Webinar Part 2

Specific Cultural and Evidence Based Practices for the Treatment of Torture Survivors

Richard F. Mollica MD, MARProfessor of Psychiatry, Harvard Medical SchoolDirector, Harvard Program in Refugee Trauma

Massachusetts General Hospital

Over the past 25 years medical and legal practitioners worldwide have asked “Is there anything unique about the torture experience?”

Can we know without a doubt that torture has occurred after examining the patient/victim? Is there a torture syndrome? Is there a psychological or biological marker for torture?

TORTURE

HUMILIATION

Humiliation is not a clear-cut emotion like fear, but rather a state of being, characterized by feelings of physical and mental inferiority, of uncleanliness and shame, of spiritual worthlessness and guilt, and of moral repulsiveness to others, including a god or higher being.

LOSING THE WORLD

Everything is taken away; nothing is given back

Total loss of control – recognizing that one is only part of someone else’s story

Total lack of empathy, understanding, love, and affection shown toward you

Humiliation% of the

Population

LOW HIGH SEVERE

TRAUMA TORTURE

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Bio - Psycho - Social - Spiritual Model

Scientific [Evidence] And Culture-Based Interventions In The 11-Point Toolkit Can Be Considered Using The:

Bio - Psycho - Social - Spiritual Model

The 11 Point Toolkit and The Bio - Psycho - Social - Spiritual Model

Item BIO PSYCHO SOCIAL SPIRITUAL

1 Trauma Story X X X

2 Identify Physical/ Mental Sequelae X X

3 Diagnosis and Treatment X X X X

4 Refer Severe Cases of Mental Illness X

5 Coping X X

6 Altruism X X

Work X X

Spirituality X X X

Item BIO PSYCHO SOCIAL SPIRITUAL

7 Reduce High Risk Behaviors X X X

8 Cultural Competence X X X X

9 Psychotropic Drugs X X

10 Doctor-Patient Relationship X X X X

11 Self-Care X X X X

12 [Evaluation] X X X X

Factual accounting of events

Cultural meaning of trauma

Looking behind the curtain (revelations from the trauma experience)

Listener – Storyteller relationship

ELEMENTS OF THE TRAUMA STORY

TOXIC TRAUMA STORY

Brutal factsHigh expressed emotion

The full trauma story teaches healing and survival

TRAUMATIC MEMORIES

Memory

Dreams Nightmares

THE REGULATION OF HIGH EMOTION

Critical importance of being able to regulate and/or turn off high emotionsExposure therapyEMDRNightmares

EXPOSURE THERAPY

Patient is asked to describe a traumatic event repetitively until the patient’s emotional response decreases

Goal is to gradually confront safe but fear-evoking trauma reminders

EMDR: Eye Movement Desensitization and Reprocessing

Minimal input from the therapist

Focus on traumatic emotions without trauma details

Activation of new images and thoughts with no relationship to trauma events

Suggested readings:– Shapiro, F. (2001). Eye movement desensitization and reprocessing:

Basic principles, protocols and procedures (2nd ed.). New York: Guilford Press.

NIGHTMARE CONTROLImagery Rehearsal Therapy

– Clients are encouraged to see nightmares as a result of more than simply traumatic experience

– Therapist and client practice pleasant imagery

– Client begins journaling re: disturbing dreams, then practicing to rehearse (through writing and discussion) “new dream” scenarios with therapist

CHRONIC INSOMNIA: Sleep disturbance that bothers the patient

Sleep hygiene:– Modify the environment and daily habits to

support sleep– Stimulus control– Changing negative thoughts about sleep– Relaxation

• 10-15 minutes during the day• Use in bed or before bedtime

TRAUMA TRAUMA STORYSTORY

SYMPTOMS

OBJECTIVE PHYSICALFINDINGS

EVENTS DISABILITYRESILIENCY

IMPACT OF TRAUMA

IDENTIFY HEAD INJURY

Pre-Frontal Lobe Damage

Depression and PTSD will mask traumatic brain injury and a chronic post concussive syndrome

Impaired cognition including memory and executive function

POST CONCUSSIVE SYNDROME

HeadachesFeelings of dizzinessNausea and/or vomitingNoise sensitivity, easily upset by loud noiseSleep disturbanceFatigue, tiring more easilyBeing irritable, easily angered

POST CONCUSSIVE SYNDROME

Feeling depressed or tearfulFeeling frustrated or impatientForgetfulness, poor memoryPoor concentrationTaking longer to thinkBlurred visionLight sensitivity, easily upset by bright lightDouble VisionRestlessness

IDENTIFY SEXUAL TORTURESexually Transmitted Diseases

HIV/AIDS

Pelvic Inflammatory Disease

Infertility

Genitourinary Tears and Abrasions

IDENTIFY SEXUAL TORTURE

Bladder Incontinence

Dyspareunia

Cervical Cancer

PTSD, Depression

Nightmares

Phobias

COMBINATION THERAPY

Reliance on monotherapy of any type rarely brings about full remissionAdd on to conventional counseling– Body Pain Acupuncture– Chronic Arthritis & Joint Pain Physiotherapy and

Physical Rehabilitation– Chronic Insomnia Sleep Hygiene– Flashbacks/Nightmares EMDR/Exposure Therapy

(E.T.)/CBT– Depression/PTSD Psychotropic drug combinations

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THE SELF-HEALING PROJECT

What traumatic events have happened?

How are your body and mind repairing the injuries sustained from those events?

What have you done in your daily life to help yourself recover?

What justice do you require from society to support your personal healing?

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SOCIAL RESILIENCY AND RISK FACTORS

Altruism

Work Spirituality

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• Learn the culture’s major folk diagnoses for psychiatric illnesses

Start/Join a Balint Group

12. Evaluation: Results-Oriented Treatment

Monitor over time using concrete simple measures the effectiveness of your treatment.

Remember: your treatment approach is based upon your disease explanation and clinical worldview.

And it always needs to be checked out.

Creativity and Science in the Care of The Torture Survivor

Scientific and Cultural Knowledge

Reflection and Intuition

Clinical Experience

• HPRT website www.hprt-cambridge.org

Resources

• HPRT Bloghttp://healinginvisiblewounds.typepad.com

• Cochrane Library www.cochrane.org

Resources

• BookMollica, Richard F. Healing Invisible Wounds: Paths

to Hope And Recovery in A Violent World, 2006.

• Clinical Resources- HPRT 11-Point Toolkit - HPRT Screening Instrument Manual