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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
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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
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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.
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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
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Humiliation% of the
Population
LOW HIGH SEVERE
TRAUMA TORTURE
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Old #1 slides!!!!!!!
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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
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The 11 Point Toolkit and The Bio - Psycho - Social - Spiritual Model
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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
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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
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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
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TOXIC TRAUMA STORY
Brutal factsHigh expressed emotion
The full trauma story teaches healing and survival
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TRAUMATIC MEMORIES
Memory
Dreams Nightmares
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THE REGULATION OF HIGH EMOTION
Critical importance of being able to regulate and/or turn off high emotionsExposure therapyEMDRNightmares
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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
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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.
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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
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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
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TRAUMA TRAUMA STORYSTORY
SYMPTOMS
OBJECTIVE PHYSICALFINDINGS
EVENTS DISABILITYRESILIENCY
IMPACT OF TRAUMA
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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
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POST CONCUSSIVE SYNDROME
HeadachesFeelings of dizzinessNausea and/or vomitingNoise sensitivity, easily upset by loud noiseSleep disturbanceFatigue, tiring more easilyBeing irritable, easily angered
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POST CONCUSSIVE SYNDROME
Feeling depressed or tearfulFeeling frustrated or impatientForgetfulness, poor memoryPoor concentrationTaking longer to thinkBlurred visionLight sensitivity, easily upset by bright lightDouble VisionRestlessness
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IDENTIFY SEXUAL TORTURESexually Transmitted Diseases
HIV/AIDS
Pelvic Inflammatory Disease
Infertility
Genitourinary Tears and Abrasions
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IDENTIFY SEXUAL TORTURE
Bladder Incontinence
Dyspareunia
Cervical Cancer
PTSD, Depression
Nightmares
Phobias
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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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Old #4 slides!!!
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Old #5 slides!
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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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Old #6 slides!
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SOCIAL RESILIENCY AND RISK FACTORS
Altruism
Work Spirituality
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Old # 7 slides
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• Learn the culture’s major folk diagnoses for psychiatric illnesses
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Start/Join a Balint Group
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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.
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Creativity and Science in the Care of The Torture Survivor
Scientific and Cultural Knowledge
Reflection and Intuition
Clinical Experience
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• HPRT website www.hprt-cambridge.org
Resources
• HPRT Bloghttp://healinginvisiblewounds.typepad.com
• Cochrane Library www.cochrane.org
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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