Group therapy model for refugee
and torture survivors
Ibrahim A. Kira PhD*, Asha Ahmed PhD*, Vanessa Mahmoud, Msw* & Fatima Wassim, MA*
The paper discusses the Center for Torture and Trauma Survivors’ therapy group model for torture survivors and describes two of its variants: The Bashal group for African and Somali women and the Bhutanese multi-family therapy group. Group therapies in this model extend to community healing. Groups develop their cohesion to graduate to a social community club or initiate a community organization. New graduates from the group join the club and become part of the social advocacy process and of group and individual support and community healing. The BASHAL Somali women’s group that developed spontaneously into a socio-political club for African women, and the Bhutanese family group that consciously developed into a Bhutanese community organization are discussed as two variants of this new model of group therapy with torture survivors.
Key words: group therapy, refugees, wraparound approach for torture treatment, community healing
There is an increased concern about the relevance and effectiveness of current mental health programs and existing interventions
*) Center for Torture and Trauma Survivors CTTS, Georgia, USA. firstname.lastname@example.org
that are derived from individualistic western cultures and based mostly on addressing single personal identity trauma, for example sexual abuse, with clients from different cultures and with refugees and minority populations who are cumulatively traumatized with personal and collective identity traumas.1-3
In general, treatment of refugees who have survived violence and torture is complicated and not manuals-bound. Most evidence-based traditional group therapies have been developed to address specific single personal identity trauma, e.g., sexual abuse, or post such single trauma symptoms using different cognitive behavioural, psycho-dynamic or other theoretical and technical approaches. However, refugees and torture survivors went through, and are possibly still going through, a host of different trauma types that include personal and collective identity traumas and which have cumulative effects. Cumulative trauma dynamics are different from the dynamics of single trauma.4 Additionally, refugees and torture survivors usually belong to different cultures which are more collective than individualistic and may belong to different religious heritages other than those form which such group therapies were developed.5 It is important to adapt current evidence-based group therapies, regardless of their theoretical and
technical approaches, to address cumulative trauma and collective identity traumas that clients endured, or are enduring, in order to be acceptable and effective with refugees and torture survivors. Most refugee populations and torture survivors come from collective cultures and the core (or index) traumas for most of them are collective identity traumas. In the case of ethnic persecution, which is a collective identity trauma, the group character is even more evident. The traumatized refugees have become victims of persecution and or torture because of their belonging to a certain group. In collectivistic culture, healing usually take place within the group context. When people get persecuted because of their group characteristics, a group therapy seems logical and has more therapeutic potential. In collectivistic cultures, it is common for families and community elders or religious or political leaders to be the first source of support for personal problems or health concerns. Family group therapy and community work can be especially effective. Using modified or newly designed group interventions can be a potentially effective component in a wraparound multi-component, multi-model process for treating victims of political violence.6-8
Torture consists of different traumas that target an individual or group. Collective identity is an important factor in this complex trauma. The multi-systemic, multi-component, wraparound psychosocial rehabilitation approach for torture treatment addresses the three systems affected by torture: The individual, family members and the group.6-8 Group therapy for torture survivors is an important component of this model. Group therapies in this model extend to community healing. Groups develop their cohesion in order to graduate to a social community club or initiate a community organization. New graduates from
the group join the club and become part of the social advocacy process and of group and community support and healing. Following this model, the Centre for Torture and Trauma Survivors (CTTS) currently conducts family and women’s groups for Iraqis, a Burmese men’s group, a Bhutanese family group, and an African women’s group of members who survived both torture and HIV (caused by rape during torture). In the following, we describe two of these groups as two variants of the model where each ends up establishing a sustainable community organization, the Bashaal women’s group and the Bhutanese multi-family group, albeit in different ways.
Bashaal: a comforting shoulder In August 2006, CTTS began a thera peutic group for Somali, Ethiopian and other Sub-Saharan women who had suffered war trauma and torture. The group was led by a Somali case manager/community liaison and a consulting therapist. They were able to combine the case manager knowledge of Somali culture and language with the therapist’s experience with trauma and dissociation. They began the group by focusing on the common thread of female genital circumcision.
In the following months the group focused on the women’s support of each other, the importance of their faith and culture in their survival, and their need for help in interfacing with systems. In the process of addressing day-to-day concerns and health problems, the women began to talk about the trauma they had experienced.
Three group changes have marked the growing empowerment of the women. In November 2006, the group members took “ownership” of the group by naming it Bashaal, which refers, in Somalia, to a late afternoon women’s gathering in the pres‑
C L I N I C A L EXPERIENCE
ence of wise elders, a time to share their stories of troubles and triumphs. They share ginger tea and dates, while relaxing after the day’s chores. The second significant change was to move the group from the offices of CTTS to a community room in the heart of the Somali and Ethiopian community, near the main Masjid mosque. The organization and use of the center was negotiated by the physician, with the support of the Somali community. The room is furnished in a traditional Sub-Saharan manner and is cared for by the women. In the summer of 2008, a new therapist started a second women’s group with the Somali case manager/community liaison, while the first group continued as a self-sufficient group, sometimes mentoring the new group!
The group has interpreters and various interns who assist and visit and who help members reach the goals they have set for the group. The goals of the group are:
a) To give members a safe place to gather and to talk about their concerns, including their recovery from torture;
b) To assist in the acculturation and immigration process by discussing cultural and religious differences they encounter;
c) To increase members’ feelings of personal empowerment and mastery in various aspects of their lives through trad itional women’s handicrafts and basic living skills;
d) To diminish symptoms of PTSD, anxiety and depression through psychotherapy and support;
e) To form a social organization that brings women out of isolation and that can eventually be maintained by members with a steady core membership.
After an initial assessment of the potential group members’ experiences with torture and trauma, using the instruments devel‑
oped for the Center for Torture and Trauma, approximately 20 members were selected by the case manager for membership in the group. Meetings are held once a week, on Fridays, prior to Jumah (Friday) prayers. Participants are transported to meetings or arrive via public transportation. Refreshments are often served, particularly tea and sweets. Members greet each other traditionally and get to know the rules of the group. Confidentiality, privacy and safety are emphasized in the group.
The therapist facilitates a therapeutic group process, incorporating relaxation breathing and guided imagery for stress relief, pain management, and relief from intrusion phenomena. The group is organized around a theme or activity each week, pre-selected by the members and the therapist the week before. Themes include: immigration experiences, parenting, marriage, communicating with doctors, tribal conflict, difficulties in protecting and raising sons, finding husbands for daughters, maintaining authority with children, memories, nightmares and dreams, financial difficulties, cultural differences, divorce, losses, grief, rage and loneliness. Activities can include crocheting, knitting, quilting, drawing, sewing, simple automobile maintenance, driving tests, scrapbooking, jewelry making, etc. These activities are all activities they can continue outside of the group. They are normalizing, calming and soothing to the members. While they are working on a project they hold their discussions, just as one might on a visit to a friend. Within this context, the shame and guilt that they might otherwise feel when thinking or talking about many issues is diminished. Members look forward to these meetings every week. They report using their crafts as ways to calm and soothe themselves at home when times are difficult. They are supportive and respectful of one
another. They cry and laugh together and celebrate each person’s small triumphs or significant losses. In this way, the group is truly a comforting shoulder for each woman.
Bhutanese Multi-family Therapy Group for Torture Survivors’ Families
The group started in November, 2008, consisted of between five and eight families. The group was led by a bilingual mental health counsellor, and a Bhutanese case manager/ community liaison co-facilitator who has a masters degree in Political science from Nepal. The goals of the group are:
a) To give members a safe place to gather and to talk about their concerns and their stories, including their recovery from torture;
b) To assist in the socio-cultural adjustment;
c) To increase members’ feelings of personal empowerment and mastery in various aspects of their lives;
d) To diminish symptoms of PTSD, anxiety and depression;
e) To form a social organization for Bhutanese torture survivors who continue to support each other after the group and advocate against torture and oppression, which helps with the continuation of personal and community healing, advocacy and social support.
However, the focus in the first stage switched to survival issues, because of the new added traumatic stress, arising from the dire economic situation in US at the time. The therapy focused, at this stage, in developing assertiveness training, problem solving skills, using humour, laughter and other skills, for example, journaling and making to do lists.
Clients are encouraged to share their story but they are not pushed to. Most of
the members are interested in discussing religious topics. They are also interested in discussing the politics of Nepal and Bhutan. The experience one time of a member who was very quiet in all sessions, but who spoke up for the first time about politics and gave his opinion, shows the relevance of this topic to group participants.
General Principles for torture groups:
1) Helping clients regain control of their life. Also, providing a safe space to practice control during group time. For example, letting them have cell phones and giving them the choice to answer it (it could be from their job agency, sick relative, etc.)
2) Giving them choices and teaching them to choose for themselves. Letting them make the rules for the group and then adding more important ones if necessary.
3) Abstaining from re-traumatizing by recalling memories of torture. Encourage, not force them to share about their torture. Most of them are afraid, guilty, embarrassed, feel responsible for what happened to them.
4) Most importantly, establishing and gaining their trust. Making them feel very comfortable in any way possible. Talking about their history, where they came from, history behind their country, learning about their culture and its practices. Letting them educate the therapist and case managers about the conditions they came from. Talk about politics and religion, their favorite movies, songs they like.
5) Using laughter and humour: Laughing is the shortest route to the heart. Strat egies of telling jokes and laughing in the moment helps them forget about their pain for now. Talking about the
new host culture, inviting them to share any funny events relating to the host culture that they experienced are helpful interventions.
6) Using art and other creative activities. Collage was liked by all members. Telling stories by looking at some emotion cards, writing letters of gratitude, accultur ation activities, educating about the new culture and its practices, having them draw their interests, hobbies, strengths, accomplishments, successes, and positive focused therapeutic activities were all utilized.
7) Balancing power dynamics in the group was important. Getting down to their level and accessing them, reflection of power in dress, seating in the group, not practicing too much control, or making strict rules were important.
8) Letting them vent and complain because they have no place else to do that. Listen to them closely without any judgements, supporting them, but not letting them obsess about complaining and intervening when they are complaining too much.
9) Help problem-solve. Brain storm with them to solve the current problems in their life (ranging from filling forms to accessing transportation, getting jobs, learning English, etc.).
10) Help create a cohesive bond between them, so they have access to support outside the group setting. They can help each other which will help them feel good about themselves if they can help others.
11) Teach basic coping techniques with stress, adaptation to a new culture, find out how well they cope currently and find strengths in them. Learn their ways of coping and help reinforce those if they haven’t been coping well.
12) Psycho-education about their symptoms and how it relates to their overall traumatic experiences, about PTSD, how it is affecting their life and how they can minimize the symptoms, cope with them, take care of themselves.
13) Teach them the importance of self-care. Most of them are very modest, generous, put others first and leave themselves out.
14) Getting them involved with community events. Invite them to attend events related to the celebration of torture survivors, cultural celebrations, and potlucks.
15) Teach them assertiveness, conflict resolution, parenting skills. Help them practice/role model newly learned techniques in the group and get feedback.
16) Letting them tell their story without forcing them, but a little probing may be necessary. Make sure they feel safety and trust.
17) Find out about their religion and spiritual strengths and practices. For most of them that is the first resource or coping strategy to turn to their religion.
18) Involve their family and community.
The Bhutanese group provided another model for achieving the community organization goal. While community organization in the Bashaal group happened spontaneously, in the Bhutanese group it happened intentionally. The case manager, the co-facilitator of the group, who is a Bhutanese community leader and previous political science professor in Nepal, initiated the call for group organization after the sixth session, and started to help them apply for non-profit status. In this model the case manager, a Bhutanese leader himself, who has a master’s degree in political science, initiated establishing the non-profit organiza‑
tion for the Bhutanese community of torture and non-torture survivors. The organization celebrated cultural events and organized art and craft expositions and participated in the Georgia coalition of refugee stakeholders.
Summary and conclusions
Torture consists of different traumas that target an individual or group. Collective identity is an important factor in this complex trauma. The multi-systemic, multi-component, wraparound psychosocial rehabilitation approach for torture treatment addresses the three systems affected by torture: The individual, family members and the group. Group therapy for torture survivors is an important component of this model. Group therapies extend to community healing. Groups develop their cohesion to graduate to a social community club. New graduates from the group join the club and become part of the social advocacy process and of group and community healing. The Bashal Somali women group and the Bhutanese multifamily groups are variants of this model. The women’s therapy group has developed to be a social club for Somali torture survivor women that convenes and arranges social activities and work on arts and crafts. They hold their events to celebrate and sell their products and to lobby against torture in the community at large. The Bhutanese group provided another variant of the model for achieving in community organization goal. While community organization in the Bashaal group happened spontaneously, in the Bhutanese group it happened intentionally. The case manager, the co-facilitator of the group who is a Bhutanese community leader, initiated the call for group organization. While the CTTS group therapy model with its variants have a theoretical face and validity, future studies are needed to provide empirical evidence of its effectiveness in achieving and sustaining its goals.