Uganda is currently facing an overwhelming refugee crisis due to tribal wars and armed conflict in the neighboring nations of South Sudan, Congo and Burundi. There are currently over 240,000 refugees in Uganda. Due to the refugee crisis, as well as drought, the food supply is strained in Uganda – South Sudan’s primary source of food. Security concerns in South Sudanese refugee camps have resulted in additional surges of civilians fleeing into Northern Uganda. The South Sudanese refugee crisis is a microcosm of the global challenge to skillfully and compassionately address trauma, not only for the refugee community but also for the humanitarian aid staff, peacekeepers, and the psychological and medical teams that work with them.
A Good Beginning
ICMHHR faculty Gaea Logan and Gina de la Chesnaye led a total of 79 male and female humanitarian aid workers, mental health professionals and/or legal workers from the Refugee Law Center in Kampala attended the ICMHHR training at Makarere University. Due to armed infiltration at one of the UN Peace Keeping missions at the South Sudanese Border, twelve registered participants were unable to attend. The UN Peace Keepers barricaded staff headquarters inadvertently preventing the refugees from escape which then resulted in a massacre. The Peace Keepers fled their posts. After the incident, refugees had little sense of security or sanctuary to call upon. Another surge of refugees poured into the camps of Northern Uganda.
This tragic example is a testimony to what can happen during and in the aftermath of a critical incident: acute dysregulation resulting in the loss of executive functioning. The majority of our participants shared the experience of feeling overwhelmed and unprepared to work with refugee trauma. Few participants felt they understood how to work with trauma or prevent vicarious traumatization. They reported hearing countless stories of rape, beheadings, catastrophic loss, disease, starvation, and death. Many witness death in the camps. Most felt they would “burn out” but did not want their employers to know. Others, while stoic, complained of back pain, stomach aches, sleep disturbance, depression, anxiety, obsessive-compulsive rituals, explosive outbursts and emotional numbing. No one knew the difference between emotional contagion, empathy and compassion. Many suspected they might be re-traumatizing the refugees given their lack of interviewing skills. All acknowledged they did not have a consistent “self-care” practice or the ability to find sanctuary within themselves. The consensus was that it would be selfish.
Calm Creates Calm
At ICMHHR, we believe that “calm creates calm.” Mental health professionals and humanitarian aid workers must start with themselves if they are to create a calm environment. Refugees cannot find their calm in the midst of the storm if the staff cannot. Without specific training, self-regulation skills can be out-stripped by the enormity of the stressor. The risk of burn out in the humanitarian field is great – and even greater – if the staff is working in an environment or culture that is not trauma-informed.
Our definition of trauma lies in the differential between the brain’s emergency circuitry and the body’s ability to self-regulate. Our program, at the intersection of neuroscience, contemplative science and group psychotherapy, is designed to help strengthen self-regulation skills for humanitarian aid workers, mental health professionals and refugees.
Outcomes of the Makarere Training
In qualitative feedback, participants shared that they felt more knowledgeable about trauma and were excited to return to work to implement the training. Equipped with CBTRT skills and their own efforts at self-regulation, participants felt they could be a resource to themselves, colleagues, and refugee/client populations because they could calm themselves. Many reported physiological indicators of stress reduction; decreased back pain, shoulder stress, stomach upset, anxiety, improved sleep and mood after the 4 day training.
All felt that the training and CBTRT certification would be helpful for present and future employment. Fifty of the original participants enrolled in the 8-week Portable Calm follow- up program with the goal of establishing a daily contemplative practice and becoming a CBTRT Level 1 Instructor. (curriculum below)
Based on the success of the CBTRT program, the School of Public Health, School of Nursing, the Counseling Center and the office of the Chancellor at Makarere University are developing a multi-disciplinary partnership with ICMHHR to build a Trauma and Resiliency Institute at Makerere University. It will be the first of its’ kind in Africa!
ICMHHR’s field manager has identified 16 NGO’s working in the camps of Northern Uganda to conduct a pilot study of the efficacy of CBTRT (see metric below) Depending upon outcomes, the plan is to expand curriculum based on the CBTRT model throughout the UN network in Jordan, Kenya and the EU with funding from the UN Foundation.
Contemplative Based Trauma and Resiliency Training
The CBTRT 4-day training includes:
1) Basics in the neurobiology of trauma
2) Contemplative practices that strengthen self-regulation and neural integration: breath-work, sanctuary, intention setting, yoga, grounding/mindful awareness, compassion practice, therapeutic writing
3) Instruction on trauma sensitive group intervention for adults and children in individual and group setting. Participants attending all sections of the training receive the CBTRT Basic Certification.
CBTRT Instructor Level 1: Level 1 Instructors must complete the initial CBTRT training and then the 8-week Portable Calm.
The Portable Calm is an a-synchronous distance learning program with weekly “on the cushion” and “off the cushion” instruction. The goal of the Portable Calm is to support a daily contemplative practice. The “group contract” is to post 1-2 times weekly via the weekly email thread, in a learning cohort.
Level 1 Instructors are enabled to teach the CBTRT 8-week curriculum for children (Calming Minds) and adults (Portable Calm)
CBTRT Instructor Level 2: Level 2 Instructors have completed Level I requirements, specific graduate school training in the helping professions, 300 hours of CBTRT clinical supervision, and demonstrated effective teaching/ training capacity. Certified Level 2 Instructors can lead CBTRT trainings for humanitarian aid workers and mental health professionals globally.
Pathways to Neural Integration – Powerpoint
The CBTRT Field Manual includes:
1.The Portable Calm
On the Cushion
Focus on the Breath Sanctuary
Intention Setting Yoga
Grounding Compassion Practice
Off the Cushion – throughout the day
Return to the breath
Noticing beauty, gratitude
Tracking intention / choice points / journaling Noticing sensation
Returning to the moment
Noticing the quality of relationships
2.Calming Minds: 8-week CBTRT group curriculum for children
Arousal Assessment Grounding Script
10 Mindful Movements for Kids
10 Trauma Sensitive Yoga Poses for Adults
Additional educational videos and podcasts are in production
The aim of the study is to validate the Contemplative Based Trauma Resiliency Training (CBTRT). We will conduct a simple T-Test study in order to see if the CBTRT curriculum has significant outcomes for the instructors. The curriculum is designed to reduce depression, anxiety, and trauma symptoms while increasing mindfulness. In order to measure this outcome, we will employ three standardized measures for the participants before they enroll and after they complete the curriculum. Our team will employ the Hopkins Symptom Checklist (HSCL), Trauma Symptom Inventory (TSI), and the Mindful Attention Awareness Scale (MAAS). All of these measures are self-report and can be administered in-person or online. Our hypothesis is that there will be a significant positive correlation with the MAAS and a negative correlation with the HSCL and TSI from pre- to post-curriculum.
This initial study will act as a pilot to see if the curriculum has an effect on the participants. If our hypothesis is validated, we plan to expand our study over the next few years. We will aim to increase its validity by performing a between-groups study. We will be comparing the pilot data to the data from future cohorts in order to strength our findings. Additionally, we will gather data from different populations and from different instructors in order to minimize the effects of confounding variables.
We intend to create a practice log in order to determine how the instructors integrate their CBTRT practices into their lives. This can open us up to a “within-subjects study” in which we can compare high and low practitioners.
Jim Lavelle of the Harvard Program in Refugee Trauma – Global Mental Health will be consulting with our research designer, Marc Azoulay, as we take our next steps.
In response to the devastating Texas wildfires of 2011, ICMHHR created the Community Response Network (CRN) to provide trauma training for educators and mental health professionals throughout several school districts in the Central Texas area. CRN links ICMHHR faculty and interns with other key local mental health professionals and offers a new paradigm in healing trauma based on the theoretical framework of the SSR model and its clinical implementation.
The SSR model stresses the primary importance of cultivating strategies for self-regulation for the care-giver. In the aftermath of the tragedy at Sandy Hook Elementary School, CRN returned to the Leander School District to conduct an additional training in Acute Crisis and Trauma Prevention and is offering the training to mental health professionals locally, nationally and internationally.
At the invitation of the Department of Health of the Tibetan Government in exile, ICMHHR developed The Dukar Project, a culturally sensitive, neuroscience informed trauma recovery training program to address the multi-generational trauma associated with on-going and prolonged human rights violations. The three-year program integrates mindfulness and compassion based interventions, and is informed by current neuroscience research, group psychotherapy and traditional Tibetan medicine. The training was created for Tibetan health workers, social service workers, school teachers, monks and nuns to help develop the clinical skills needed to assist individuals and families within the Tibetan exile community suffering from PTSD and developmental trauma (complex trauma), depression, anxiety and other symptoms painfully common to the refugee experience. The Center for Compassion and Altruism Research and Education, a division of the Stanford Institute for Neuro-Innovation and Translational Neuroscience at the School of Medicine will be collaborating with ICMHHR on research and implementation.
Based on the evaluative results of our efficacy research, we plan to implement this protocol with specific cultural adaptation for other “wounded communities” throughout the world, including our own homecoming veterans. To heal from the devastating impact of trauma enables individuals, families and whole communities to become sustainable.
International law students are currently assisting the development of a position paper for ICMHHR on the legal and moral responsibility of host nations to provide PTSD treatment for incoming refugees, particularly those who have endured the prolonged and ongoing stress of religious, ethnic and political persecution or torture.
Films Explore Human Rights and a Refugee Community from a Mental Health Perspective
(Austin, TX): Tibetan Stories, a new documentary web series consisting of monthly video portraits of Tibetan refugees, launches today via the website www.tibetanstories.org. The multimedia project is produced by The International Center for Mental Health & Human Rights (ICMHHR) and Kestrel Filmworks and highlights the personal struggles and aspirations of a wide diversity of Tibetans in exile.
At the invitation of the Health Ministry of the Tibetan government in exile, ICMHHR developed a trauma recovery training program for Tibetan health workers, doctors and teachers working on the front lines of mental health related issues within their community. Gaea Logan, internationally recognized psychotherapist and Founding Director of ICMHHR says,”Tibetan Stories raises awareness about the many faces of the refugee experience and honors the suffering and resilience of ordinary people who have found it necessary to flee their homeland for the hope of a better life. Refugees are not statistics. They are people … people who dream, who suffer, who hope, and who love.”
The series opens with The Monastery Cook about the head cook of a monastery in Dharamsala, India where the Dalai Lama resides and conducts regular teachings. As he prepares a meal for 5000 people, the cook discusses the trials as well as the courage of his own family. The other initial short film is The Graduates about two seniors from a school in a refugee settlement, who write and self-publish an independent newspaper. A new and unique film will be released every month throughout 2014. The website offers viewers either a three minute, or a ten minute version of each film.
Tibetan Stories is beautifully crafted by Russell Avery, an internationally recognized photographer and filmmaker who has worked with Terrence Malick and Academy Award winning cinematographer Emmanuel Lubezki. “I was inspired by projects like The New York Times’s One in Eight Million and wanted to show a spectrum of narratives rarely seen by the international community, but which are vital to understanding the contemporary Tibetan experience in exile, while free of the romanticism or victimization often attributed to the Tibetan struggle,” said Avery. More work can be seen at www.kestrelfilms.com.
The International Center for Mental Health & Human Rights (ICMHHR) is a non-profit organization established to strengthen communities through trauma recovery while preserving a culture of human rights and dignity.
Thelma Young, Kestrel Filmworks (208) 599 2169
Gaea Logan, ICMHHR (512) 694 1393 firstname.lastname@example.org
Official Hashtags: #tibetanstories #icmhhr