Whole Person Approaches

In Individual and Communal Healing of Trauma

 

Steve S. Olweean 

Common Bond Institute
International Humanistic Psychology Association

In
Integrated Care of the Traumatized: A Whole-Person Approach
Ilene Serlin, Stanley Krippner, Kirwan Rockefeller, Editors
Rowman & Littlefield Publishing Group
2019

CBI outreach services to Syrian refugee children. Amman, Jordan

While disastrous psycho-emotional trauma can be triggered by a variety of events, both natural and human-caused, the most devastating and lasting are those intentionally perpetrated at the hands of others. When such disaster is inflicted on an entire society it can permeate all levels of the community to place its members at even more risk of prolonged and debilitating suffering (Butler, Panzer, & Goldfrank, 2003).

Particularly in societies with massive and growing at-risk populations and underdeveloped or seriously compromised mental health service systems, the challenges are monumental. Further complicating the situation are issues we see as not uncommon when dealing with catastrophic events impacting entire communities, especially in developing societies.

  • Humanitarian aid to communities suffering from such catastrophes historically tends to focus more on the most visible and concrete needs, such as food, clothing, shelter, medical, economic, etc., and most often to the neglect of less immediately visible psycho-emotional wounds (Olweean, 2003); wounds that over time can become embedded in the personal and collective consciousness and identity to be passed on into future generations as inherited trauma (Milroy & Zubrick, 2005).
  • At the same time emergency treatment providers that do attempt to address mental health needs – particularly those coming from outside the community and culture – can tend to approach these recovery needs from an overly specialized, standardized, and culturally biased perspective that seeks to frame the individual and communal experience within specific models they are most familiar with and effective in using (Wessels & Monteiro, 2001). They can also tend to focus more exclusively on purely psycho-emotional treatment needs to the exclusion of those that are more concrete but essential to day to day stability and survival (Wessels & Monteiro, 2003).
  • When there is a significant lack of local treatment skill resources, the limited number of outside therapists available at any one time compared to the immense size of the local victim population, coupled with treatment being only temporarily available due to foreign therapists eventually leaving the community, and taking their services with them, results in a minimal impact at best on the most current level of need in conditions where the need is growing and becoming more chronic (Silove, Ventevogel, & Rees, 2017).
  • Current models and methods in the field of contemporary mental health designed for individual, family, and small group treatment are inadequate alone for addressing trauma at the large societal scale (Davis, Pinderhughes, & Williams, 2015). Even in the face of obvious implications for the future of an entire community imbedded with unhealed trauma, this lack of readily available means to treat systemic trauma at the communal level may lead to reduced expectations for communal healing, or for even addressing the need, and an attitude that it is “too big to heal.”

We have found that the effects of profound trauma due to war and violence on individuals and the communities they make up create exceptional challenges to mental health treatment that highly specialized, standardized, and culturally limited approaches, a too narrow focus on types of recovery needs attended to, and attempts by small numbers of outside therapists to temporary treat massive numbers of victims on an individual, family, and small group basis fail to adequately address.

Our assessment is that a culturally sensitive, whole person approach is the most useful in promoting a broader, more in-depth understanding and response to the healing and recovery process, as well as a fuller benefit to both an individual’s and an entire community’s overall quality of life, stability, and sense of meaning, purpose, dignity, and identity.


THE FOCUS OF THIS CHAPTER

The focus of this chapter is to share observations and programs that have grown out of our directly working with communities in developing societies experiencing pervasive and catastrophic communal trauma by:

  • identifying key interrelated factors that influence healing and recovery outcomes,
  • illustrating the Catastrophic Trauma Recovery (CTR) Model, as an integrated, holistic, and local capacity building model informed by these factors for promoting individual and communal healing, renewal, and post-trauma growth,
  • and offering the example of the Social Health Care (SHC) training and treatment program based on this model currently being used to address the Syrian refugee crisis in the Middle East.


KEY FACTORS

Over more than 2 decades of Common Bond Institute (CBI) working with societies in regions of conflict that have produced countless refugees, we have identified 4 key factors that substantially influence the potential for adequately healing and recovering from community-wide trauma and loss. These Factors are:

  • Whether the multi-faceted and interacting nature of the full experience is acknowledged and attended to.
  • Whether both the quantitative and qualitative dimensions of the individual and communal experience of loss and wounding are attended to.
  • Whether the experience is addressed within the cultural context, and at both the individual and communal level.
  • Whether the community is equipped with the capacity to be the primary provider of its own healing and recovery. 


Multiple Interacting Aspects of the Experience

Victimized populations can face numerous significant stressors, often concentrated within the same period of time. These stressors can relate to both basic daily living and existential needs, can overlap, interact, and merge to magnify the overall power and durability of the loss experience. 

The most immediate example of working with Syrian refugees in particular since 2011 has led us to consider a number of compounding stress factors. These include:

  • psycho-emotional and physical trauma
  • general health decline
  • loss of loved ones and close social relationships
  • loss of community cohesion and sense of belonging
  • loss of individual and communal esteem, confidence, and dignity
  • loss of civil society and institutional support systems
  • loss of individual, family, and social-cultural role and identity
  • loss of home and worldly possessions
  • loss of education, occupation, socio-economic means, and self-sufficiency
  • persecution, exploitation; and diminished civil rights as a marginalized refugee
  • for those settling in lands far from their home culture: culture shock in an often new, foreign, and uninviting society.

The emotional and psychological toll of multiple disrupting life changes can cause substantial strains and drains on the energy, stamina, and internal resources required of a person to adequately adjust to these changes. When they occur within a brief period or essentially all at once, and particularly when acute trauma is present, the cumulative effect can be incapacitating. Being able to regain some degree of balance and stability in a person’s original sense of security, familiarity, and belonging better allows for a steadier, more successful recovery and adjustment to difficult conditions and disruptive life changes. Given this, support of full recovery requires acknowledging and where feasible offering assistance in responding to as many of these elements as possible.


Quality of the Experience

A second key influencing factor has to do with what “type” of needs are attended to – whether both the quantitative and qualitative elements of loss and wounding are adequately dealt with. While the quantity of stressors plays a significant role in creating difficult and compounding obstacles for those struggling to recover to a previous level of daily functioning, the qualitative impact of severe psycho-emotional harm on the individual, and in turn the impact on the community they make up, is most often the deepest, longest lasting, and most difficult wound to recover from. The presence of such harm can also amplify the overall stress of major loss and life changes.

Profound trauma can permeate all dimensions of an individual’s reality, and along the way previously secure positive beliefs can be fundamentally shaken, or even shattered, to be replaced by debilitating and damaging negative beliefs and fragmented perceptions of reality that color all aspects of day to day life from that point forward. If unhealed, the underlying meaning an individual attaches to the experience can galvanize into a system of beliefs about themselves, others, the world, and their place in it that perpetuates the wounding and a victim narrative into their future, and potentially that of their children (Olweean, 2002).

On a communal level, the process is more complex. Trauma at this large scale, penetrating all levels of a society and going unhealed, can become embedded in the group ethos to create shared and socially reinforced legacies of unresolved communal trauma and victim identities that extend into future generations as transgenerational trauma (Volkan, 1998). The dynamics of a reciprocal relationship between communal trauma and the individual trauma of its members further complicates matters, as will be discussed later in this chapter.

“Psychological and emotional injuries may in fact be the most enduring effects of war and violence, yet historically they are the least addressed in terms of either individual or communal recovery” (Olweean, 2003, p. 271). Treating large civilian populations suffering from pervasive trauma poses unique challenges for contemporary treatment models. In societies where human services are seriously underdeveloped or absent, or where the integrity of the existing social support system is critically weakened, these challenges can be all the more overwhelming (Olweean, 2003). However, we find that when there are a significant number of traumatized members of a community, approaches that do not also include addressing the community as a whole are likely to be limited, less than adequate, and fall short.


Cultural Context of the Experience

A third influencing factor is the cultural and spiritual context of the trauma and loss experience, and whether framing both the experience and the various approaches to treatment and recovery directly relates to this context.

Applying perspectives, models, and methods from outside that are not adapted to or reflective of the local culture can create additional barriers and inhibit the community in fully embracing or owning the healing and recovery process. Thus, in addition to adaptations of more contemporary mental health treatment methods it is important to enlist vital traditional resources of the society, such as its cultural and spiritual healing and recovery practices. Framing the trauma and loss within this context and providing services tailored to and within it are essential to achieving and sustaining recovery, resilience, and growth beyond the trauma (Wessels & Monteiro, 2001).

To ensure this cultural sensitivity and relevance, we have found it invaluable to enlist local members of the community, including team members, partners, and trainees, as cultural consultants in appropriately assessing symptoms, needs, and priorities, adapting treatment methods, and incorporating traditional elements and practices so that the end result is a system recognized by, grounded in, and belonging to the community in support of it’s unique identity.


Empowerment of the Community

A fourth influencing factor is whether capacity for recovery is instilled within the effected community. We have found individual and communal trauma and healing to have a reciprocal and perpetuating influence on the each other, and that each in some sense is embedded in the other to effect either alleviating trauma for recover to a healthy state of equilibrium and functioning that supports a positive identity at both levels, or prolonging the trauma and it becoming more deeply entrenched. One of the central aspects of this relationship is reflected in the natural interdependency on essential resources at each level:

  • The individual’s reliance on stable communal resources and support – both informally in terms of social relationships, community identity, and belonging, and formally in terms of civil society systems. When these usual stable social and civil resources of family and community deteriorate or are absent, an individual’s ability for adequate healing and recovery is severely diminished.
  • The community’s reliance on a stable resource of skilled and capable members available to maintain civil society systems and social structures, and to reflect the community identity. When there is a scarcity of such competent members, the community’s ability to adequately supply support to it’s members is weakened, or in extreme conditions essentially absent, and the community as a whole risks further decline.

As a result, we have found it necessary to concentrate efforts on simultaneously addressing recovery at both levels.

An underlying principle in this is employing the human resources of the community itself and empowering it’s members with the resources needed to resume it’s central role as the most effective and visible provider of overall well-being for it’s members. Local capacity building is particularly indispensable in regions of conflict where service structures, skill resources, and material resources are lacking. In these circumstances directing aid toward individual and social healing, while actively investing in the local human service system to develop a growing pool of skilled community members, can promote a fuller and more sustainable recovery and post traumatic growth at all levels of a society. Benefiting from the same dynamic reciprocal relationship we regularly observe between the individual and communal experience, the deeply powerful symbolism of a community healing itself is vital to regaining the sense of security, esteem, dignity, strength, and balance – with the outside world and within itself – that is threatened and undermined by the trauma experience.

As a result, an effective response to these factors requires using an integrated, whole person approach for attending to the multiple nature of the refugee experience, and the psycho-social-biological-spiritual nature of the severe trauma experience within the local cultural context, while equipping members of the community with varying degrees of practical knowledge, skills, and experience needed to be a self-help community in support of a competent and wholesome community identity.

Focusing assistance on all 4 key factors of the community-wide trauma experience has shown us this allows for more successfully endorsing and supporting the healthy internal resources of the individual and their community to strengthen and promote positive transformation in the face of adversity and momentous change.


THE CATASTROPHIC TRAUMA RECOVERY MODEL (CTR)


The Example of Kuwait:

Immediately after the Iraqi troop withdraw from it’s invasion of Kuwait in January, 1991 a doctor in the main Kuwait City hospital was being interviewed on the radio. As the reporter was focused on physical destruction at the ransacked hospital and asking the doctor to detail what immediate aid they needed from other countries, prompting him with a list of items like medicine and specialized medical equipment, the doctor stopped him short, saying: “We don’t need equipment or medicine. We can buy and replace all that quickly and easily. We need therapists.” He went on to say: “We have many thousands of people who are emotionally traumatized and we just don’t have the capacity here to help them.”

“The pervasive sense of helplessness and threat experienced by most of the population due to the violence and arbitrary nature of the repression used by the Iraqi troops was the contributing factor to the high levels of distress. Unlike many populations that have experienced time-­limited events, such as natural disasters, this population was subjected to seven months of traumatic stress” (Eskedal & Behbehani, 1997, p. 142).

At the time Kuwait had one clinically trained mental health therapist in the country, Dr. Jaafar Mohammad Behbehani, who had coincidentally interned under me in the mid 1970’s in Kalamazoo, Michigan.

The radio interview caught my ear and, unaware if Behbehani had returned to Kuwait or not after obtaining his PhD in England, I contacted the Free Kuwait office in Washington DC to ask what help I could offer. The office was in the process of being dismantled and staff returning to Kuwait, but the office director passionately asked for assistance in securing mental health treatment for the massive number of traumatized citizens, among who were his close family members.

In addition to providing cultural orientation to US therapists planning to travel to Kuwait for brief missions in the weeks and months that followed, I began searching for professional mental health contacts in Kuwait to communicate with regarding conditions on the ground. Through this search I was eventually reconnected with Behbehani who, after practicing in London and leading the Association for Free Kuwait in London, had moved back to Kuwait City to assist his country. In our phone conversation Jafaar indicated that, as the only trained therapist in the country, he had been spending all his time literally living at the hospital attempting to treat as many victims as possible while working to train a few MA level psychology academics on hand in basic treatment methods to assist him. He sounded much sadder than the perpetually cheerful young intern from years before, and uncertain about the prospects for the future of his society. The call ended with a promise to actively pursue support for his efforts, and in the ensuing years CBI solicited assistance from within it’s international mental health network and regularly referred treatment professionals, organizations, and training resources to Behbehani and his colleagues.

Although there had been assessments of wide spread trauma that included concerns about immediate and long term implications for the society, our search for existing mental health treatment programs by large international professional, humanitarian, or government systems appropriate and adequate enough to address trauma healing at this large scale unfortunately failed to find any to direct our colleagues in Kuwait to. Instead we found the standard approach in addressing such massive need continued to be temporary visiting therapists from outside the region utilizing predominantly Western models and methods limited to treating at the individual, family, and small group level, rather than following a more culturally appropriate, multidimensional, and integrated continuum from the individual to the communal experience.

For his part, Jaafar Behbehani remained in Kuwait to devote himself to developing the local mental health service system, and went on to become one of the pivotal contributors to the development of contemporary Kuwaiti psychology, an expert on PTSD, and a revered teaching mentor to a new generation of mental health professionals in his country prior to his death in 2009.


The Example of The Balkans: 

In 1992 CBI and it’s Russian partner, HARMONY Institute, established the Annual International Conference on Conflict Resolution (ICR) in St. Petersburg Russia. Over the 15 years it was held communal and transgenerational trauma increasingly emerged as frequent themes among participants and in the program. In the late 1990’s near the end of the recent Balkan wars CBI and HARMONY began bringing representatives of non-governmental (NGO) relief and conflict resolution organizations from Kosovo, Serbia, Bosnia, Albania, and Croatia to the ICR Conference to take part in a series of special roundtables on the wars impact on their societies. The first such roundtable occurred with rising tensions on the afternoon the Chinese compound in Belgrade was bombed.

Aside from any difference in perspective between roundtable members on causes of the conflict, a central and unanimous agreement was on the devastating impact of pervasive psycho-emotional trauma experienced at all levels throughout their societies due to the war, the immediate and urgent need for therapy, and the lack of a viable mental health service infrastructure in the entire region to address the massive need. A second point of agreement was concern that the most current trauma was tapping into past unhealed communal wounds and victim identities dating back generations and even centuries, and their fear of what this held for the future of their societies potential for continued and perpetual violence as the single most threat to peace and reconciliation in the region.

One example of these unresolved communal traumas being embedded in a transgenerational narrative was revealed by a Serbian participant who, although aligned with joining a highly interactive peace conference with members from opposing countries, shared his struggles with mixed feelings that offered a window into a cultural victim identity used to fuel and justify much of the inhumane treatment of the Muslim populations in Bosnia and Kosovo. During a time when Serbia was being heavily criticized internationally due to genocidal policies and tactics against civilians by it’s army, within the Serbian narrative this criticism was felt to be unfair and unjust – particularly coming from their fellow “Christian brothers and sisters” in Europe. The ethnic narrative of the Serbs was that the majority of their male youth had spilled their blood and been slaughtered on the Kosovo field hundreds of years earlier on a day commemorated as St. Vitus Day, in a devastating battle acting as a human shield to invading Muslim Ottomans sweeping into Christian Europe from the East. As a result their society was overrun and subjugated for generations.

The Serbian victim story said this profound sacrifice, on a site they called the Field of Blackbirds and considered hallowed ground, had slowed the invaders long enough for Europe to prepare for preventing what they believed would have been the complete fall of Christian Europe. Although other major geopolitical factors were also in play at the time, the chosen Serbian cultural story, embedded with the trauma, said it was their sacrifice alone that had saved Europe. Now, centuries later, while being viewed by most of the world as the perpetrator of violence against civilians, a society looking through the lens of it’s own unresolved transgenerational wounds perceived itself as again fighting the descendants of those Muslim invaders to drive them out of Bosnia and Kosovo and seek just revenge for their past martyrdom, even as it created new victims and communal wounds in contributing to a cycle of violence, trauma, and more violence.

There are many such examples in history pointing to the implications of profound unhealed psycho-emotional wounding and loss at the communal level, and the toxic energy of even centuries old transgenerational trauma in fueling future suffering, fear, hostility, and violence – both within and between communities – that further underscore the critical need for developing effective models and methods in adequately treating at this societal level.

Since CBI and HARMONY are NGOs founded and operated by psychologists, we were asked by these Balkan participants for our help in securing treatment for their communities. Again, as we experienced with Kuwait several years earlier, we found assessments by large international humanitarian aid systems indicating wide spread trauma throughout the Balkans, along with concerns about immediate and long term implications for these societies. However, as before, our search for existing treatment programs oriented and adequate to address trauma at this massive societal level did not produce any. In considering how to respond to these requests it was obvious that attempting to temporarily drop into the region to provide traditional direct therapy for hundreds of thousands of people was unrealistic and could only be minimally effective at best, even for the largest international aid organizations let alone grassroots NGOs with limited resources and staff capacity.

In the face of such challenges it was determined that a different approach was called for, and one that NGOs such as ours could, in fact, implement successfully. Rather than a limited number of outside organizations supplying short term treatment, the idea was to instead focus fully on building local capacity for treatment by instilling the requisite skills and service delivery templates within the impacted community itself; enabling it to become the primary provider of it’s own healing and recovery – a service that could grow faster, reach more people, and be more permanently sustained.

We began this process by providing trauma treatment skills training to raise the skill level of local key stakeholders already working to aid their communities. Each year health care professionals and aid workers from regions of conflict and violence, primarily including the Balkans, Caucuses, and Middle East, were brought to St. Petersburg for the 6-day working conference – where the focus included exploring a deeper understanding of individual and communal trauma, and then held over for several days after the event to receive intensive training. Although progress was being made in increasing the amount and quality of treatment services in their communities, as we operated these trainings it was also increasingly apparent that the ratio between the slowly growing pool of trained service providers and the massive, more quickly growing need in their communities placed great limits on what could be achieved. We understood that if trauma permeated all levels of a society, healing capacity needed to be focused and present at all levels as well.

Further expanding on the idea of local capacity building, then, meant finding ways of tapping into and enlisting the human resources of the entire community and promoting a continuum of internal healing practices and resources at multiple levels across the society – extending from public education, self-help, and mutual support to highly skilled therapy – as a way to promote becoming an empowered self-help community. The approach also needed to be oriented to the local cultural context and identity, including incorporating traditional healing and recovery customs and being open to on-going cultural adaptation, so that it is recognized and owned by the community to ensure the most acceptance, integration, effectiveness, & sustainability of the treatment practices. And so the perspective on treatment, healing, and resilience building was widened to include a spectrum of strengths and skills that could be woven into the community at various stratum to contribute to overall individual and communal wellness.

To help in organizing and framing the different aspects of this concept, I first created a structural outline as a guide for further expounding and improving on it, that I then developed into the Catastrophic Trauma Recovery (CTR) Model as an integrated, whole-person training and treatment approach to addressing large-scale, community-wide trauma and loss due to catastrophic occurrences, particularly in regions where the local human service infrastructure is absent, underdeveloped, or compromised, and where skill and hard resources are scarce.

Its central principles are local capacity building, cultural adaptation, and community empowerment through becoming the predominant source of its own repair utilizing both proven skills and cultural strengths – seen as essential to regaining, supporting, and maintaining a confident, positive, and resilient community identity.


The CTR Model Is Based On A Pyramid Structure For:

  • Establishing a broad foundation within the general public of mental health education, along with self-help and peer support skills for the lay person, to reach and assist the most people, help bolster mutual support, and reduce mental health stigma in the immediate short term.
  • Supporting community service providers, such as medical practitioners, teachers, and clergy, with basic intervention skills and knowledge of trauma-related symptoms and behaviors to help them better understand, respond to, and support those they encounter who exhibit them.
  • Progressively building an expanding number of increasingly skilled para-professionals and professionals with expertise in psychosocial treatment and recovery services in the long term.
  • Establishing pilot community-based psychosocial service projects to demonstrate service delivery templates that can be successful in communities where the mental health service system is underdeveloped and where skill and hard resources are scarce.

Rather than being limited to any one particular specialized treatment method, it promotes an interdisciplinary, eclectic, and culturally adaptive approach employing a variety of therapeutic practices and modalities tailored to the needs and character of the individual and community, addressing both psycho-emotional-bio-spiritual needs and interrelated concrete socio-econ needs necessary for achieving full day to day stability and recovery. It also incorporates traditional aspects of the culture as it supports and promotes strategic collaboration with indigenous stakeholders and human services to benefit from group strengths and promote the system being fully owned by the community.

Its features include:

  • Public Mental Health Education: to increase mental health awareness and promote good health practices in support of community well-being.
  • Self-help, Coping, and Personal Development skills: instilled in members of the community to increase capacity for self-care and mutual emotional support.
  • Socio-Economic-Educational Support and Stabilization.
  • Communal Healing and Resilience Building. Events and activities that:
    • employ and incorporate traditional, spiritual, and newly created healing and renewal rituals and ceremony,
    • build and reinforce cultural narratives of recovery, resilience, solidarity, and communal esteem,
    • tap into the internal community resources to develop an empowered, self-help identity.
  • Community Intervention, Mediation, and Victim Advocacy: to model and nurture community acceptance and build capacity for support of victims, particularly victims of rape and sexual abuse who often face a secondary trauma of blame and rejection.
  • Trauma-informed Community Services: Support of Local social service providers (such as medical practitioners, clergy and spiritual leaders, teachers, and law enforcement) by equipping them with basic psychosocial orientation and intervention skills to more effectively identify, engage with, and assist individuals exhibiting behavioral and emotional trauma symptoms, and assess for referral to more in-depth treatment where indicated.
  • Community Intervention, Mediation, and Victim Advocacy: to model and nurture community acceptance and build capacity for support of victims, particularly victims of rape and sexual abuse who often face a secondary trauma of blame and rejection.
  • Psychosocial Skills Training, and Direct Treatment Services:
    • Investing in the local human service and educational systems to create a regularly expanding number of treatment personnel by providing professional and paraprofessional certified skills training, in partnership with local universities, professional institutes and associations, social service and community organizations, and government bodies.
    • Utilizing trainees in establishing and operating community-based direct service programs, or supporting existing programs, as demonstration projects to provide:
      • Crisis Intervention and Stabilization services: Site-based, phone, and outreach.
      • Trauma-informed Therapy for individuals, families, and groups. Availability of a broad spectrum of interdisciplinary and culturally adapted approaches and methods for treating trauma and other mental health issues.
      • Community healing and resilience building
  • Support And Sustaining Of Local Psychosocial Service Providers and Services:
    • Self-Care and Burn-out Prevention,
    • Training of Trainers,
    • Service Program Design, Development, and Implementation based on tailored templates and strategic collaboration,
    • Ongoing Consultation and Mentoring Support,

Since the CTR model was first developed community-based, local capacity building training and treatment programs based on it have been conducted through our work in various regions where local services and skill resources are limited. The most current example is the certified Social Health Care (SHC) training and treatment program CBI and the International Humanistic Psychology Association (IHPA) have operated in Jordan since 2012 to address the Syrian refugee crisis. In recent years this partnership has expanded to include Michigan State University Department of Psychiatry, as well as all Jordanian medical schools, the Queen Rania Center, International Federation of Medical Student Associations-Jordan (IFMSA), and local human service NGOs.


THE SOCIAL HEALTH CARE (SHC)
TRAINING AND TREATMENT PROGRAM

Brothers at CBI field clinic. Zaatari Refugee Camp, Jordan

Today as we witness yet another immense humanitarian crisis with Syrian refugees scattered across the Middle East and increasingly across the globe, widespread and devastating psycho-emotional wounds once again pose a profound and lasting threat to the long term stability and wellbeing of an entire society, as well as the region they are a part of; underscoring the imperative for developing new models and methods in treating trauma at this large scale.

In addition to the suffering of the Syrian population, countries in a part of the world already challenged by severely limited resources and facing the sudden and catastrophic need of massive numbers of refugees pouring across their borders seeking safety from the conflict are increasingly overwhelmed. This is particularly the experience of Jordan; a poor country with an enormous unemployment rate which for nearly ¾ of a century has struggled with accommodating the needs of a steady influx of refugees fleeing conflict and turmoil from countries bordering it (Chatelard, 2010). It is here that CBI has been applying the CTR model in developing and conducting a tailored humanitarian aid program to address the Syrian refugee crisis.

At this writing, the now nearly 8 year old Syrian civil war has seen an even greater surge in refugees entering the country and further straining the limits of it’s abilities to care for their most basic needs, while also attempting to care for it’s own population. As millions of Syrians escape the danger and turmoil, many arrive in Jordan and surrounding countries suffering from profound and debilitating psycho-emotional trauma (Hadid, 2016).

At the same time, the mental health service system in Jordan and the region in general is seriously underdeveloped and ill equipped for the demands. Other than for a small portion of wealthy citizens able to access the tiny pool of trained professional therapists in the country, mental health treatment beyond medication or being confined to hospitals for the most extreme at-risk cases is essentially nonexistent for the Jordanian population, and particularly so for refugees (International Medical Corps, 2017).

In our meetings with the administrations of all Jordanian universities it was confirmed that at the root of this deficit in growing an adequate local mental health service system is a lack of practical academic or professional mental health training programs within the country. Historically students in mental health disciplines seeking practical skills training have been required to seek internships outside of Jordan and the region. Of the small number who are accepted and have the financial means to take advantage of these opportunities, very few ever return to benefit their home society. The result has been a continual talent drain, as their society’s need for these services only multiplies.

In response to the most recent crisis in the Middle East CBI and IHPA established the SHC program in 2012 – an integrated, certified training and pilot service initiative utilizing a psycho-social-biological-spiritual approach that focuses on individual and social healing, sustainable recovery, and self-determination, while actively investing in the local human service and educational system.

In keeping with the CTR model, emphasis is on innovative, local capacity building approaches to utilizing the internal human and socio-cultural resources of the community, and promoting individual and communal narratives and identities of resilient, empowered survivor and psychosocial growth. It teaches a humanistic, holistic, and interdisciplinary orientation, with a strong focus on developing an eclectic repertoire of treatment methods adapted to the local culture.

There are 2 interrelated features of the SHC program: Training and Treatment:


Training:

 1. Instilling restorative resources within the community thru equipping it’s members at all levels with varying degrees of practical knowledge, skills, and experience, ranging from self-help to in-depth psychosocial therapy to promote a self-healing community.

 2. Investing in the local human service and educational systems through providing certified training for professionals in mental health related disciplines, in partnership with local universities, as well as for paraprofessionals, humanitarian aid workers, and civil society service providers working with refugees and vulnerable populations.

To The Public And Service Recipient Community:

  • Public mental health education.
    Public education to service recipients and the general public on mental health issues and symptoms, to reduce stigma, increase mental health understanding and knowledge of available treatment resources, and promote good health practices.
  • Self-help, coping, and personal development skills training to service recipients to:
    • increase the ability for self-care in management of stress, mood, and behavior to build emotional stability, self-control, confidence, and self-esteem.
    • increase the ability to offer mutual emotional support and reassurance to family, neighbors, and other community members using learned self-care and supportive listening skills

To Local Service Providers Working With Refugees And Vulnerable Populations:

The certified professional and paraprofessional training program utilizes a variety of interdisciplinary therapeutic approaches, methods, and techniques, adapted to the local culture, for treating trauma and other mental health issues. Examples include:

  • Psychosocial assessment and treatment planning
  • Crisis Intervention and Brief Therapeutic Intervention methods and strategies
  • Expressive Arts therapies
  • Somatic therapies
  • Group therapy and support group facilitation
  • Faith and Spiritual-based therapies
  • In-depth, longer term psychotherapies.
  • Medication where indicated for symptom relief in support of therapy:

Targeted trainees include local students, NGO staff, social and human service providers, and relief workers in relevant fields, including: psychology, psychiatry, social work, counseling, medicine, teaching, and religion. Priority is given to members of the refugee community, those working with refugees and other vulnerable at-risk populations, and those who are in oppositions to model and teach skills to others.

Components of training to service providers include:

1. Psychosocial Specialty Training (PST) For Medical Students and Practitioners.
A landmark, fully certified professional training and field experience program in psychosocial assessment and treatment skills, incorporated into the formal medical school academic programs for all 5th and 6th year medical students in Jordan. The certified training is provided in partnership with all five Jordanian medical schools, Michigan State University Department of Psychiatry (MSU), and the International Federation of Medical Student Associations-Jordan (IFMSA-J), and offers two levels:

* preparing medical doctors of all specialties with essential skills they can incorporate into their general medical practice,
* providing longer term, more in-depth training and experience to medical students wishing to specialize in psychiatry, leading to  opportunities for additional advanced training with MSU Department of Psychiatry in preparation for future psychiatric internships.

The programs humanistic psychology and interdisciplinary team orientation, strong focus on developing an eclectic skill set, and emphasis on therapy are geared to preparing psychiatrists to play key roles within an interdisciplinary community mental health team model.

2. Community-Based Psychosocial Skills Training Program.
A certified progressive training and practice in psychosocial support and treatment skills generally open to local trainees. Both professional and para-professional service providers are prepared to deliver a range of direct treatment services, from coping skills and crisis intervention and stabilization, to more advanced psycho-social treatments. Trainees include university students and faculty, local humanitarian aid NGO staff, nurses, aid workers, teachers, and other human service workers.

3. Certified Diploma In Clinical Social Work.
A university based certified practical diploma program preparing social work students in Jordan with training and field experience in practical social work enabling them to administer direct services to at-risk and unserved populations. The program is conducted by CBI and certified in partnership with Yarmouk University, Queen Rania Center for Jordanian Studies and Community Service, and MSU.

4. Psychosocial Training for Clergy and Religious Teachers.
First developed by MSU Department of Psychiatry, CBI and IHPA partner with MSU to conduct this inter-religious faith-based training component specifically for religious leaders, students, and teachers on psycho-emotional symptoms and behaviors, basic responses and supportive counseling to assist those exhibiting symptoms, learning when referral to a professional therapist is indicated, and handling unique situations and stresses clergy and religious teachers encounter when working with many people who who are suffering from mental health difficulties. The training component is conducted in partnership with Yarmouk University Department of Religion.

5. Training of Trainers.
Development and support of a local pool of expert trainers and mentors, through advanced certified training and supervised experience in teaching and supervision skills for those completing the SHC training program at a high level of proficiency.

6. Growth, support, and sustaining of local service providers and community services.

* Self-care and burn-out prevention for service providers: to manage the anticipated stress and high potential for burn-out.
Stress management skills training
Peer support and supervision groups: for ongoing support and consultation
* Service program development and innovation: Modeling and demonstrating creative innovations in designing, implementing, scaling up, and replicating pilot service programs, with an emphasis on working within scarce resources and promoting a model of strategic collaboration and partnership to further build capacity for providing and quickly expanding services on a continuing basis.
* Ongoing consultation and mentoring support by clinical training faculty.
* On-going access to CBI and university on-line training resource libraries, including multimedia professional materials and modules (such as audio and video programs, taped training sessions, web-based interactive training programs, written manuals and program materials, assessment tools, and journals).

Proposed future development:

1. Practical MA in Community Mental Health Treatment.
A two year Certified Practical MA in Community Mental Health treatment in partnership with Jordanian universities and Michigan State University.

2. Formal psychiatric internship based within Jordan.

3. Bi-Regional cross-training for psychosocial services to refugees.
A bi-regional collaboration between professional groups in Jordan and countries hosting
Middle Eastern refugees to share culturally adapted psychosocial treatment services and cultural competency training


Treatment

Psychosocial Treatment Activities Provide:

  • Direct treatment, along with coping and personal development skills training for refugees and vulnerable populations.
  • Field experience opportunities for trainer/therapists to demonstrate and model methods and for trainees to practice learned skills in the field under supervision.
  • Practical pilot service projects to demonstrate designing, implementing, scaling up, replicating, and sustaining holistic, community mental health services that local NGOs and trainees are prepared to operate.

Current Treatment Components Include:

  • Disaster Health Care Field Clinics.
    Short term intensive field clinics providing direct psycho-social and medical screening and treatment services to refugee children and their families.
  • Community-Based Pilot Service Projects.
    • Projects are created in cooperation with local SHC team members and trainees and NGO partners, who are prepared for operating, further developing, and sustaining them on-going.
    • Services and activities address multiple inter-related need areas essential to recovery and long-term stability, and are designed to be scalable, portable, and replicated,
    • Service recipients and local site staff are also provided with English language lessons to increase efficiency in better communicating with visiting clinical team members and accessing English language based services and resources.

Service project examples include:

1. Residential Service Center.
A secure, supportive living environment exclusively housing 40 families made up of Syrian refugee widows and their children, where recovery activities are provided to adult and child residents, including a variety of psychosocial treatment services, medical health screening, support groups, coping and personal development skills training, vocational and educational skills support to prepare heads of household for independence, and recreational and resilience building activities. Residential management staff are offered basic support and intervention skills training to increase their ability to support residents.

2. Women’s Safe Spaces.
Dedicated spaces in partnering day service centers where vulnerable refugee women and girls can gather to feel secure in receiving a variety of support services, including psychosocial counseling support, support groups, coping and personal development skills training, parenting skills, education and materials on women’s health issues, medical health screening, support for pregnant women and new mothers, basic personal needs, educational and vocational skills support, exercise, crafts and creative activities, and a mutual support system to reduce stress and exploitation, promote self-esteem, resilience, and empowerment.

3. Trauma-Informed Schools – Educational Recovery Project.
Coping and Resilience Building for students:  Stress management, self-soothing,
non-violent communication, and conflict resolution skills training for students, and promoting incorporating this material into the regular school curriculum to become a “trauma-informed school.”
Training for school teachers and administrators:  In identifying, understanding, and being sensitive to trauma symptoms, and learning basic supportive responses to students and their parents.
Basic training for parents:  In psycho-social-educational support of their children.
Student and School Support:  Assisting students and schools for refugees in obtaining needed school tuition, materials, and supplies to recoup from educational deficits and maintain access to schooling.
English as a Second Language:  ESL training to allow students and teachers access to English-based educational resource materials and on-line classes, and to communicate more effectively with English-based humanitarian aid services.

4. Youth and Community Resilience Building.
An activities program to bolster and nourish internal resources and capacity of individuals and the community for recreation, peer interaction that promotes positive values and nonviolent communication, appreciation for communal traditions, child protection, and joy for refugee children, their families, and community. Examples include nature excursions, recreational activities, community social-cultural events, and teaching self-help skills, mutual support, and teamwork using games, cooperative sports, and expressive arts.

5. Socio-Economic Empowerment Project.
Equipping vulnerable Syrian refugee women, widows, and adolescent heads of household with the means to care for the economic, health, and security needs of their families, and to increase self-sufficiency, self-confidence, dignity, and reduce exploitation. Services include training in coping and personal development skills, marketable vocational skills, employment preparation, and small business/cottage industry start-up mentoring.


PROFESSIONAL DEVELOPMENT, RESEARCH,
AND COALITION BUILDING

To promote and support the qualities of collaboration, shared knowledge, and shared experience among psychosocial professionals, and to provide further professional learning for our trainees, CBI regularly conducts and integrates activities to place issues of individual and communal trauma on the public table for awareness raising and mutual exploration through topical training conferences, research activities, and related publications. Included in the research aspect is study of the SHC program and it’s various components.

These activities are:

  • Annual International Conference on Transgenerational Trauma (TT):
    CBI has a history of organizing now over 50 international professional conferences on social healing and conflict transformation since 1992 in various countries, and particularly developing societies in regions of conflict. It’s most recent conference series is the Annual International Conference on Transgenerational Trauma held each fall in Jordan. The TT Conference is an international working conference that brings together practitioners, trainers, and researchers from around the world to share practical skills, theory, and research, develop new culturally adaptable models and methods for better addressing large scale communal and transgenerational trauma, and formulate recommendations and guidelines for communities and public policy makers.
    CBI’s conferences are highly interactive and action oriented, promoting skills acquisition and practical outcomes and applications. The SHC program grew out of these conferences, and as a part of their SHC program trainees participate to gain additional skills through presenter workshops.
  • Transgenerational Trauma Research Network:
    A developing collaborative network promoting concerted interdisciplinary and cross-cultural study of the dimensions, dynamics, and implications of communal and transgenerational trauma, and the development of practical approaches to trauma at the large-scale.
  • Journal of Communal and Transgenerational Trauma:
    A new virtual international professional journal being established in support of the TT Conference and research network. It is a multimedia publication geared to both the professional and lay public.


Additional Applications For Refugees Beyond Jordan:

Increasingly CBI is offering consultation, training, and service models designed to help meet unique needs to organizations within host communities in countries outside of the region that are receiving refugees. Examples of assistance include working with war trauma, cultural competency, and trauma-informed educational and cultural transition programs to assist refugee students arriving with limited formal schooling, local language skills, and cultural orientation.


CONCLUSION

The CTR model, and the SHC program based on it, is one example of a whole person, cross-cultural approach to addressing the complex dynamics of catastrophic trauma at the individual and communal level. It is an evolving model, and in the case of it’s application in Jordan, by design it is intended to increasingly take on the local cultural character over time as it develops into a uniquely Jordanian version.

Linked to the principles of local capacity building and cultural adaptation for social healing that are at the center of the model, is an emphasis on and commitment to strategic collaboration with other like-purposed organizations, particularly including local colleagues, NGOs, and institutions in the impacted community. CBI and IHPA work closely with these colleagues and organizations in developing, adapting, and implementing these initiatives within their home society. As we contribute our skill resources and supporting networks we also rely on local partners to assist with on-site staffing, providing and coordinating training and service site logistics, identifying and enlisting trainees, and helping to network with other organizations and government entities.

Partnering with and mutually supporting local humanitarian service organizations and colleagues, as well as vital institutions such as universities, is fundamental to our historical philosophy and has been essential to the success of our efforts in various regions over now 3 decades.

Given this, our view over these same years has been that, in the face of massive human suffering and hardship – most in regions of the world where trauma has become systemic and humanitarian aid systems and resources are scarce, any approach to healing trauma at the large scale requires a commitment to such a model of cooperation, collaboration, and mutual support. The sheer size of catastrophic humanitarian crises increasingly seen across the globe is ill-served by stand-alone initiatives working in isolation, or at times even in competition with each other, that serve to generate gaps, duplication, wasted resources, and missed opportunities. 

There are now over 68 million refugees in the world being driven from their homes, with nearly 26 million fleeing for their lives from armed conflict and violence. Of these over 16 million have fled just in 2017, at an increasing rate of more than one person uprooted every two seconds (UNHCR, 2018). Confronted with this unprecedented mass displacement it is painfully evident to anyone directly working in these settings around the world that even the largest organizations attempting to operate on their own are continually falling behind, as the crisis only grows. We see the lack of adequate coordination and cooperation by humanitarian aid organizations as one of the major challenges to meeting the needs of traumatized communities; a challenge that calls for new thinking and commitment to a new model of strategic collaboration.

Although pervasive communal trauma, and the prospect of transgenerational trauma it can lead to, pose significant and mounting challenges to the field of mental health globally, through shared knowledge and concerted efforts these challenges can be increasingly and effectively addressed, if we act together. The most practical and responsible path with the most promise is through a willingness to engage and collaborate with all stakeholders; learning from our mutual efforts to compliment, support, and build on each other’s work; where truly effective organizations provide the essential pieces of a larger humanitarian assistance puzzle that combines to reach further, faster, and accomplish more in service to those in desperate need.

 


 

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