Volume VI, Issue 4, Article 5 (December, 2000)

Reports From the Field
Editorial Note: This section of the Journal is devoted to reports by traumatologists who have experience in applying traumatology principles in the field and have a perspective to share that the Editors believe is valuable but are published as they are submitted. Like a letter to the editor, this means of communication assures that the authors are able to share their perspective quickly and unedited. As with all articles published in this Journal, the Editorial Board encourages responses from the readership.
Psychological Approach to Albanian Kosovar Refugees
with Considerations for Brief Post-crisis Services in General
Howard Lipke, PhD
North Chicago DVA Medical Center
Chad Glang, PhD
Private Practice, Colorado Springs
“...there is nothing either good or bad but thinking makes it so... Oh God! I could be bounded in a nutshell and count myself a king of infinite space, were it not that I have bad dreams.”
Hamlet 2/2
        The following observations and proposals come out of a specific experience, but may be useful more generally. Early in 1999 Sandra Tinker-Wilson, of the Spencer Curtis Foundation, a group active in humanitarian clinical psychological trauma work,was put in contact with staff from the Maltesers, a centuries old humanitarian group which was administering a refugee camp in Hemer Germany for three to six hundred Kosovar Albanians. The initial request for psychotherapy services focused on the young children who had been traumatized in the war, and were showing psychological distress and behavioral problems related to the experience. Using a variation of group therapy which integrated standard methods of child treatment including art therapy with a variation of EMDR considerable improvement was noted in the children.[1]
        Subsequently there was a request for further EMDR work for teenagers and adults. The current authors (as did other volunteer therapists), responded to this request, and came to the camp for a week in January of 2000. We expected a project similar to that in Oklahoma City, following the bombing there, in which EMDR therapy was successfully (as judged by clinical observation) offered on an intensive basis by therapists who stayed as little as a week, backed each other up, and were backed up by local therapists. While there were some similarities to the Oklahoma City situation (i.e. the request for psychotherapy services following trauma, the follow-up therapists) the differences and limitations were mostly stacked against success. On the positive side, in Germany, there was an EMDR trained psychologist who was assessing potential clients for appropriateness for treatment, and the treatment would be offered by highly experienced therapists in a supportive setting. On the negative, and powerfully negative side at that, the clients would generally not have cultural experience or even language in common with the therapists. The work would have to be done through translators, and as we learned, the translating was going to have be done by intelligent but non-expert English speaking young adults, who were themselves refugees living in the camps.
        We rapidly learned that a standard EMDR model in which treatment would as quickly as possible focus on the "worst" traumatic incident would not be successful for many teenage or adult clients. The first problem was with the idea of treatment itself. The standard belief appeared to be, despite the widespread acceptance of the treatment of the children, that only a "crazy" person would go to a psychologist. While this may also be a widespread belief in much of the United States, it is far less so than it appeared to be among Kosovo Albanians. The second problem was that extensive evaluation, rapport and alliance building through an interpreter would be extremely difficult to accomplish quickly. In addition to these problems of providing treatment where it was judged by the camp psychologist to be needed, was the concern that treatment not be "imposed" on people who had already had their choices limited by the travails of war.
        In our effort to avoid attempting to impose services that were not desired, but also to use our skills to benefit the refugees, we decided to offer direct individual services to the few initial volunteers, but also to offer them and any others who wished a lecture/discussion how the brain responds to trauma, with a focus on dreams and nightmares. This group activity was advertised by word of mouth through the translators, and by posters placed throughout the camp. The decision to offer information focused groups on this subject matter was influenced by: (1) the personal experience (HL) that such groups had been helpful to clients who had acknowledged problems but had not yet been willing to engage in more intensive counseling work; (2) the recent work by David Clark (1999) indicating that normalizing, that is explaining that the "symptoms" that follow traumatic stress are an often transitory normal reaction, may have a powerful therapeutic effect in reducing destructive reactions; (3)  the idea that introducing the issue through a topic, dreams, most people find intellectually interesting, presented in a relatively non-threatening scientific-educational, rather than illness-medical model would have the best impact. Note: Care must be taken to understand cultural and previous individual belief about the meaning of dreams in general during the presentation and discussion of this material (van der Veer,1993, 1995); (4) the empirical support in both the literature, and from clinical experience, for both the effectiveness and safety, of the type of nightmare intervention used. Eichelman (1985) Halliday (1987) and Kellner (et al. 1992) have presented research on this subject; (5) the concrete nature of the subject which allowed for relatively easy translation, and; (6) the fact that using a group format in which the the potential therapists demonstrated their expertise in a group lecture/discussion could expedite the establishment of rapport and alliance, which could translate into potentially effective individual sessions. Or alternatively, if the group presentation, either in style or substance did not meet potential individual client needs the client would be able to make an efficient and relatively painless judgment of that, and following some introductory comments is an enumeration of what appeared to be the best of the presented material. When this material was presented, a board was available for drawing, and a large circle was drawn to represent the brain, with a line bisecting the top (waking) from the bottom (sleeping) brain. The various elements were charted in as visual aids.

        Even though the written words were in English having the graphic representation appeared helpful, at least to the translator. The manner of presentation was informal. The best advice one of the authors (HL) received years ago in beginning to work with people who had been severely traumatized was that clients would have little tolerance for a distant authoritarian manner. Heeding this advise has been helpful in working with traumatized veterans and it appeared to apply in the current situation. On the other hand, over familiarity- too much "I know what you feel"- is likewise destructive. It should also be noted that personal and family experience of the presenter (HL) were used. Examples such as an aunt's experience as a refugee, her subsequent success and her advise (to never give up hope), as well as personal grief reactions to family deaths, were not out of bounds. Care was taken to note sharing these experiences did not mean claiming to understand the depths of the client's experience; only some relevant experience was shared. Although such personal material can be used clinically, it should be noted it is not recommend unless the clinician is experienced and comfortable with this kind of self reference, and how to use the possible elicited negative reaction to the clients' benefit.

The Group Content

        1. It is the job of the brain, or mind, to take in all kinds of experience (sights, sounds, smells, etc.) make sense of it, learn from it, plan, act and then solve problems for the person to have a good life.

        2. For this discussion, lets say there are two parts of the brain that this information comes into, the waking brain and the sleeping brain. All the information comes into both, but each does its own kind of work with the information. They do communicate, usually to help each other, but sometimes causing each other problems.

        3. The waking brain deals with all kinds of experience, but words and emotions/feelings are often emphasized over pictures. For the sleeping brain pictures and emotions/feelings are most important. Most of the time, for most people, these parts of the brain do their jobs with some, but not major problems. Sometimes there are problems and each part may not do its work well, or may actually interfere with the other.

        4. The waking brain when it is doing OK: When something bad happened in your life, to give an an easy example, lets say the teacher yelled at you when you were in school. You may feel bad (afraid, sad, angry, confused, etc. This, and other times, below, where examples are given in parenthesis, may be good times at which to ask for participation.) at the time and think bad things about yourself (stupid, lazy, weak, etc.) Later your waking brain may remember that you are smart sometimes, and do some things well. You may even talk to your friends about it, and then don't feel so bad. Later on you may even be happy for the experience, because you learned a lesson. Sometimes a very bad thing, a traumatic thing, happens and you can't think of a way to solve the problem. When that happens, sometimes it is helpful to talk to someone like a counselor. It is also sometimes helpful to do therapy which can help connect the positive solution (like the idea that you could learn something from this, or it is part of growing up, or it is in the past, or that God can help you) to the negative thoughts, feelings, and even pictures in your mind. Then you might feel better and be better able to solve your day to day problems.

        5. The sleeping brain when it is doing OK: The sleeping brain takes in information during the day, then dreams about it at different times throughout the night. While dreaming the sleeping brain seems to have two jobs.

    First, to combine things we know in new ways to help the waking brain find unexpected answers.  Many people have had the experience of falling asleep with a problem and waking up with the solution, hence the phrase: "Let me sleep on it." There is one famous example in which a scientist won a Nobel Prize after dreaming of the answer to a problem[2]. We may also have dreams that are strange and frighten us. These dreams can be helpful in preparing us for difficult times ahead (Winger and Kapp, 1972), or our worst fears, realistic or unrealistic.

    Second, to find some kinds of satisfaction we can't find in waking life. For example, dreams may be about people who have died, with the person coming alive in the dream in a positive way. When that happens dreams do two things at once, they solve the problem of helping us realize that even though we have lost our loved one we can cherish the good memory rather than dwell in the pain of loss. And, we can enjoy the pleasure of the reunion that is not possible during waking time.

        Some people don't remember any dreams at all, but the dreams are still doing their work. When dreams are not remembered it is probably because dreams are easily forgotten, and the person usually wakes up after the dream is over. Those of us who do remember dreams only usually remember one or two dream per night, and only if we wake up during or soon after it ends. It appears that dreams can help us whether we remember them or not.

        6. Problems in the sleeping brain are similar to problems in the waking brain. The waking brain may dwell on negative destructive thoughts over and over, and be blocked from solving problems to make our lives better. The sleeping brain may have a similar problem, it can get stuck in the first stage of dealing with a bad situation. That probably happens because the person wakes up when the dream work starts because of the fear. So, the dreams never get to finish their work; they never get to the stage where there are all kinds of strange combinations, and problems are solved and/or we can find satisfaction in our dreams.

        When the upset feelings and mental pictures from dreams don't get worked on they carry over to the waking brain. Some people have let their waking brain help their sleeping brain by changing the dream, after they wake up, to a different ending than really happened. This may help the sleeping brain get past the worst parts, and finish the work of making up new and different solutions. In this way the waking brain acts like the nightmare is a movie in which the ending can be changed. If a person has a trauma dream that is a repeat of past events they may practice rewriting the dream ending during the day or before they go to bed.

        7.  It is also important to know that it is normal for people who have been through very bad events, especially those that involve death and injury, or threat of death or injury, to have problems other than nightmares such as: (a) hearing or seeing things from the event after it is over; (b) being reminded of it easily; (c) having trouble concentrating or remembering, and ; (d) having bad feelings (sad, angry, feeling no happiness), for long times and/or being surprised by these feelings.

        It is important to remember that these reactions do not mean you are crazy, this is just part of the way the brain heals from traumatic events. In fact, it is the people who take these experiences to mean they are crazy or weak, not just going through a normal painful process, who keep the problems longer and more intensively. The work you do with your waking brain to help your sleeping brain, can help the waking brain with these problems.

Comments on the group meeting

        Throughout the group meetings therapeutic discussion occurred. One interaction led a participant to see that when the inventory of his business was lost, he did not lose his greatest asset, his intelligence; he showed noticeable relief. The group meetings appeared to provide as it was hoped both intrinsic value and good preparation for the individual sessions.

Individual sessions

        Following the groups (primarily the work of the first author, HL) in which variations of the above information was presented individual sessions were offered to the participants.(Descriptions of these sessions reflects primarily the clinical work of the second author, CG.) Depending on a variety of factors, the same that go into any offering of services, individual sessions were conducted with emphasis on further assessment,education, helping to build coping skills, and/or trauma processing with EMDR. As in more conventional settings, it is required that potential clients are informed of the possibility of increased distress with any psychothrapeutic approach.

        What made trauma processing a possible treatment on such short notice was: preassessment by the camp psychologist and previous project staff, the possibility of extended daily contact with the therapist, the supportive setting of the camp, the fact that EMDR does not require the extensive self revelation and verbal interaction required by more traditional approaches, as well as the expectation of follow-up therapists.  Still it is acknowledged that there is risk in providing trauma treatment, it is the experience of the authors that the risk of not receiving assistance in processing trauma is far greater than the risk of proceeding, therefore the client is give the informed choice.

        Intensive direct trauma work with EMDR was, in fact, the exception in our therapy with the Kosovo-Albanian refugees.  With most individuals,a "solution-focused" approach was used, with eye movement used to enhance positives.  Each of the three sessions described below were markedly different, however all began with work on positive thoughts or imagery (positive associative networks), and each of these adolescent clients came to some resolution, either through putting events in social or spiritual context. For each of these clients it is possible that more extensive trauma work needs to be done in a situation more conducive for it.

        Labinot (all names have been changed), 15, had been forced from his home along with his family. With hundreds of others, they had been surrounded by tanks as they saw their homes burned to the ground. Labinot's family had been robbed by soldiers, and he had witnessed several brutal beatings and murders. He was experiencing frequent intrusive thoughts about these events.

        In our only session, which lasted approximately two hours, Labinot was asked to tell about his life before the war. He described several positive memories, each of which was processed with one or more sets of eye movement (EM).These were: Playing football with friends; a family vacation at the seaside, when he was eleven; when he flipped over in an inner tube and swallowed some water (much laughter), followed by chocolate ice cream. At seven years old, chasing frogs with his buddies. At the same age, his first day of school. At six, going to the zoo.

        Labinot was asked to create a graph on flip-chart paper. The horizontal axis representing his age, the vertical going from very sad to very happy. He drew a small picture to represent each memory (swimming, frog, etc.), plotted according to age and feeling. He was quite engaged in the process. Asked how he felt, seeing all these memories represented as a graphic whole, and he said "good” (EM) then he drew a tank to represent the war. We noted that while these are very painful memories, they also exist in the context of a very happy life. EM.  He seemed to "get" this. We then targeted the tank image, using several sets of EM.  "It's not so bad...it's a better picture...I see a light moving toward me...more light...a good feeling."  We retargeted, and SUDS were 1-2.  "I am beginning to erase it...It's hard to bring the tanks back..."  Ending PC's:  "I am stronger,"  "I am sure I'll forget it," "I can put it behind me and have a happy life."

        Had more time been available, two follow-up sessions could be envisioned. First using space remaining on the “life graph” for the future, Labinot could have drawn some future hopes and dreams, to be followed by EM. Such work would need to be approached tentatively, with discussion of the uncertainties of life back in Kosovo.

Second: a family meeting may have helped Labinot to "ground" his work in the family  system, as he told them about his session, using the graph as a visual aid. Not only can such sharing help the child further internalize his progress, it is also useful for parents to gain the information which can help them nurture the changes.

For the second client the work appeared to clear the way emotionally, for the reestablishment of relationships which had been disrupted by events in the war.  Gentiana is a sixteen year old young woman who, in addition to suffering similar traumas to Labinot, had lost her uncle. He is survived by three young sons, and his wife, Pull. This family remains in Kosovo.

Gentiana cares deeply for all four of them, and has been unable to talk to her Aunt Pull on the phone, fearing that she'd cry and upset her. All the issues around emotional protection and the distance it causes seemed too complex for the level at which we could communicate, so we focused on the more narrowly-defined problem.

We began with finding Gentiana's safe place: a nature image with mountains, fields, river...a sunny day.  She then described the images which come into her mind when her parents talk to Pull on the phone: seeing her three nephews asking where their father was, and the moment she learned of the death. In the family's protective style, they had kept this news from her for many months however, she'd overheard it two months earlier when her mother told someone on the phone.

Rather than processing either of these targets, Gentiana was asked to recall happy memories--in this case to include Aunt Pull. Each was processed with one or more sets of EM.

Working with these positive memories, she eventually came to the positive cognition “My love for Pull is stronger than my sadness." She reported that the image of her three nephews no longer bothered her.
She was asked to hold a disconnected telephone to her ear, and imagine talking to Aunt Pull. She told her about the time she had cooked an omelette for the family, how she rocked the baby, and the delicious spinach pie Pull had cooked. Gentiana spontaneously said she thought she was now ready to talk to her aunt. It was suggested that she give herself permission to talk or not talk as she felt at the moment, and that if she chose not to, she could have someone else mention these happy memories on her behalf. She wrote them down, to give to her mother.
For the third client comforting spiritual thoughts and images came to the fore, and were apparently enhance with EM. Endrit, 19, is fortunate in that he knows of no deaths in his family, or network of friends. The problem he identified is that sometimes at night he cannot sleep, and becomes "cold with fear" as he imagines getting news that someone he knows has been killed. This is a rational fear, as his village was totally destroyed.
Endrit’s session took an unusual turn at the very beginning. To facilitate learning that EMDR does not involve effort, but rather free association and observation the a word-association “game” can be played with clients (Dunton, 1994). In response to the first word "blue" Endrit said "God." This striking response seemed worth pursuing. Endrit was asked if he had an image of God in his mind. He said no, that God had created everything, so he felt God's presence everywhere. Questioned further, he came up with the image of a flower garden. We added the cognition "Thank you God," and processed this with a few sets of EM. This seemed to take Endrit deeper into a peaceful state.

Seeking to bridge our language difference, a compass was drawn for Endrit; in place of North, he was asked him to write "Thank you God" in Albanian. We focused this with EM. It was suggested that Endirt experiment with keeping his personal "compass" set on gratefulness, and watch to see if this brings him happiness, as it does many people.

He was then asked for other memories which involved feeling God's presence. Edmond recalled cutting firewood a year ago, being detained by the police and threatened with beating. He was released without incident, and smiled as he recalled the image of running through the woods a long way before stopping to drink deeply from a stream.

 We focused on this with EM, as well as two other positive memories: at sixteen, hanging out with friends at school, drinking Coke and smoking cigarettes; and making a dramatic save as goalie in a soccer game. We concluded by picturing the image of laying in bed, cold with fear. At this point, he reported zero SUD level. Edmond then moved his eyes while imagining the flower garden image and thinking "Thank you God."

Conclusions

We chiefly used a combination of group and individual work highlighting education, and the accessing of positive material (historical, social, and spiritual, where appropriate). Our approach evolved so that trauma material was generally not initially targeted, but rather dealt with as it emerged. This appeared to yield positive results in both the group and individual sessions. This impression was strengthened by positive informal feedback received from contact with camp staff in the following weeks. It is, of course, recognized that the work presented here is preliminary, and the suggestions tentative. Further development would ideally include rigorous examination, as difficult as that is to do with a refugee population still in transition.

References

Cohen, D. (1974) Toward a theory of dream recall. Psychological Bulletin, 81, 138 -154.

Dunton, R. (1994) Personal communication.

Eichelman, B. (1985) Hypnotic change in combat dreams of two veterans with posttraumatic stress disorder. American Journal of Psychiatry 142, 112 - 114

Kellner, R.; Neidhardt, J., Krakow, B., Pathak, D. (1992) Changes in chronic nightmares after one session of desensitization or rehearsal instructions. American Journal of Psychiatry, 149, 659 -662.

Halliday, G. (1987) Direct psychological therapies for nightmares: A review. Clinical Psychology Review, 7, 501 -523.

Mauer, M.; Lopez Cano, T; De Godoy, M.; Alacala, N.; Artigas, L.; Jarero, I. (1999) Children's Post-traumatic Stress after Natural Disasters: Integrative Treatment Protocols. Annual Meeting of the International Society for Traumatic Stress Studies, November, Miami, FL.

Steindl-Rast, D (1984) Workshop at the Lama Foundation, Taos, New Mexico.

van der Veer, G. (1993) Psychotherapy with young adult political refugees. In: Wilson, J.P. & Raphael, B. International Handbook of Traumatic Stress Syndromes. New York:Plenum. pp 651 - 657 .

van der Veer, G. (1995) Psychotherapeutic work with refugees. in Kleber, R,J,, Figley, C.R., & Gersons, B.P.R. Beyond Trauma. New York: Plenum.

Winget, C. & Kapp, f. (1972) The relationship of the manifest content of dreams to duration of childbirth in primiparae. Psychosomatic Medicine, 34, 313 - 320.

[1] This method has been called the "butterfly hug", after the cross armed self shoulder tapping used to substitute for the EMDR eye movements. Successful results with this method with Honduran children who survived a hurricane were reported at the 1999 ISTSS convention (Mauer et al., 1999). Research on the work with children in the German refugee camp will be reported by Wilson and her colleagues in the future.
[2]  Otto Loewi, 1936 Physiology- shared the prize for discoveries aobut neurotranmitters.
Volume VI, Issue 4, Article 5 (December, 2000)