training program to provide on-site practical training in crisis intervention, trauma resolution, and support skills to large groups of local professionals and relief workers in the Balkans currently working directly with refugees and victims of violence. This program has subsequently been expanded to include trainees in the Middle East.

The goals of this “training of trainers” are the following:

1) To create an extensive, permanent pool of local health professionals and paraprofessionals equipped with skills to assist the large number of people throughout the region suffering from psychological trauma;
2) To provide self help skills and resources to the general population;
3) To make an investment in the quality of future health services of the region, and
4) To encourage cross-border cooperation among service providers.
The CTR model is presented here as one example of a comprehensive, integrated treatment and training model designed to be culture-sensitive and particularly suited to regions experiencing violent turmoil where health services are underdeveloped and the society’s infrastructure has broken down. Trainees are instructed in each aspect of the model.

THE CATASTROPHIC TRAUMA RECOVERY (CTR) INTEGRATED MODEL

A brief description of the main components of the CTR integrated model are presented below.

1) Brief Therapeutic Intervention Process. For immediate symptom relief, there are a number of highly effective, new brief therapies useful in alleviating psychological trauma symptoms. For the purposes of this model we have selected Eye Movement Desensitization and Reprocessing (EMDR). Major factors in selecting EMDR for this component of the model are that it provides quick results and can be learned in a relatively short time by both professionals and paraprofessionals. It is also felt to be easily adapted culturally (Shapiro, 1989).

2) Survivor Support Groups. On-going, programmed groups can be designed to be self-run and offer support, safety, and acceptance to victims, as well as to augment direct therapeutic services. The role of survivors support in providing contact for as many people as possible can not be emphasized enough, due to the sheer size of the victim pool, the limited capability of mental health services in the regions, and the demonstrated benefit of this type of assistance in a variety of applications and settings.

3) Crisis Phone Lines and Drop-in Centers. The development of existing services, or the establishment of new ones where absent, is necessary for providing immediate crisis intervention and support, as well as referral to available area services for ongoing treatment.

4) Triage and Assessment. For both immediate and long-term treatment, it is necessary to prioritize the severity of need and appropriate available treatment resources. It is also necessary to identify those who need more extensive follow-up services in the future. During this time, an assessment is made of currently available mental health services in the area, with suggestions for developing essential components and networking with outside organizations and resources to support this development.

5) Stress Management Training for Aid Workers. Self-help skills are needed to help workers manage the anticipated stress of this work and reduce burnout potential. Direct contact with relief workers cooperating on the project confirms that burnout is not only a high potential; it is unfortunately an inevitable occupational hazard for many who continue to do this relief work. There is obvious need for effective mechanisms to assist with burnout recovery as well as prevention.

6) Counselor/Trainer Support Groups. These groups are needed for ongoing support in managing stress, peer consultation, and to help develop a cohesive pool of mentors in the region. Laying the groundwork for local professionals to eventually take on primary responsibility for providing these services, training, and supervision of others is emphasized.

7) Community Support, Advocacy, and Intervention for Victims. The community needs to be mobilized to assist with nurturing community acceptance and support for victims, and to avoid re-traumatizing experiences. An orientation to the culture and predominant religions of the region is provided to project trainers to ensure sensitivity in applying training within this context. Teams work with community and spiritual leaders to encourage and aid them in taking an active role in developing community support for victims, particularly of rape and sexual abuse — some who may have given birth as a result, to reduce the social isolation and shunning that often occurs.

Representatives of like cultural and religious traditions from other regions are enlisted to cooperate in meeting with local counterparts and offer assistance in sensitizing the general population to the need for acceptance, support, and reassurance of victims. In general, it is essential that the indigenous cultural and religious institutions that hold the society together are enlisted wherever possible to ensure long term success in healing trauma.

One of the most under-reported and lamentable dynamics of trauma where rape, sexual abuse, and torture occur, is the re-victimization of individuals who are rejected, accused, and alienated by their family members and/or community. Shame and fear of such unfair oppression by those already victimized causes many to deny their trauma and refuse treatment. The added presence of children born from rape who are themselves rejected, oppressed, or even punished by their society only further carries and imbeds victimization into the next generation.

8) Public Education. There are many benefits to the providing of general education to the lay public relative to psychological health, common symptoms of trauma, and available services. Local resources, such as media outlets, educational institutions, hospitals, and religious organizations are utilized to disseminate this information.

9) Mediation and Dispute Resolution. As there is often some degree of increased domestic and community conflict in regions victimized, invariably workers may encounter such situations in their work. This component provides basic skills and helpful guidelines for coping and assisting with conflicts arising within the community being served. An extensive list of alumni of the Annual International Conference on Conflict Resolution is often utilized as a resource to draw on for trainers in this area.

10) Training Resource Library. It is essential to establish and maintain a growing on-site and Internet based archive of video and audio programs, taped training sessions, as well as written manuals and program materials, for the purposes of continuing education, review, and utilization by local trainers conducting future sessions.

11) Ongoing Consultation and Team Support. This support can be provided by training team members, and by establishing an international network of cooperating organizations. They can be of help to local workers and trainers in the region via e-mail, Internet web-based communications, fax, and telephone. All trainers agree to be available for ongoing consultation between and after training sessions. Following initial training visits, brief refresher courses are built into subsequent sessions to help maintain and advance the skills of previous trainees. For example, a core group of higher skilled professionals from throughout the Balkans has been identified to receive more in-depth instruction to promote a permanent local pool of mentors who can carry on training at the local level.

An added benefit of such a regional mentor pool is to build regular contact and encourage cooperation and mutual support between professionals and relief organizations across borders in healing their respective societies. As one outcome of this emphasis, there is as current effort by professionals involved in the CTR Project to establish a region wide Balkan Psychological Association.

A core concept in treating trauma at the societal level is a transfer of skills to both indigenous service providers and the general population as a means of giving the society the means to heal itself. A comparison can be made here with the manner in which telephone crisis intervention has been taught to paraprofessionals, and in which Cardio-Pulmonary Resuscitation, emergency first aid, and stress management have been taught to the general public in the United States.

The CTR model offers one example of an integrated approach to promote the psychological healing of a society. Further research and development are required to construct and use more models such as this to treat large population trauma. We must meet this challenge if we are to assist immediate suffering and prevent future generations from inheriting trauma and the archetypal role of victim as part of their ethos.