Continuous Traumatic Stress

Craig Higson-Smith, Monitoring and Evaluation Advisor, the Center for Victims of Torture
I'll start by just giving a short introduction to "continuous traumatic stress" so we're all on the same page. Often, when we talk about the mental health of torture survivors, we’re talking in terms of PTSD or POST-traumatic stress disorder. One of the signs of PTSD is that people feel threatened and frightened even when they’re no longer in danger. PTSD treatment approaches generally assume that the trauma is in the past and that the survivor is now in a relatively safe environment. But many torture survivors seek treatment when they are still in great physical danger. So, when we speak about “continuous traumatic stress,” we’re talking about people living under conditions where there is a real risk to their safety.

The term “continuous traumatic stress” was originally proposed in the 1980s by South African psychologist Professor Gill Straker. She and her team of mental health professionals were providing psychological support to victims of torture and political violence under the Apartheid regime. Similar concepts have emerged from researchers and practitioners in Latin America and the Middle East. For those who wish to explore this topic more deeply I suggest reading some of the papers in a special edition of Peace and Conflict: The Journal of Peace Psychology. 

International Models of Care and the Assumption of Safety
Most models of trauma care assume safety as a starting point for therapeutic work. That’s what makes this work controversial and important. Many of us find it very hard to accept that we should not provide services to people who are suffering if they are still in danger. Remember, in many cases the danger has been present for years, and will likely continue for many more. How long must such clients wait for help? So we started asking what kind of work might be possible in situations of continuous traumatic stress. And we have found that actually a great deal can be achieved. Today, we’re pointing out the limitations of conceptualizing forms of human suffering as “POST traumatic” and calling for a more nuanced understanding of the complex political and social conditions under which so many survivors live today.

Types of Ongoing Threats
These threats are real, not imagined, and they’re beyond people’s control. They’re also more immediate and closer than past traumatic experiences. This is something that I’ve been studying recently and so I’ll provide some examples from my own research: 

1) continued harassment by the original torturers or their colleagues, for example the family of a detained human rights activist that is visited daily by police so no one in the community will talk to them; 
2) Ongoing threat from police, army or other government agent, such as a roadside vendor whose stand is repeatedly destroyed by police for not paying a bribe; 
3) Threats from the community and neighbors, for example refugees who describe how enemies from their home country attacked them in their host country; and,
4) And also domestic violence, for example a woman who is forced to move into the home of abusive in-laws after her husband is arrested, or a husband’s physical abuse of his wife after he returns from prison.
5) A final category is sexual harassment – many women experience almost constant sexual harassment on the streets of major cities in sub-Saharan Africa.

Craig:
So let’s start with Monica Bandeira from the Centre for the Study of Violence and Reconciliation in South Africa. Monica, would you start off by describing the clients that your centre serves, and the environment in which they live?

Monica Bandeira, psychologist and senior researcher, Centre for the Study of Violence and Reconciliation in South Africa
Our clinic serves people who have suffered traumatic events, with torture survivors making up a substantial part of our client populations. Some of these are asylum seekers and refugees who were tortured in other countries on the continent. Others are South Africans. Most of our clients live in and around the city of Johannesburg. It’s a big city with a serious violent crime problem. Levels of sexual violence are very high, and for foreigners there are the added threats of xenophobia. Where people are living on the streets, in the inner city or informal settlements, it is very difficult to be safe.

Craig:
Monica, I know that your team has recently done some important work refining your clinical approach. Can you tell us how you went about that, and how continuous traumatic stress featured?

Monica:
Well we went through a research process to identify the key impacts that our past clients had suffered and the key interventions that our clinicians had employed. We then assembled a Delphi panel of experts from around Africa and a few from the developed world, and asked them to give us their views on both the impacts and our interventions. Finally, we presented all this information back to our clinical team who reflected on their work and developed our new clinical model. Ongoing safety concerns and repeated victimization emerged as an important challenge facing many of our clients. These dangers are often exacerbated by people by vulnerable to exploitation due to their poverty, and not having enough money to rent a room in which they can live alone and be safe, at least at night.

You can find a report on the research here and you can find a summary of our clinical model here. 

Craig:
How does your clinical model respond to these safety concerns?

Monica:
Our clinicians start by exploring any safety concerns mentioned by the client in more detail. Here we are trying to tease out what parts of the client’s experience are actual, present dangers, and what parts are perceptions of threat related to the client’s trauma. This is very difficult since we know that many of the danger are real, but at the same time, many of our clients are hyper-sensitive to threat. Depending upon the nature and degree of danger we then begin work on safety planning and problem solving to try to mitigate real threats, and we work with psycho-education and the development of reality testing skills for assistance with perceived threats. Also, because so much of the danger is related to questions of income and accommodation we work closely with other agencies who can support our clients with these basic needs.

Craig:
And what results are you seeing?

Monica:
I think our clients really appreciate the time we take to understand the dangers that they face on a daily basis. And they do learn to think more clearly about threats in their lives and how those might be reduced. I’d like to tell you the story of one of our clients who had been tortured. She was gang raped during the time that she was coming to us for therapy. When describing this event she told her counsellor that she used the work that she had done in therapy to help survive the event in the moment and in the immediate aftermath. She knew how to regulate her affect and talk herself through a terrible and protracted attack. It’s a horrible story, but it really says something about how effective this work can be when we engage seriously with current dangers.

Craig:
That's great work Monica. Thank you for sharing it with us. Now, Let’s bring Eugenia Mpande from the Tree of Life in Zimbabwe into this conversation. Eugenia, would you describe the environment you’re working in?

Eugenia Mpande, Clinical Coordinator, Tree of Life in Zimbabwe
Zimbabwe is a country where people have lived through many different forms of conflict over the past 40 years. Organized violence and torture are very real and very serious, especially during election times. Rural areas have been the focus of violence carried out by a very sophisticated system. This system creates bases in communities and co-opts local leaders, local institutions and community members into naming political opponents and committing acts of mob violence and “political education.” The result is very intentional. It’s to create a dysfunctional society where people can’t depend on local institutions or local leaders. This has far reaching community effects: families are fragmented; support structures are less effective and sometimes become the source of violence. Social problems like addictions, domestic violence and child abuse increase. People who have been victimized feel helpless. It is all this that Tree of Life is working to heal.

Craig:
Tell us more about the process Eugenia.

Eugenia:
We’re developing and implementing group interventions that reconnect people and help them recover the power they have if they can work together to reclaim a sense of community. We take a very careful, non-partisan approach to community engagement and include local authorities, traditional and religious leaders. We work with several communities around Harare and in some affected rural areas. In some ways, it’s very different from traditional Western approaches to mental health counseling that work with the individual in a very confidential setting. We’re working with neighbors to create a healthier community.

Craig:
How do you manage the problem on ongoing threat in your process?

Eugenia:
You must appreciate that our circles only take place after months of careful and respectful relationship building within communities. We proceed very cautiously so as not to danger our target communities or ourselves. We’re working with groups of neighbors to create a safer environment, where there are no secrets or possibility for conspiracies against one another. We try to build community so that people will do more to protect each other from organized violence. People understand that we can’t guarantee anyone’s physical safety, but with trust in oneself and others can provide the emotional safety that is necessary for personal and community healing and reconciliation to take place. In the case of Tree of Life, we should note that this is the result of continuous relationship building over many difficult years and we believe that is part of the reason our interventions are successful. We also have highly skilled facilitators with years of experience in responding to traumatized individuals.

Craig:
What is the impact of Tree of Life’s work?

Eugenia:
I can say that overall, we’re working with people that have a very high level of exposure to organized violence and torture. People tell us all the time about how our work is changing their lives, their families and their communities. The fact that we struggle to keep up with the requests for our work says a lot to me. Last year we completed an impact assessment of our program, and we published this research in the journal that Craig referred to previously. The results showed that people report fewer psychological symptoms after the healing workshop, and greater engagement with other people in their community.

Craig:
Thank you Monica and Eugenia. I’m afraid we’re past out time limit for this discussion and we need to close up. This has been a great discussion about a topic that I think is so important to our field. I would just like to say what a privilege it is to work with you both, and how proud I am to have three voices from the South talking about our work.

Thank you also to all who asked questions or watched the conversation. We are grateful you could join us. This has been a great discussion about a topic that I think is so important to our field.  Again, I want to thank the US Agency for International Development for funding our work with torture survivor centers worldwide.

Questions and Comments posted during the chat:

Dave:
Many survivors in countries of refuge also experience threats, discrimination and even attacks from local residents due to xenophobia and other sources of resentment or disparagement.  The seriously difficult and dangerous circumstances Monica is describing are faced, for example, currently, by refugees from Central African Republic living in Cameroon.

Craig:
That is so true David and makes this conversation relevant to people all around the world. Thank you for the reminder.

Monica
It is important to keep in mind that many developing countries are the largest recipients of refugees and asylum seekers. In addition, places like South Africa, have high levels of violent crime, which often affects the most vulnerable the most.

Carlos:
In many treatment perspectives the assurance of security is pre-requisite for the processing trauma. How can continuous trauma stress then be processed?

Veronica:
Carlos, in developing the model with the clinicians we also talked a lot about the concept of "relative safety," that conditions of safety and lack of safety are often fluid and a client might have a period of time where they feel "relatively safe," perhaps because they are staying in a shelter or with a friend for a few months. This allows, if appropriate, for some direct trauma processessing. The clinicians noted that through processing some of the clients' past traumas, the clients were becoming more resilient in handling more current traumas or dangerous situations.

Cathy:
Eugenia, I’ve read your (and Craig’s) paper on Community Intervention during Ongoing Political Violence…can you speak a bit to those findings? I think the community aspect is key.

Eugenia:
We used the Self reporting questionnaire SRQ 20, people showed significant drop in psychological symptoms. We also used another tool the Zimbabwe Community Life Questionnaire ZCLQ which Tree of Life developed, it showed that people became more engaged after the workshops.

Cathy:
Thanks Eugenia. There’s such a specific time frame for each Tree of Life event, 8 circles, 3 days. How does this time frame work for most people? Is that time frame itself a concession to the ongoing insecure environment (or is it just really practical)?

Eugenia:
Thank you Cathy. The workshops are done in 3 days for practical reasons because the people need to go back and continue with their work in the fields. These people are followed up in the community on an ongoing basis by our community facilitators and they continue to meet.

Sandy:
Hi there, I'm a doctoral student in counseling psychology at the University of Minnesota. I read the Special Issue on Continuous Traumatic Stress in The Journal of Peace Psychology and took a lot away from it. Craig, in your article on Counseling Torture Survivors Under Ongoing Threat, you noted the tough choices that counselors face - like how much one can support and advocate for their clients - in contexts of ongoing traumatic stress. Would you say that we know much about the impact of these tough choices on counselors, or how counselors approach these challenges/decisions? Might this be a potential area for further research?

Craig:
Sandy, thank you for your question, and it's always great to know that someone is actually reading one's work. I do think those tough choices are very hard on counselors, and I've certainly been very troubled by them myself. One can't afford to ignore real danger, but at the same time one must hold in mind that people who are traumatized may not accurately appraise the threat that they face. At all times we want to be in the position of helping people think more clearly about their situation but never be seen to be disbelieving. Especially, since very often the threats are very real. Monica, do you have something you'd like to add to this?

Monica:
Sandy, when we developed our model with the clinicians, they reflected on how empowering and helpful it was for them to clearly define their role as being "in the room" working with the client and building their internal capacity to cope with ongoing threat (and other stressors). Before this, clinicians found themselves engaged in attempts to solve problems beyond their ability and control (leading to increased feelings of helplessness). Clearly defining what you as a clinician are able to do is vital to ensuring reduced rates of vicarious traumatization, especially in context like ours. But, yes more research is needed, especially as it relates to the impact of working with complex trauma survivors in contexts of ongoing threat.

To read the full conversation on CVT’s Facebook page, click here and go to February 12, 2014 post.