1. 1
Providing Culturally
Appropriate Services to
Refugee Survivors of
Torture & Trauma
Chris Lobsinger
Clinical Social Worker
&
Greg Turner
Community Psychologist

2. 2
Chris Lobsinger
Social worker/ Priviate practice
Individul, Couple and Family Therapy
07 33673367
lobsinger@bigpond.com
www.users.com.bigpond/lobsinger/r
Greg Turner
Community Psychologist
Director, Global Community
Consulting
Education & Development
Coordinator, Qld. Transcultural Mental
Health Centre
globalcommunity@powerup.com.au

3. 3
Material for this workshop is
derived from The Need for
Understanding (© 2002,
QPASTT & QTMHC), written &
researched by Chris Lobsinger.
We would like to acknowledge
and thank the Queensland
Program of Assistance to
Survivors of Torture & Trauma
(QPASTT) and the Queensland
Transcultural Mental Health
Centre (QTMHC) for giving
permission to utilise this material.

4. 4
Contents
This workshop cover the
assessment care of migrants
as well as refugee survivors
of torture and trauma.
The refugee experience
Trauma
Torture
Culture shock
Response to victims
Psychiatric Disorders
Impact on families
Vicarious trauma

5. 5
Exercise 1: Warm-up
As a large group:
Take it in turns to share
with the group who you
are, where you work and
your interest in today’s
program.

6. 6
Exercise 2: Defining trauma
In groups of two or three,
come up with a definition of
TRAUMA
Have one of your group
members act as a scribe and
write down your group’s
ideas.
After five minutes each group
will take turns sharing their
definition and ideas with the
larger group.

7. 7
Definition of trauma
Dictionary definition
trauma, n., pl. -mata -mas 1.
Pathol. A bodily injury. 2.
Psychol. A startling experience
which has a lasting effect on
mental life; a shock. - traumatic,
adj. The Macquarie Dictionary
New Budget Edition (1985).
Working definition
trauma: an inescapably
stressful event that overwhelms
people’s existing coping
mechanisms.

8. 8
Exercise 3: Defining torture
In the same groups of two - three
as you were in during the last
exercise, take five minutes to
come up with a definition of
TORTURE
Have one of your group
members act as a scribe and
write down your group’s ideas.
After five minutes, each group
will take turns sharing their
definition and ideas with the
larger group.

9. 9
Definitions of torture
“A systematically programmed intentional
and calculated activity which results in
physical and psychological suffering and
which inflicts a violent attack on personal
integrity”.
Bustos, E. (1990) Dealing with the unbearable. Reactions
of therapist and therapeutic institutions working with
survivors of torture. In Suedfeld, P. (Ed.), Psychology and
torture. Hemisphere Publications: New York.
“Extreme and deliberate form of violence
inflicted upon a victim who experiences it
consciously and who has no control over its
form or duration. It produces pain and
mental or psychological stress and is
intended to destroy the victim’s will in an
attempt to perpetuate a determined order of
power relationship”.
Bendfeldt-Zachrisson, F. (1985) State (political torture):
some general, psychological and particular aspects. In
International Journal of Health Services 15(2), p. 339-349.

10. 10
Forms of torture
Beatings to the body and head
- Falanga: the beating of the soles of the feet with
instruments of wood or metal
Being forced to maintain crippling positions for long
periods
Burning
Electric shocks
Forced to watch loved ones being raped, killed or
brutalised
Isolation and solitary detention
Mutilation
- All parts of body
- Teeth: drilling, extraction
Near-fatal drowning or suffocation
Other forms of violent abuse used variably and
unpredictably
Sensory and sleep deprivation
Sexual violence and rape (of men, women and children)
Sham executions
Starvation and exposure to heat and cold
Strapping, binding the victim with ropes, straps, etc.
Suspension
- By arms
- By knees using a stick in hollow of knees
Use of mind-altering drugs

11. 11
Organised violence as state
terrorism
Systematic state terrorism (SST) is the most pernicious
kind of terrorism, as its target is the whole
population, carried out by the forces of state and
condoned by the government.
Systematic state terrorism includes:
EXTRAORDINARY
EVENTS
 Mass executions
 Disappearances
 Spectacular raids
 Torture
"ORDINARY EVENTS"
 Systematic harassing
 Pressuring
 Labelling
 Moral discrediting
SST has pathological consequences for individuals, but
also has important collective consequences resulting in a
population terrorised by an internalised fear, with no
alternative but to comply with the imposed political
options.
Martin-Baro, I., Aron, A. & Corne, S. (1994) Writings for a liberation
psychology. Harvard University Press.

12. 12
The economy of torture
Definitions of torture emphasise the intentionality of
those who conduct it. Their ultimate goal is not the
infliction of pain on the individual, but the cumulative
effects of pain, unpredictably and intentionally
inflicted. Primary among the responses of the
tortured individuals are the loss of self-esteem,
autonomy and a sense of meaning, anxiety,
depression and dissociation.
When such an individual is returned to his or her
community, a ripple effect is seen in the lives of
others with no direct experience of torture. The
community takes on the fears and insecurities they
see in the damaged individual, and suffer similar
losses of self-esteem, autonomy and meaning.
Beyond this, the successful torturer ensures his/her
internalisation in the victim, who thereafter tortures
himself or herself from within, even in the absence of
the torturer.
These, then, are the economies of scale of torture.
Helen Pavlin (1998), QPASTT

13. 13
Key messages
Torture is routinely practiced in
over 100 countries in the world
today.
Torture is about the control of:
- Individuals
- Communities
- Nations
Torture and human rights
violations are inextricably linked,
one is not possible without the
other.
Trauma is fundamentally the
overwhelming of the individual’s
coping mechanisms, and torture
is a method for achieving this.

14. 14
Refugee experience
“Arriving in a new country as
a refugee is like arriving as a
new born baby. We come
without clothes, without
baggage. We come without
knowledge about the world in
which we find ourselves,
without the language to find
out. We are totally
dependent on the good will of
those around us to ensure
that we survive, and also for
the quality of that survival”.
Pittaway, E. (1991) Refugee women - still at risk in Australia.
AGPS: Canberra. (p. 1)

15. 15
The difference between
refugees and migrants
On the whiteboard, two headings:
Migrants Refugees
Experience…… Experience…….
As a large group, brainstorm the
differences between the two experiences.

16. 16
Refugees and migrants.
What’s the difference?
MIGRANTS REFUGEES
 Choose their new country
carefully and find out all
they can about it before
they leave.
 Take the quickest way out
of their country, often not
knowing where they will
finish up.
 Plan their move carefully
in advance.
 Leave hastily, often to
escape from midnight raids
and soldiers with guns.
 Take time to get their
passport and visa ready.
 Leave secretly, often not
daring to advertise their
intention of leaving by
arranging travel documents.
 Pack all their belongings
up and organise for
everything to be sent to
their new home.
 Leave with whatever they
can carry, often no more
than the clothes on their
backs.
 Say goodbye to friends
and family.
 Often cannot tell anyone
that they are leaving for
fear that friends or family
will be tortured to reveal
the information.
 Leave a forwarding
address.
 Often dare not get in touch
with anyone in case they
are suspected of having the
same beliefs and tortured or
held to ransom.
 Can go home if things
don't work out in their new
country.
 Will probably never be able
to go home.

17. 17
Impacts to consider
Savdie, T. & Carey, L. (1999) Families in cultural transition.
STARTTS: NSW.

18. 18
Life events, stress
and refugee status
The following conditions represent risk factors for psychological
disorders among refugees:
1. Stress-provoking conditions and events leading up to the
decision to migrate or flee.
2. Conditions associated with the actual flight (eg. loss of
family, possessions left behind, dangers on the journey).
3. Conditions on arrival in a host community (see below).
4. Further migrations and resettlement, although the initial
move is usually the most stressful.
The conditions of settlement in a host community can also
produce possible risk or stress factors, including the following:
1. Differences between the culture of the refugee and the host
culture; migration within one’s own country may be less
stressful.
2. Status loss, loss of possessions, loss of employment, and so
on.
3. Lack of family or other social support.
4. Difficult living conditions, for example, in camps, due to
resettlement schemes, poverty and violence.
5. Continued worries concerning family members left behind or
otherwise separated.
6. Discrimination by the host community against the refugees.
Orley, J. (1994) Psychological disorders among refugees: some clinical and
epidemiological considerations. In Marsella, A., Bornemann, T., Ekblad, S. &
Orley, J. (Eds.), Amidst peril and pain: the mental health and well-being of the
world’s refugees. American Psychological Association: Washington DC.

19. 19
Culture shock
The term culture shock refers to emotions
which can occur in people who find themselves
in a strange cultural environment.
1. The loss of love and respect, as this was
experienced in the relationship with friends and
family.
2. The loss of social status, which may or may
not be accompanied by discrimination.
3. The loss of a familiar social environment,
with its mutual obligations and dependencies
which gave meaning to life.
“As a result of the loss of familiar cultural
backing, the ability to integrate new
experiences is reduced: familiar frames of
reference cannot be applied to the flood of new
experiences and impressions”.
Coelho, G. (1982) in Nann, R. (Ed.), Uprooting and surviving.
Reidel Publishing Co: Dordrecht. Cited in van der Veer, G. (Ed.),
Counselling and therapy with refugees and victims of trauma:
psychological problems of victims of war, torture and repression.
John Wiley & Sons: Europe. (p. 101-107)

20. 20
Overcoming culture shock
1. The first phase is one of euphoria: everything in
the new situation is beautiful and impressive, or
challenging and mysterious. One could add that
refugees also experience relief because they are free
from persecution.
2. Then there is a second phase of disappointment
and related anger. The society in which the refugee
finds himself turns out not to be so ideal and in some
respects it is inaccessible. In exile the refugee is also
confronted with injustice, violence, bureaucracy,
human error and indifference toward the misery of
their fellow men, and so on. In this phase, some
refugees strongly accentuate their cultural roots, eg.
he starts to play the traditional music of his country,
while previously he considered the music as boring or
primitive. (cf. Garza-Guerrero, 1974).
3. Finally, there is a phase of adaptation, when the
refugee starts to learn the language, build up a
supporting social network and establishes emotional
relationships, without denying their own cultural
heritage.
Coelho, G. (1982) in Nann, R. (Ed.), Uprooting and surviving. Reidel Publishing
Co: Dordrecht. Cited in van der Veer, G. (Ed.), Counselling and therapy with
refugees and victims of trauma: psychological problems of victims of war,
torture and repression. John Wiley & Sons: Europe. (p. 101-107)

21. 21
Key messages
Migrants hope to improve their
lives by migrating, and have
time to plan and prepare.
Refugees often have no choice
and must leave to survive.
Return to their country of origin
would result in imprisonment,
torture, death or persecution.
Migration is inherently stressful.
Culture shock is common
among all migrants and is
generally worse in refugees.
The core experience of refugee
survivors of torture and trauma
is that of the profound
discontinuity in almost all areas
of their lives.

22. 22
Exercise 5: Responses to
trauma victims
In groups of two or three, each person reflects upon
a situation in which a past patient/client was
traumatised.
** Please do not use yourself or the experience
of someone close to you as an example
Have one person in the group act as a scribe and
write down the group’s answers to the following
questions:
In what positive ways did people
respond to the traumatised person?
In what negative ways did people
respond to the traumatised person?
After 8-10 minutes, each group will share their
answers with the large group.

23. 23
Positive responses
Sympathy/empathy offered.
Material assistance offered.
Moral and social support
offered.
Government and other groups
develop programs and policy to
aid victims of trauma.
Legal and medical professions
validate the trauma victims
suffer.

24. 24
Blaming the victim,
a common response
“Family members and other sources of social support can be
so horrified at being reminded of the fact that they too can be
struck by tragedies beyond their control that they start
shunning the victims and blame them for what has happened
- a phenomenon that has been called ‘the second injury’”.
Symonds, M. (1982) Victims response to terror: understanding and
treatment. In Ochberg, F. & Soskis, D. (Eds.), Victims of terrorism.
Westview Press: Boulder CO. (p. 95-103)
“Society’s reaction to traumatised people are rarely the
results of objective and rational assessments. Rather, they
are primarily the results of conservative impulses in the
service of maintaining the belief that they world is essentially
just, that good people are in charge of their lives and that bad
things only happen to bad people. Although people are
capable of profound bursts of spontaneous generosity to
victims of acute trauma, the continued presence of the
victims as victims constitutes an insult to the belief (at least in
the western world) that human beings are essentially masters
of their fate. Victims are the members of society whose
problems represent the memory of suffering, rage and pain in
a world that longs to forget. (p. 29)
Individuals and even entire cultures build up elaborate
defenses in order to keep these stark realities out of
conscious awareness”. (p. 43)
Van der Kolk, B., McFarlane, A. & Weisaeth, L. (1996) Traumatic stress: the
effects of overwhelming experience on mind, body and society. Guildford
Press: New York.

25. 25
Key messages
Torture and trauma are harmful to
experience, to witness or simply hear
about.
Feelings of compassion, anger and
repulsion are normal for those
working with survivors of trauma.
Positive responses to survivors are
also common but can be
overshadowed by the inherent
repulsiveness of the trauma itself.
Blaming the victim of trauma is
common even among professionals
who have experience working with
traumatised people.

26. 26
Exercise 6: The effects of
torture and trauma
In the large group, brainstorm as
many answers as possible to the
question:
“What are the effects of
torture and trauma?”

27. 27
Psychiatric disorders
associated with the refugee
experience
Adjustment Disorder
Distress and disturbance interfering with social functioning
and performance which occurs in a period of adaptation to
significant life changes or to the consequences of a stressful
life event.
Acute Stress Reactions (Acute Stress Disorder DSM-IV)
Severe, transient, short lived
Related to an overwhelming trauma incident
Lasts hours, two - three days
Symptoms include arousal, avoidance of stress evoking
stimuli and dissociation
Post Traumatic Stress Disorder
A delayed protracted response to a stressful event
(memory phobia)
Symptoms include arousal, avoidance of stimuli and
memory, dissociation and re-enactment
Enduring Personality Changes
As a result of a catastrophic event, concentration camp,
torture or disasters.
Orley, J. (1994) Psychological disorders among refugees: some clinical and
epidemiological considerations. In Marsella, A., Bornemann, T., Ekblad, S.
& Orley, J. (Eds.), Amidst peril and pain: the mental health and well-being of
the world’s refugees. American Psychological Association: Washington DC.

28. 28
Stress or PTSD
“What distinguishes people who
develop PTSD from people who
are merely temporarily stressed,
is that they start organising their
lives around the trauma”.
“It is the persistence of intrusive
and distressing recollections and
not the direct experience of the
traumatic event itself, that is the
actual driver of the biological and
psychological dimensions of
PTSD”.
Van der Kolk, B., McFarlane, A. & Weisaeth, L. (Eds.) (1996)
Traumatic stress: the effects of overwhelming experience on mind,
body and society. Guildford Press: New York.

29. 29
Effects of torture on the
individual
1. PSYCHOSOMATIC
Pains, headaches
Nervousness
Insomnia
Nightmares, panic
Tremors, weakness, fainting, sweating, diarrhoea
2. BEHAVIOURAL AND PERSONALITY CHANGES
Withdrawal, irritability, aggressiveness, impulsiveness
Suicide attempts
Sexual dysfunction (severe)
3. AFFECTIVE
Depression, frequent crying
Fear
Anxiety
4. MENTAL FUNCTION
Confusion, disorientation
Memory disturbance
Loss of concentration, attention blocking
5. PHYSICAL DAMAGE
Scars, burns
Fractures
Deafness
Weight loss
Other (teeth broken, tendons torn, rashes)
Reid, J. & Strong, T. (1987) The health care needs of victims of torture. NSW
Department of Health: NSW.
Cunningham, M., Becker, R. & Aroche, J. (1995) Eye of the needle trainers kit.
STARTTS: Sydney.

30. 30
Four key components of the
trauma reaction
CHRONIC FEAR, LOSS OF
CONTROL, HELPLESSNESS
DISCONNECTION FROM
SIGNIFICANT ATTACHMENTS
SHATTERED CORE
ASSUMPTIONS OF MEANING
GUILT, SHAME AND
HUMILIATION
Kaplan, I., Victorian Foundation for Survivors of Torture (1998).

31. 31
Key messages
1. There are four key components of
trauma reaction:
 chronic fear, loss of control,
helplessness;
 disconnection from significant
attachments;
 shattered core assumptions of
meaning;
 guilt, shame and humiliation.
2. PTSD overlaps affective,
somatoform, dissociative and anxiety
disorders.
3. What distinguishes people who have
PTSD from people who are stressed
is that they start organising their lives
around the traumatic memory.

32. 32
Exercise 8: The impact of
trauma on the family
1. In groups of two or three share one
experience about a family who suffered a
traumatic event.
2. Remember to protect confidentiality and not
to draw on your personal or family history for
this exercise.
3. After everyone has shared in the small
groups, the large group then brainstorms
their ideas about the following question:
“What are the impact of
torture and forced migration
on families?”

33. 33
The impact of trauma on the
family
Often several members of a family have been
victims of, or witnesses to, torture and trauma.
The impact of torture and trauma interacts with the
demands of settlement to produce many changes
in the family system.
1. Roles within the family are commonly drastically
altered. The father may no longer be the
breadwinner.
2. Patterns of responsibility shift. Children may carry
the burden of communicating with institutions and
service providers in the new country. They may
also carry primary responsibility for caring for
younger children and parents.
3. The exposure to new values can produce
generational conflict. Parents and children usually
adapt at different rates and to a different extent.
4. Parents may lose their protective and nurturing
roles due to current dysfunction and changes to
parents’ reduced capacity for intimacy.
5. Extreme disturbances in the form of violence,
suicidal behaviour and psychotic breakdown
constitute new traumatic events for the family.
6. Loss of employment, financial and social status
add enormous burdens.

34. 34
Exercise 9: The impact of
trauma on children
In a large group, brainstorm answers
to the question:
“What signs and symptoms might
be evident in children aged 1-5
years who have experienced
traumatic stress?”
Write down all the answers on the
whiteboard.
Discuss.

35. 35
Pre-school age
signs and symptoms
Thumb-sucking (after having stopped)
Bed-wetting (after having stopped)
Afraid of being left alone (separation
anxiety)
Seems afraid of strangers
Irritability
Confusion
Clinging to parents, loss of
independence
Immobility
Nervous tics
Speech disorders (eg. stuttering,
selective mutism)
Nightmares and disturbed sleep
Savdie, T. & Carey, L. (1996) Families in cultural transition.
STARTTS: Sydney.

36. 36
Symptoms criteria of PTSD in
children
1. Child experiences unusual event(s) that would be markedly
distressing to almost anyone.
A. Directly experiences events
B. Vicariously experiences events
i. Personally witnesses events
ii. Events experienced and conveyed by significant
others
2. Re-experiencing phenomena
A. Intrusive recollections/images
B. Traumatic dreams
C. Repetitive play
D. Re-enactment behaviour
E. Distress at traumatic reminders
3. Psychological numbness/avoidance
A. Avoidance of thoughts, feelings, locations, situations
B. Reduced interest in usual activities
C. Feelings of being alone/detached/estranged
D. Restricted emotional range
E. Memory disturbance
F. Loss of acquired skills
G. Change of orientation towards the future
4. Increased state of arousal
A. Sleep disturbance
B. Irritability/anger
C. Difficulty concentrating
D. Hypervigilance
E. Exaggerated startle response
F. Automatic response to traumatic reminders
Marsella, A. et al. (Eds.) (1996) Ethnocultural aspects of post-traumatic stress
disorders: issues, research and clinical applications. American
Psychological Association: Washington DC. (p. 393)

37. 37
How war affects children
THE BETRAYAL
Let down by adults/parents
The collapse of society
The fall of the world order
THE LOSS
Loss of close relatives
Friends, teachers, others
Loss of home, culture, nation
THE TRAUMA
The distorted mind
Intrusive memories
Trying to avoid
Increased arousal
Reduced responsivity
Raundelen, M. (1997) Centre for Crisis Psychology, Bergen, Norway
- Brisbane presentation.

38. 38
Refugee experience
“Arriving in a new country as
a refugee is like arriving as a
new born baby. We come
without clothes, without
baggage. We come without
knowledge about the world in
which we find ourselves,
without the language to find
out. We are totally
dependent on the good will
of those around us to ensure
that we survive, and also for
the quality of that survival”.
Pittaway, E. (1991) Refugee women - still at risk in Australia.
AGPS: Canberra. (p. 1)

39. 39
Exercise 1: Keys to
assessment
In the large group, watch the video ‘Eye of the
Needle’.
While you are viewing, keep in mind the key
areas of assessment below.
ASSESSMENT OF TORTURE AND TRAUMA
SURVIVORS
KEY AREAS
Presenting problems/complaints
Current life situation
Cultural formulation
Current health status
Previous functioning
Trauma history
- Torture
- Migration
- Organised violence/oppression
- Racism
Current functioning

40. 40
Gus van der Veer’s List
1. The therapist’s first impression of the refugee.
2. Complaints and statements about problematic behaviour, the concrete
situations in which both these complaints and this problematic
behaviour manifest themselves, and factors or conditions that make
the disturbing effect of the complaints or problematic behaviour more
or less severe.
3. Information about aspects of the psychological functioning of the
refugee which are not problematic, but adequate or even charming, or
environmental factors that suggest points of application for
professional help, like the availability of a social network, such as a
family or a compatriot community which can provide emotional support
(Boman & Edwards, 1984; Figley, 1985; Wren, 1986).
4. Information about the way in which both the refugee and people in his
or her social environment experience his or her problem, and their
ideas about what caused or provoked the complaints or problematic
behaviour.
5. Information about traumatic experiences that the refugee may have
undergone.
6. Information about the course of the refugee’s personality
development, and the level of his or her development in various
dimensions.
7. Information about the political field or forces to which the refugee is
subject, and other environmental factors that are burdening him or her,
such as uncertainty about legal status, having to live in a
neighbourhood with a high incidence of delinquency, worries about
relatives who have remained behind, and so on.
8. Signals that indicate the possible presence of psychiatric symptoms,
like disturbances in perception and reasoning and so on.
9. Statements about the kind of help the refugee asks for or explicitly
rejects, in relation to experiences he or she possibly had with other
helping professionals.
* This information has to be evaluated against the refugee’s
cultural background of course.
Van der Veer, G. (1992) Counselling and therapy with refugees and victims of
trauma: psychological problems of victims of war, torture and repression.

41. 41
Key messages
When making
assessments, be curious
and attentive.
Organise your thoughts, not
the client’s thoughts.
Avoid the risk of being
perceived as the
interrogator.
Increase the likelihood that
you will be perceived as a
safe presence.

42. 42
Exercise 3: Use of cultural
information
In groups of two or three come up
with at least one example of each
situation:
A situation where there was……..
1. A misunderstanding of a client’s
culture which led to less than
appropriate treatment.
2. A misunderstanding of a client’s
culture based on a generalisation
which turned out not to be the case.
3. Consideration of the client’s culture
which resulted in appropriate
treatment interventions.

43. 43
Flexible use of technique
“Everyone who seeks assistance
for mental problems wants to be
treated by an expert whom he can
consider as trustworthy (cf.
Pederson, 1981). But the criteria
by which someone is considered
as an expert and as trustworthy
are not the same in all cultures.
The same goes for specific
therapeutic techniques: what is
considered as useful and credible
in one culture, may be thought of
as stupid or immoral in a second
culture. The therapist has to be
attentive to these differences, and
flexible in the use of techniques”.
Van der Veer, G. (1992) Counselling and therapy with refugees and
victims of trauma: psychological problems of victims of war, torture
and repression. John Wiley & Sons: Europe. (p. 101)

44. 44
Cultural formulation
1. Cultural identity
• Cultural reference group(s)
• Language
• Cultural factors in development
• Involvement with culture of origin
• Involvement with host culture
2. Cultural explanations of distress
• Predominant idioms of distress and local illness
categories
• Meaning and severity of symptoms in relation to
cultural norms
• Perceived causes and explanatory models
• Help-seeking experiences and plans
3. Cultural factors related to psychosocial environment and
level of functioning
• Social stressors (eg. migration itself)
• Social supports
• Levels of functioning and disability
4. Cultural elements of the clinician-client relationship
• Use of interpreters
• Attendance of family or cultural members
• Culture-bound behaviour, manner, rituals, dress and
attitudes
5. Overall cultural assessment
Acknowledgments to the Qld Transcultural Mental Health Centre for adapting
this from the DSM-IV

45. 45
Questions to elicit the client’s
explanatory model
What do you think has caused your problem?
Why do you think it started when it did?
What do you think your sickness (or injury) does
to you? How does it work?
How severe is your sickness (or injury)? Will it
have a long or short course?
What kind of treatment do you think you should
receive?
What are the most important results you hope to
receive from this treatment?
What are the chief problems your sickness (or
injury) has caused for you?
What do you fear most about your sickness (or
injury)?
Qld Transcultural Mental Health Centre (2002) Managing cultural
diversity mental heath. Brisbane.

46. 46
Minimising bias during
assessment
1. The practitioner should examine his or her own
bias and prejudice before engaging in the
evaluation of clients who do not share the
practitioner’s race and ethnicity.
2. The practitioner should be aware of the potential
effects of racism.
3. The practitioner should include an evaluation of
socioeconomic variables and use them.
4. The practitioner should try to reduce the
sociocultural gap between the client and himself or
herself.
5. The practitioner should include an evaluation of
culturally related syndromes.
6. The practitioner should ask culturally appropriate
questions.
7. The practitioner should consult paraprofessionals
and folk healers within the particular multicultural
group.
8. The practitioner should avoid the mental status
examination.
9. The practitioner should try to use the least biased
assessment strategies first, then consider the most
biased strategies under special circumstances.

47. 47
Barriers to cross-cultural
communication
1. Language difficulties - this may mean
- Lack of vocabulary
- Lack of idiomatic expressions
- Different intonation and emphasis
- Choice of vocabulary and phrasing
2. Non-verbal communication differences - these non-
spoken clues or body language can impede
communication, even if the words used are being
understood - high and low context styles of
communication.
3. Preconceptions and stereotypes - based on
assumptions and value judgements can lead to
discrimination and racist behaviour - everyone’s
shorthand understanding of the world needs to be
checked out and understood in context.
4. Evaluate behaviour - cross-cultural conflict can still
occur when one person can recognise the cultural
patterns/context of the other person, but evaluates their
behaviour as good or bad against their own cultural sets
of values.
5. Stress and lack of time - building trust and relationships
is time consuming.
6. Not using adequate interpreters or interpreters in a
professional manner.
7. Not knowing the context - eg. is the person a migrant,
refugee or indigenous person, how long have they been
in Australia, etc.
8. Always use professional interpreters.
Rossi, D. QPASTT, 1999

48. 48
Key messages
Stereotypes are natural - but
inadequate sources of information
about a client.
Information about a mental health
client should, if at all possible, be
obtained from a range of sources:
family, friends, medical practitioners,
bicultural mental health workers, as
well as the client himself/herself -
through an interpreter if necessary.
Finding out what people believe to
be the cause of the illness and how it
might be treated can inform the
health professional about how to be
most helpful to the client.
Qld Transcultural Mental Health Centre. (2002) Managing cultural
diversity in mental health. Brisbane.

49. 49
Some general assessment tools
Global Assessment of Functioning (G.A.F) Scale
Social and Occupational Functioning Assessment
Scale (S.O.F.A.S)
Harvard Trauma Questionnaire
Hopkins Symptom Checklist 25
Children’s Assessment Proforma
The tools shown are used by QPASTT to undertake
more rigorous and in-depth assessment for clinical
and advocacy purposes.
None of the instruments included here can or should
be used in an exclusive manner.
Use of any of these instruments outside a therapeutic
context, and without a therapeutic intent and without
a therapeutic alliance, is not appropriate. The
instruments included are at most adjunctive to
counselling or psychosocial reports, and/or as part of
the semi-structured interview process.

50. 50
Global Assessment of
Functioning (G.A.F) Scale
(DSM-IV p. 32)
Consider psychological, social and occupational functioning on a hypothetical continuum of
mental health illness. Do not include impairment in functioning due to physical (or
environmental) limitations.
Code Note: use intermediate codes when appropriate, eg. 45, 68, 72)
100-91Superior functioning in a wide range of activities, life’s problems never seem to get out of
hand, is sought out by others because of his or her many positive qualities. No symptoms.
90-81 Absence of minimal symptoms (eg. mild anxiety before an exam). Good functioning in all
areas, interested and involved in a wide range of activities, socially effective, generally
satisfied with life, no more than every day problems or concerns (eg. an occasional
argument with family members).
80-71 If symptoms are present, they are transient and expectable reactions to psychosocial
stressors (eg. difficulty concentrating after family argument); no more than slight
impairment in social, occupational or school functioning (eg. temporarily falling
behind in school work).
70-61 Some mild symptoms (eg. depressed, mood and mild insomnia) OR some difficulty in social,
occupational or school functioning (eg. occasional truancy or theft within the household), but
generally functioning pretty well, has some meaningful interpersonal relationships.
60-51 Moderate symptoms (eg. flat affect and circumstantial speech, occasional panic attacks) OR
moderate difficulty in social, occupational or school functioning (eg. few friends, conflicts with
peers or co-workers).
50-41 Serious symptoms (eg. suicidal ideation, severe obsessional rituals, frequent shoplifting) OR
any serious impairment in social, occupational or school functioning (eg. no friends, unable to
keep a job).
40-31 Some impairment in reality testing or communications (eg. speech is at times illogical, obscure
or irrelevant) OR major impairment in several areas such as work or school, family relations,
judgement, thinking or mood (eg. depressed man avoids sirens, neglects family and is unable
to work; child frequently beats up younger children, is defiant at home and is failing at school).
30-21 Behaviour is considerably influenced by delusions or hallucinations OR serious impairment in
communication or judgment (eg. sometimes incoherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in almost all areas (eg. stays in bed all day; no job,
home or friends).
20-11 Some danger of hurting self or others (eg. suicide attempts without clear expectation of death;
frequently violent; maniac excitement) OR occasionally fails to maintain minimal personal
hygiene (eg. smears faeces) OR gross impairment in communication (eg. largely incoherent or
mute).
10-0 Persistent danger of severely hurting self or others (eg. recurrent violence) OR persistent
inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of
death.
0 Inadequate information
Client Name: ……………………………………………………………………………………..
……………....
Date Scored: ……………………...… Score: …….…… Scorer’s Name: ...………………….....
………………
Date Scored: …………………...…… Score: …….…… Scorer’s Name: ……………………...
………………

51. 51
Social and Occupational
Functioning Assessment Scale
(S.O.F.A.S) (DSM-IV p. 32)
Consider social and occupational functioning on a continuum from excellent
functioning to grossly impaired functioning. Include impairments in functioning due to
physical limitations, as well as those due to mental impairments. To be counted,
impairment must be a direct consequence of mental health physical health problems;
the effects of lack of opportunity and other environmental limitations are not to be
considered.
Code Note: use intermediate codes when appropriate, eg. 45, 68,
72)
100-91 Superior functioning in a wide range of activities.
90-81 Good functioning in all areas, occupationally and socially
effective.
80-71 No more than slight impairment in social, occupational or
school functioning (eg. infrequent interpersonal conflict,
temporarily falling behind in school work).
70-61 Some difficulty in social, occupational or school functioning,
but generally functioning well, has some meaningful
interpersonal relationships.
60-51 Moderate difficulty in social, occupational or school
functioning (eg. few friends, conflicts with peers or co-workers).
50-41 Serious impairment in social, occupational or school
functioning (eg. no friends, unable to keep a job).
40-31 Major impairment in several areas such as work or school,
family relations (eg. depressed man avoids friends, neglects
family and is unable to work; child frequently beats up younger
children, is defiant at home and is failing at school).
30-21 Inability to function in almost all areas (eg. stays in bed all
day; no job, home or friends).
20-11 Occasionally fails to maintain minimal personal hygiene;
unable to function independently.
10-0 Persistent inability to maintain minimal personal hygiene. Unable to function
without harming self or others or without considerable
external support (eg. nursing care and supervision).
0 Inadequate information
Client Name: …………………………………………………………………………..
……………....
Date Scored: ……………………...… Score: …….…… Scorer’s Name: …...…….....
………………
Date Scored: …………………...…… Score: …….…… Scorer’s Name: …………...

52. 52
Harvard Trauma
Questionnaire
(Focus on PTSD and its features)
“The Harvard Trauma Questionnaire (Mollica, Wyshak &
Lavelle, 1987; Mollica & Caspi-Yavin, 1991) is a guided
interview that begins by assessing 17 trauma experiences
specific to Indochinese refugees. The second interview
section includes an open-ended question about the
refugee’s perceived worst experiences, so that salient
aspects of the stressor can be delineated. The third
section elicits 30 symptoms related to torture and trauma,
16 of which overlap the DSM-III-R criteria. One strength of
the measure is that it is available in English and three
Indochinese languages. Perhaps more important is that it
represents an effort to assess trauma exposure and
symptoms cross-culturally, a task few investigators have
undertaken to date”.
Newman, E., Kaloupek, D. & Keane, T. (1996) Assessment of
posttraumatic stress disorder in clinical and research settings. In
van der Kolk, B., McFarlane, A. & Weisaeth, L., Traumatic stress:
the effects of overwhelming experience on mind, body and society.
The Guildford Press: New York. (p. 263)
Hopkins Symptom Checklist 25
(Focus on anxiety and depression)
This instrument includes 25 questions, 10 regarding
anxiety and 15 regarding depression.
It was developed by Mollica in 1986 in co-operation with
the U.S. Office of Refugee Resettlement.

53. 53
Assessment of children
From the health assessment of adults and their history of
persecution you will know if children have been exposed to
trauma and what level of insight parents have. Some questions
are:
How have the children been?
Has each child got any health problems?
Have you noticed any changes in your child’s behaviour since
the troubles/war began?
How do you think they coped with…….?
By this time, if little information has been elicited and there is
evidence of exposure to traumatic circumstances, ask
How have they been sleeping?
Any nightmares?
Have you noticed if they’re forgetful?
Do they misbehave in ways they didn’t before?
Do they enjoy things?
Have they made friends?
Do they get sad?
How are they doing at school?
Link these questions to information provision by saying “I’ve
asked you lots of questions about the children and this is
because we know that children are affected by having
experienced or witnessed terrible things”.
It is difficult for some parents to bear the burden of children
being traumatised and one should not shatter their defences.
Dr Ida Kaplan, The Victorian Foundation for Survivors of Torture Inc, 1998.

54. 54
Key messages
Regard all instruments as a
partial tool only, not as the
entire assessment.
Beware of the temptation to
over-rely on any instrument.
Cross-cultural assessment is
possibly best done in a semi-
structured interview style.
Self administered tests are not
considered as appropriate as
clinically administered semi-
structured interviews.

55. 55
Carlson’s Framework of the
effects of trauma
Traumatic events
Perception of event as negative
Suddenness
Lack of control
Core responses
Re-experiencing
Avoidance
Secondary responses (results of the social
environment)
 Depression
 Aggressiveness
 Poor self esteem
(result of core responses)
Associated responses
 Identity disturbances
 Relationship problems
 Guilt
 Shame

56. 56
The core points of PTSD
treatment
“….the core problem in PTSD consists of a
failure to integrate an upsetting experience
into autobiographical memory….”
“….traumatic memories need to become like
memories of everyday experience; that is,
they need to be modified and transformed
by being placed in their proper context and
reconstructed into a meaningful narrative”.
“…treatment consists of finding ways in
which people can acknowledge the reality of
what has happened without having to re-
experience the trauma all over again”.
“Talking about the trauma is rarely if ever
enough; trauma survivors need to take
action that symbolises triumph over
helplessness and despair”.
Van der Kolk, B., McFarlane, A. & Weisaeth, L. (Eds.) (1996)
Traumatic stress: the effects of overwhelming experience on mind,
body and society. The Guildford Press: New York.

57. 57
Exercise 6: Vulnerability to
PTSD
In small groups discuss the
question:
“Why do some people
appear to be more
vulnerable to PTSD than
others?”

58. 58
Vulnerability to PTSD
1. Genetic constitutional vulnerability to
psychiatric illness.
2. Adverse or traumatic experience in
childhood.
3. Certain personality characteristics (such as
those found in antisocial, dependent,
paranoid and borderline patients).
4. Recent life stresses or changes.
5. Compromised or inadequate support system.
6. Recent heavy alcohol use.
7. A perception that the locus of control is
external rather than internal.
Davidson, J. & Foa, E. (Eds.) (1993) Epilogue. In Posttraumatic
stress disorder. DSM-IV and beyond. American Psychological
Press: Washington DC. (p. 229-235)

59. 59
Controlled exposure in a safe
context
1. “The person must attend to trauma-
related information in a manner that
will activate his or her own
traumatic memories.
2. In order for the person to form a
new, non-traumatic structure,
trauma-discrepant information must
be provided.
3. The most important new
information is probably the fact that
the patient is unable to confront the
traumatic memory with a trusted
therapist in a safe environment
(van der Hart & Spiegel, 1993)”.
Van der Kolk, B., McFarlane, A. & Weisaeth, L. (1996) Traumatic
stress: the effects of overwhelming experience on mind, body
and society. The Guildford Press: New York.

60. 60
Key messages
The core problem of
PTSD is that of failure to
integrate an overwhelming
experience into memory.
The core treatment
principle compatible with a
number of treatments is
that of controlled exposure
to the traumatic memory,
within a safe context.
PTSD is a biological,
psychological and
sociological phenomena.

61. 61
Overview of three stages of
rehabilitation
STAGE I - SAFETY
Regaining control and putting order into daily existence
personal safety
i. Re-establishment of bodily integrity
ii. Safety in life and home
iii. Safety in broader community/country
Establishment of safety networks
i. Identity personal strengths
ii. Develop patterns of control and routine in daily life
iii. Establish personal support systems and networks
iv. Identify secure places
STAGE II - REMEMBRANCE AND MOURNING
Sharing the trauma and learning to grieve
i. A decision to remember
ii. Maintenance of safety and health
iii. Sharing the traumatic experience
iv. Grief and mourning
v. The integration of affect, memory and cognition
STAGE III - INTEGRATION
Building a future with meaning
i. Helping the survivor to claim his or her world
ii. Reconnecting with others
TRANSACT (1996). Companions in the search: multidisciplinary guide to assist
in the rehabilitation of clients who have experienced torture and trauma
before settling in Australia. TRANSACT: Canberra.

62. 62
Judith Herman’s three stages
of rehabilitation
Stage I Safety
This stage emphasises the re-establishment
of a person’s sense of safety and bodily
integrity.
Stage II Remembrance &
mourning
In this stage the client focuses on the retelling
and mourning of their traumatic experience/s.
Stage III Integration
In the integration stage the client works
towards being able to re-establish
relationships and interact with the world
again.
Herman, J. (1992) Trauma and recovery: the aftermath of violence
from domestic abuse to political terror. Basic Books: New York.

63. 63
Exercise 7: Staged recovery
In the large group, using the whiteboard write up in
three columns, J. Herman’s stages.
Brainstorm possible strategies for achieving each
stage and list them under the heading.
Stage I
Safety
Stage II
Remembrance
& Mourning
Stage III
Integration

64. 64
Some treatment methods
“Alphabet therapies”
E.M.D.R or Eye Movement Desensitisation and Reprocessing
T.I.R Traumatic Incident Reduction
V.K.D Visual Kinesthetic Dissociation
T.F.T Thought Field Therapy
Art therapy
Cognitive behavioural therapies
Exposure therapy
Anxiety management therapy
Direct therapeutic exposure techniques
Counting method
Flooding
Imagery
Implosive
Systematic desensitisation (exposure therapy) as in CBT above
Testimony method
Group therapies
Couple therapy
Family therapy
Psychodynamic approaches
Insight therapy (IRCT Denmark)
Psychoanalysis
Psychodynamic oriented psychiatry
Pharmacotherapy
Others
Homeopathy
Massage
Sand play
Yoga
Meditation
Working cross-culturally requires a flexible technique

65. 65
Group work
1. Stabilise psychological and
physiological reactions.
2. Explore and validate the experience.
3. People understand the effects of past
experience.
4. People learn new ways of coping.
5. People rebuild meaningful
connections.*
Adapted from: van der Kolk, B., McFarlane, A. & Weisaeth, L.
(1996) Traumatic stress: the effects of overwhelming
experience on mind, body and society. The Guildford Press:
New York.

66. 66
Group work purposes
Educational
Groups
Therapeutic
Groups
Support
Groups
One Two Three
Therapeutic
task
Safety Remembrance
& mourning
Reconnection
Time
orientation
Present Past Present, future
Focus Self-care Trauma Interpersonal
relationships
Membership Homogeneous Homogenous Heterogeneous
Boundaries Flexible,
inclusive
Closed Stable, slow
turnover
Cohesion Moderate Very high High
Conflict
tolerance
Low Low High
Time limit Open-ended or
repeating
Fixed limit Open-ended
Structure Didactic Goal-directed Unstructured
Example Twelve-step
program
Survivor
group
Interpersonal
psychotherapy
group
Herman, J. (1992) Trauma and recovery: the aftermath of violence from
domestic abuse to political terror. Basic Books: New York. (p. 218)

67. 67
Universal components of
effective intervention
1. Intervene immediately or promptly after the
traumatic event.
2. Focus on presenting complaints or current
distress.
3. Use specific and possibly directive techniques.
4. Deal with any guilt and self-blame early and
directly.
5. Experience and communicate empathy readily.
6. Strengthen the client’s sense of competence,
autonomy and self-worth.
7. Help clients make sense of the traumatic event in
the context of their lives (including culture).
8. Deal with any object losses early and directly.
Draguns, J. (1996) Ethnocultural considerations in the treatment of
PTSD: therapy and service delivery. In Marsella, A., Friedman,
M., Gerrity, E. & Scurfield, R., Ethnocultural aspects of post-
traumatic stress disorders: issues, research and clinical
applications. American Psychological Association: Washington
DC. (Chapter 18, p. 459-479)

68. 68
Key messages
Work with refugee survivors of torture
and trauma can be thought of as
having stages:
1. Safety
2. Remembrance & mourning
3. Integration
There are a number of treatment
models and approaches which can be
used to achieve the goals of each
stage.
No one method has yet proven to be
the definitive method with refugee
survivors of torture and trauma.

69. 69
Exercise 8: Culture provides
As a large group take a few minutes
to consider the following questions.
Record your answers on the
whiteboard.
“What does a person’s
culture provide for
them?”

70. 70
Culture provides security and
protection from trauma
Social support
Values
Norms
Shared expectations
Relationship with the spiritual
Relationship with meaning
Materialistically as a health
maintenance system
Marsella, A., Friedman, M., Gerrity, E. & Scurfield, R. (1996)
Ethnocultural aspects of post-traumatic stress disorders: issues,
research and clinical applications. American Psychological
Association: Washington DC.

71. 71
Key messages
Culture acts as a protector,
part of an integrated
system of the individual.
Culture is a double-edged
sword. Because of human
beings’ dependence on it,
its loss becomes traumatic.
De Vries, M. (1996) Trauma in cultural perspective. In van der Kolk,
B., et al., Traumatic stress: the effects of overwhelming
experience on mind, body and society. The Guildford Press:
New York.

72. 72
The relationship in treatment
“Emotional attachment is
probably the primary
protection against feelings of
helplessness and
meaninglessness; it is
essential for biological
survival in children, and
without it existential meaning
is unthinkable in adults”.
De Vries, M. (1996) Trauma in cultural perspective. In van der Kolk,
B., et al., Traumatic stress: the effects of overwhelming experience
on mind, body and society. The Guildford Press: New York.

73. 73
What is culture?
Is much broader than just ethnicity and includes:
- Age
- Gender
- Place of residence
- Status (educational, economic, etc.)
- Affiliation (formal/informal)
- Nationality
- Ethnicity
- Language
- Religion
Is learnt not innate.
Is changing and dynamic.
Is complex and no one can hope to learn every
aspect of culture.
“There may well come a time when we will no
longer speak of cross-cultural psychology as such.
The basic premise of this field - that to understand
human behaviour, we must study it in it’s
sociocultural context - may become so widely
accepted that all psychology will be inherently
cultural”.
Paul Pederson, p. 352.

74. 74
Exercise 9: Cross-cultural
competence
Break up into groups of two and
discuss the question:
“What qualities should a
person have to be cross-
culturally effective?”

75. 75
Characteristics of intercultural
competence (Hammer 1989)
Flexibility towards ideas of others.
Respect towards others.
Listening & accurate perception of the
needs of others.
Trust.
Friendliness & cooperation with others.
Calm & self control when confronted by
obstacles.
Sensitivity to cultural differences.
Tolerance for ambiguity.
Interaction management skills (negotiating
skills).

76. 76
Key messages
Relationship is an important factor in:
- protecting people from the effects
of traumatic experience;
- helping people to come to terms
with traumatic experience.
The extent and quality of the
client’s/patient’s holding environment
(relationship) is an important
consideration and predictor of
outcome.
The counsellor/helper is likely to be
more helpful and successful if
intercultural competencies are
pursued by the professional.

77. 77
Case vignettes
FEMI
Femi was a teacher in a West African country, who was politically active on behalf of his tribal group.
He experienced discrimination, harassment and victimisation from a very young age. On one of his
missions, he was targeted, gagged, blind-folded and taken away in the middle of the night. He was
then confined without water, food or toilet and beaten, ending up in a cell with 100 people.
As a student, he spent one and a half years in a refugee camp in Austria. Currently, he has been in
Australia for a similar length of time as an asylum seeker. For three years, he had virtually no
contact with any family members, even with his defacto wife and child, as he considered this was too
dangerous. His parents remain in their village and his siblings are scattered.
At first, as his English was limited, work was begun using an interpreter who spoke his local
language, but issues of trust in the small, divided community lead to problems. More recently,
interpersonal work has proceeded primarily through the medium of art, which has provided a new
avenue of expression for him.
MOHAMMED AND NAVAH
Mohammed and Navah are a refugee couple from Iran who arrived in Australia recently with their
three young children after spending two years in grim conditions in Turkey following the destruction
of their home. The trip to Turkey itself was horrific, with conditions so bad that one young mother in
the group of travelling refugees placed her baby in the sea, rather than subject it to further
deprivation.
It is clear now that Mohammed was politically active, but his way of protecting his family was to
refrain from mentioning or explaining anything that he did. Thus, one day, he just disappeared, and
one day, much later, he reappeared. He has not yet talked in detail of his prison experience, except
that it was underground and he slept on wet concrete.
In Australia he was inpatient with himself, for not being quicker to master English and find
employment. He was impatient and grumpy - ‘a different person’ - with his family. He was impatient
and resistant with his therapist.
A patient, accepting approach, moving gradually into basic western family therapy techniques has
helped this couple start to move forward and leave some of their trauma behind. The beauty of
music has helped break the pattern too.
MARIJANA
Marijana is a 6 year old girl from Former Yugoslavia who arrived in Australia with her grandmother
earlier this year to live with her uncle and aunt who sponsored them, having been in Australia for
some years.
She was an only child who last year became an orphan, her parents being killed six weeks apart.
She never saw her mother’s body, though her father tried to explain that she had been killed. She
was found beside her father’s body after he had been shot, and was trying to wake him up.
In Australia, she and her grandmother continue to be close, and she can hardly wait each day until
her grandma picks her up from school. Her English remains limited, and she appears shy about
accepting friendly overtures from other children. She is serious. It is not known whether she has
nightmares. She sleeps well if a story is read to her, but sweats heavily in her pyjamas each night.

78. 78
Strategies for health
professionals
1
RESTORE:
CONTROL
SAFETY
REDUCING FEAR AND
ANXIETY
 Restoring health through screening and
treatment.
 Establish patient's previous experience with
health professionals to anticipate concerns.
 Explain procedures.
 Give choice about proceeding with
investigations.
 Provide information about diagnosis, prognosis.
 Provide opportunity for patient to ask questions.
 Use an interpreter.
 Expect anxiety in patients.
 Medication for anxiety and symptoms of PTSD
(GPs).
 Making referrals for counselling and other
services.
2
RESTORE:
ATTACHMENT
CONNECTIONS
OVERCOMING GRIEF
AND LOSS
 Respectful treatment conveys possibility of
meaningful relationship.
 Expecting grief in patients.
 Medication for depression (GPs).
3
RESTORE:
IDENTITY
MEANING
PURPOSE
 Respectful treatment and genuine concern.
 Acknowledgment of difficulties.
 Expecting distrust, withdrawal, anger, demanding
behaviour and accommodating emotional
reactions.
 Knowledge of human rights violations and
effects.
4
RESTORE:
DIGNITY
VALUE
 Respectful treatment and genuine concern.
 Anticipation of reluctance to self-disclose.
 Respect for privacy.
 Expecting fear regarding invasive procedures.
Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered lives training guide.
Victorian Foundation for Survivors of Torture Inc: Victoria. (p. 169)

79. 79
Summary of general
frameworks
FOUR KEY COMPONENTS OF TRAUMA
REACTION
1. Chronic fear of loss of control/helplessness
2. Disconnection from significant other
3. Shattered core assumptions of meaning
4. Guilt, shame and humiliation
PHASES OF TREATMENT
1. Safety
2. Remembrance and mourning
3. Integration
NECESSARY ELEMENTS TO INCLUDE
• Social injustice critique
• Cultural appropriateness and sensitivity
• Therapeutic relationship

80. 80
Exercise 12: Emotional
responses
In groups of two or three discuss
the following question:
“What do you think the
emotional responses of
a person working with
survivors of torture and
trauma would be?”

81. 81
Emotional response of
workers
1. Helplessness
2. Guilt
3. Anger
4. Dread and horror
5. Idealisation
6. Personal vulnerability
7. Avoidance reactions
8. Fulfilment
Special thanks to the Victorian Foundation for
Survivors of Torture Inc.
Aristotle, P., Kaplan, I. & Mitchell, J. (1998) Rebuilding shattered
lives training guide. Victorian Foundation for Survivors of
Torture Inc: Victoria. (p. 148-152)

82. 82
Modes of empathic strain in
counter-transference reactions
(CTRs)
Reactive style of therapist
TYPE OF REACTION
(UNIVERSAL, OBJECTIVE, INDIGENOUS REACTIONS)
Normative
Empathic Disequilibrium
Uncertainty
Vulnerability
Unmodulated Affect
Empathic Withdrawal
Blank Screen Façade
Intellectualisation
Misperception of Dynamics
Type II CTR
(Over-identification)
Type I CTR
(Avoidance)
Empathic Enmeshment
Loss of Boundaries
Over-involvement
Reciprocal Dependency
Empathic Repression
Withdrawal
Denial
Distancing
Personalised
(PARTICULAR, SUBJECTIVE, IDIOSYNCRATIC REACTIONS)
Wilson, J. & Lindy, J. (1994) Countertransference in the treatment of PTSD. The Guildford
Press: New York. (p. 15)

83. 83
Vicarious traumatisation
The transformation of the person’s inner
experience resulting from empathic exposure to the
client’s material (Pearlman, Saakvitne 1995)
Occupational hazard
Effects are cumulative and permanent
Vicarious traumatisation is a response to the
effects of traumatic exposure on our clients.
EFFECTS
Includes changes in the person’s:
Sense of identity
Relationships with self/others/world
Beliefs about self/others/world
Tolerance of feelings
Psychological needs
Memory and imagery changes (vulnerable to PTSD
symptomatology)
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists.
In Figley, C. (Ed.), Compassion fatigue: secondary traumatic
stress disorders in those who treat the traumatized. Brunner-
Routledge: New York.

84. 84
Exercise 13: Risk factors
Brainstorm in the large group:
“What might be some risk
factors for developing
vicarious
traumatisation?”

85. 85
Risk factors for vicarious
traumatisation
Too high demands from self.
Too high demands from others and the
situation.
Lack of resources, personnel and time.
Lack of control over the situation.
Lack of support from leaders, organisations,
colleagues.
Unrealistic expectations.
Lack of acceptance and acknowledgment.
Smith, B., Agger, I., Danieli, Y. & Weisaeth, L. (1996) Health
activities across populations: emotional responses of
international humanitarian aid workers. In Danieli, Y. et al.
(Eds.), International responses to traumatic stress:
humanitarian, human rights, justice, peace and development
contributions, collaborative actions and future initiatives.
Baywood Publishing: New York.

86. 86
Contributing factors of
vicarious traumatisation
Characteristics of work
- Clients with traumatic histories
- Clients who are continually exposed to
danger
- Clients who are difficult to understand
Characteristics of the worker
- Vulnerabilities
- Experience of personal trauma
- Ideas, values
- Ability to attend to their own care needs
Characteristics of society
- Society’s tolerance of abuse
- Society’s attitude towards violence and
social justice eg. misogynist, racist and
hetero-sexist and victim-blaming contexts.
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised therapists.
In Figley, C. (Ed.), Compassion fatigue: secondary traumatic
stress disorders in those who treat the traumatized. Brunner-
Routledge: New York.

87. 87
Exercise 14: Strategies to
reduce risk of vicarious
traumatisation
Brainstorm answers to the
following question:
“What strategies and/or
techniques have you, or
could you use, to reduce
the risk of vicarious
traumatisation?”

88. 88
Reducing the risk of vicarious
traumatisation
PERSONAL STRATEGIES
Maintain a personal life
Use personal life
Identify healing activities
Attend to your spiritual needs
PROFESSIONAL STRATEGIES
Arrange supervision
Develop professional connection
Develop a balanced work life
Remain aware of your goals
ORGANISATIONAL STRATEGIES
Attend to physical setting
Arrange for adequate resources
Create an atmosphere of respect
Develop adjunctive services
Pearlman, L. & Saakvitne, K. (1995) Treating traumatised
therapists. In Figley, C. (Ed.), Compassion fatigue: secondary
traumatic stress disorders in those who treat the traumatized.
Brunner-Routledge: New York.

89. 89
Where to from here?
Invite the group to discuss any closing house-
keeping.
Allow them to have time to explore any future
directions they may wish to pursue as a group of
workers.
Examples
More training?
Regular case discussion?
A literature review group?
A peer support group?

90. 90
“History, despite its
wrenching pain, cannot
be unlived, but if faced
with courage, need not be
lived again”.
Maya Angelou