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Title: Working with Traumatized Clients in Prisons and Detention Centers: Barriers and Strategies for Advocates


1
Working with Traumatized Clients in Prisons and
Detention Centers Barriers and Strategies for
Advocates
  • Kate Porterfield, Ph.D.
  • 212-562-8719
  • Bellevue/NYU Program for Survivors of Torture
  • Portek01_at_med.nyu.edu

2
Goals of this session
  • Provide overview of effects of torture and
    interpersonal trauma on humans
  • Understand barriers that advocates face when
    working with a traumatized individual
  • Gain strategies for working with traumatized
    clients

3
Cases
  • Case 1 52 year old male, imprisoned since 35,
    with no possibility of parole. African-american,
    Diabetic, history of childhood abuse by father.
    No family contact except one daughter who writes
    letters sporadically.
  • Case 2 30 year old Liberian male in an
    immigration detention center, awaiting
    deportation. History of imprisonment in Liberia
    and possible history of torture. Wife and two
    children are in Liberia in a refugee camp, but he
    has had no contact with them since leaving
    Liberia three years earlier.

4
Cases, contd.
  • Case 3 25 year old Pakistani female, held in
    pre-trial detention on charges of material
    support for terrorism, after assisting a family
    member who went to Pakistan for alleged terrorist
    activities. Has been unwilling to speak to
    lawyers.
  • Case 4 35 year-old male, held on death row,
    awaiting appeals. White, convicted of murder in
    the context of hate crime, member of a white
    supremacy group in jail. History of childhood
    abuse, question of mental retardation.

5
What is trauma and what does it do to us?
  • Event outside normal range of experiences
    (life-threatening, threat to bodily integrity)
    that results in
  • Experience of terror, horror.
  • Man-made trauma (torture, abuse, war) vs.
    Natural disasters

6
What is Torture?
  • Severe pain or suffering (physical or mental)
  • Intentionally inflicted
  • For a purpose eg. to obtain information or
    confession as punishment for a suspected act or
    for purposes of humiliation, intimidation and
    coercion
  • Inflicted by or at the acquiescence of public
    officials
  • UN Convention against torture and other cruel,
    inhuman or degrading treatment or punishment

7
Occurrence of Torture
  • Studies show torture among refugee populations
    varies from 5 to 35. (Baker, 1992 Jacobsen
    Vesti, 1990 )
  • Torture and ill-treatment are widespread in 111
    countries worldwide.
  • (Amnesty International Report , 2009)
  • It is estimated that 400,000 Survivors of Torture
    live in the U.S.
  • (Center for Victims of Torture, report to the DJJ
    Office of Victims of Crime, 1998)

8
Sitting with a severely traumatized client
  • Must understand that the traumatic history is in
    the room and playing a part in the clients
    perceptions/interactions with you
  • The more you understand the effects of long-term
    trauma, the more you can recognize and address
    barriers that exist in your interaction

9
TRAUMA UNDERSTAND THE PHENOMENA BEFORE THE
DIAGNOSIS

Post Traumatic Stress Disorder
TERROR
Depression
LOSS/ POWER- LESSNESS
10
PTSD A disorder of memory and arousal
  • Amygdala and hippocampus-involved in
  • 1. registering danger (fight or flight) and
  • 2. formation of memories
  • Fear Network (cognitive, sensory, physiological,
    emotional experiences) is established with
    faulty connections arousal linked to memory

11
Posttraumatic Stress Disorder (PTSD)
  • Reexperiencing intrusive thoughts and images,
    flashbacks, nightmares
  • Hyperarousal poor sleep, irritability, startle
    response, poor concentration
  • Avoidance numbing, emotional constriction,
    avoiding reminders of the trauma

12
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13
Complex Trauma
  • Often seen in those with early and chronic
    trauma Can come out of extensive adult trauma
  • In 2006, almost 500,000 substantiated cases of
    abuse/neglect of a child under 7, 83 were abused
    by parent or primary caretaker
  • Almost half were reported abused or neglected
    again within 5 years
  • (American Academy of Experts in Traumatic Stress
    www.aaets.org/article174.htm)

14
Complex Trauma impacts multiple aspects of a
humans functioning--i.e. the whole system
  • Alterations in
  • Regulation of affect and impulses
  • Attention or consciousness
  • Self-perception
  • Relations to others
  • Body functioning and integrity (somatization)
  • Systems of meaning
  • (Roth et al., (1997-full citation at end)

15
What does it feel like to be with someone with
Complex PTSD?
  • And what can you do to do good, effective work?

16
General Principles
  • Recounting the events of abuse is extremely
    stressful and potentially retraumatizing for the
    victim.
  • Listening to accounts of torture/trauma can be
    very stressful for the interviewer as well.
    (Vicarious traumatization.)
  • Establishing a rapport and eliciting a thorough
    and complete history takes time.  

17
General Principles (cont.d)
  • There is variability in
  • the degree of physical and psychological signs,
    symptoms or consequences which a torture victim
    will manifest.
  • the manner in which trauma/torture victims
    conduct themselves in interviews and in
    recounting the events of their abuse.
  • the amount and detail of information which an
    individual will recall with regards to the events
    of the trauma.

18
When working with a traumatized individual
  • Anticipate barriers
  • Create strategies for addressing those barriers
  • Set realistic goals for yourself and for the
    client
  • Be aware of and attentive to your own reactions

19
Potential Barriers to Effective Communication
  • Environmental barriers
  • Lack of privacy or a comfortable setting
  • Inadequate time
  • Reminders in the room
  • Physical Barriers
  • Pain, fatigue, sensory deficits
  • Sociocultural Barriers
  • Gender issues, interpreters, reaction to
    authority,

20
Psychological barriers to communication for a
traumatized person
  • Disruptions in memory, concentration and
    cognitive abilities
  • Impairment in reality testing
  • Interpersonal discomfort/distortion
  • Avoidance of conversations about trauma
  • Detachment from emotional responses
  • Increased anxiety when remembering
  • Narrative inconsistencies
  • Shame when recounting

21
Communication Strategies
  • Help client anticipate Lay out the time
    frame/structure of the interview tasks, goals,
    and why you are asking about what you are asking
    about
  • Allow time to build rapport, trust
  • Talk about talking
  • Invite questions
  • Normalize reactions Many people feel
  • Provide closure Discuss experience of interview
    at the end and anticipate the next step if
    possible

22
Types of client problems
23
The withdrawn client
  • Strategy Try to gently engage by normalizing and
    providing a feeling of control
  • Sometimes people have a hard time answering
    these questions. I know that you have been asked
    a lot of questions and that you are probably
    concerned about answering any more. Is there
    something that you would like me to know before I
    ask you some of my more specific questions?

24
Strategy Return to education about why you are
asking detailed questions about particular issues
  • We really need to convey to the court what you
    have been through and how much you have suffered.
    Often times these are the most difficult things
    to discuss, but they can be the most important
    things for the Court to understand in order to
    know the truth about how you were treated.

25
Strategy Return to the reason for the question
and how it can be helpful to the client
  • One thing that is difficult about our legal
    system is its adversarial nature, which means
    that it is the job of the lawyer on the other
    side to try to argue with or challenge your
    story. This means that we have to anticipate
    these challenges and address them ourselves so
    that we are prepared.

26
The flooding client
  • What is flooding?
  • --An overload of information/expression
  • --Content/facts
  • --Emotions
  • --Often feels hard to stop or contain

27
Strategy Try to contain, both by providing more
structure in the interview, suggesting short
breaks, and explaining why you need to focus on
certain issues
  • I can understand how important it is for you to
    make sure I understand what you are telling me. I
    want to hear the things that are important to
    you. I also have some specific things I want to
    hear about today, so Id like to make time to
    talk about those things.

28
Strategy End the interview if necessary
  • Client is unable to contain emotions at all
  • Client is incoherent, even after attempts to ask
    more basic questions
  • Client becomes aggressive, overtly hostile

29
The hopeless client
  • Strategy Reflect back what you see and empathize
  • I can see that you dont believe its worth it
    to try to do anything to fight for your case. I
    know that I am not in your position and cant
    imagine how you feel. But I really understand
    that you are telling me you cannot fight this
    situation anymore.

30
Strategy Share your commitment
  • Even though I hear what you are saying about not
    wanting to fight anymore, I want to explain my
    position and my beliefs. I believe that you and
    your case are worth fighting for. Id like to
    tell you why

31
Strategy Make small work commitments together
  • I know you are saying you dont want to keep up
    this fight forever. How about if we agree to keep
    working for the next month and see how you feel
    after that?

32
HUMANIZE
  • THE SINGLE MOST EFFECTIVE STRATEGY WITH A
    TRAUMATIZED PERSON
  • How?
  • Genuineness
  • REAL Listening
  • Self-disclosure (CAREFULLY)
  • Transparent expressions of desire to understand
    and assist

33
Other interview challenges
  • Delivering bad news
  • Be direct
  • Do not try to spin it right away
  • Share your reaction if appropriate but it is not
    about you
  • Ask for reaction/Reflect back what you hear
  • Recognize that it takes time to deal with bad
    news
  • Ending your work with a client
  • Use above principles
  • Do not avoid
  • Be genuine

34
Self-care for the evaluator
35
Vicarious traumatization
  • Can occur in those who work with survivors of
    severe trauma
  • Can be a normal reaction to hearing very vivid,
    distressing narratives.
  • Manifests itself in distress and symptoms of PTSD
    (e.g., nightmares, irritability, anger).
  • Feelings of demoralization and depression are
    also frequent.
  • Can feel like you are a victim/perpetrator

36
Strategy managing boundaries
  • Clarifying the limits of your role with your
    clients
  • Clarifying what you CAN do for your client
  • Tolerating feelings of guilt and helplessness
  • Recognizing fantasies of rescue and omnipotence

37
Strategy Attending to and processing team
dynamics
  • Recognizing team members different ways of
    coping with the stress (e.g.-the staff member who
    gives extra, the staff member who withdraws,
    the staff member who rants).
  • Building time for team to process experiences
    together.

38
Sources
  • Robins, et. al., (2005) Psychiatric problems of
    detainees under the Anti-Terrorism Crime and
    Security Act 2001, The Psychiatrist (2005) 29
    407-409.
  • Cook, A., Blaustein, M., Spinazolla, J., van der
    Kolk, B. (2003). Complex trauma in children and
    adolescents. White paper from the national child
    traumatic stress network complex trauma task
    force. Los Angeles, CA National Center for Child
    Traumatic Stress
  • Cook, A., Spinazzola, J., Ford, J., Lanktree, C.,
    et al. (2005). Complex trauma in children and
    adolescents. Psychiatric Annals, 355, 390-398.
  • Roth, S., Newman, E., Pelcovitz, D., van der
    Kolk, B., Mandel, F.S. (1997). Complex PTSD in
    victims exposed to sexual and physical abuse
    Results from the DSM-IV Field Trial for
    Posttraumatic Stress Disorder. Journal of
    Traumatic Stress 10, 539-556.

39
Sources (contd.)
  • Leave No Marks Enhanced InterrogationTechniques
    and the Risk of Criminality. Physicians for
    Human Rights/Human Rights First. Available at
    www.phrusa.org
  • Scott Allen, M.D. Center for Prisoner Health and
    Human Rights, The Warren Alpert Medical School,
    Brown University

40
Extra slides follow on Complex Trauma
41
Complex Trauma impacts multiple aspects of a
childs functioning--i.e. the whole system
  • Attachment-boundary problems, mistrust,
    isolation, difficulty attuning to others or
    enlisting others as allies
  • Biology-sensorimotor problems, coordination/balanc
    e problems, somatization
  • Emotional regulation- high intensity emotions,
    pervasive negative feelings, emptiness,
    oscillation between over-expression and
    over-inhibition of emotions
  • (American Academy of Experts in Traumatic Stress
    www.aaets.org/article174.htm)

42
Complex Trauma impacts multiple aspects of a
childs functioning--i.e. the whole system
(contd)
  • Dissociation-alterations in consciousness,
    amnesia, multiple states of consciousness
  • Behavior/Impulse control- poor control
    self-destructive behavior, aggression,
    sleep/eating disturbance, substance abuse
    difficulty with rules repetition
  • Cognition- attention, concentration, executive
    functioning/planning, impairment in language,
    visuospatial, acoustic processing
  • Self-Concept- fragmented sense of self, poor
    self-esteem, shame/guilt, poor sense of
    separateness, body image
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