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    War and persecution cause not only material harm out also produce extreme psychological suffering for those who must both live and survive under such circumstances This statement is self-evident ot the point that one is always surprised by the fact that up until recently it was not an issue in humanitarianhelp andi n development cooperation. Until recently help has always focused on material goods and general economic development.

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    War and persecution cause not only material harm out also produce extreme psychological suffering for those who must both live and survive under such circumstances This statement is self-evident ot the point that one is always surprised by the fact that up until recently it was not an issue in humanitarianhelp andi n development cooperation. Until recently help has always focused on material goods and general economic development.

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    Becker - Dealing With The Consequences of Organised Violence in Trauma Work

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    War and persecution cause not only material harm out also produce extreme psychological suffering for those who must both live and survive under such circumstances This statement is self-evident ot the point that one is always surprised by the fact that up until recently it was not an issue in humanitarianhelp andi n development cooperation. Until recently help has always focused on material goods and general economic development.

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    Reflecting on Peace Project (Collaboration for Development Assistance CDA), nap: sbvereedeie coon Relief Web, hap ftv lepine ins/ovbaf ‘Swedish iniernatonal Development Cooperation Agency (SIDA), itp/hvwsida.se United Nations Comraission for Human Rights (UNCHR), hp: /hmewan United Nations Development Program (UNDP), hup:/Arwinudporglend ‘United Nations High Commission for Refugees (UNHCR), hip:fivwwunlicrch United Nations Office Fo the Coordination of Humanitarian Afters (OCHA), Inap-sivwvereicfvebindocka_oVindex hin! United Nations Ofie fer Project Services (UNOPS), hp/frwweunops.org United Nations Research Institue for Social Development (UNRISD),hnpi/uwanrisdorg LUNRISD - WWar-iom Societies Project htp/ww.wsp-interational. or, ech hp thoweunrid.orghesp United Stes Agency for Inerational Development (USAID) - Office of Transition Initiatives, ‘up:/bomxustid gov Women Building Peace Campaign (Intemational Alert) hip//www.interational ler orglpaltytvomen. hem Women, War and Pene. ip: Ahwwamifemorghinder php? page pid= 149" ‘World Bunk Conflict Prevention and Reconstrtion Unit (CPR), ap-tivew.vertibankorghonflc, ip:/ilevelopmentgateway:ors World Bank — Post Coaflct Unit, p:/Arwnusworldbant.orgfpostconflct | Alok hershey, Hoy teen tesdia/, Meshal Ropu (Eds)? (Roustevacnig EMius folbcal Coulvcf- Ths Bual, Haro 600 V5 Wiedaduc 200t Dealing with the Consequences of Organised Violence in Trauma Work 1. Introduction 404 2 Trauma theore 405 3: Potential and limits of psychotherapy 409) 4 Beyond the framework of therapy: the importance of truth, 42 | ste respect nd empathy | Respect | Comprerension Relationship Psychosocial work as a method for dealing with individuals and their social context | 5. The danger of traumatisation of the trauma worker: a7 burn out prevention and supervision 6. Conclusions a7 7. Reference and Further Reading a8 ed ocr Dealing with the Consequences of Organised Violence in Trauma Work David Becker Introduction War and persecution cause not only material harm bu: also produce extteme psychological suffering for thase who must both live and survive under such eiscumstances ‘This statement is self-evident to the point that one is always surprised by the fact that up unt recently itwas nota issue in buranitrin help and in development cooperation. Until recently help has always focused on material goods and general economic development, What people feel within the context of poitial and social destruction seemed o be o ite interest: at bet, it was an issue For religion; at worst, it was @ Luxury to be dealt with once the ‘rea’ problems hhad been solved. Although this has changed somewhat in recent years (and nowadays We find trauma programs in most crisis egions of the world), the basic atitudeof international agencies is still quite ambiguous, Professional opinions vary widely about both what trauma work is and what it should éo, “This chapter does not pretend to olfer a simple introductcn to trauma therapy, nor is ia bese guidetineon how to heal aura throughout the word, Trauma can only be understood and addressed with eference to the specific contexts in which it occurs. Any attempt towards ‘globalize’ presentation and dicussion of trauma is therefore useless. Te basi aim within hs chapleriso offer informacion aboutthe concepts curently under discussion in trauma work and to share a certain amount of prctcal experience as an invitation tothe reader to reflect on his orher own experiences have worked fr many yours as part of the team ofthe Latin-American Insitute for Mental Health and Hurnan Rights (ILAS) in Santiago de Chile, which aims to help vietims of politcal persecution. My opinion hs been constituted by this experience, as well as by consultative work with similar institutions in Central America, Angola and the former Yugoslavia Section 2 will provide an overview, definitions and finly a review of existing trauma theories. Kelson’ concept of sequential traumatisation is ccnsidered to be the most useful conceptual framework we have to date. One of the main events that drew light upoa the Jimitations of both trurra coacepts and terminology was the attempt to address the conse- ‘quences of the Holceast. In response to this inadequacy, the resulting concepts are eulied with eference to the extreme tratrmatisation’ experienced by the victims. t wil be argued that traumna concep pees to be continually reinvented and always contextualized within the specific social reality in which the tsumatisation occurs. The third section will examine both the potentials and limitations of psychotherapy. These are explored through three questions: "How des it feel like to be traumatised and is it possible to understand these feelings", "How do we relate toa traumatised person or group?” and "What isthe basi aim of weatment with reference to trauma?" The fourth section focuses upon three central aitudes that can be employed in Into Consaguee trauma work. After this, the wider application of wauma work, which lis beyond therapy is ilustrated through case studies. Special emphasis is given to an iterdisciplinary approach that integrates aspects of psychology, economics and education. The penultimate section draws tention to the difficulties, needs and hazards that trauma workers themselves face and potential ways in dealing with this vulnerabily Trauma theorie “The word trauma! orginally comes from the Greck language wher it means wound hisanalogous utilization i psychology and psychiatry began athe end ofthe ninewenh cexuury 1s part ofthe effort to explain certain mental disorders, Trauma, thus, was the cause ofthese illnesses and understocd as a psychological breakdown caused by extemal evens that exceeded te capacity ofthe psychological structure to respond to them adeqnately. ‘By the end of World Wa I the military had become interested inthe problem when ‘ney realized that condition of 'shel- shock’ needed 0 be addressed and explained and could not be reduced to simple cowardice. Ie was during the Vietnam War thatthe United States finally csablished a set of identifiable symptoms, the so-called "Post Traumatic Siess Disordec" (PTSD) which was included in the Diagnastical and Starstical Manual of Mental Disorders (DSM) of the American Psyehiatic Society. This resulted in the recognition of trauma by mainstream psychiatry. The negative impact, which occurred from te mainstreaming, was the categorisation of trauma as one more mena illness amongst many. Box : Definitions of Trauma In trauma theory, we need to distinguish between the traumatic sitation, the trauma and the symptoms resulting from trauma. A traumatic situation is defined as an event or several events of extreme violence that oceur within a socal context: exempli- fied by war, Such a traumatic situation is # necessary but not a sufficient condition for trauma to oceur. While trauma implies the destruction of individual andor collective structures, it does not always follow that such destruction causes immediate symptoms. PTSD isthe best knowo classification of symptoms tat persist vith the victim ofa tau- ‘matic situation. Tis may cover accidental events such as natural disasters or instigated events such as combat, crime, cape, kidnapping and imprisonment, (Currently, trauma is conceptualised in thre diferent ways: + Trauma as 2 medical concept, e PTSD, where the aim isto essblsh a more or less complete catalogue of symptoms + Trauma tigger highly complicated psychological processes (intrapsychic) that need 10 be analysed, This ean be exemplified by the therapeutic work with vitims of the Holocaust that was carted out primarily by peychoanalysts (see Bergmann and Jucovy 1982 and Beuelheim, 1943, + Trauma asa social and politcal process: recent workin Latin America has established that acon fom War: Racontniton vrs st Peace ‘taumatisation is not only an ind vidual process but also a social process that refers to the society a a whole. These studies have also shown tht trauma can only be understood withe specific cultural and politcal context, Concerning PTSD analysis, i is important to outine several important limitations ‘As mentioned above, PTSD diagnosis focuses on the symploms without reference to the cause ‘ofthese symptoms. The traumatic situation itself i either ignored or nt addressed which allows the analysis to cluster what are in essence different situations in the sume category (stesso such as heart attacks, erupting voleanoes or human rights abuses, The shortcomings of PTSD, diagnosis canbe summarized as follows: amily diagnosis is impossible within PTSD categories. A tortare victim, far exemple, can hhave PTSD but his wife and ehilren cant, even if their symptoms can only be understood in the context ofthe destruction athe victim, PTSD provides a lst of Frequently eccurring symptoms; however, i ignores many others While one can say that iT PTSD symptoms are present, then traums his occured, there no arantee that trauma has pot happened if these symptoms do not appear. Somatic and psychosomatic symptoms in particular, as well s social behaviour indicative of trauma, are not included in the deiitions provided by PTSD. PTSD works within a rigid definion of time. Consequently, this may lead to an incorect slagnosis if symptoms do not oseur within 2 cerain time span (For example six months). ‘This time limit conradiets everything we know sbou trauma symptoms with reference to ‘man-made disasters. For example, the symptoms of Holocaust survivors can appear ten, ‘weaty ard up oi years the orginal traumatic event, This same experience has been confirmed with survivors of politcal persecution in Latin Americ, There is considerable data to confirm that trauma can be transmitted tans-generatonaly from parents to thee children, PTSD diagnosis does not deal with this phenomenon (fora more detiled critique fof the PTSD concept, see Becker 1995), Incontras to PTSD, a parallel and different development accurred with reference to. trauma in psychoanalysis, especially amongst those working wih survivors ofthe Holocaust. tn 1943, Bruno Betetheim wrote abouts time in a concentration camp and justified the need for 8 pew term to deserie the experieaces he and his fellow prisoners had suffered: "What characterized it most vas its inescapabiliy; its uncertain duration, but potentiality for lifes the fact that nothing about it was predicuble; that one's very life was in jeopardy at every moment and that one could do nothing about it (Betcelheim 1943, 418) Thus Bettelheim suggested the term “extreme situation” to describe bis experiences. He was the first to clearly ilstate that ‘raumatisaion resulting fiom 2 manmade disaster could ot be categorized in the usual psychiatric or psychoanalytical language. New terminology was required to describe this type of truyma. Inthe years following the Holocaust (referred to as post-Shosh), the term “extreme ‘raumatisation” was developed. The word ‘extreme’ conveyed the special nature ofthe trauma, hich neither in its way of happening, no i its short and long term consequences, nor in its symptomatology, nor in its socio-political implications could be compared to ther traumatic events such as accident, an earthquake ora heat attack. Froud provided the ide that trauma ean also be a product of several experiences (CLaplanche and Pontais 1977). This was further developed by Kihan and led to his concept of ‘urmultive trauma’ (Khan 1977), through which the dimensions of time and relationship are introduced into the discussion of trauma, According to Khan, trauma canbe producto series of individually non-aumatic experiences, which develop and accumulate within an iateracive framework and finally lea to a breakdown. These ideas are highly important because, although intially limited tothe mother-child relationship, they transfer the emphasis from the uma to the tramatie situation. Tis converts the event into a process and, without denying te intra psychie wound, focuses onthe importance of the interactive framework. Both Bettelhein’s and Khan's ideas were ater developed by Hans Keilson in his concept of "sequential traumatization”(Keilson 1992, fist published in German in 1977). Ia his important follow-up study of Jewish war orphans in the Netherlands, he identifies three traumatic sequences: nemy occupation of tke Netherlands andthe beginning of terror” (Keilson 1992) aainstthe Jewish minosity This implies attacks on the social and psychological integrity of Jewish fares, he period of direct persecution" (Kelson 1992), which was the deportation of parents and children, the separatior of mother and child, the hing of children in foster families and the direct experience within the concentration camps, 5. "The postwar period dering which the main isue was tat of the appointment of guardians (Keilson 1992). The alternatives were 1 leve the childen with theie Dutch foster Families ‘or return them to theiroriginl Jewish environment Keilso's concep implies a radical change in the understanding of trauma. Instead ‘of an event that has consequences, we are now looking ata process in which the description of the changing traumatic situation isthe framework tha organizes our understanding of trauma. Keilson demonsraes, for example, that a severe second traumatic sequence and a god! third traumatic sequence implies better long-term health perspectives for the vitim than 2 nots 2 temible’ second traumatic sequence and a "bad! third taumatic sequence. This is extremely important in explining why trauma continues, even when the active persecution has stopped ‘We are thus able to understand not only why patients might develop symptoms immediately alter the original raumatis event, but also why they might do so twenty, thy oferty years later, Finally, Kelson’s concept illustrates that, since there is no ‘post in trauma bat only & continuing waumatic process, the elpers (the people who deal with the vitims) are also always part of the traumatic situaion and do not operate outside o it ‘One of the advaniages of Kellso's concep is that it can easily be used indifferent cultural and political settngs. Unlike PTSD, it does not define a fixed set of symptoms oF situations but actually onl invites one to look closely ata specific historical process it allows the quality andthe quanti of the traumatic sequences to be very different in various context ‘One sequential change tat seems to be relevant in most parts of the world is the change ‘between active war and parsecution and the period that follows. In many eases, this‘alterwards reeds tobe divided into dffeent sequences. For example, the war in Angola has coninued for the lat thiny years, being interrupted by small periods of supposed peace; in the former ‘Yugoslavia there is now acondition that is diffrent to war while not etally being peace ‘Not being able o use PTSD with reference to our own patients and finding Bttelicim, Khan and Keilson extremely useful, we have adopted the term “extreme trumatization” recovering om war kaconstucon versus st Peace (Becker and Casio 1990; Becker 1992) fo he situation in Chile and defined it a follows: Extreme traumatisation isan individual and collective process that refers and is dependent on a given social contest: a process that is marked by is intensity. it euirenely long duration and the interdependency berween the social and the psychological dimensions. I exceeds the capacity of the individual and of social sirucmres 10 respond adequately #0 this process. is aim is the destruction of the Individual, of hs sense of belonging 10 society and of his socal activities. Extreme Iravmatsvien is characterized bya structure of power within the suciety that is based (nthe elimination of same of is members by other members of the same society. The process of exreme trounatisation isnot limited in time and develop sequentially tis possible to seein our ‘Chilean’ definition that we incorporated many ofthe ideas described above, but placed greater emphasis oa the collective aspoet ef trauma, This Was an tier to transcend the individual level (without denying it) and include the social reality Tam uncertain whether our definition is really beter than the others Ihave described, Nevertheless, the definition atleast acknowledges a basi difficulty, inherent to all tama theories: on one hand, they must deal wit individual intrapsychic processes: while onthe othe, they have to deal with society Conceptually, itis very dificult to do justice to both atthe same time, This fesults in either the individual or the collective aspect of trauma becoming overstated o lundersuted. Nevertheess, believe that our definition is contextually important. In Latin ‘America, and especialy in South America, the issue of the long ight against dictatorship was central, Many people krow nothing about Chile, but nearly everybody has heard of is dictatorship and its eenra symbol, Augusto Pinochet. In this context, avery politica’ definition of trauma is therefore appropriate. In other cegions of the world it mightbe different, ‘A good example ofthe relevance of contextuaising our trauma definitions was an experience Ihad during a small workshop in a refugee camp in Bosna, {asked my colleagues, to forget everything hey knew about psychological and psychiatric diagncss, and to write don, ‘neveryday language, what they thought constiute the efugees'traums. Tis is what they wrote: The destructien caused bythe war, the grenades, the living intents the cold, the ack of food, the insecurity of when or whether they can return, the economic situation the legal problems, the loss of family members, the memories of torture and Concentration camps, the insistence of privacy, the rejection by the ical community. In fac, thelist was a lot longer and included more deals thn can be writen here. Although it was oot a clinical definition, and did not fit into any standardised way of dealing with trauma, did pot exen differentiate well beeween the traumatic situation and the trauma, (0 iy mind, itis one ofthe best definitions of trauma | have ever met. In terms of conerete information sbout the specific characteristics ofthe suffering ofthese refugees in Bosnia, it was excellent. It permited us t stat doing useful work because a good diagnosis is half the treatment. With this descripsion ia mind, it was posible to understand that ‘reatment in this case had Hite 10 do with typical therapy’, but much more concerned vith improving living conditions, initating community work and facilitating collective grief processes. In surnmry, Iam suggesting that in each different social context people should create their own definitions of trauma within a framework, in which the basic focus is not so ‘much onthe symptoms fa person buton the squential development of te traumatic situation, Whereas It wil always be important io register che specifi sympwoms of a patien (mainly because of the metaphoric message that symptoms convey about the illness), our primary approach must focus on the repressive experiences. Thus, we would cferenite between a person who has experienced torture in Chile, a Bosnian refugee or a Vietnam veteran much tore than beeen depressive, hysteric or obsessive symptoms. We would not hold that psychosis is a gypieal consequence of torture, but if we teat a psychotic patient and lear that he was tortured, our treatment strategy and our way of understanding his psychosis would ‘change. In general, our diagnosis must include the specific social contet in which the ilness sppears. Respecting the fact that political taumatisation is always tied te the context obliges us to understand that a Turkish, a Chilean or a Vietnamese refugee might present similar symptoms, might even have some comparable experiences, lke torture, but each one of them, in effect, suffers originally from a dffeem illness. What might constiute thie similarity is that they are all refugees coming from the same country and therefore undergoing the same traumatic sequence. Box 2: Trauma and Organized Violence The basic framework for trauma when dealing with the consequences of organized violence can be defined as follows 1. ‘Trauma implies a notion of tearing, of rupture, of structural breakdown, 2, Trauma can only be defined and understood with reference 10a specific context, wich must be described in detail 3, Trauma is a process, which develops sequentially. 44, Trauma contains both an individual intra-psychic dimension and a collective, macro- social dimension that are interwoven. Potential and limits of psychotherapy ‘The ‘treatment’ of extremely traumatised persons neither begins nor erds in a ‘heraiat mom. Nevertholes, therapy may become the ist social space in which victims might begin to overconve their difficulties. The relative intimacy of therapy permits uso learn, ina more implicit way, about a number of key issues of trauma that ate aso always present in other contexts. These issues can be formulated as questions: |. What dos it feel like to be traumatized and is it possible to understand these eeirgs? 2. How do we relate toa traumatized person or group? 13. Whats the basic aim of treatment with eference to trauma? ‘Sandor Ferenczi noted in his clinical diary on February 21,1932 chat fragmentation ight be a wseful defence in surviving traumatic sivation, Confonted with unbearable aggression, child might ‘give up his soul, mentally ‘dying, while physically surviving deah, Afterwards, the pre-traumatc personality structure wil be partially re-established, but a part of the person ‘will ave ceased to exist, will goon Being dead or losin the agonies of fear. The task ofanalysis would be to overcome this process of spliting, Tis at this point where the dilemm arses. IT Recovering fon Wr: Reconstruction ees st Peace the traumatic experience isreconstructed through a cognitive process, then he spliting between the destroyed part and the part that is looking atthe destruction is maintained, thereby denying any real access tothe traumatic experience. However, ifthe patient makes a'cathartic regression to the stage ofthe trumatie experience, he fels. once again, his suffering, but cennot think anymore, and doesnot understand what happens to him. Once wake, the evidence immediately ‘isoppears and the trauma is agsin only perceived from the exterior, without the coresponding feolings (Ferencai 1988). In shor, it seems that nether upproach canbe successful Ferencai bere offers short and precise answers to some of the questions sated above Forhim, trauma atits core would fe! lke extreme agonies of fear tat led othe psychological experience of death, which means that a basic split has to happen. This, Ferenca shows, i helpful inorder to survive trauma alinough inthe aftermath it implies sustained fragmentation part ofthe person stays dea, while snother part begins to function again. To overcame trauma, Fragmensaion would need o be overcome, but that is nearly impossible, because, within’ the ‘waumatic experience, there are only agonies, no words, and no capacity for reflexive thinking. ‘Outside’ of the aura, thinking works and words exist, but without being totally connected to the traumatic experiences. So when dealing with traumatized persons, we always confront a ouble reality, on one sie there iss person that can talk about, think about, and even tellus about what happened to ther. On the other side, we have a person lost inthe experience of

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