DOCUMENT RESUME

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AUTHOR Somach, Susan D., Comp. TITLE Issues of War Trauma and Working with Refugees. A Compilation of Resources. INSTITUTION Center for Applied Linguistics, Washington, DC. Refugee Service Center. PUB DATE 95 NOTE 167p. PUB TYPE Collected Works General (020) Reports Evaluative /Feasibility (142)

EDRS PRICE MF01/PC07 Plus Postage. DESCRIPTORS Adults; *Child Development; *Children; Childrens Rights; Coping; Delivery Systems; English (Second Language); Foreign Countries; *Immigrants; Posttraumatic Stress Disorder; *Refugees; Second Language Learning; *War; World Problems IDENTIFIERS Cambodia; Holocaust; *Traumas; Yugoslavia

ABSTRACT The Center for Applied Linguistics has compiled these resources on the subjects of war trauma and working with refugees to guide refugee service providers and classroom teachers. The materials include background information about trauma and posttraumatic stress disorder and specific information about problems of refugees and victims of war trauma. The selections in the compilation are designated Appendixes. The United Nations, through its High Commissioner for Refugees and its statement on the rights of the child (Appendix A) has recognized the problems children, especially those from Bosnia, face. Two appendixes (B and C) discuss trauma, posttraumatic stress disorder, and refugees. Two selections focus on children and trauma and consider general developmental issues and coping with grief and the aftermath of disaster. "War Trauma and Refugee Children" contains a description of a film about the effects of torture on children, a discussion of traumatic human rights abuse, and a two-part article on the effects of massive trauma on Cambodian children. "Children of Holocaust Survivors" contains two articles on the symptoms and treatment of child survivors of the Holocaust. A brochure produced to help refugees from the former Yugoslavia cope with trauma is included, and the final section contains six selections on war trauma as an aspect of educating students in the English as a second language classroom. (Contains 19 references.) (SLD)

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A Compilation of Resources Summer 1995

r PERMISSION TO REPRODUCE AND U.S. DEPARTMENT OF EDUCATION DISSEMINATE THIS MATERIAL Office of Educational Researcn and improvement HAS BEEN GRANTED BY EDUCATIONAL RESOURCES INFORMATION XCENTER (ERIC) This document has wen reproduced as D. emnatian eceived from the person or organization riginating it. C Minor changes have been made to improve C A.L reproduction quality. TO THE EDUCATIONAL RESOURCES Points of view or opinions stateo in this docu- ment do not necessarily represent official INFORMATION CENTER (ERIC) OERI position or POliCY.

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Center for Applied Linguistics Refugee Service Center 1118 - 22nd Street, NW Washington, D.C. 20037 (202) 429-9292 fax (202) 659-5641 REST COPYAVAILABLE

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TABLE OF CONTENTS

Introduction and Acknowledgements Summary of Contents

Appendices

A. Recommendations of the European Consultation on Care and Rehabilitation of Victims of Rape, Torture and Other Severe Traumas of War in the Republics of Ex-Yugoslavia

The Rights of the Child United Nations Economic and Social Council, Commission on Human Rights

B. Refugees as Victims of Torture and Trauma Frederico Allodi

C. Psychological Sequelae of Traumatic Human Rights Abuses Glenn R. Randall and Ellen L. Lutz

D. Children's Reaction to Trauma and Some Coping Strategies for Children National Organization for Victim Assistance

E. Facts for Families: Children and Grief and Helping Children After a Disaster American Academy of Child and Adolescent Psychiatry

F. Children and Traumatic Human Rights Abuse Glenn R. Randall and Ellen L. Lutz

G. The Psychiatric Effects of Massive Trauma on Cambodian Children: I.The Children J. David Kinzie, M.D., William H. Sack, M.D., Richard H. Angell,M.D., Spero Manson, Ph.D., and Ben Rath The Family, the Home and the School William H. Sack, M.D., Richard H. Angell, M.D., J. David Kinzie, M.D. and Ben Rath

4 H. Children of Holocaust Survivors Shirley Ann Segal, M.S.

I. An Intergenerational Program Designed for Holocaust Survivors and Their Children Dr. Yael Daniell

J. War Trauma and Recovery (Serbo-Croatian, English Translation) (rena Sarovic, M.Ed., Psychologists for Social Responsibility

K. Educating Educators: Bosnian Survivors Amer Smajkic, M.D. and Stevan Weane, M.D.

L. Crisis Intervention for the ESL Teacher: Whose Problem Is It? Cao Anh Quan

M. Can TESOL Teachers Address the Mental Health Concerns of the Indochinese Refugees?, Excerpts from Draft Paper J. Donald Cohon, Jr.

N. Overview: ESL for Survivors Lorena Bekar, Canadian Centre for Victims of Torture (CCVT)

0. Primary Prevention and the Promotion of Mental Health in the ESL Classroom, Excerpts J. Donald Cohon, Ph.D., Moira Lucey, Michael Paul, Joan LeMarbre Penning

Contact List Bibliography

5 INTRODUCTION AND ACKNOWLEDGEMENTS

In response to many requests for information about the effects of trauma on refugees, the Center for Applied Linguistics (CAL) has complied resources on the subject of war trauma and working with refugees. The materials include background information about how trauma and posttraumatic stress disorder affect both children and adults as well as specific information about the effects on refugees and implications for ESL teaching.

We hope these resources will guide refugee service providers and classroom teachers in their work with refugees from war-torn countries. We also hope the materials will be useful to program administrators in their search for funding for refugee mental health programs.

We would like to thank the following people for their contributions and assistance: Anne Anderson, the National Coordinator for Psychologists for Social Responsibility, Lorena Bekar, ESL Program Coordinator at the Canadian Centre for Victims of Torture, Irena Sarovic at Progressive Life, Cheryl Tyaska at the National Organization for Victim Assistance, and the Science and Human Rights Program at the American Association for the Advancement of Science.

6 SUMMARY OF CONTENTS

Recognition of Severe Mental Health Issues for Bosnians

At a European conference organized by the United Nations High Commissioner for Refugees (UNHCR) and the Pharos Foundation for Refugee Health Care, The Netherlands, in collaboration with the WHO/EURO, the final recommendations included recognition of mental health problems and psychosocial needs of refugees, including "specific training dealing with psychosocial needs, [and] reactions to traumatic experiences...targeted at...teachers...." The UN Economic and Social Council (UNESCO) Commission on Human Rights in a statement outlining the rights of the child recognized the particular vulnerability of children to psychological damage from the war in the former Yugoslavia. (See Appendix A)

Trauma, Posttraumatic Stress Disorder and Refugees

"Refugees as Victims of Torture and Trauma" discusses the types of torture experienced by refugees, the long-term effects of the torture, and the stages of healing from trauma. The chapter also challenges the widespread myths that the countries from which refugees come are very different from the United States and always have experienced the kinds of conflicts that have led to today's refugees. (See Appendix B)

"Psychological Sequelae of Traumatic Human Rights Abuses" reviews the common responses to the human rights abuses suffered by many refugees. The psychological diagnoses include posttraumatic stress disorder (PTSD), major depression, maladaptive responses such as the presence of coping mechanisms (e.g., denial, intellectualization, isolation, repression), psychosomaticor psychophysiological disorders and substance abuse.Refugees also have added psychological consequences as a result of being a refugee. (See Appendix C)

Children and Trauma

"Children's Reaction to Trauma" is a general outline of the developmental stages of children and common reactions to trauma experienced by children at different ages. "Some Coping Strategies for Children" provides some basic advice for dealing with traumatized children. Both handouts are produced by the National Organization for Victim Assistance. (See Appendix D)

"Children and Grief" and "Helping Children After a Disaster" are part of the series "Facts for Families from the American Academy of Child and Adolescent Psychiatry." Both provide general information about typical reactions of children and suggestions for how best to deal with children traumatized by death or disaster. (See Appendix E)

7 War Trauma and Refugee Children

The Canadian Centre for Victims of Torture (CCVT) recently produced "War is not a Game," a 32- minute film exploring the effects of torture on children. The film was produced in cooperation with Frame line Productions and is available through Mulugeta Abai, Executive Director, CCVT, 25 Merton Street, Toronto, Ontario, Canada M4S 1A7 (include a purchase order for $100-Canadian).

"Children and Traumatic Human Rights Abuse" discusses the effects of trauma on children and analyzes the differences between the reactions of children and adults. The chapter also raises the intergenerational consequences of severe trauma and the effects on children of survivors.(See Appendix F)

The two-part article "The Psychiatric Effects of Massive Trauma on Cambodian Children" is a report of a study of Cambodian adolescent refugees. The first part, "The Children," reports the findings from standardized interviews by psychiatrists of 40 Cambodian high school student in the United States. The article discusses the psychiatric diagnosis and major symptom patterns of the students who endured separation from family, forced labor and starvation, witnessed many deaths because of the Pol Pot regime and spent two years living in refugee camps before coming to the U.S. as refugees at the age of 14. The second part, "The Family, the Home, and the School" reports the findings of home interviews with the families of the students and an analysis of school performance and adjustment based on teacher ratings and school records. (See Appendix G)

Children of Holocaust Survivors

"Children of Holocaust Survivors" describes the symptoms exhibited by holocaust survivors and their children, explains the transmission process whereby the children begin to exhibit the same PTSD symptoms as their parents, and offers some suggestions for clinicians working with these children. (See Appendix H)

"An Intergenerational Program Designed for Holocaust Survivors and Their Children" describes a program model used to deal with the sense of isolation and alienation common among Holocaust survivors and their children. The program focuses on developing mutual support for healing and rebuilding a sense of extended family community through inter-generational community assistance. (See Appendix I)

S War Trauma Brochure (Serbo-Croatian, English Translation)

"Ratna Trauma i Oporavak" ("War Trauma and Recovery") is a brochure prepared by Irena Sarovic and published by Psychologists for Social Responsibility for people from the former Yugoslavia who have been exposed to ongoing traumatic war experiences and life-threatening situations.The purpose of the brochure is to help them understand common reactions to war trauma and some ways to cope with it.(See Appendix J)

War Trauma in the ESL Classroom

According to Irena Sarovic, a Croatian psychologist, the most important response to a child experiencing trauma is to acknowledge the horrible experience that is causing the trauma and then try to bring the child back to the reality that he/she is safe now. She agreed to be contacted regarding issues of trauma (202-842-2016) and has experience counselling refugees from the former Yugoslavia.

"Educating Educators" analyzes the complexities of teaching English to newly arrived Bosnian refugees within the context of key historical, cultural, social, political and psychological dynamics. The article discusses the issues of genocide, PTSD and the multitude of barriers to English language learning faced by Bosnian refugees in the United States. (See Appendix K)

"Crisis Intervention for the ESL Teacher: Whose Problem Is It?" reviews the mental health problems associated with refugee resettlement, the diverse roles of the ESL teacher, and guidelines for crisis intervention. (See Appendix L)

A final comment in the draft paper "Can TESOL Teachers Address the Mental Health Concerns of the Indochinese Refugees" notes that while TESOL teachers may be in the best position to notice psychological problems experienced by their students, most teachers lack training in the evaluation and diagnosis of mental disorders. The article also warns teachers to exercise caution in dealing with mental health issues in the classroom. (See Appendix M)

"An Overview: ESL for Survivors" explains some mental health issues considered in designing the ESL program at the Canadian Centre for Victims of Torture (CCVT). The article discusses creating a positive classroom atmosphere and limiting class size as ways to raise the confidence of learners. (See Appendix N)

An excerpt from "Primary Prevention and the Promotion of Mental Health in the ESL Classroom" discusses various roles an ESL teacher can assume and the characteristics of an classroom most conducive to the promotion of mental health. Issues of curriculum, materials and teaching approach are also included. (See Appendix 0)

9 CONTACT LIST

Anne Anderson, National Coordinator Psychologists for Social Responsibility 2607 Connecticut Avenue, NW Washington, D.C. 20008 202-745-7084

Lorena Bekar, ESL Programme Coordinator Mulugeta Abai, Executive Director Canadian Centre for Victims of Torture 25 Merton Street Toronto, Ontario, Canada M4S 1A7 416-480-0489 fax 416-480-1984

Irena Sarovic, M.Ed. (Croatian psychologist who prepared Psychologists for Social Responsibility pamphlet "War Trauma and Recovery") Progressive Life 202-842-2016

Leila F. Dane, PhD Director, Institute for Victims of Trauma, McLean, VA 703-847-8456

Cheryl Tyaska National Organization for Victim Assistance 1757 Park Road, N.W. Washington, D.C. 20010 202-232-6682 fax 202-462-2255

0 wl9203a war 7Temal Workiin g idaRefugees

10 BIBLIOGRAPHY

Allodi, F. (1986).Refugees as Victims of Torture and Trauma.Refugee Mental Health in Resettlement Countries. Washington, DC: Hemisphere Publishing Corporation, 245-252.

American Academy of Child and Adolescent Psychiatry (1991). Facts for Families from the American Academy of Child and Adolescent Psychiatry:Children and Grief.No. 8 (September 1991). ED340976.

American Academy of Child and Adolescent Psychiatry (1991). Facts for Families from the American Academy of Child and Adolescent Psychiatry: Helping Children After a Disaster. No. 36 (July 1991). ED340976.

Bekar, L. (1994). An Overview: ESL for Survivors. Canadian Centre for Victims of Torture Quarterly. No. 9 (September 1994), 1-2.

Benedek, E.P. (1985). Chapter 5: Children Traumatized by Central American Warfare. Posttraumatic Stress Disorder in Children (137th Annual Meeting of the American Psychiatric Association in Los Angeles in May 1984), 10-120.

Cohon, J.D., Jr. (1980).Can TESOL Teachers Address the Mental Health Concerns of the Indochinese Refugees? Draft of paper presented at the Spring Convention of the Teachers of English to Speakers of Other Languages (San Francisco, CA, March 8, 1980), 19-20. ED204471.

Cohon, J.D., Lucey, M., Paul, M., Penning, J. (1986). Excerpts from Primary Prevention and the Promotion of Mental Health in the ESL Classroom. American Council for Nationalities Service, 12-15.

Danieli, Y. (1988).An Intergenerational Program Designed for Holocaust Survivors and Their Children. Reasons for Living and Hoping: Proceedings from the Multi-Disciplinary, Inter-religious Conference on the Spiritual and Psycho-Social Needs of Southeast Asian Refugee Children and Youth Resettled in the United States (The International Catholic Child Bureau, Washington, DC, October 16-18, 1988).

European Consultation on Care and Rehabilitation of Victims of Rape, Torture and Other Severe Traumas of War in the Republics of Ex-Yugoslavia (1993).Recommendations. (Organized by UNHCR and Pharos Foundation for Refugee Health Care, Utrecht The Netherlands, June 17-19, 1993). Kinzie, J.D., Sack, W.H., Angell, R., & Manson, S. (1986). The psychiatric effects of massive trauma on Cambodian children. Part I.The children. Journal of the American Academy of Child Psychiatry, 25:370-376.

National Organization for Victim Assistance (1994). Children's Reaction to Trauma.

National Organization for Victim Assistance (1994). Some Coping Strategies for Children.

Quan, Cao Anh. Crisis Intervention for the ESL Teacher: Whose Problem Is it? ED271951.

Randall, G.R. and Lutz, E.L. (1991). Chapter 3: Psychological Sequelae of Traumatic Human Rights Abuses. Serving Survivors of Torture. Washington, DC: American Association for the Advancement of Science, Science and Human Rights Program, 147-156.

Randall, G.R. and Lutz, E.L. (1991). Chapter 10: Children and Traumatic Human Rights Abuse. Serving Survivors of Torture.Washington, DC: American Association for the Advancement of Science, Science and Human Rights Program, 147-156.

Sack, W.H., Angell, R., Kinzie, J.D., & Rath, B. (1986). The psychiatric effects of massive trauma on Cambodian children. Part II.Family, the home and school. Journal of American Academy of Child Psychiatry, 25:277-387.

Sarovic, Irena (1993). War Trauma and Recovery. Brochure produced by Psychologists for Social Responsibility.

Segal, S.A. (1983). Children of Holocaust Survivors. Paper presented at the Annual Meeting of the National Council on Family Relations (St. Paul, MN, October 11-15, 1983). ED241859.

United Nations Economic and Social Council Commission on Human Rights (1994). Rights of the Child. E/CN.4/1994/NG0/53.

12 G,GDPEHMI EUROPEAN CONSULTATION ON CARE AND REHABILITATION OF VICTIMS OF RAPE, TORTURE AND OTHER SEVERE TRAUMAS OF WAR IN THE REPUBLICS OF EX-YUGOSLAVIA

Utrecht, The Netherlands, 17-19 June 1993

Consultation initiated and organized by UNHCR and the Pharos Foundation for Refugee Health Care, The Netherlands, in collaboration with the WHO/EURO. Co-sponsored by UNHCR and the Government of the Netherlands.With the collaboration of IOM for travel arrangements. Recommendations

1.It must be recognised that the war in former Yugoslavia is having an impact on the physical and mental health of the entire population, especially that of refugees and displaced persons.

2., Psychosocial assistance to refugees must be recognised as a priority and launched during the emergency phase. Assistance should be targeted towards and at-risk vulnerable groups (1) and priority given to those who have not yet been assisted.This is essential in order to tackle existing mental health problems and to prevent future problems from occurring.

3. Where there is a large presence of refugees, awareness should be raised and special training given in recognition of mental health problems and psychosocial needs.Related information should be offered to refugee community, host population and professionals involved with the organisation of refugee's lives.Specific training dealing with psychosocial needs, reactions to traumatic experience and pathological conditions must be organised and targeted at mental health professionals, PHC professionals (GPs, pediatricians, gynecologists, nurses and others) social workers, teachers, directors of camps, volunteers and all people engaged in organised protection and assistance.

4.Mental health professionals should organise and support outreach workers to identify acute psychosocial needs, conduct sensitive interventions, designed to reduce the stigma associated with violation and to plan a programme of long-term interventions at an individual, family and community levels.These programmes should be realistic, concrete, economical, flexible, unstigmatising, culturally sensitive and non-medicalised whenever possible. Systematic monitoring must be part of the process.

5.Socio-economic self-sufficiency should be encouraged by minimising dependency of refugees on humanitarian assistance and encouraging the reinforcement of existing human resources. Interventions at all levels should be aimed at empowering refugees and displaced persons to play an active role in the management and protection of their mental health.

6.Early family reunion, access to communication with absent family members and support of foster families are of major importance for mental health and should be a priority.

7. Governments, local authorities, non-governmental organisation, international organisations and others should urgently seek ways of normalising the lives of refugees and displaced persons. Protection and assistance are a fundamental part of this.

8. All the above-mentioned parties should work in close cooperation and ensure a rapid exchange of relevant information to the benefit of the refugees.

9. The rights and interests of refugees must be respected and considered before and during any assistance or research project, exposure to mass media and other activities.

10. These recommendations can be systematically applied in other conflicts worldwide.

(1)These are:children, unaccompanied minors, adolescents, victims of torture and sexual violence, the polytraumatised, ederly, psychiatric patients, ex-detainees, prisoners of war, relatives of missing persons and other priority target groups which may emerge. 14 BEST COPY AMIABLE UNITED NATIONS RECEIVED APR2 5 1994

oak.. ftINA Economic and Social Distr. srv_ GENERAL ,aso07k'. Council E /CN.4/1994/NGO/53 8 March 1994

Original: ENGLISH

COMMISSION ON HUMAN RIGHTS Fiftieth session Agenda item 22

RIGHTS OF THE CHILD

Written statement submitted by InternationalEducational Development, Inc., a non-governmental organization on the Roster

The Secretary-General has received the following writtenstatement which is circulated in accordance with Economic and SocialCouncil resolution 1295 (XLIV).

[24 February ],994]

The rights of the child

1. International Educational Development/HumanitarianLaw Project brings to the attention of the Commission the situation ofchildren in the armed conflicts in the former Yugoslavia.

2. According to statistics gathered for the period July1991 to November 1993, in the Republic of Croatia there havebeen 171 children killed and 712 wounded. Most of the children killed were from eastern Slavonia (51 per cent) and Dalmatia (23 per cent). Forty-three children are severely permanently disabled and another 12 have required amputationof a limb.

3. A total of 4,056 children have been left with onlyone parent and 44 have lost both parents. An additional 86,000 children are displaced andmore than 140,000 are refugees. As a further result of the war, there aremore and more children without needed social and medical services.

4. In Bosnia and Herzegovina the situation of children iseven worse, especially because there, children must depend almostentirely on humanitarian aid from the international community. Supply of needed aid is constantly endangered because of the day-to-day realities ofa war zone.

GE.94-12363 (E)

15 E/CN.4/1994/NG0/53 page 2

5. Ninety-one per cent of Bosnian children are exposed to shootingand an estimated 40 per cent have witnessed a death or wounding of anotherperson; 80 per cent of Bosnian children think that they will die withina year due to the wars

6. The psychological damage from this war will affectthese children throughout their lives. Whereas adults can learn to place the horrorsand hardships of war in some perspective, childrenare far more vulnerable and usually unable to develop constructive coping mechanisms.

7. International Educational Development/Humanitarian Law Projectappeals to the international community to take adequatemeasures to assist the children of all wars, and especially those of Croatia and Bosniaand Herzegovina. We urge the international community to ensure that psychologists and psychiatrists receive training in war trauma of children. We urge provision of medical teams to treat the physical wounds ofwar as soon as possible so that the process of rehabilitationcan begin. Finally, we urge the international community to assist the Governments ofthis region to provide long-term programmes, including adoption in the bestinterest of the children and enriched education opportunities.

16 17 andMental Refugees Health of Immigrants Refugees as Victims of Torture and Trauma SponsoredProceedings by of a Conference by Federico Allodi There are some myths surrounding immigrants and refugees that WorldHogg FoundationFederation for Mental Health and lenged.Twoanneed untruth mythsto be that, clarified.in particular untested, (I am are isusing quite the widespread term "myth" and in its not repeated as history and accepted as truth.) pejorative sense:generally chal- from other ANN 1.4". countries,loving, fair, not and countries tolerant. like History Firstours isshowswith the governments belief otherwise. that refugees are people who come otherAll countries,in their history includ- that are peace there,niesandhaveing the persecution andproduced as United Greatrefugees, States refugees.Britain, after in andthe1784. flew The WarCanada, toSitting "Empire ofCanada Independence atBull, one (100,000 the time chief or Loyalists," fearing discrimination between theof them) 13 colo- andof the settled Sioux nation, withsandsCanadarecently, other of surviving asaftermanycitizens draft the thousands dodgersof chiefs,battle her own of soldiers, duringof the land,young Little thethe and U.S. Big VietnamAcadians, their citizensHorn war.River intocrossed families, took refuge in Canadaforcible sentin 1876. thou- exile Or south more the border to ofManitobathe the Mackenzie-Papineau Unitedborder in 1837 States.in 1755. and 1885,Still and on their theRiel leaders Canadian rebellions flew side, in into Ontario, afterexile to the collapse ofQuebec,various andfrom parts always ..X.41401 onedidthose have time experienced thoseor another kinds have ofby conflicts. today's hadThe problems refugees.second Again, myththe Think, reality is that for is instance,countries that ofwhere refugees come and internal conflicts similar to all countries at "civilized" againstpeopleoftheEurope China, Stalin duringinthe regime,1964or Khmer the the and massacres Nazior people ofthe regimethe devastation re-education in inCampuchea,in SouthGermany, unleashed East camps or orAsia of ofin the by theagainst Sovietthe current Unionthe People's Republic Khmer Rouge polosSukarno de under 4S, lastdesarrollothe two 100,000 decades. (in fact, detained nothing and but disappeared militarized villages) people ofin LatinGuatemala BEST COPY America in the and of1 Mill 1 11111111 MAKE =IP WEI apt 246 Any country, under any ideology, can be guilty of committing Mental Health of Immigrants and Refugees Victims of Torture and TraumaThe agents use a multiplicity of methods, all of them designed to 247 annualcausinggrosspolitical violations reports them and onadministrativeto of becomeover human 60 countries refugees.rights system. against that AmnestyIt commit some tortureInternational of its asown part citizens, ofissues their is also worth noting that the fromvictiminflictphysical coarse painto submit and punching, psychologicalsuffering to the will beating, for of thethe needs purposeagent and to deprivationtheand refined use of punishing or coercinghis regime. theconfuse Techniques and vary destroy the of theof mostchemicals, basic elec- arenograndparentsrefugees differentus. we from orhost ourselves us. nowadays They undershareMuch in otherwithourhas midstus beencircumstances. the written couldsame havehistory in theThe been last ofrefugees man. twoour decadesTheyown are on torture. Lawyers thedocumentedphysicaltricity, last and 15and psychologicalyears. psychologicalin the Mostmedical Thecommon techniquesintegrity literature effect symptomsof andthethese that person,human techniques are as on individual victims has beenrights wellpublications ofof a psychologicalnoted in Table 1. demonstratedmoraland humanitarians universe. that Social it have has scientists, ashown systemic us physicians, thatnature. torture Torture andcan ispsychologistsoccur part inof aa legalcomplex have and centration,natureacute insomnia, anxiety, nightmares,depression, jumpinessdifficulties andwith Table 1 suspiciousnessallattention of and con- aalsmachinery, philosophy'fieri,' and ultimately to make;carefully of rational the that constructedlegal is, justification toand make moral and lawful fabric (fromwell andrun, ofthe a legal whichLatinsociety. what 'ius,'destroys Torture isthe unlawful law, individu-requires and and MethodDeprivation Frequency of Reported Methods of Torture (n=41) n Percent ofillegal). citizens It also or victims requires of an this agent philosophy. to implement the philosophy and a body WaterFood deprivation deprivationand water deprivation 121615 293937 premacyatrocitiesand political of of the Stalinculture State"; were in the which conducted FrenchThe the philosophy used abuse under the appears. idea theor ideologyofassumption mission In recent of civilizatrice torture of times, the can"su- the to change to suit the times OverstimulationPhysical torture BrightSensory lights, deprivation etc. 12 29 justifyships"national torture of the in security" Southerntheir Algerian (Corn cone warblin, of (Maran,Latin1979), America and 1989); in the theused current military the conceptconflict dictator- of of the StrikingSlapping,Beating with kicking, heavyrifle buttpunching whip, baton, or torch 253240 617898 ologymilitary-dominated or justification governments is "counterThe agentsinsurgency." of Central implementing America the this prevalent plan constitute ide- a whole system of Suspension,ElectricBurnsCold from shock water, cigarette, hanging showers, bychemicals, fingerssubmersion hot water, or electricity 122715 29663712 accordinginterrogationspecial police, to basic and military andtorture, simple intelligence, who principles. are selected,death The squads, transformation trained, and and specialists of rewarded a human in Psychological torture VerbalRapeOther physical abuse torture (nail removal, asphyxiation, etc.) 3212 6 781529 torturebeing,regard arequires normaland act thecitizenevenupon inhibition his own a brotherof neighbor his own or sister orhuman a friendintoas non-humannature, an so agent andhe can as of an ThreatsFalseThreats accusations againstof death,against self, execution family further and torture friends 23313513 56768532 crimes.andaction.enemy. psychological. This The An reward, stateevil act, will Oneamnesty thus,reward of themis such fortransformed is crimes deedsto grant committed,in impunity intomany a ways,duty for will suchor material, gain even actions impor- a social,noble and OtherSham psychologicalsexualexecutions molestation torture or torture(degradation, excrement in food, etc.) 1214 2934 21 institutiontance as the of kingdomslaw and reckoning of terror andapproach. torture crumble and the times of re- torture:Adapted A fromCanadian Table study. 1 Canadian Journal of Psychiatry, BEST COPY MAKE in Allodi, F. & Cowgill, G. (1982). Ethical and psychiatric aspects of 27 (2), 98-112. I am Nil ow as am as am am ain ION MI MI MI OM OM 1111111 248 Mental Health of immigrants and Refugees Victims of Torture and Trauma 249 thatTablewhich often 2. may followed be present thoseSpecific and refined criteria even years after the original trauma, for the diagnosis of the clinical as noted in condition vehiclemaritalmay expectaccidents, separation, to encounter financial death at least of a dear person once in their lifetime, such as divorce or relative, minor motor or new;NamedStatisticalare in spelled Post-Traumatic both Manual, the out First in theThird Stressand American the traumasEdition and stresses,(DSM-III-R) as infirst the Disorder (PTSD), this conditionSecond World Wars,Psychiatric descriptions Association's published in 1980. case of torture, Diagnostic was not comparingclinicaltortureThe descriptions,introduction and across other national humanof this borders rights a more accurate diagnosis, and the concept of PTSD into thereverses, study of and migration to another violations has permitted reports on various groups of more completepossibilities of victims of country. generallygrossshelltraumatised stress shock, follows reaction. disorderlysoldiers massive PTSD and is understood actions of the heart, combator civiliansunusually were severe reported stresses, under such as a cluster of symptoms that exhaustion, and the names of as concen- of standardvariousEventually, treatment criteria. the followmodalitiesFollow up studies permit the up of victims and the study of the will be more accurate, distinction between short- and given this list of outcome of victims. long- shouldmassacrestration be camp distinguished or hostage-taking experience, from episodes. being a victim of the more commonTable 2 stresses These man-made experiences rape, or being involved in that people yearstraumaticsubsideterm after outcomewithinthe situation. trauma. a few ofEven Amonthsthe community torture experience.so, a significant Acute level of distress once the victim is away and safe from survey in Toronto, using standard- symptoms tend to may remain for the PhysicalEffect Long-term Effects of Torture (n=41) n Percent countrybetweenized measures of origin refugees andof psychological whoimmigrants had suffered torture and persecutiondistress, showed significantfrom the same regions of differencesthe world in their WeightDeafness,FracturesScars, loss burns blurred vision 1021 58 24122051 andcalRojas,who distress family were 1985). functions. did living not It was in Canada also discovered seem to interfere significantly with their without that traumatic that their inner state of experience (Allodi & major socialpsychologi- Psychosomatic Nightmares,NervousnessPains, headaches night panic 331422 8054 ingood Toronto, mental Southeast health. Such AsiansChildren of victims living in was the case of Latin American children exile, on the other hand, seem to enjoy living Aff ective Tremors,Insomnia weakness, dizziness,diarrhea, fainting, sweating 2628 636834 Europe,Soviet and children in Canada in the (Foster UnitedWomen as torture victims have States (Allodi,& 1989).Sandler,in 1987; the United Allodi &States been studied in South Africa, or Australia, and in Fears,AnxietyDepression phobias 123629 298871 thetortureThe sameconclusions by repressive as for of victims these regimes, of the studies appear to be that consequences of which are very much women are subject to Stiasny, 1990). Behavioral SuicideSexualWithdrawal, dysfunction, attempt irritability, severe aggressiveness, impulsivity 13 4 3212 symptomsavoidance and may conflicts, last for theTreatment of torture victims is years after the initial trauma. rape in civilian crime. Sexual anxiety aimed at alleviating their psychological and Intellectual and mental LossMemoryConfusion, of concentration loss disorientation 12 5 291210 tionsbeenchotherapy dedicated the primary and to counseling, approaches.the both care of victims of torture have However,main consequences most professionals of theon an individual and group basis, have trauma.or emphasizedorganiza- Psy- o torture:'Adapted A Canadian from Table study. 2 Canadian in Allodi, F. & Journal of Psychiatry, 27Cowgill, (2), 98-112. G. (1982). Ethical and 13 psychiatric aspects of 32 theservices,psychological Phillipines, including treatmentSouth health, Africa,There legal, are a number of or counselingcenters within in a Europe, networkand NorthLatin of America America, which and social services. provide integrated integratedAustralia, 23 IM SIMI NS NS UM NS UM IIIIIII 1111 ND OM to EST COPY MORE IIIIIII 11.11 111111 MI MI IIIIII 250 Mental Health of Immigrants and Refugees 1986). Victimsempathy of Torture with a and therapist. Trauma Empathy must transcend political and ideo- 251 Thecommunity-orientedchiatricand center assessment, network, in Toronto, crisis volunteerservices consolidated intervention, for support, torture in group 1983, victimsEnglish counseling, runs (Reid as programs a &Second Strong, on information and 'com- medical and psy- Language intake intoalertnesslogical a new barriers, for concept negative requiring of theor Thepositive self on final andthe counter-transference. stagepartof society of deals the therapistwith the integration a great of the experience and consequent actions. It of trauma deal of andfinanciallymunityclasses, operatesjob consultation, readinesssupport supported as toa partnershiptraining.international byreferral government, It tohas between legalprojects, a community private,and the public other community, and Boardcommunity international of including theDirectors, is agencies, funds, oftensurvivors calledrequires engage "survivor's years into ofreparatory mission." therapyThese concepts andwork support. within or stages a particularIn have been applied not successful cases, the only to individual social context, erstheirgovernment.refugee are families fromsector, Everycountriesfrom the over yearUniversity reported 40it serves different of toToronto,between becountries. in a 300the state corporateTheand majority500 new world, of turmoil and having of newcom-victims and and the communitiescases,disappearedproposedof the but Jewish they forand persons HolocaustVietnamhave nations. been in veteransLatinFogelman in proposedIsrael America and has to similarfor(Allodi applied the &interpretationsfamilies Rousseau,them to of 1989; have explain reactions of whole the detained/the survivors Fogel- been mentaltoviolated normal50 percent health human reparative nature of rights them processes(Allodi that declare year.Once & Simalchik, begin Ontothe have avictim tofirst develop. in intake ispress). in a interview,safeIn most place cases betweenand away from the source needs of a psychological or of trauma,the victim 30 beentheman, relationship broken.1988). In legalbetween terms, theWithin this state covenant a andlarge its isnational citizens; addressed context, their by torture represents a breakdowncovenant inthe Universal has andworkcannot becommunity that be helped discussedmost considerablypeople groups, with enjoy, them. even by such Professional thoughcontacts as family,the experiences counseling friends, can of trauma may with the natural support net- religious leaders, speed up and stitutionalconceptmustDeclaration be rights repaired,and of agreements.the Human practice if the Rights nation Thisof compensation,and ruptureis goingother between nationalto be whichmade citizenand international con- haswhole been again. recom- The and the state patient-therapistworkinfluence with favorably torture relationship,victims. the outcome CommonlyA number grief of the reaction of mentionedtrauma. issues and and theare basic mourningtrust concepts of have been mentioned in within the the toamoremended psychological achieve recently and some carried in need Latinrestitution, out ifAmerica, the within victims albeit theis not morearecontext only to symbolic aof the Jewishthan Holocaust feel whole and safe again andlegal requirement, but also material, for the they suf- and processthatmentlosses the in suffered solidarityof victim healing. aswill groups a haveresult and to of goactivities.the at trauma, his orThe survivor'sher counselor own paceguilt, and engage- should be aware through the lossReferencesfered. of family, community, personal health, and dignity that offrom denial, trauma: both (1) the denial, client (2) andThree acceptance, the dynamic counselor and stages avoid, (3) integration.have minimize, been At outlinedor in the process of the stagedeny the healing Allodi, F.F. & (1989). Cowgill, The G. (1982).children Ethicalnalpsychological of victimsof andMental psychiatric of Health,politicalstudy of aspects17(4), persecutiona Latin 3-8. of American torture: and A torture:refugee community. International Canadian Jour- A everydayenemyimportancepainful of counseling. tolife, ofremember. workthe traumatic onTraumatic theBoth present, experience.patient experiences and burytherapistDenial are the is past. wantindeed Thereto getthe ongreatis no difficult to discuss and with Allodi, F., & Rojas, A. (1985).violencestudy. Psychiatry:The Canadian health in Latin The and Journal America. state adaptation ofof the Psychiatry,In P.art: of Pichot, victimsVol. 276. P. New(2), Berner, 98-112. York and R. Wolf,London: & K. Plenum Thau (Eds.),of political Press. 25 2 4experience. Acceptanceavailableconspiracy defense is in facilitated this; mechanism most byThe commonly a secondrelationshipto avoid itstage pain. of of trust healing and involves acceptance of the is a simple denial as the most traumatic Allodi, F., & Rousseau, C. (1989).Studies,America.of The victims trauma October, Paperas Post-Traumatic of forcedpresented San Francisco,disappearance at Stress the meetingCA. Disorder. in the of theAn analysisSociety forof fifteenPost-Traumatic cases in Central families Stress I um we as INN MI MI 1111111 1111 EST COPYMID AMIABLE OM IND Mil IS MI OM MINI 252 Mental Health of Immigrants and Refugees Allodi,Allodi, F., F., & Stiasny,& Simalchik, J. (1990). 1. (in press).Womenchiatry,integrated The 35, 144-148. service approach. Canada's as Canadiantorture victims, Centre Canadian forMental Victims Journal Health. of Torture: of Psy- An CombAmerican lin, J. (1979). Psychiatric Dos Ensayos Association. Inc.Sobretal (1987). disordersla (3rd ed.). Washington, DC: AmericanSeguridad Psychiatric Nacional.Diagnostic Association Santiago: and Arzobispado Press, statistical manual of men- Foster,Fogelman, D., &E. Sandler, (1988). TherapeuticD. (1987).Davidsecondde Detention Santiago,alternatives Philip. generation. and Chile. for The Psychoanalytic Review, 75(4), 619-640. torture in South Africa. Capetown:survivors of the holocaust and Reid,Maran, 1. C., R. & (1989). Strong, Torture: T. (1987). TheHealthrefugeeYork: Torture role Praeger Sciences. ofvictims andideology Publishers. in New South Wales, Sidney, trauma in the health careAustralia:in needs the French-Algerian Cumberland of College War. ofNew

26 BEST COPY AVAILABLE 27 II1 MI NM NM MI OM- INS SE - NB 11111111 liAPPEDDE 28 fatigue,Japaneserestlessness, anorexia, and irritability,Serving Survivors of exhibited severe Torture and insomnia. malnutrition and vitamin British troops who were captured by th e 51. Oboler, DisabledEditor,and American legs,Post -and Traumatic Steven, (1987) optic atrophy. gastrointestinal andVeterans, AmericanStress Prisoners Disorders: cardiovascular A Handbookof War: An symptoms, pares thesia of Overview, infor Clinicians,deficiencies, suffered Williams, Toth, the feet from 54.53.52. Id. Id.Segal, a nationwide at all 172 al., supra, n. 8. Veterans Administration pp. 131-143. This medical centers since examination program has 1983. Cincinnati: operated 3. Psychological Sequelae Traumatic human rights abuses ofRights Traumatic Human Abuses whether physical or psychological inevi- adifferentlythoseprotectivetably limited leavewho number sensedeliberatelyto psychological his ofor of invulnerabilityher psychological experience,seek scars. to harm Victims asresponsesthe orthey human destroy of are such to renderedbrain them.a abuseparticular is capableWhile helplesslose typetheir each of andmanifestingof psychologicallysurvivor stimuli. dependent reactsThus, only on 0 difficultyawakeextent,the psychological orwithin asleepconcentrating, an in identifiable nightmares, sequelaeCommon irritability, range most generalized responses of survivors and responses. depression. lossto abusesexperience of trust includeMany in others,fall, survivors recurrent to hypervigilance,a greater satisfy reminders or thelesser of the trauma while onlyclinicalincludingsurvivorsmajor some criteria depression, of substanceto the exhibitfor elements the which abuse psychiatrica variety incorporate ofto maskthese of diagnoses other psychologicaldiagnoses. many psychological of of post-traumatic these In sequelae, addition, sequelae. responses maladaptive itstress Othersis commonto disorder their experience attempts trauma for or 23 preexistingthattheresurvivorat coping, affect is mountingis psychological anda refugeesurvivor's psychosomatic evidence or immigrantpsychological problems that complaints. trauma who or problems responses.is canadjusting These cause resulting sequelae to biological life in frommay a new changes bethe land. compounded fact inIn that theaddition, thebrain by BEST COPY followingknownperson. thatBut the frompsychological trauma the fewIt islongitudinal sequelaeimpossible may studies to predict be lifelongand the the natural many and may case history occur reports, of atstress itany is responsenowtime in any particular even as long as 30 years later.' Studies of concentration 30 I MI MI MIAMI MI INN Ell RIM MI MI NM 30 Serving Survivors of Torture r Psychological Sequelae of Traumatic Human Rights Abuses 31 bancesNorwegiancamp survivors 20 or concentration more confirm years that aftercamp post-traumatic their survivors, return 99 scquelac to normal life; percent87 percent still had had psychiatric distur- can last for decades. Of 226 poor POST-TRAUMATICTABLE I DIAGNOSTIC STRESS CRITERIA DISORDER FOR mostpercentmemory commonly had and sleep inability occur disturbances;Not towithin allconcentrate; survivors a few and years 52 develop 85 percent percentafter symptoms trauma, had were nightmares? the immediately. While nervous and irritable;post-traumaticlatency sequelae period may be 60 A. spouse,threatexperienceThe person to orone's other andhas life that experiencedclose or wouldphysical relatives be anintegrity;markedly and event friends; seriousthat distressing is sudden outside threat to destruction orthealmost harm range anyone;to ofone's one'susual e.g.,children, homehuman serious or diminishes,defensemany years mechanisms other or even psychic finallydecades' associations become The onset overwhelmed, may be delayed the until are made, or other losses become too great., stress of flight or relocation well-established B. Theinjuredcommunity; traumatic or killed or eventseeing as the is anotherresultpersistently of person an accidentreexperienced who has or physical recently in at leastviolence. been, one or isof being,the following seriously Post-traumaticPSYCHIATRIC Stress DIAGNOSES Disorder (3)(2)(1) wreacuysrr:suddenrecurrentrepetitive acting distressingandplay intrusiveinor whichfeeling dreams distressingthemes as if ofthe orthe traumatic aspectsrecollections event of event the of traumawere the event recurring are (inexpressed) young (includes children, a sense traumaAssociationnew and .° isThis still to diagnosisdescribe controversial'As thewas a range psychiatricsubsequently It was of createdsequelae diagnosis, refined in experienced 1980 when post-traumatic by the stress disorder (PTSD) is relatively by survivorsAmericanAmerican of Psychiatricsevere Psychiatric (4) aspectintenseepisodes,of reliving of psychological thetheeven traumaticexperience, those thatdistress event, illusions,occur includingat uponexposure hallucinations, awakening anniversaries to events or and whenthat of dissociative the symbolize intoxicated) trauma (flashback)or resemble an theedition)Association disorder (DSM typify revised III) survivors in 1987.'its Diagnostic of There traumatic is and humanStatistical Manual no question, however, that the symptoms of rights abuses as well as other types of Mental Disorders (3rd (1)C. effortstheresponsivenessPersistent following: to avoid avoidance thoughts (not present of stimuli or feelings before associated associatedthe trauma), with thewith as trauma indicatedthe trauma or numbingby at least of threegeneral of TortureChester,of human-induced in former Minneapolis, director stress.' reported ofIndeed, psychological that evidence 70 services of the validity of the PTSD percent of the 38 patients at the center who diagnosis is growing? Barbaraat the Center for Victims of (4)(3)(2) inabilitymarkedlyefforts to to recall avoiddiminished an activities important interest or aspectsituations in significant of the that trauma arouseactivities (psychogenic recollections (in young children, amnesia)of the trauma loss of tionalreceivedfirst U.S.A. year complete of study operation psychologicalof survivors were diagnosed of and torture psychiatric 38 as having PTSD.'° In the Amnesty Interna- percent fulfilled all the criteria for the assessments during the center's (5)(7)(6) senserestrictedfeelingrecently of of acquired a detachmentrange foreshortened of developmental affect; or estrangement e.g.,future; unable e.g.,skills does tosuch from have not asothers loving expecttoilet trainingfeelings to have or a language career, marriage, skills) ClinicMollica,studyPTSD was indiagnosis." Boston,M.D., completed, and recently Of James theall butsurvivors undertook Lavelle, one fulfilled with staff whom membersall the the authorscriteria have for thatworked diagnosis. since that Richardof the Indochinese Psychiatry (1)D. indicatedPersistentchildren, orby symptoms a at long least life two of increased of the following: arousal (not present before the trauma), as hadResearcherspatients survived and two foundin Portland to fourthat half years similarly of inthese concentration diagnosed met the DSM a six-month outcome study of 52 Indochinese PTSD in 13 Cambodian refugees who III diagnosticcamps. Thesecriteria latter for PTS two D." studies (4)(3)(2) difficultyhypervigilanceirritability concentratingfalling or outburstsor staying of asleep anger ofconfirm fortraumatic PTSD that humantheare diagnosisset rightsforthCertain in abuses."has Table criteria cross-cultural 1.All of havePTSD appear to occur with greater frequency among survivors experiencedapplicability." Criterion A, The "an diagnostic event that criteria (6)(5) exaggeratedoutaspectphysiologic in a of sweat thestartle reactivity traumatic when response entering upon event exposure any(e.g., elevator) a towoman events who that was symbolize raped in or an resemble elevator an breaks 32 31 harmdefinitiondistressingis outside to one's theto almost range children, anyone."of normal spouse, The human description "serious threat to one's life or other close relatives and friends; sudden experience and that wouldor be physical markedly integrity; seriousof threat the types or of events that satisfy this Disorders,ReprintedE. withThird permission Edition, Revised. from the Copyright DiagnosticDuration 1987 and of Americanthe Statistical disturbance Manual (symptoms in B, C, and D) of at least one month Psychiatric Association. of Mental 1 In Ell IIIIII OM MI II1 MI IMO all UM MID MI been,destruction32 or is being, of one's seriously home or injured community; or killed or seeingas the resultanotherServing of personan Survivors accident who of hasor Torture physical recently withassociated Armenian with thegenocide trauma. and Avoidance Nazi concentration can last for camp decades. survivors The authors who only have recently spoken Psychological Sequelae of Traumatic Human Rights Abuses 33 disastersabusesviolence" inare ormind. morecar accidents,Furthermore, likely to andproduce DSM-III-R that "the the disorder recognizes isthan likely that stressors traumatic to be more such human severeas natural rights and seems to have been written with survivors of traumatic human rights worked,record.theyrecounted not Avoidance whobeen their were convinced stories maypolitically for also that the explain activetheirfirst time. testimonywhyin their Theyseveral countries, wasprobably survivors necessary avoided would with to involvementneverwhom preserve have the theauthors done in historical political so have had eventsdistressingformlonger that of lasting symbolizerecurrentdreams when of and orthe theCriterion resemble intrusiveevent, stressor and B,an distressingis persistent aspectintense of human of psychological thereexperiencing recollections design."" traumatic event.distress of the As atevent, the exposure following occursrecurrent to most frequently in the rightsor solidarityhand,for byabuses becausediminished activities than rarely among interestinPsychogenic the are survivorsUnited therein significant States,witnesses amnesia of other although activities. appears who types thiscan ofto behavior elaboratetraumaticbe less commonmay onstress. alsoa survivor's beinOn survivorsaccoun the other trauma ted of traumatic human schoolexampleapprehendedwhichwere student, detained illustrates,time they was atogether secondwere thesearrested repeatedly forms in time atsqualid schoolare and tortured.often conditionskilled. along intertwined. AlthoughSincewith for several hisa periodH.H., all release, wereof a hisof male released, threeclassmates.H.H. Ethiopian months has several had They highduring daily were ofstory, furthertoDuringa Salvadoran him amnesia inhistreatment the hospitalization may past.survivor beand After more recuperation. who hehe common wassuffered unablestabilized, than He a psychotic tothen it recall appears. he began was who break placed Itto he was recall was and observedin or waselementsa whathalfway hospitalized. hadin ofthe happenedhouse his case past for remindAmericanscausesWhenevernightmares him he ofrathertoand hears hiscry on friends thanand Ethiopianoccasion feelEthiopians and frightened. hishasmusic, detention. awakened because he Herecalls Hesays thefamily alsohis physicalhe torturereports prefersmembers features andbecoming to imprisonment.makewith of his symptomaticfriends Ethiopians screams. withThis hisquentexperienceloving horrific life infeelings experiencesincluding the United commonlyFeelings his States. into detention, his ofThe occur life.detachment amnesia torture, among may release, orsurvivors haveestrangement periodgiven of himtraumatic of from hiding,time others to human andreintegrate andsubse- rights loss of ability to have theirhimhewhenever became oftrauma the he largeanxious are sees reexperienced.black groups and rubber Youngfearful of high mallet childrenatWilliam schoolthe sightused survivorsArroyo,students. toof beata reflex M.D., engageDuringhim hammer. duringdescribed inhis repetitive physical torture He the said play sessions.playexamination it remindedbehavior in which themes or aspects of exhibitedbrutalizedinabuses. others In caused bysurvivorsby survivorsanother by of theMarked humantorture, and experience interfere being.diminishedthis appears Theseofwith being interesttheto sequelae be developmentrendered related in aresignificant to helpless,among a generalized of new theactivities humiliated, mostrelationships. loss common also of trust andoccurs in survivors of one"Heresidences,of forcesa quickfive-year-oldrepeatedly on handstroke, militaryone sideplayed Salvadoran raidsand stating withthe on guerrillas nearbythe that boy available they whohomes, on all theregularly died toy andother soldiers, localbecause and witnessed streetsthen positioningthey knocking riddled wereaerial all them with bombingsthe bad."" militarycorpses:down It withisof Ethiopianinterestselementittraumatic is sometimes ofbecause humanman coexisting described unclear ofrights physical, depression, abuses,whether above, social, though wasthis or cultural, isis among causedthe result survivors by ofthe an traumatic inabilityliving in experience,the United States is an avid amateur soccer player before leaving or linguistic barriers. H.H., the young to pursue former an alsoSalvadoranveterans."back" common episodes, But forgirl Dr. childrenwho which Arroyo, wasSurvivors commonly to incarcerated depict describing the their areauthors for reportedthetrauma two case have days in ofby examineddrawings aandthose 17-year-old, raped who orhave by workartwork. her notpolitically jailors,with reported Vietnam reports active dissociative or "flash- prisonersignificantattributablehis country; who activities to in was PTSD. the active UnitedThe in complex Statesthe human he mechanisms rights movement that contribute before being forced are illustrated in the case of K.M., a former Czech political never plays. His loss of interest probably is to diminished interest in previously describedthethat girlshe "frightfullysuffered as being dissociative-like completelystaredCriterion and screamed indistractible C, states. persistent Onfor twoapproximately avoidance during occasions, these of stimuli atwostates." relative minutes. associated observed She with was that the traumatic event and asAlthougharrived,his a blue-collar his he Englishhad worker. The realizationcountry. that In the United States he displaysbeen no interesta professional in politics. in Czechoslovakia, When he first thewas only poor work and hehe couldhad difficulty find adapting to his new environment. he might never again see his chronically ill to leave was 34, 33 situationshumandiminishedfrequency. rights that responsiveness abuses,arouseThe most recollections though common to notthe external all ofavoidance manifestationsthe trauma world, behaviors and are efforts ofcommon this are toresponse efforts avoid in survivors thoughtsto occur avoid ofwith or activitiestraumatic feelings equal or continuesdepressedheavilyfather, who upon to and shun him. developed also was politically active and for that reason politics butShortly has found after satisfaction arriving in in the artistic United pursuits. States, K.M. became severely an ulcer. While both problems are now under control, he was denied a passport, weighed SIM NM MI OM MO i11111 =II 1 I= INN I= MI Psychological Sequelae of Traumatic Human Rights Abuses 35 34area foreshortened adjusting, with future, varying thoughFew degrees of the survivors with whomServing the Survivors authors of Torture this question was rarely explored. Most are refugeesof success, to life in the United States. Several were have worked have expressed a sense of who regime.worrysurvivorsacquaintances that While from the survivors'are newcountries spies government andfears that are arehave circumspect oftenwill experienced topplevalid, aboutinand some a bechange interacting replacedcases in part government with or all others.a are repressive paranoid tend Even to talkedrequirementsforcedtraumatic of to not give livingexperienceand up thus professional much have orlonger, theirhad careersto thoughcoming accept becauseit to is termshard theyto with the process lower career expectations. Older persons have tell whether this is the resultcould ofnot their satisfy statein licensing detail by Lenore Terr, who of aging. Majorideation Depressioncaused by pastMajor trauma. depression is another frequent, and commonly missed, diagnosis exhibited by documentedthatamongkidnapped includes children theand such sequelae temporarilythan Theself-defining sense in children buriedof aelements foreshortened from as Chowchilla, a career, future spouse, was described adults." Adults are much more likely to have a alive." This response may be more common California, whochildren, were a home, and life framework featuresinsurvivors?' MinnesotaDepression of Fordepression in commonly example,1977 were without nearly is diagnosed observed satisfying all of asain representative havingpatients all the major criteriawho depression."samplealso fora fulfill majorof Hmong the Other depressive diagnostic refugeessurvivors episode.criteria living have for orchildrenwithmaterial to believematurity. mayand thatfinancialbe Withoutless they likely can means. years successfullyto be They ofable life alsoto experienceput have their greater to achieve ordinary life goals. Without these traumatic experience into context bolsterself-awareness them, traumatized that comes PTSD.inabilitydreamsrelatives, The of diagnosticto employment,how adapt the to criteriafuture aDepression new home, may forlanguage major havemoney, may depressionorbeen; occurnew social or culture. spontaneously;may arestatus, setbe forth provokedself-esteem, in Tablemay by causesbe2.self-worth, related such to oras the loss of friends, goalsafteraoccurred. physician. their his futurestraumatic Before After may his hisexperience, tortureH.H., appeartorture the he workswasEthopian a goodin a describedmenial student job.2' above, was high he lost sight of this goalshort and and now, bleak. more than and his ambition wasschool to become age when his trauma 10 years believedsurroundings,his place would of business. torturedbe hisFor grave. During withexample, Now electric his aC.M., detentionrefugee shocks, a printer living he and was fromin forced the kept a United Central toin digcold, States, Americana ditchinhospitable he thatsuffers country, he was arrested at ofthatasleep, anger symbolize difficulty also are or commonconcentrating,resembleCommon butan aspectappear Criterion and physiologicalof to the occurD symptoms are increased arousal, difficulty traumatic event. Irritability and outburstswith less intensity than they occurreactivity in upon exposure to events falling or staying activities,fromlessinsomnia, major than loss indepression and ofthe fatigue.a past,significant characterizedand He feels also amount experiencesthatSuicide byofhe weightdepressedhas attempts less frequent (20 zest aremood,pounds for boutsone life. loss ofin of thea ofanxiety,six-month mostinterest serious socializes inperiod), many manifestations far of major depression. otherResearchersvors." traumatized Survivors have groups complain found suchSleep frequent of as disturbancesnightmares, hospitalized awakening insufficient are from among sleep,the most common Vietnam veterans. REM sleep,complaints decreased of torture REM survi- and daytime fatigue. attemptedthwartedtwiceProvoked attempted with on by bothone's depression, suicide occasionsown hand by despair, overdosing byor hisby orprovokingwife. feelings on J.R., medications someoneaof Salvadoran isolation surreptitiouslyelse. or R.R., futility, an Iranianthe collected, suicide survivor, but man, had a specific plan for may be was thesesleep,veterans.rights survivors?'absent abuses The stage-4 but latter is sleep,of tendHypervigilance a different toshort be jumpy appearsand always to be looking universal among charactertotal from sleep that time,reported and inlow studies sleep of efficiency Vietnam among survivors of traumatic human over their shoulders for committingthepositioning hope suicidethat himself they by would jumpingforSuicides the kill jump. off me." ora bridge.Hesuicide also He had decided several against confrontations it at the lastwith minute the police after "in attempts may be precipitated by stressful events that occur after thelikelysurvivorshuman enemy. to rights Thebe who hypervigilant natureabuses experienced of tends theIn forhypervigilanceaddition,to unanticipated beauditory related survivors to experienced theirphysical livingspecific byin trauma exile often clues of impending attack. exhibit fearful or even paranoid assault while blindfolded are survivors of traumatic experiences. Thus, hisprocesstrauma.final story hearing.of Forin seekingthe example, adversarial Counselors political MP., whoanasylum African worked in Canada, man with who him committed was to suicide the night before his courtroom environment or the possibility of deportation." surmised that he could not bear to relate appear in court as part of the 3 a countries where traumatic human rights abuses still occur oftenfearthere.doingbehavior are the guardedManyor authoritiessaying related are anythingafraid to inthe theirto political tellthat countries their could circumstances stories have will repercussionsto be United in their informed. Others act as though new States government officials for for family or friends livingcountries. Persons from about nisms,CopingMaladaptive which Mechanisms ResponsesEveryone has may be helpful or may maskcoping or exacerbate mechanisms psychological to deal with sequelae, stressful events. These mecha- 36 I 111 NM UM MN NMI Mil In II11 IMO 36 Serving Survivors of Torture TABLE 2 DIAGNOSTIC CRITERIA FOR denial,of hismay or be intellectualization, her adapted experience. from one Common situation isolation, defenses to another,repression, and Psychological Sequelae of Traumatic used by survivors to can color a survivor's perception suppression, dissociation,Human Rights Abuses cope include 37 A. weeksymptoms periodAt least and isfive either represent of the (1) following depressed a change symptoms frommood, previous orhave (2) beenloss functioning; of present interest atduring orleast pleasure. theone same of the(Do two- not MAJOR DEPRESSION Sequelaenismssomatization, and may for theirbe and more effect undoing." orPersons on less the troubling survivor's working depending with survivors should look management of psychological sequelae. for signs of these oncoping the person's coping strategy. mecha- (1) delusionsincludedepressedday, symptoms or nearly hallucinations, mood every that (or are day,can clearly incoherence, beas irritableindicated due to mood aoreither physical marked in bychildren subjective condition,loosening and adolescents)account mood-incongruentof associations.) or observation most of the by appearsandMany periods survivors to beof denial.coping vacillateSurvivors During fairly between well." periods who periods useof denial, denial of intrusive as sequelae are masked and the symptoms and recollections person (2) ofday,markedlyothers apathy nearly diminishedmost every of daythe interest time)(as indicated or pleasure by subjective in all, or accountalmost alt, or observationactivities most by ofothers the wheneverothers.thatconnection remind R.P., someone between them an Iranian of camethethe traumaticman,event, to his was even door, afraid when and had the eventa coping and mechanismtheir post-traumatic fail to acknowledgereactions to answer his phone, hid in connection is readily apparent a cupboard to items the to (3)(4) significantinsomniachildren,of body weightweight consideror hypersomnia lossin a failure month)or weight to nearly ormake gaindecrease every expectedwhen day ornot increase weightdieting gains)(e.g.,in appetite more nearlythan 5 everypercent day (in sion,documentationresult sought of his reassurance trauma, interview, but A.D.,that was he convinceda South American his was normal and requested that his family behavior was normal. At the other psychological sequelaesurivior with PTSD and depres- close of a as a be (7)(5)(6) feelingsfatiguepsychomotormerely or of loss subjectiveworthlessness agitation of energy feelings or nearly retardationor excessive of everyrestlessness nearly day or inappropriate every or being day slowed(observable guilt (which down) by may others, be not Intellectualizationmechanismsinformed that in there that is wastheyaIntellectualization, process nothingare attempts in which isolation, repression, wrong with him. to isolate affectthe survivor or feelings engages from in excessive and suppression are all related thoughts. abstract coping (9)(8) (eitherdiminishedrecurrentdelusional) by subjective ability thoughts nearly accountto think every of death oror day concentrate,as (not (notobserved just merely fear orby self-reproachofindecisiveness, others) dying), recurrent or nearlyguilt suicidal about every beingideation day sick) belonged.killed.menthinking were They to Theyarrested avoidwere believed detaineddisturbing following that and thefeelings. 1973 torturedabuse by members to them ofwas the somehow service coup Ford'etat example, in which two President former AllendeChilean to which they military was B. (1)suicidewithout disturbanceIt cannot a specific be and established plan, (2) theor actisturbance suicidethat an organicattempt is not factoror a a normal specific initiated reaction plan and for maintainedto committing the death the of a survivorsneouslytorture of because whowomen prisonersaffectIn isolationis a survivor is kept fromwasunable wrong. consciousness." to experience thoughts Isolation is common in and feelings justified,simulta- but that the C. moodlongAtloved no as timeonesymptoms two (uncomplicatedduring weeks developedthe in thectisturbance absence bereavement). or after haveof they prominent there have been remitted). mood delusions symptoms or hallucinations (i.e., before the for as horrificwitnesses.other experiences official context. In giving are required to describe what occurred with little or no affect and therefore testimony they characteristically to themdo not in appear court toor bein somecredible describe the most D. disorder,Not superimposed or psychotic ondisorder schizophrenia, NOS. schizophrendomi disorder, delusional inexperiences. which the RepressionsurvivorIn repression the survivor is unable to remember is reinterviewed after theis hard to detect, though it passage of time.disturbing For example, feelings,becomes thoughts, evident in situations or a 3 7 Mental Disorders, Third Edition, Revised. Copyright 1987 American PsychiatricAdaptedE. and reprinted with permission from the HasDiagnostic never had and a Statistical manic episode Manual or ofan unequivocal hypomanic episode. thanenceexperienceChilean one when survivorin vivid witness to the reexamined a year later. Repression who was intervieweddetail, was unable to recall same event is interviewed. a month after his torture descibed his significant mayelements also be of detectedhis when more experi- Association. BEST COPY AV iLABLE experiences.activitiesamong survivors. that Suppression, Some accomplishremind this ahim core or part her of of the disturbing PTSD diagnosis,In suppression the survivor by becoming too busy intentionally avoidsproblems,is a common thoughts desires, coping feelings,mechanism to reflect. Therapists or 38 I NM MN NM MI MO - MI OM MI 38 Serving Survivors of Torture Psychological Sequelae of Traumatic Human Rights Abuses 39 resultingusingprocesses behavioral in an is independent split modification off fromDissociation functioning the sometimes rest of is ofa an person'sthis teach unconscious suppression thinking defense or accompanying mechanism inaffect, which group of processes and thus a loss as a coping technique. a group of mental Acaptured,whois completenot escaped complained from his of home intermittent while hisparalysis family of was both being legs,limited detained lasting to a pain butfew wasorminutes. a laterdisturbance in sexual functioning. A.G.,medical a Chilean and neurological man evaluation of this man, who had been beaten traumafrozenof the usual frightmay beinterrelationships." related toDepersonalization, dissociative Two typessequelae in of which dissociation later." a person depersonalization dissociates actual experiences from are commonly invoked during severe trauma. Dissociation during those and physicalseriouson his disease. illness and It is persists based on despiteHypochondriasis the interpretation medical reassurance." is of the physical fear or signsHypochondriasis preoccupationback, or sensations was normal. withmay as the belief that one has a "Theythemhavethat torturedare depersonalizedtorturing perceived, my me body, whileis a their butcommon floating they torture did defense above may not torturedescribe them." mechanism me" These their during experience survivors or "I imagined that I watched torture. Survivors who are more likely into terms such as leadduringsubjectedgain toa traumafootholdhypochondriasis. to something, that if someone a person's C.S.,a culturally believes bodya Central or defined brainthat American because will harm be peasant, permanentlywill he ensue. or shebelieved Suggestions witnesseddamaged before canor electricmade was also perceivedoccuruse during dissociation hope and of aftersurvival as sexuala coping depends abuse. mechanism onFrozen his or herfrightafterward. commonly Depersonalization occurs in situations in which persecutor. Persons who dissociate a trauma victim's only may also toldquentlyshock during torture thought torture that that histhat his heart her heart mind would had would beenexplode be irreversibly altered under bysuch damaged. the treatment experience. Similarly, and She he S.G. subse-subse- was punishmentknowcognitivein this that manner functionsif theyas anexhibit cry example workingout cooperative or react to normally, others." with behavior rage Maladaptivebut theywithout during risk the deathfrozen associated fright trauma, with motor and or selection for further may later occur affect. They claimSubstancequently and hadintensified uncontrollable Abuse Survivorsher belief intrusive thatwho she are imagery, hadtrying suffered whichto control addedbrain intrusive damage. credence PTSD to her symptoms abuser's or sleep distur- outsideundoing,believed the thattraumaa survivor they context should symbolicallyUndoing when have is triggeredthoughtanother makes defenseor amendsby behaved associative mechanism for differently that during occurs in survivors, especially or negates previous thoughts, cues. trauma." By those who alcohol,theirbances trauma, sedatives, may abusebut inanxiolyticsThe ouralcohol DSM-III-R experience or (substances drugs." groups prior Some problems11 to classes maydecrease have are of rare. abusedabusedanxiety), substancessubstances and hypnotics intobefore three main groups: fellheandactions, probablyshort murder or of feelings. his ofresponded a ethical neighbor, For standards outexample, but of fearremained and 0.T., to protectblames a hidden Central himself,himself and American did forhe not the intervene.refugee, neighbor's now perceives that his conduct witnessed the Whilerape at thedeath. time This man availableSurvivorshallucinogens,(sleeping and medicines);most the most commonlyphencyclidine socially cocaine, abuse acceptable (PCP), amphetamines, substances or of similarlythe abusedin orthe actingother first substances. group. sympathomimetics;arylcyclohexylamines. Alcohol For example, is readily and Psychosomaticis now working as a socialorFor Psychophysiological many worker survivors in a refugee it is more acceptableDisorders culturally center. to suffer from physical ailments executions,H.M.inIranian hisdeveloped arms survivor and following adeprived pattern of two torture. of detentions foodalcohol Before and abuse. waterwho his had detentionHeand wasbeen had a watched hebeaten,middle-aged, rarely athreatened drank fellow well-educated alcohol. detainee with shamdie At the physicalmodel;symptoms.than from the conditions" psychological DSMCurrent III andtheoryand group DSMcomplaints. explains psychosomatic IIIR use psychosomatic Others the phrase misconstrueillnesses "psychological illness under their using the feelingsrubric as physical"somatoforma biopsychosocialfactors affecting arefour-fifthstime available of his of examination a by quart prescription, ofAnxiolytic vodka several area night medications yearseffective to enablelater in suppressing hesuch him as alprazolam PTSD (Xanax) and diazepam (Valium), was drinking between one-halfto sleep and and control his intrusions. symptoms; survivors which 39 psychologicalfunctioningsiondisorders." disorders Somatoform that and conflict suggests hypochondriasis.34 disorders orThe need."a physical essential most The relevantdisorder, symptomsfeature to of butthe a conversion survivoris in population disorder is an alteration or loss of physical fact an expression of a are conver- Otherwith access Psychological to these medicationsOther psychologicalSequelae sequelae may allowoccasionally themselves seento become in survivors dependent include on them. schizophre- 40 I MN an ONO calsymptomphysical factors aredisorder intentionally, etiologically or known the related symptompathophysiologic to the is symptom, not culturally mechanism. the sanctioned, In addition, and the MEM =I cannot beINN explained IN by any INNperson is not producing the psychologi- symptom commonnonrefugeeSchizophreniania andIIIIII briefare populations brief reactive reactive psychoses, but psychoses. mental These retardation, OM VIM MI occursMI statistically MIN more frequently in refugee populations than in occurs in only a small percentage of refugees. More are psychotic conditions preceded by and learning disorders. Nil am Rpm a40 stressful event that have a short duration and a goodServing prognosis.' Survivors Survivors of Torture who have reduced working capacity and earn less than controls." Psychological Sequelae of Traumatic Human Rights Abuses 41 learning."headfamilywere injuries members malnourished are during more in Farflight, likelychildhood, more under tocommon suffer torture,starved ismental complicatedor later because inretardation life, they bereavement. or "disappeared"have or hadproblems Survivorshigh fevers with who or have lost friends or were or supportfromas Jewish Vietnam, network Holocaust have in place done Notsurvivors, toall well help survivors materially Cubans,them resettlehave Armenians, but been eachand financiallystart of Persians,these communities unsuccessful. and ethnic Certain new occupations. The Nazi populations, such has had aChinese anorexia,bewildermentprecipitatedmurdered weight have followed by loss, reasonthe loss)and by to sufferingproblems ismourn. resolved. andMourning with distress.Grief concentration, is is expressedPhysical the process breathing,syMptoms as by a feelingwhich andinclude griefof sleeping. numbness weakness,(the feelings and orchiefogyconcentration moneyfor contributes preoccupationsHolocaust for fear camp to Survivors of material anothersurvivor of these success.and Holocaust. literaturefamilies Their Yael Childrenwas indicatesJewish Danieli, survival men,in that Newa andresearcherwho post-traumatic York,that during in the the Holocaust Group Project reportedthey that would one of hoard the food psychopathol- ablame,throughoutyears. part ofAlthough centering normal their somelives,grief.on what peoplemostNormal was rekindle haveor grief was grief-related feelingsnotsubsides done of overwith symptoms,well-being timerespect and tofeelings,and for the productivity.the deceased, most and behaviorspart is Self-oftenis expended in one or two Whobecameterribleunable Made to compulsivefate, provide It," made were for workers.""earning particularly their families' aOne living" "successful": group survival the of focussurvivors, of their who Danieli or protect their loved ones from a post-trauma lives and called "Those were Theseliteraturesquad persons activity, provides lack or genocidefamily numerousBereavement and by community governments. examples may be ofto complicated Thesoleshare Nazi survivors their concentration griefby ofmultiple and extended deaths families. as a result of camp survivorsupport them war, death theonMany "makemaking namelessness, survivors it a big," big namein if thisthey humiliation, forgroup were themselves, wereliberated, degradation, motivated to consciouslyin order by and shameto defeat they the had Nazis. experienceda Some wartime focused fantasy and desire to or unconsciously counteract "disappeared"beenthrough received, the mourningand thethe deceased'sgovenmentBereavement process. bodyhas may not has alsoacknowledged not be been complicated recovered, the arrest, if no or reliabledetention, word about the death has a person has or primarilystatus,Persistentlyduring forfame, the the and Holocaust. orbenefit singlemindedlywealth. of SometheirAs with children were they other soughtmotivated rathersurvivor higher by families, a powerfulthan need for theirto bear own witness. enjoyment'seducation, social and political they used their money mourningsituationsrefugeedeath."' Familycamp, process. individuals safely members living Majoror familiesmay abroad, depression hope may thator in maybe their unacknowledged unable occur loved into one theinitiate iscontext in detention. transit, of complicated alive In these in bereavement. When or complete the a OtheraccumulateOther Conceptualizationsresearchers wealth who without worked any with accompanying of Holocaust Psychological Sequelae survivorsdesire have toreported enjoy it."this need to continueseenretardation,symptoms in survivors. working ofoccur, depression, in theSurvivors, their diagnosisDownward chosen such when asof professions socioeconomicfeelingsmajor they becomedepression of because worthlessness refugees,drift should of is licencing another bemay and considered." not psychologicalrequirements,psychomotor be able to sequela sometimes notingasequelae variety are ofdiscussed learned other ways helplessness above,In the addition constellationspsychiatrists to the psychiatricof diagnoses and alexithymia. and psychologists have symptomsconceptualized survivors exhibit. Two worthand descriptions of post-traumatic in fewerseparatedleveloflinguistic themselves of members income difficulties,may as find aremiddleor socialearningit orharder orother statusupper income to refugee-related maintain inclass theiror maybecause adopted an find adequate problems. morethat country. they than standard Thosecannot Families whomaintainof living that thebecomebecause once thought same situationoccursLearned when leads subjects Helplessness survivors perceiveLearned that helplessness their is to doubt their ability to control their emotionsa term and borrowed from behavioral psychologists behavior does not affect their environment. lives. This and 4 reportedcongregatesupported. that Themay non-Jewish highalso But forcecost downward Norwegianofsurvivors living socioeconomicin to concentrationmany accept metropolitan a lower drift camp standard may survivorsalso of be living. a sequela had lower of one household mustareas be where refugeestrauma. Leo Eitinger thebasicdevastating, capacitypost-traumatic decisions." environment.Learned helplessness that typesto take of human control rights even abuse when is it denial is within of control theirFaced with real helplessness, develops during trauma may later be One of the most common, some victims feel that they have lost power to do so. These over even the most as well as mosttransferred into 42 IP OM MIN thanworking controls." capacity Several and stability studies and,have despite shown liberalthat Vietnam pension benefits, fared far MP WIN OM war combat veterans also worse so feelingsthat survivors may be retained after the traumait= has ended alai believe they cannot learn NEI new coping strategies, lack the motiva- and mayANIII become generalized 4MIN NMI 42Lion to try, and feel distressed. In essence, they haveServing learned Survivors to be of helpless.° Torture adjustmentsfreedomspower relationships of whichis termed their within "culture parents the family shock"do not to beapprove.and altered. is characterized The Tensions sum of may theby the aboveoccur anxiety-provoking ifdilemmas children wantand Psychological Sequelae of Traumatic Human Rights Abuses 43 theAlexithymiaSifneostion."" constriction Alexithymia to describe of affect, is multipleAlexithymia a cognition, psychotherapeutic psychological andis "the action; inability concept disabilities and to a bedisorder that aware that was ofsurvivors of developed hedonic and to commonly tolerateregula- by P.C. basic feeling states; subjectedthanneed their to act shareto while outward of being scarce discrimination, confrontedMinorities resources already by and racism, unfamiliar are living therebyor xenophobia.in social the depriving host norms country Those them.and may behavioral who Survivors feel have that experi-cues."may the refugeesbe are getting more Thus,emotionspatients?'exhibit." a personIt and has Persons to been withselect described withalexithymia the alexithymia proper in post-traumaticisemotion unaware lack when the or populationsabilityinteractingless aware to monitor with andof basic the in properly psychosomaticexternal feelings world.their and encedrefugees.logicalfrightened past cost. discrimination by This discrimination,Worldwide is Thetrue tremendousfor onthe Russians quotas,the incidence basis or adjustments segregationinof of Norway,ethnic psychiatric or of refugeeseasternracial their diagnoses owncharacteristics Europeans typically or other is higher makeethnic in may Canada, aregroups.among be not without psycho- cannotabstractdo occur use thoughts, theirand cannotemotions and recognize hasas guidelines a decreased these for feelings, abilityaction, to hasis feel unable a decreasedpleasure. to tolerate ability feelings to conceive that outLaotiansHungarians of Pakistan, in thein mainland England United States."andChinese Canada,Refugees in Taiwan, Cubans who and dwell in theVietnamese, on United their States,desire Cambodians, toIndians return moving andto their homeland often have a hadrefugeesAdded on them orPsychological immigrants. are inextricably NearlyTheir Consequencestrauma intertwinedall survivors stories with of and traumatic the the ofadditional effects Being human their stressesa rightsexperiences Refugee abuse of being haveoutside a their countries are difficultresumptioninis nottheir time possible homelands adapting of politicalseem alsoto tolife ortend,acculturate in solidarity the to newacculturate faster.workcountry, may Those more while be slowly,whotherapeutic. those maintain whothough accept A active amongsuccess that political survivors, return in one's ties stressors,refugeethe traumatic or migration immigrant. human stressors,The rights stresses and abuses arrival of immigration that stressors. drove the Premigrationmay person be divided to stressorsbecome into three ainclude refugee parts: premigration whoreasonoccupation move to exist fromcan to bea the country helpful Anotherexclusion inof thefirstsignificant of processallasylum else. stressor, ofto acculturationa third secondary country. but Itmigration, mayalso becomeoccurs is experienced when one's by refugees processandcoupled other iswith circumstances.orderly: the refugee's the survivorMigration pretrauma obtains stresses economic,a visa, depend travels social, on to, the and cultural, nature enters ofpolitical, the migration medical, process. For some, the the new country newculturalmembersrefugees environment; affairs. move of their Secondaryto thea national new stressful location migration or effectsethnic in the forcesofgroup host readjustment the countryor torefugee enjoy to may be togreater closer oronce may againtoparticipation not family be adjust offset or other to byin a a prolongedexperiencesrisk,without such incident. periodas arebeing inthemselvesBut asubjected refugeefor others camp, traumaticto thepirates, processor entering and traveling complicate is chaoticthe through new and post-traumaticcountry combat involves zones, great sequelae. staying personal for unlawfully. Such difficultydifficultthe potential the adjusting acculturation advantages to lifeThe inof process.greater athe large move. thecity. For cultural Aexample, and social distance between two peoples, the person who speaks a non-Indo-European a subsistence farmer may have more exhilaration.canlearn take a new months A language,tremendous or years Arrivallook foramount for refugees in employment, the of newenergy to face country and the generallywillingnessbreaking is usually ofsettle psychological toaccompanied adapt, in are findcharacteristic. houSing, by feelings of optimism and and physical It acculturationsocial,language political, may style,have andLastly, whethergovernmental people adaptive acculturate institutions. in different more difficulty learning English or getting used to Western ways and to different degrees. A survivor's oftensupports,bondsacceptance subject with must their to adjustof a homelands achange less-skilled to a new in economic and culture, job. become Their and position, socialmay homesick. have resultingstatus to Theylearn and in theahave new needdynamics lostlanguage. for familiar retraining and social or hierarchyThey are intertwinedBiological with Responsesand affectRecent research, while inconclusive, indicates or be affected by post-traumaticin the Brain sequelae. to Trauma or destructive, almost certainly will be that many psychological re- 44 4 aj stayedwithinrelyin the their oninside family. them families the Becauseto homeact may as may chigo-betweenschange ldren suddenly dramatically.adapt withfind and themselvesthe learn host For new example,community. languages to be the women This onlymore can employedwho quickly, cause traditionally adults person often traditional sponses to severe mechanisms,toTrauma person, elicits which depression, a variety of cognitivetrauma andhave affective a biologicalcan inchide activities, component. cognitive varying coping fromAs Walton person strategies, T. Roth unconscious writes: defense anxiety, and even hallucinations and delusions. All these 1111111 1111111 f11111111 dm air moo eir mi. tor" Alit IOW i111111 Mil Oil OW UM 41110 44 Sinceneurophysiologicalactivities 1956, have when both psychological Hanssubstrates." Se lyeServing studiedand Survivorsbiological changes of aspects, Torture in the have adrenal both meaningscortices ofand rats overOther their environment BiologicalResearch and Responses stress to investigatein which to subjects theStress differences have no between control indicatesstress in which that the subjects retain control Psychological Sequelae of Traumatic Human Rights Abuses 45 recollectiontrauma.humananatomicsubjected subjects Some andto of prolonged studiesevents,endocrine have examined memory,involve stress, effects." parts aresearchersdreams, broader Moreof the and range recentlybrain havefear of that(such beenneurobiological researchers play asaware the an limbicimportant that using consequences stress system animal role can and in have andthe theof exposedthisoccasions.'coworkerspsychological was was only Both used equal true and times 10 in in biological humanboth onethe subjects trials.trial. volunteers effects The were researchersamount oftold and the they exposed oftwo thennoisecould types measured themtostop ofwhich the stressto hypothalamicnoise,a theloud differ. volunteers though noise Breier inpituitary reality on two were and responses"kindling,"magnificationlocus coeruleus). to involving stress and Others aspersistence electrical they endeavor are manifested activityof PTSD to inprovide symptomsthe in thebrain. a immune functional Still through others and explanationthe endocrine view phenomenon the biological systems, for the of Theseandsion.function, depression, neurochemical In the electrodermal controlled and showedand stress neuroendocrine activity, increased situation and theneurochemicalselfratings effects subjects lasted ofreported helplessness,well and beyond neuroendocrinegreater the anxiety,anxiety, cessation helplessness, activity."and of depres- the producingtheirneurochemical metabolites stimuli and inand, neuroendocrinebloodThe in turn, locus and activates urine. coeruleus, activity, other a fearandpart centersbiologically of the inhindbrain the active brain. in substancesIf humans, stimulated, isor activated by fear - possesseshormonesstimulus and duringduring far traumalongerstress"Research canthanThis affect theresearch shows expectedthe severitythat suggests objective release of that sequelae. period thephysiologic amount of neurochemicals of measurements control and are indicators of post- a person nightmares.it producesintrusivefearless. VanfearphenomenonVan derandder Kolk KolkalarmThe of presentsand states; PTSD.56 locus colleagues evidencemonkeys coeruleus suggest thatwhose helps this that locus regulatepart changes of coerulei the sleepin brain the are andlocus is destroyed involved is coeruleus involved inare the in the production of sufferingratioscontrols."responsetraumatic are tofromfairly Insequelae. sound, addition, otherreliable researchers psychologicalBy urinein studying distinguishing and studying blood blood disorders." veteransmeasurements personspressure, distinguished suffering pulse, of norepinephrine:cortisolandfrom PTSD skin PTSD resistancepatients from from those in ofcause brainwhichnightmares." changes that exact repeats invisualization other in partsanIn unpredictablekindling, ofof eventsthe brain. repetitive, occurs sequenceThese rather subthresholdchanges thancauses normal, account much chemical more greaterfor nightmares dreamlike orneurological electrical typesin stimulation of the whichtoareCalabrese these very stress researchers,similar and influences coworkers to those Immunologicthe the inhypothalamic-pituitarynote bereavedimmune that immunologicchanges system. and chronically have Neuroendocrine abnormalities beenaxis stressed reportedis the mechanism people." in humans exposed seen in depressionto stress. Joseph According through rapidsurvivorsandtion behavioral heartbeat can suffer lead responsesand psychologicalto seizures." sweating than whenThe expected."or psychophysiological phenomenon exposed In toresearch objects of kindling animals orsequelae events may this suchthat explain sort symbolize as of anxiety stimula-why some oror conditionedthelymphoid immune (immune response."systems."Recently system) Thus, R. organs when Adler suggest and V. Cohen have shown stress causes immunosupression, other stimuli a link between the neuroendocrinethat the immune and system is capable of a cells in the various resemblebechemicallyof noxiouskindled. an aspect tophysicalAfter their ofkindling, brains. theirandFor example,psychological trauma.'This reactions electrochemical victims to stimuli future of torture stimulithatstimulation theircommonly reminiscent senses may are causetransmit exposed of the electro- braintorture to an to unpredictable series of thisfindingassociated hypothetical that with survivors that model stress for maycausing later are more likely than controls to suffer from physical illness.' cause immunosupressiondisease are profound,"as well. The and implications may explain Eitinger's hypothesizedasshould a normal be much result that greater an of underlying Thesuch than kindling stimulation. those physical experiencedeffect change has been duringsuch shown as the an anatomictotorture be of or long synaptic those duration expected reorga- and researchers have REFERENCES1. In one reported ANDCivilianManagementmore Situations,that 30 ofyears Post-Traumatic in Williams,after combat. 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IDaniel Nery Washington, Mental S.; Manner, and Disorders D.C.: C.; American Lindy,175: 25-276. J.D.; Psychiatric Press. Green, B.L.; Grace, M.C.;Statistical and Manual ofMental camps,survivorspost-traumaticsituations, survivors of a prisonerswide sequelae. of range torture, of His ofwar, typessurvivors model refugees of is trauma notof from sexual trauma-specific including war, abuse, witnesses survivors veterans and to is humanof intended of Nazi war rightsconcentration and to applycombatviolations, to 8. PTSD7. Id. Ahas working been documented group Theis inclusionnow Nationalin otherconsidering inpopulations Vietnam the next the Veterans editioninclusion of Readjustmenttheof DSM. of survivors of Studyhuman-induced found that 15.2 a victimization disorder for percent, or stress. personality,understandingwaysurvivors in which trauma, of kidnappings, thatexpected and person post-trauma post-traumatic responds and survivors circumstances to response. his of or nuclear her aretrauma, uniqueattack. Horowitz' andWhile will each influencemodel survivor's helps the in female.)male,arerate479,000, 1.1 dramaticallyfor Kulka, femalepercent of the Richard Vietnam 3.14 female)higher million A.; theatrethan orSchlenger, malecivilian rates veterans Vietnam for comparable is 8.5 Vietnam counterparts (1.2 percent male,theatre 0.3 veterans currently have PTSD.percent of 7,200 women. These figures era veterans (2.5 percent percent The orfear,tion."alternating exhaustion. sadness, The process phases and TheAccording ragemayo refusal f "denial" beassociated arrested to to face andHorowitz, with "intrusion,""workingaat memory any outcry thestage canofnormal ora lead disastermay response to through,"become panic, during dissociative pathologic.andto denial trauma finally may reactions,"comple-Thusis "outcry,"lead the to followed by tiveReportKathleen; Summary, of FindingsMarmar,PTSD Research fromCharles also the hasTriangle R.;National a high Weiss, Institute, prevalence Vietnam Veterans ReadjustmentDaniel S.,Study,William (November E.; Fairbank, 7, 1988) p.John Contractual 2. A.; Hough, Execu- B. charactertothoughtsmayextreme psychosomatic lead avoidanceof toreflected the disturbing, event. responses, andin theThe possiblepersistent inability inability depression, substance to toimages, love,complete feel abuseanxietycompulsive emotions,the toworking reactions, ease reinactments, or the through work. pain. or distortionsHorowitz, processIntrusive and mayrecurrent supra, thoughtsof one's lead n. POWs,Theatreabuses.traumas andPOWs Accordingclosely two and resembleof to11three one studied study,those PTSDexperienced percent of European Theatre POWs, 42 Vietnamamong war ex-prisoners POWs (the ofthird war (POWs), occurred in 28 percent of World War II by survivors of traumatic human percent of Korean war refused psychiatric a group whose Pacific rights acuteanother2, p. 41. trauma modelFor more response: to Dr. describeon Tomthe shock, denial Williams,post-traumatic impact, and intrusion a researcherand sequelae. resolution. phases who Williamssee During works n. 28 theidentifies withand shock accompanyingVietnam phasethree veterans,phases survivors text. of has developed 10. Chester,9. Engdahl Barbara, and Eberly, Williams,examination). supra, Oboler, Steven, (1987) n. 1, pp. 131-143.(1990) Because Mercysupra, Has n. 5. American Prisoners of War - An Overview, in copingandexperienceand anger, mechanismsTreatment immobilizationself-doubt, of and Survivor and come and depression; denial;toGuilt accept - duringThe thewhile Bad thetrauma. during Penny,impact Williams, the phase in resolutionWilliams, theyTom, experience (1987) supra,phase Diagnosis n.they anxiety1, p.test 76. I I. Allodi, Federico; PsychiatricVictoria;Editor, Psychology Effects Kolff, CornelisRandall, A.; Glenn Deutsch, R.; Lutz, Ana;ofand EllenTorture: Doan, Torture, L.; Two Washington, Medical Studies,D.C.: a Human Heart, in Suedfeld,Quiroga, Peter, Jose;Hemisphere. Zunzunegui, MariaRoscius, (1985) Physical and for Clinicians,Follow-upand(Acosta, the supra,Healing, Carolyn InteractionSimilar pp. inA.; 239-251. Williams, McHugh, modelsfor the See AdulthaveEditor, Mary also beenRape L.,Warner,Post-Traumatic [1987]postulated Victim, Carmen Sexual in Warner,by StressG., researchersAssault [1982ICounseling CarmenDisorders: Victims: working and AThe Braen,Handbook andwith Trauma survivors G. of rape 12. Mollica, Comas-Diaz.Torture:Elena 0., An Editors, Richard F.; Lavelle, James OverviewLillian; of Griffith,the Psychiatric Ezra EH., Care Editors, The Breaking of Bodies and Minds, P.. (in press) The Trauma of Mass of the Southeast Asian Refugee, New York: inW.H. Stover, Freeman. Eric; Nightingale, Violence and in Assessment,mentrefugeesRichard, on Depression Editors,from Intervention, war Management (Beiser, in Southeast and Morton,Counseling, of Asianthe [1988] Physically Refugees, Long Influences Beach: and Am./ Emotionally ofCapistranoPsychiatry Time, Ethnicity, Abused: 145:Press 46-51). Ltd.), Emergencyand Attach-Lenoreand 13. Kinzie, PosttraumaticMental Health,PsYchialry 141: J. David; Fredrickson, Stress Disorder Among NewSurvivors York: 645-650.John Wiley and R.H.; Ben, Rath; Fleck, Jenelle; Sons. of Cambodian Concentration Camps, Clinical Practice in Cross-Cultural Karts, William, (1984) Am 48 MI IMO TMwho described survived the kidnapping natural history (Ten, over Lenore, time of[1983] sequelae Chowchilla of Chowchilla Revisited: schoolchildren The Effects of IPIlt BEST COPY AVAILABLE 11111 as low 14. This is MIR based on the 11111 MS WM Oil al* Ulf MOB NOauthors' data and observations. There are no published studies on 48 15. DSM-III-R, p. 248. the frequenciesServing of the PTSDSurvivors criteria of Torture among this population. lievedpersonalities. in the predictability The pre-trauma of life.personality This personality enjoyed Psychological Sequelae of Traumatic Human security andcannot tranquility, be harmonized and be- with the Rights Abuses 49 17.16. Birkheimer,Arroyo, William, Lois J.;(1985) Devane, Children C. Lindsay;ington,Spencer; Traumatized D.C.:Muniz, Pynoos, American by Carlos, CentralRobert. (1985) Psychiatric AmericanEditors, Post-traumatic Post-Traumatic Press,Warfare, p. 113. inStress Eth, Stress Disorder in Children, Wash- control"andbearproducedtraumatized feelingsto modulate process by thisto personality recur reflectsconflictit. These in the abecomes controls morethat occurrence emerged controlled overwhelming,act as of afterward.brakes relative manner. to reduce Horowitz This anxiety statesmental of controls denial and must intrusion. be brought Each to postulates"release, that control, if the release,stress and allow thoughts namWilliam;CompDisorder:173; Veterans Psychiatry Mellman, Schwartz, Characteristics with 26: ThomasPosttraumatic Mark; 304-310; and Wallen,A.; Pharmacological Davis,Hendin, Stress Vincent, Glenn Disorder,Herbert; (1984) C., Response Haas,(1985)Comprehensive The N.P.; RelivingCombat-Related in theSinger, Veteran Psychiatry.Experience Paul; Population, Flashbacks Houghton, 25:in Viet- 165- in tion.stoppingExcessivepsychologicalcycle Horowitz, causesthe process use supra.,subtle masteryof controlsor changesn. overwhelming 2,of p.the or 94. inaevent, lackthe inneremotionalofwhich controls model Horowitz flooding lead calls as the individual struggles to obtain to non-completion due to either completionand continued or congruence. traumatiza- 19.18. Ten,Arroyo, Lenore, supra, (1983), n. 16, supra,p. 111. n. 4,Psychiatry pp.Posttraumatic 1543-1550; 46: 379-382. (1985)Stress Disorder: p. 53. Phenomenology and Similarity to Panic Attacks, J Clin 30.29. Id.,Affect p. 312. is defined as the experienceEd.,by of others. Baltimore:emotion Kaplan, expressed Williams Harold by and I.; the Sadock, Wilkins, patient Benjamin J., (1988) Synopsis p. 169. of Psychiatry, 5th and observed 21.20. SeeData chapter from the 10. National Vietnam VeteranssuggestsandVietnam for Readjustment some, thatveterans this especially sequela experienced Study those is notconfirm with confineda sense more that of severe tomany foreshortened children, problems, though future even it must at both the be uponpresent noted their thattime. return many This 32.31. Symmonds, See, e.g., Martin,Jaffee, R.,(1982) (1968) Victim Dissociativein"SurvivorInt Responses Ochberg, J Psychoanalysis PhenomenaSyndrome," to Frank Terror: M.; 49: Understandingin bu Soskis,310-312;Concentration J Psychoanalysis David Niederland, A., Editors, 49: W., 313-315. (1968) Victims Clinical Observations on the andCamp Treatment, Inmates, 23.22. Astrom,Id. C.; Lunde, I.; Ortmann, J.; Boysen,bancesveterans G.; in were TortureTrojaborg, not Survivors,much W.. more (1989) Acta than Sleep Neurol children Distur- Scand when 79: they 150-154. went to Vietnam. Supra, n. 3. 34.33. DSM-III-R,Westermeyer p. found 395. frequent medicalHmongWestview conditions adult Press, refugees pp. 95-104. in the United States. Westermayer,of a psychophysiological supra, n. 24. nature Garcia- in 97 of Terrorism, Boulder: 24. DSM-HI-R, pp. 218-224. See also Fairbank,Westermeyer,VeteransF., in(1983) the John withUnited Some A.; Post-TraumaticJoseph, Keane, PreliminaryStates: (1988) Terence A Point DS StressData M.;M-III Prevalence onDisorder, Malloy, thePsychiatric Psychological PaulJ Study, Consult Disorders Am Clin Characteristics J PsychologyPsychiatryAmong Hmong 51:145: of 912, VietnamRefugees 197-202; 917; AssistanceogydepressiondisorderPeltoniemi in Refugees, and assertsProgram-Mentalwith hypochondriasis somatic thatPrepared while delusions. Healthforsomatic are the Garcia-Peltoniemi, TechnicalNational complaints Institute not. These are commonly misdiagnosed Assistance Centerare of common the University in refugees, of somatization Rosa E., of(1987) Mental Psychopathol- Health's Refugee as psychotic Westermeyer,sphere,Editors,Report frompp. Refugee 113-130. Joseph, Asia Mental and (1986) the Health United Indochinese in States,Resettlement Refugees in Williams, Countries, in Community C.L.; Washington, Westermeyer, and Clinic:D.C.: Joseph, Hemi- A 37.36.35. DSM-III-R,Increased incidence p. 257. Minnesota (Contract No. 278-85-0024 pp. 259-261. of alcohol and drug dependence has CH) pp. 40-41. 25.26. Westermeyer, Genevieve Cowgill,J.; Vang, (1989)T.F.; Neider, personal J.,Not (1983)communication.Scales Using A in Comparison a Cross-cultural Psychiatric of Service:Refugees Context, An Using J OperationalAnalysis and of PsychiatryDSM-III Criteria 14: 36-41. and Self-rating 38. Garcia-Peltoniemi, MenLaufer,researchersVietnam of theR.; VietnamGallops,studyingVeterans: M.,Vietnam Recent Generation, Arch Gen Psychiatry 41: (1984) Some ProblemsResearch, Associated Hosp with Comm Psychiatrveterans. 33: 901-908; Egendorf, A., (1982) The Postwar Healing 327-333. been commented on by War Experience in Yager, T.; of 27.28. DSM-111-R, Horowitz hasp. 394. developed models to explainmodel.He suggests how This phases revision that afterof takesintrusion a traumatic considerable and denial experience time develop. and a effortperson because must revise each new his oraspect her innerof the 40.39. See Id., chapter Kaplan and Sadock, pp. 39-40. 8. supra, n. 34, pp. 37-38. eachchanged change inner may model elicit must painful be accomplished responses and by thereby adjusting inhibit the or older arrest model. the process Furthermore before Textbookand Bereavement .41. in Kaplan, Harold I.; Sadock,supra, Benjamin n. 29, pp. 52-55; Carr, Arthur C., (1985) Grief, J., Editors, Comprehensive Mourning 9 completion.worldviewsinjusticesdenial phases. Horowitzor iscruelty paired Survivors uses do with not a concept occur.anlose incongruity their This he calls sense incongruity "incongruity"between of the in worldtheir their to pre-trauma pre-traumaasexplain an orderly the and and intrusion post-trauma placepost-trauma where and 43.42. ee, . Egendorf,of Psychiatry A. (1982) //V, The Baltimore: PostwarHo;umStranomiti,esApareels, Healing of Press. Mortality and MorbidityWilliams after Excessive and Wilkins, Vietnam Veterans: Recent pp. 1286-1293. Stress, 50 r imp ma NEI imit MI MB an Mt BEST C PY AVAiLABLE S1973), 11111 1111 111M 11111 11111 Mil 11111 50 Research. Serving Survivors of Torture II osp Comm Psychiatry 33: 901-908; New Study Blames Vets' Problems on Status of f acculturationpercent) with syndrome a large percentage that does not having resolve chronic within six adjustment to 10 years disorder after migration. or citrons( The Psychological Sequelae of Traumatic Human Rights Abuses 51 VietnamCombat. Veterans Part I: Psychosocial San Francisco Chronicle, July 25, 1985, p.Characteristics, 4. But, see Health (1988) and emotional problems in Vietnam JAMA 259: 2701-2707. thephenomenon stress of acculturation was previously and called the failure "refugee of complete neurosis" acculturation and was thought combining to result to cause from self-report of symptoms. Westermeyer, 44. Danieli, Yael, (1988) The HeterogeneityveteransIn thatfor characteristics study did researchersnot lower at their entry found social to that the psychologicalservice. and economic attainment as a group when of Postwar Adaptation in Families of Holo- adjusted later(1988),a loweredmore they adjusted were level less of Whento coping anxious,their the surroundings and Vietnamese but an were increased frustrated depression first arrived and paradoxically homesick.in America As anxietyincreased. the refugees symptoms It took becamesupra, severalprevailed; one year n. 24. 45.46. Id., Bittner, pp. 120-121. Egon, (1968) Life AdjustmentHolocaustcaust Survivors, and of in Its Braham, Aftermath, Randolph Boulder: Social Science Monographs, p. L., Editor,after Severe Persecution, The Psychological Perspectives of the Amer J Psychiat 115. 124: ResettlementtheMing;months United Masuda, for States, refugees of Minoru; Migrant in Nann,to realizeTazuma, Families Richard their Laurie, and C., situation Children,Editor, (1982) and Problems to psychologically of Vietnamese "arrive." Refugees Lin, Keh- in Uprooting andSurviving AdaptationDordrecht, and Holland: D. Reidel, p. 22. 47. Leo Eitinger, following interviews87-94.withfound post-traumatic that retention ofoutcome. the ability Eitinger, to make Leo, with more than 2,000 concentration camp survivors, one's own decisions had a positive correlation(1974) Coping with Aggression. Mental 55.54. Selye,Roth, WaltonHans, (1956) T., (1988) The RoleBrunner/Mazel,Ochberg, of Medication Frank, p. Editor, 41. in Post-Traumatic Therapy, in The Stress of Life, Post-Traumatic Therapy and Victims of Violence, New York: McGraw Hill; Kandel, Eric R., New York: 48. II Rhinescapable Soc"Animals shock,who have which been has actively widespreadThe bestprevented biological from model for learned helplessness 1: 279-301. behavioral and physiological consequences. escaping severe physical stress, such involves exposure of animals to Neuroscience,(1982)Stress.Kling,Experience Environmental Michael Bereavement, and A.; Learning, Gold, Determinants and Philip Depression:in Kandel,W., (1987), of BrainE.R.; Focus Alterations ArchitectureSchwartz, on Neuroendocrine in J.H.,Immunocompetence and Editors, of Behavior: Regulation, Early during New York: Elsevier, North Holland, pp. 620-632; Calabrese, Joseph R.; Principles of Am J learningas electricdifferenthavingnew contingencies, to been shock,escape environment given loudfrom andone noise,novel shortly (3)session aversivechronicor afterwards. of inescapable situations, submersion in cold water,evidence later ofshow subjective (1) deficits distress. in For example, after When placed in a shuttle box they fail to jump shock, dogs(2) fail a decrease to avoid in shock motivation in a to learn 56. The locus coeruleus exerts controltheprimaryPsychiatry overcerebellum, sourcethe autonomic ofand noradrenergic to a nervouslesser degree innervationsystem the and hypothalamus. of is the the limbic system,It also plays the cerebral a major cortex,role in 144: 1123-1134. thatupshocks,across has the aled helplessnesswhile barrier to the urinating, to term terminate syndrome learned defecating is not and whining. shock. Instead they passivelyhelplessness. lie down, Controlled enduring experiments have merely due to shock per se, but rather to the lack The impression that they have given established repeated 57. van der Kolk, (1988)temporalmemory The retrieval neocortex, Biological by means allResponse of whichof neural to are Psychic connections involved Trauma, in tomemory. the in Ochberg,hippocampus, van der Kolk, amygdala, Bessel andA., et al., supra, n. 48. supra, n. 54, p. 30. produceof controltumorand(1985) motivation, loweredgenesis." that Inescapable the social animal such dominance, inescapable Shock,has in terminating Neurotransmitters, aversive events (van der Kolk, Bessel; Greenberg, immunosuppression and increased incidence of shock. In addition to deficits in andlearning Addiction to Trauma:Mark; Toward Boyd, Helene;a in Krystal, animals John, have been shown to 58. McNamara, James O.; Bonhaus,Gellman,postulateCritical Douglas Randy Review, that W.; L.; repetitive Shin,Giacchino, Cheolsu; psychological Jeannie Crain, L., Barbarastress(1985) mayThe J.; Kindlingbe capable Model of activatingof Epilepsy: critical A CRC Crit Rev Clin Neurobiol 1: 341-391. Post and Kopanda also 49. Krystal, Henry, (1987) The ParadigmTrauma.PsychobiologyBaltimore, Paper Md. ofpresented Post Traumatic annual meetingStress, Biol of of Adult Catastrophic Trauma and Infantile SocietyPsychiatry of Traumatic 20: 316.) Stress Disorders, sis,sameandlimbic that way.mechanisms these Post, mechanisms Robert involved M.; mayKopanda, in theallow modulationAm environmentalRichard, J Psychiatry (1976)of emotional events Cocaine, to and sensitize Kindling, cognitive patients and behavior, Psycho- in the 133: 627-634. 50. Nemiah, J.C.; Sifneos, P.C., (1970) AffectButterworth,Disorders, in p. Hill, 126. 0., Editor, Modern Trends in Psychosomatic Medicine, and Fantasy in Patients withConcepts in Psychosomatic Medicine, Psychosomatic London: in 61.60.59. Id.Id. 51.52. Knapp, Lin, Keh-Ming;Peter H., (1985) Masuda, Current Minoru, TheoreticalCultures:Kaplan and Southeast Sadock, Asian Refugees in America, supra, n. 41, p. 1119. (1983) Impact of the Refugee Experience, Los Angeles: Special Service Bridging for 62.63. Kandel, Breier, Alan; Albus, Margot; Pickar,inPaul, Mood Steven and NeuroendocrineM., (1987) Controllable and Psychophysiological and Uncontrollable Function, Stress in Humans: Alterationssupra, n. 55. David; Zahn, Theodor P.; Wolkowitz, Owen M.; Am J Psychiatry 144: 5_ 53. Groups,Id..the AsianUnited American StatesWestermeyer is atCommunity least twicestates Mental that thatp. of the33. the rate U.S. of psychiatric Health Training Center p. 34.disorderspopulation among (43 Hmong percent refugees versus 15-20 in 64. Id.nephrinehormone1419-1425. and(ACTH), increased electrodermalIn their study, activity. hypothalamic pituitary function and increased sympathetic activity was reflected by plasma epi- was measured by adrenocorticothrophic 52 alle MN Mt NO MI HS MIS .1111111t MI BEST COPY AVAILABLE Mil III WO 'MI Ma 11111 11111111 IMO 65.52 Id. In addition, Thomas R. Kostensensitivity to learnedServing helplessness Survivors of and Torture andcatecholamine John Krystal sensitivitynoted genetic differences suggest- variationreactions in to ProcReceptorsEarl Sac L.; Biol Southwick, in Psychiatry, Post Traumatic Steven Psychological Sequelae StressM.; Disorder Perry, and Bruce Other D., of Traumatic Human (1987) Blood Element Affective Disorders. (Abstract), Rights Abuses Adrenergic 53 stressors.ingmeeting,learned at least Theyhelplessness. an (1987) element have Baltimore, also ofPaper naturalnoted presentedMd. at that previousresistance mastery or heightened decreases sensitivity in Society for Traumatic Stress Studies annual Gerardi, Robertthe J., incidence of 68. Calabrese, Joseph R.; Kling, docrineImmunocompetence Regulation, Am During Stress, Bereavement, J Psychiatry 144: 1123-1134.No. 285 Mitchel A.; Gold, and Depression:Philip Focus W., (1987) Alterations inon Neuroen- 66. Blanchard, Edward B.; Kolb, Terence(1983)Veterans, A M.,Psychophysiologic (1983)Psychiatric Validation Q 54: Study of 220-228; a Lawrence C.; Pallmeyer, Thomas P.; Multimethodof Post Assessment Traumatic of Stress Posttraumatic DisorderMalloy, Paul F.; Fairbank, JohnClin Psychology A.; 51: 488-494. in Vietnam Keane, Stress 69. /d. They also note that lymphokinescentralimmunebehavioralmay gainnervous response access responses system to to the norepinephrine central an antigento an(foreign invader substance) that have nervous system and (substances potential survivalmay promote value. adaptive endocrine secretedthere is by evidence white blood of decreased During the cells) and 67. Kosten and coworkers investigatedDisorderssympatheticin hospitalized in Vietnam nervous-system PTSD Veterans, patients. overactivity! ConsultThe mean depressiveurinary norepinephrine disorder, paranoid and epinephrine schizophrenic, and (which would benorepinephrine expected) and levels was greaterin PTSD indicated elevations PTSDarehypothalamic patientsseen with described thesenuclei.Furthermore changes. Decreased recalling the increased levels norepinephrine turnover and an increased of epinephrinecontent and in peripheral lymphoid firing in specific organs undifferentiatedthanoutwardlyhospitalization. that found and schizophrenicin withIncreased bipolar, hypervigilance. major norepinephrine patients. The These meanlevels depressive disorder, paranoid levelsepinephrinehave were been sustained linked levels with inthroughout PTSDdiverting patients theanger schizophrenics, and production.tiesacuteare as anaphylaxis) potent compared Linn regulatorsand withand mayB of the be immune coworkers, using the HPA above, it is cellknown abnormalities that through responsible for the predominance system (as indicated by the both norepinephrine their effect on glucocorticoid use ofof epinephrine T cell abnormali- in norepinephrine in and epinephrine undifferentiatedweremedicationthanpredominantly higher that found thanuse schizophrenics, orin inmajor differences bipolarthe normal patients. insignifyingranges the level thus more Neither of these levels could be suggestingexplained bythatof hormonal activity. The levels measured may have test to results were adrenal activity. It was not higher Similarly,Eventsreducedtoin bereavedmixed Calabrese Dysphoric natural lymphocyte subjects, killer Mood found cellculture. activity. that They and Immune Responsiveness, those who were Linn, M.W.; Linn B.S.; also found that examination more depressed hadchecklist reduced as a Jensen B.S.,Psycho! (1984) measure of depression stress or lonelinessRep 54: 219-222. responsesS tressful changeKosten,traumaticLaurie, less Thomas to (1987) cause Stress R.; Sustainedpsychological Disorder, Mason. UrinaryJohn W.; Psychoneuroendocrinology 12: 13-20. Norepinephrinedysfunction and Epinephrine than to cause Elevation endocrinologic in Ciller, Earl L.; Ostroff, Robert B.; Harkness,disorder. Post- 70. Adler, R.; Cohen, V., maticdiminishedimmunocomptence Med 37: lymphocyte333-340. with quantitative(1975)and Behaviorally changes colleagues Conditioned reported, responsivitiy." Calabrese, suchleixtreme as decreased physical T et al., supra, n. 68. Immunosupression, stresscell diminishes number and Psychoso- islowerpatients surprising than described in becauseallMason the by other andaKosten low groupscolleagues urinary above. except investigated cortisol would noturinary beThey expected free-cortisol found withthat overtthese levels PTSDlevels in the andwere same paranoid group schizophrenia. This significantlymechanism signs of result of conditionedifanimalspression) they also were stimuluswith had given saccharin been saccarin at a later time they given cyclophosphamide.They (apaired sweetener cyclophosphamide with no immunomodulation had an immunosuppressed They were later able (a drug causing immunosup- properties). When response as anxietysuppressiveestablishedexerts and a depression.selective thateffect certain oninhibitory They urinary psychological concluded corticosteroid of the adrenal cortex byinfluence ACTH in thesein the persons pituitary adrenal axis. defenses, especiallythat denial, some specificcan exert psychological a stronglevels even when the subject is It has been exposed to produced 71. For requiring immunosu an in-depth discussion lu response to immunosuppressppression as ble to decreaseof other biologically treatment. morbidity and mortality active substances and in a therapeutic in diseased animals way using only to use this normalnewW.;suggesting stress.Free-cortisol Ciller,responses Overstimulation Earl a psychological (that L.;Levels Kosten is, thein Posttraumatic adrenalThomas suppressive R.; Stress itself worked properlyOstroff, upon Robertmechanism artificial B.; Podd, of ACTH Linda, stimulation. Mason,Disorder Patients,! Mew Nery Dis (1986) Urinary stimulation) 174: 1-5. John 312-327,31:cal Philip Manifestations348-353, W.;Philadelphia: Goodwin,413-420; of Depression: RelationDysregulationFrederick K.; in Chrousos,Golden, Robert N.; Affective Disorders, to thePutter, Neurobiology William of Z., GeorgeStress,N P., (1988)Clinical Psychiatric Can (1986) Neurochemical stress seeand Gold, Biochemi- Engl. /Med N Am 9: wereKosten,individual able to Thomas discriminatebasisMason had R.; Harkness, aboutand all groups colleagues 80 percent Laurie, then calculated a from the PTSD patients. The use (1987)sensitivity. Elevation Mason. of JohnUrinaryurinary W.; norepinephrineGiller, to cortisol of this ratio onNorepinephrind an Yale U. School ratio and Earl L; BiologyDepression, andof Anxiety, Strom, supra,in Frazier, in Frazier,Philadelphia: Shervert W. W.B. Saunders; Rothschild, B. Saunders,H., TheS.H., Medical Clinics supra, pp. 791-814. pp. 765-790; Teicher, Martin Anthony J., (1988)ofNorthAmerka: Anxiety awlBiologyH., (1988) of ofCortisol Medicine, Ratio West in Post-traumaticGiller Haven and V.A.coworkers StressMedical measured platelet receptors Disorder, Dept.Ctr., of Psychiatry,unpublished.in humans) and found a decrease (receptors from the central in certatn nervous also n. 42. 53 plateletsystemandthatfound the affinityarereceptors altered high unavailable in levels platelet bothin PTSD, of peripheral forcatecholaminesaffinities measurementbipolar inplatelet disorder, PTSD may and sites and in the central nervousbe related to changespersonalityand manicin the disorder patients. patients. These receptorresearcherssystem. Gffia They believe num_...7 BEST COPY AMIABLE 54 1111. 11111 111 W11 MIR NB MN Mt 11111 all 1111 11111 Eft Nip

)w NATIONAL ORGANIZATION (202) 232-6682 ("232-NOVA") FOR VICTIM ASSISTANCE ® FAX: (202) 462-2255 1757 Park Road, N.W. Washington, D.C. 20010

Children's Reaction to Trauma

I. Caveats about Children A. Regression B. Double Loss C. Live in Present D. Growth E. Change H. Developmental Stages of the Child A. Age: Birth - 2 Years 1. Language capability: pre-verbal. 2. Communication mode: physical activity. 3. Thought processes: distinguishes self from others and other things. 4. Growth emphasis: sensory perception and response. 5. Primary need: physical human contact for reassurance. 6. Primary relationship: with caretaker(s). B. 2 Years- 6 Years: Pre-School 1. Language capability: development of language/verbal expression. 2. Communication mode: expression of feelings primarily through play, butcom- munication of needs often through words. 3. Thought processes: pre-conceptual thinking but engages in primitive problem-solving. active imagination but grounded in reality fantasies are about things similar to those they have experienced. minimal concept of time and space. inability to concentrate on any one thing for more thana few minutes. 4. Growth emphasis: physical independence; dressing, feeding, and washing self.

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© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE. 5. Primary need: need for nurturing. "who will take care of me?" wants structure and security. 6. Primary relationship: with family.

C. 6 Years - 10 Years: School Age 1. Language capability: language well developed. 2. Communication mode: Still uses play for primary expression but supplements play with emotive language. 3. Thought processes: uses problem-solving techniques but also trial and error approach to prob- lems. understands time and space concepts. strong orientation to the present but has some sense of future and past. makes choices. 4. Growth emphasis: toward independence in establishing new relationships; exploring new environments. 5. Primary need: trust. 6. Primary relationship: still family but movement toward establishing strong peer relationships. D. 10 Years - 12 Years: girls' pre-adolescence 12 Years- 14 Years: boys' pre-adolescence 1. Language capability: Language may be more advanced than concepts. 2. Communication mode: "acting out" is common form of expression; poetry developing. 3. Thought processes: prone to extreme feelings and idealized emotions or life styles. judgmental about the world and self. thoughts become integrated with feelings and engender beliefs, biases, and prejudices.

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© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® 4. Growth emphasis: towards emotional independence: involves swings back and forth from child- like states to imitations of adult life. growth of sexuality and concern with sexual identities. emotional turmoil heightened by physical changes. 5. Primary need: support and self-esteem. 6. Primary relationship: back and forth from family to peers. E. 12/14 Years - Adult 1. Language capability: uses and creates language to express self. 2. Communication modes: Drama and physical activity is preferred recreation since it provides a socially accepted way of acting out feelings; poetry still intense. 3. Thought processes: understands "cause and effect." can consider possibilities and explore options without experiencing them. judgmental about everything sees things in black and white. can conceive of future activities but does not think of future in terms of self the Peter Pan dream. prone to taking irresponsible risks and failing to think through the conse- quences of actions. reflection on symbols and possibilities. decentering. development of critical faculties. emotional turmoil may include periods of depression and euphoria. 4. Growth emphasis: independence from adult world particular target of con- flict is usually parents. ego-orientation and self-centeredness. feels strong need for privacy and secrecy. body and sexual image is highly important. sense of immortality.

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© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® creation of dance, style, world. 5. Primary need: stability, limits and security. 6. Primary relationship: with peers. III. Child Reactions To Trauma A. Overview: Children's reaction to a trauma will involve not only the impact of the catastrophe on their lives (what they saw, heard, felt, smelled and so on) but a sense of crisis over their parents' reactions. The presence or absence of parents and terror over a frightening situation one that has rendered the children's parents helpless all contribute to children's distress. "A central theme that emerges from exploration of children's responses to disaster situations is that, in a way that is not generally appreciated, they, too, experience fear of death and destruction... Particularly influential in the young child's experi- ence are the presence or absence of his parents and the terror of overwhelming physical forces that seem to render the 'all powerful' adult parents frightened and powerless." B. Birth - 2 Years 1. High anxiety levels manifested in crying, biting, throwing objects, thumb suck- ing, and agitated behavior. 2. While it is unlikely that the child will retain a strong mental memory of the trauma, the child may retain a physical memory. C. 2 Years - 6 Years: pre-school 1. Children may not have the same level of denial as do adults so they take in the catastrophe more swiftly. 2. Engage in reenactments and play about the traumatic event sometimes to the distress of parents or adults. 3. Anxious attachment behaviors are exhibited toward caretakers may include physically holding on to adults; not wanting to sleep alone; wanting to be held. 4. May become mute, withdrawn and still. 5. Manifest a short "sadness span" but repeat sadness periodsover and over. 6. Regress in physical independence may refuse to dress, feed, or wash self; may forget toilet training; may wet bed. 7. Sleep disturbances, particularly nightmaresare common.

5E © 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® 8. Any change in daily routines may be seen as threatening. 9. Does not understand death (no one does) and its permanency reaction to death may include anger and a feeling of rejection. D. 6 Years - 10 Years: School age 1. Play continues to be the primary method of expression. Often art, drawing, dance or music may be integrated in the play. 2. The sense of loss and injury may intrude on the concentration of the child in school. 3. Radical changes in behavior may result the normally quiet child becoming active and noisy; the normally active child becoming lethargic. 4. May fantasize about event with "savior" ending. 5. Withdrawal of trust from adults. 6. May become tentative in growth towards independence. 7. Internal body dysfunctions are normal headaches, stomach aches, dizziness. 8. May have increasing difficulty in controlling their own behaviors. 9. May regress to previous development stages.

E.10 Years - 12 Years: girls' pre-adolescence 12 Years- 14 Years: boys' pre-adolescence 1. Become more childlike in attitude. 2. May be very angry at unfairness of the disaster. 3. May manifest euphoria and excitement at survival. 4. See symbolic meaning to pre-disaster events as omens and assign symbolic reasons to post-disaster survival. 5. Often suppress thoughts and feelings to avoid confronting the disaster. 6. May be self-judgmental about their own behavior. 7. May have a sense of foreshortened future. 8. May have a sense of meaninglessness or purposelessness of existence. 9. Psychosomatic illnesses may manifest themselves.

60

© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® F. 12/14 Years - 18 Years 1. Adolescents most resemble adult post-traumatic stress reactions. 2. May feel anger, shame, betrayal and act out their frustration through rebellious acts in school. 3. May opt to move into adult world as soon as possible to get away from the sense of disaster and to establish control over their environment. 4. Judgmental about their own behavior and the behavior of others. 5. Their survival may contribute to the sense of immortality. 6. They are often suspicious and guarded in their reaction to others in the after- math. 7. Eating and sleeping disorders are common. 8. Depression and anomie may plague the adolescent. 9. May lose impulse control and become a threat to other family members and him/herself. 10. Alcohol and drug abuse may be a problem as a result of the perceived mean- inglessness of the world. 11. Fear that the disaster or tragedy will repeat itself adds to the sense of a fore- shortened future. 12. May have psychosomatic illnesses.

6

© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® -"'"fr' NATIONAL ORGANIZATION (202) 232-6682 ("232-NOVA") FOR VICTIM ASSISTANCE8 FAX: (202) 462-2255 1757 Park Road, N.W. Washington, D.C. 20010

Some Coping Strategies for Children A. Rebuild and reaffirm attachments and relationships. Love and care in the family is a primary need. Extra time should be spent with children to let them know that some- one will take care of them and, if parents are survivors, that their parents have reassumed their former role as protector and nurturer is important. Physical closeness is needed. B. It is important to talk to children about the tragedy to address the irrationality and suddenness of disaster. Children need to be allowed to ventilate their feelings, as do adults, and they have a similar need to have those feelings validated. Reenactments and play about the catastrophe should be encouraged. It may be useful to provide them with special time to paint, draw, or write about the event. Adults or older children may help pre-school children reenact the event since pre-school children may not be able to imag- ine alternative "endings" to the disaster and hence may feel particularly helpless. C. Parents should be prepared to tolerate regressive behaviors and accept the mani- festation of aggression and anger especially in the early phases after the tragedy. D. Parents should be prepared for children to talk sporadically about the event spending small segments of time concentrating on particular aspects of the tragedy. E. Children want as much factual information as possible and should be allowed to discuss their own theories about what happened in order for them to begin to master the trauma or to reassert control over their environment. F. Since children are often reluctant to initiate conversations about trauma, it may be helpful to ask them what they think other children felt or thought about the event. G. Reaffirming the future and talking in "hopeful" terms about future events can help a child rebuild trust and faith in his own future and the world. Often parental despair interferes with a child's ability to recover.

H. Issues of death should be addressed concretely.

62

© 1994 NATIONAL ORGANIZATION FOR VICTIM ASSISTANCE® GL)REHDE

63 Fa-- for Families from the American Academy of Child and AdolescentPsychiatry No. 8 (9/91) CHILDREN AND GRIEF

When a family member dies, children react differently from adults. Preschool children usually see death as temporary and reversible--a belief reinforced by cartoon characters who "die" and "come to life" again. Children between five and nine begin to think more like adults about death, yet they still believe it will never happen to them or anyone they know. Adding to a child's shock and confusion at the death of a brother, sister or parent is the unavailability of other family members, who may be so shaken by grief that they are not able to cope with the normal responsibility of child care. Parents should be aware of normal childhood responses to a death in the family, as well as danger signals. According to child and adolescent psychiatrists, it is normal during the weeks following the death for some children to feel little immediate grief or persist in the belief that the family member is still alive. But long-term denial of the death or avoidance of grief is unhealthy and can later surface in more severe problems. A child who is frightened about attending a funeral should not be forced to go; however, some service or observance is recommended, such as lighting a candle, saying a prayer or visiting the grave site. Once children accept the death, they are likely to display their feelings of sadness on and off over a long period of time, and often at unexpected moments. The surviving relatives should spend as much time as possible with the child, making it clear that the child has permission to show his or her feelings openly or freely. The person who has died was essential to the stability of the child's world, and anger is a natural reaction. The anger may he revealed in boisterous play, nightmares, irritability or a variety of other behaviors. Often the child will show anger towards the surviving family members. After a parent dies, many children will act younger than they arc. The child may

6 45 BEST COPY MAMIE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY

',(,11, 'LTA ( JI JI . )1( )r.1f) 200 I 6WO?) (ir Children and Grief, No. 8 (9/91)

tolipormily bccuilicmore infantile, demanding food, attention and cuddling, and talking "baby talk.-

lounge! childien believe they are the cause of what happens aroundthem. A young child may behexe a pin cut, grandparent, brotheror sister died because he or she had once "wished" the person dead. The child feels guilty becausethe wish "came true." Some danger signals to watch for

An extended period of depression in which thechild loses interest in daily activities and I c' cuts. Inability to sleep, loss of appetite, prolonged fear ofbeing alone. Acting much younger foran extended period. Excessively imitating the deadperson; repeated statements of wanting to join the dead person. Withdrawal from friends. 1 Sharp drop in school performanceor refusal to attend school. These warning signs indicate that professionalhelp may be needed. A child and Iadolescent psychiatrist can help the childaccept the death and assist the survivors in helping the child tluough the mourningprocess.

It Alm oh .in At adult) ot Child and Molest cm Psychiatry (AA( Al'), September 1991. Please copy and distributeor reprint this information. I he ,1.1( h. membership of Itusiihild and adolescent psychiatrists-physicianswith at least S years of training beyond medical school in adult, child and adoitscent ini)thiatry

Other 'Nets fur liamillee availabk:

I( hililon and Divorte In horning 31. When Children have Children 2 teenagers with Feting Dnatliicn. 17 hildren of Alcoholics 32. Hewn Questions to Ask lkfore Psychiatric 1 Ii.n. A144,114,1 and Other Druy,s IN Ildwelling Iltarmal Treatment of Children and Adolescents 1 the Depressed (*hold Child with a I Aing.Terin Illness 33. Conduct Disorders S (h,id AbuseThe !kitten Itruises 211 Slaking Day Care r (ii. J FArcrience 34. Children's Sleep Problems I.I iiildicn Who Can't AticnIwn 21. Psychirloc Medicriu in for Children 3.5. Tic Disorders 7 hil.ltcn Who Won', (Jo Iu Sthool 21 Normality Ilelping Children After a Disaster h( bii.lren and 21 Mental Retardation 37 Children and Firearms (h,IJ sews! Abuse 24 Kw./ When to Seek {let!) for Your Child 3l. Manic.Deprcbsive Illness in Teens InI., n 1u14 1.1c 2.5 Know Where to hind !trip for Your (had 39 Children of Parents with Menial Illnesses IIthe Aulo,or ( had 211. Know Your I lealth Insurance Iknebis 40. the Influence of Music and Rock Videos 12 (Ii.IJrcn Who Steal 27. Stepfamily Problems 41 Making Decisions About Substance Abuse Treatment II inidren and 'IV Vsolcn4 e 211 Responding lo Child ticaual Abuse 42. The Continuum of Care II( hildrcn and Family Moves 29 Children's Mayor Psychiatric Disorders 43. Discipline itI in. Adiipied Child 311 Children, Adolescents and IIIV/AIDS

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BEST COPYAMIABLE 65 Facts for Families from the American Academy of Child and Adolescent Psychiatry No. 36 (7/91) HELPING CHILDREN AFTER A DISASTER

A catastrophe such as an earthquake, hurricane, tornado, fire or flood is frightening to children and adults alike.It is important to acknowledge the frightening parts of the disaster when talking with a child about it.Falsely minimizing the danger will not end a child's concerns. Several factors affect a child's response to a disaster. The way children see and understand their parents' response is very important. Children are aware of their parents' worries most of the time but they are particularly sensitive during a crisis.Parents should admit their concerns to their children, and also stress their 1 abilities to cope with the situation. A child's reaction also depends on how much destruction he or she sees during Lnd after the disaster.If a friend or family member has been killed or seriously injured, or if the child's school or home has been severely damaged, there is a greater chance that the child will experience difficulties. A child's age affects how the child will respond to the disaster. For example, six-year- olds may show their concerns about a catastrophe by refusing to attend school, whereas

adolescents may minimize their concerns but argue more with parents and show a decline in school performance.It is important to explain he event in words the child can understand. Following a disaster, people may develop Post-Traumatic Stress Disorder (VISD), which is psychological damage that can result from experiencing, witnessing or participating in an 1 overwhelmingly traumatic (frightening) event, Children with this disorder have repeated episodes in which they rc-experience the traumatic event. Children often relive the trauma through repetitive play.In young children, distressing dreams of the traumatic event may change into nightmares of monstets, of rescuing others or of threats to self or others, 65 BEST COPY MLA AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY

;61 W1',( )11',1f J AV1ji f WA',1 11N( 1I N, D 1 200 l b(10?) 9(d/ 10(1 Helping Children After Disaster, No. 36 (7/91)

PTSD rarely appears during the trauma itself. Though its symptoms can occur soon after the event, the disorder often surfaces several months or even years later. Parents should be alert to these changes: o Refusal to return to school and "clinging" behavior, shadowing the mother or father around the house; o Persistent fears related to the catastrophe (such as fears about being permanently separated from parents); o Sleep disturbances such as nightmares, screaming during sleep and bedwetting, persisting more than several days after the event; 0 Loss of concentration and irritability; o Behavior problems- -for example, misbehaving in school or at home in ways that are not typical for the child; o Physical complaints (stomachaches, headaches, dizziness) for which a physical cause cannot he found; o Withdrawal from family and friends, listlessness, decreased activity, preoccupation with the events of the disaster.

Professional advice or treatment for children affected by a disaster--especially those who have witnessed destruction, injury or death--can help prevent or minimize PTSD. Parents who are concerned about their children can ask their pediatrician or family doctor to refer them to a child and adolescent psychiatrist.

0 AMC!. JII Academy of Child and Adolescent Psychiatry (AA(AP), July 1991.Please copy and distribute or reprint this information. the AACAP has a membership of 471 child and adolescent psychlainstsphysicians with at least 5 years of training beyond medical school in adult. 411i Id and adolescent psychiatry.

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I I t lot ion and I .toly Mew's 2/1 Rewinding to I held Sexual Abuse 41. Making Decisions About Substance IS the AdoitieJ Child 29 Children's Moir Psychietru I/moiler% Abuse Treatment tr, I r- aining I iii-iiiiiiini Vii Children, Adolew ems and 111V /Allis 42 'Die Continuum of ('are 11 When Children Dave thildon

Any boleAlt 1..ot is liec WWI a sell addicuad, b1111p0 envelope1 of the tomplele sri of 41, send a 'heck fur $71111 (Includes paialase and hau.limag) palahlc t., AACAP hiPublic Information, AMAP, Ilsix 9111L, Washington, D.C. 3110/0-11106.Bulk orders are $.23 per sheet, 1.0.1.4c and handling, and must Ire prrisoilIt °mini AMA,' fur appropriate postage and handling charges on bulk urders.) 6 7 BEST COPY AVA6LA LE 68 146 Serving Survivors of Torture HemlineCorralesof HondurasDisappearancesruled thatLCase, Rev there for March13: the wasand 507-577. "disappearances" 15,insufficientthe 1989.Inter-American See proof Mendez, of to establish the responsibilityCourt: Reflections of the on a Litigationtwo Costa Ricans. Fairen Carbi Juan E.; Vivanco, Jose Miguel. Experigovernment and Solis (1990) 17.16. InFerencz, 1975, South B., (1979) Vietnam Less had Than only SoutheastCompensation,Slaves:American Asian Community Cambridge: Refuges, Mental in Cambridge America, Health Training a handful of psychiatrists and Laos had UniversityLos Angeles: Press. AsianJewish American Forced LaborCommunity and the Center, (1983) Bridging Cultures: none. Asian Quest for 19.18. Mollies,Yamamoto, Richard, Joe, (1982) (1989) Beginning personalsupra,Mental n. Health 1, p. 44. Training Center, p. 41. communication.an Asian/Pacific Mental Health Clinic, in Nann, 10. Children and In many countries children are arrested, TraumaticRights Abuse Human detained, and subjected to torture or other witnesses to violent arrests and formsorareas.'ongoinghouse murder of mistreatment.Childrensearches trauma of a parent may orand to alsoIn hardshipsor the others close be killing traumatized familythey of orwar are maiming orhelpless by flight the arrest,offrom torture, member. In addition, children of traumatized others. Many must endure theconflict or starvation-ridden prolonged detention, parents,varietysuffer including intergenerational of contexts those including Thewho effects impact were traumatic of of their psychological humanparents' rights trauma on children has traumatized before their children were born, may post-traumatic sequelae. abuses, childbeen abuse, documented kidnap- in awar? wide The earliest studies ofping, torssexuallychildrentraumatized disasters, focused abusedat the onparental children time physicalchildren of homicide, focusedtheir weredamage trauma.' first onparental and conducted survivors mentalStudies suicide, sequelaein ofof the Naziphysically,and 1960s.' At that time investiga-such as retardation. As the persecution who were psychologically, or 68) children,traumaticfield developed, reactions stress greater todisorder strange Beginningemphasis (PTSD)surroundings, was in in 1983, placedchildren.' or investigators IQ-typeon test The taking, tests.' began focusing on Diagnostic and Statistical the symptoms of post-interaction with other mentions special skillsormanifestationsManual aspects such of of Mentalas the toilet of trauma PTSD Disorders, training Lenore arein children. expressed, or (3rd Terr,language edition, Thesewho and skills.'studied revised)lossinclude children repetitive(DSM III(RI)who were victims of recently acquired developmental of a school bus kidnapping play in which themes 7 I am as am BESTMI COPY MI AMUR I= MI in Chowchilla, California, found that followingIN severe all MI ill all unanticipated trauma, MI INN children148 differed from adults1. Children older thandenial 3 or massiveServing repression. Survivors of Torture or 4 do not become amnesticin several and ways:'do not employ attachment,traumatictraumatized experience,events before that thethey and development areconceptual unable to express in words.Children Instead and Traumatic they may Human express Rights Abuse of verbalframeworks skills may change. have For memories example, infantsof 149 3.2. Children dousually not experience dosomewhatoccur with expected.episodes of repeated dehumanization not demonstrate psychic numbing, visual flashbacks; however, they or with abuse that is though this may can day- childrenbegunthemmore through to severewho develop were may psychopathologyplay." than Butthose small who children were older traumatized once persecuted by the Nazis confirms that youngerhave some verbal recollection of events. children who were in hiding did not differ when they were perse-language ability has Researchchildren with have 4. Children's work performancedueperioddream to thein atcontrast lack will. of denial,to the decline flashbacks, (school) suffers forin performance in adults. This and numbing seen in adults. a relatively short may be trauma.fromcuted. those According interned to inCarolReactions to trauma also vary with the The degree of psychopathology in concentration camps." Mowbray, a preschool child's reactions to trauma restitutive play, compulsions, regression,developmental separa- level of the child at the time of include children:The following occurred in6.5. TimePost-traumatic distortion. play and both children and adults, but reenactment. to a greater degree in problemsresponsestionfearscent anxiety, and reactions worries,and plus nightmares,phobias, fantasies, include somatic guilt, fears anger,and problems, chronic and sadness, sleep disturbances.hostility,worries, The belligerence, school nightmares age childinterpersonal and has sleep disturbances, problems, depression, and self-deprecation. Adoles- fantasies,the same school anticipationcohesiveness.Terr also foundof Unlike a common that in children7. A foreshortened view veterans' groups in which members experienceof the and future. subsequently traumatized in groups there had formal training in is a lack of group deprecation,apathyanger,Similar hostilityand problems withdrawal, intellectualization and belligerence,have guilt, been personalityobserved including in change, abused rationalization, and interpersonal problems, school problems and phobias, chronic sadnessneglected and depression, children." self- Trauma during anxiety, and acting out." symptomstraumaticreunions, in childrenexperience traumatized preferredCalvin they children Frederick found wantedthat to the forget. most commonnot to reunite behavioral because doing are bad dreams, persistent thoughts so remindedthrived them on of combat the unit and psychological of the adolescencechild'steenagers care adultinterrupts givers roles are the in other relationlastA child's phase important to theofdependency childhood family variables. or andon Thecaregivers and the society. effect the trauma has had on the often degreethrusts ofupon dependency unprepared varies PTSDyoungeravoidancetrauma, in children,children aof belief symbolic exposedregression.9that the In eventstrauma or things, will bepsychophysiological repeated, conductto natural disorders, disasters, molestation, a study in which he compared the incidence of or physical abuse withdisturbances, and, in hyperalertness, ance,"aswith tremendousfood, age. death, shelter, For detention,example, effect and safety on a or toddler'sany otheris differentchild, forced dependence but separationthat effect on others is from that of a 15-year-old. The "disappear- from themagnified care giver in will the have child a whose for basic necessities such in the home, his grouppersecutedphysicalRobinsonadults of childrenexposedassault, before found thewhoto naturalthat ageincidence had of escaped 17disasters, among survivors of Nazi persecution, were more seriouslyof PTSD ill many among children human-induced catastrophes, wasyears higher.10 later than Similarly, a control hostagethose taking, who were or impairedordependency financialher ability as difficulties.aneeds resultto provide are of greater.post-traumatic Older, love, Evenmoreaffection, ifindependent sequelae,the care giver absence children is physically or may loss be better security, and time to the child may be of a loved one, or able to cope EFFECTS OF TRAUMAChildren's and adults' perceptions of, understandings ON toCHILDREN the Soviet Union during World War about, and expressions of II." schools,children.with traumathese orA family endurechildare other stressesmay economicChanges important have than into younger, hardship. socialmovevariables orfrom moreeconomic Thosein oneassessing dependent communitywho status were thatones. may to occur as a result post-traumatic sequelae in forced to flee theirof or in connection another, change 7 IL ondevelopmental traumatictreatmenteventsthe child's are sequelaemethods, carenot identicalgiver, and socioeconomic prognosis. and these stage, dependency on care givers as adults, important variables when While childrendifferences suffer complicate diagnosis, and the effect the trauma has had assessing children are age,many of the same post- choice of countriesbecauseII awith child must the of remains traumatizedfamily cope with inmembership. the the child same added because community, andFriends intertwined of their may he families'no or stresses longer she mayfears beof permittedof government to be socially ostracizedbeing refugees. Even reprisals.associate 72 IIIMIININ11111110111111111/11111O11111111111the child's perceptionsAge of ischanges important because as children grow older their personalities, in his or her care and environment. changes, physical health and nutrition, and patterns of T COPYso AVAiLABLE am ow as me traumaticFormerow playmates sequelae. may A child Physicalcall themwho health isnames malnourished and or ridiculenutritional or their ill status parents. are also important determinants is in a poorer positionIn to am am an of post- survive150her reparative trauma, capacity is more than likely Serving Survivors of Torture a well-nourished healthy child.to be Malnutritioninjured, and is more severely limited may alsoin his or crumbledinside my ironbefore box they had couldnone. describe....Whatever lived The inside box became me was aso vault, potent collecting that words in Children and Traumatic Human Rights Abuse 151 childrenproblemsandlead permanent may to morealso act inhave severe,orthopedic ways a poorer latethat mental deformities.'make prognosis and physical sequelae such as mental trauma more likely, or be unable afterChildren trauma. with Psychologically significant psychological retardationto develop impaired darkness,sothingsloaded intimate that withalways finally1 weight. did collecting, not it became Itspeak sank ofpictures, deeperimpossible it to anyone. as words, 1 to grew ignore.I set my older, out parents' . to so find packed glances,a group with of becoming peopleundigested . .1 set out on a secret quest, who traumaticcomplicatecreative plans responses. their for existing avoiding ForA psychological child'sexample, perceptions about what trauma. In addition, post-traumatic sequelae children are egocentric.occurred Theywill also believeproblems. color his or her post. maythat Inquestions,like trying me, were to so give possessedthat their 1 could children by reach a historythe the benefit most they elusiveofhad their never partexperiences lived. of myself." 1 wanted and teach to ask them them how ortowardeverything she did. others." A is child'soriented If a traumaticperceptionAt towardages three themof todeath five, alsodeath colors is eventnot occurs,permanent, a child but associates merely living it with on under something changed and, as a result, they tend to lack his or her reactions to trauma: empathy he haveFeaturestransmitto survive been byof characterized successfully parent-childword and deed by interactionsin overprotectionthe conditionsworld, in familiesNazi (inunder Holocaust an of effortwhich survivors to theysurvivors help oflived the the child duringNaziunconsciously cope Holocaust the better war. agecatchagescircumstances. nine, sixyou however, to and eight, take Any children death yousorrow away.is have seen associated Butattained as ifan external you see it coming in time, you canwith escape. death By is because aof more separation. adult-like From concept of death as the agent, often monsterlike, who can betweenthatby inducingconstantly the child'sloyalty suspicion warning tolife the is of parentsmuchtoward possible betteror the associating disappointments non-Jewish than the with parents' world gentiles), and disasters),(causingchildhood the burdensome theinducing or child adulthood), guiltto expec- choose (in These perceptions mustingdeathend be for takenof as life....them impermanent into thanYoung for children older or escapable.... children and Separation may experience less death anxiety because they account if treatment is to be successful.adolescents." is much more anxiety-produc- see problemsintation some that cases, orthe maladjustment child the expectation provideThe fact fulfillmentwill that develop, theone andchild is just afeeling survivor'sreplace as being of relativesworth a child survivor in thedoeswho parents'does werenot not guarantee lost.2' lives, guarantee and, that psychological CHILDREN OFSevere SURVIVORS trauma also has intergenerational consequences. Children of parents who meaningpreoccupationanniversariesHolocaustthat psychological for survivors their withof parents'their problemsevents manifest parents' lives that will throughHolocaust-derivedoccurred trauma.n ensue. their to ManyBut their interaction a parents, largeexperience behaviors, percentagewith and and the guilt,particularly accomplishments need of anxiety, children to provide on andthe of inmenthave similar survivedas a prisonerways. diverse As ofIt war, traumaticwas orsuddenly the experiences "disappearance" clear to one child of survivors of the Nazi Holocaust me, how could people go through an experience like that such as the Nazi Holocaust, imprison- of a spouse seem to be affected wrote: abusesofin thereal external orexhibit imagined similarworld." dangers problems.SomeChildren and have mistrust Somewhose post-traumatic were parentsof strangers.24 traumatized were symptoms the whentargets such they of as morewitnessedabnormal recent fearpart traumatic human rights thanaofand set the not ithistorical specificsis expect for their eventit of toparents.... what have locked their They away in textbooks and a residual effect on their children.... Manyparents went through. Yet the Holocaust is possess as their own the emotions that grew out commemoration ceremonies are ignorant no more giversocialof their who stigma, parents' is distressed or thetrauma. destructionIn and one Many has study, inadequate ofwere their85 childrenuprooted; previous emotional living sufferedsupport resourcesin Denmark system; loss ofto orfulfillwhoseeconomic live their withparents status,needs.a care were tortured in Chile childparent's of survivorstrauma and of its the Likeofmeaning Nazi their survivors, Holocaustparent's uprooting,many children persecution, to them. They often feelof survivors stigmatized. have As difficulty another expressing their wrote:and near extermination. " andintroversion,childrenmuchwere difficulty followed of thesuffered time:" noctural withclinically from inconcentration. enuresis,descending foranxiety, as long anorexia, insomnia,order, Increased as six between headache,years. nightmares,symptoms The 59 stomachache, percentfollowing were "behavior and associatedsymptoms 16 diurnal percent difficulties," withenuresis,persisted of agethe 73 morewhatFor dangerous years it was. it layI knew!than in anany carried iron shadow box slippery, buried or ghost. Ghosts combustibleso deep inside things me more that secret / was thannever sure just had shape and name. What lay sex and overparentMexico.26 six and was theHalf still length weremissing. Anotherseparatedof parental Half study fromof separation. the their looked children parents, at witnessed28 and children in one the fourthof destruction Argentine of the cases ofrefugee their one parents living in I SIM Ell MI ION IMO BEST `OPY AMIABLE me EN am Imo um insomnia,homes152 and eating the beating disorders, of onebehavioral or both regression, parents. These aggressiveness, childrenServing suffered and Survivors somatic from of Torture PROGNOSIS AND TREATMENT Char/11,-n and Traumatic Human Rights Abuse 153 complaints.aggressiveness.pearedprove with as Sleep, newtime. symptoms. Aggressiveness eatingIn a similar disorders, The study most worsened, somatization,of persistent Chilean and refugee symptoms dependenceand regression children were and livingdependency tended regression in Canada, to im- andap- traumaticsuccessfulThese include event, individual true andCertain explanations secure or collectivebehaviors and aboutcontinuous attemptsand information to solve help children cope with the fate of parents in response to questions, child care. problems caused by the the stress of trauma. violatedfear,sequelae anxiety, react included similarlyand behavioral irritability."Children to those and examined living affective as refugeesin changes, the countries in social other withdrawal, wherecountries. their depression,While parents' these human rights were emotionalof supportthe political fromsupport beliefshuman fromChildren ofrights familytheir maygroups; parents; and be buffered friends;and success play againstpolitical, further adverse effects of trauma with children who have had similar in coping with past trauma; emotional, and material by knowledge detainedchildrenassociated have examinedor with disappeared, not living had at into a aadapt mental country 78 percentto lifehealth where in asuffered clinicnewhuman country, in fromrights Chile withdrawal, theyviolations whose experience parents take 70 place.percent the had stresses 01203been had repeatedotherexperiences. forms trauma; of Counterproductive inaction, familyNegative and and social acting prognostic coping isolation; out ormechanisms aggressiveinadequatefactors include or untrue young age; longer duration of exposure or include avoidance,behavior. denial and explanations of what bance,environmentaldepression, and regression and stimuli; 70 percent 50inPhilippine behavior,percent had hadresearcher intenseschool a loss performance, generalized of Elizabeth appetite, feardependency, Protacio-Marcelinoweight triggered loss, sleepand by crying."specific distur- described three stages of happened;opinionsrelatives,parent; parental poor on classmates, childcare. physical activities health;Researchersor friends;and worsened emotions and who care economicthat have givers' result worked circumstances;ininsufficient neglect with children loss traumatized of the child; unsupportiveknowledge or divergent of a dominant in the anxietybeginsstagesstress-coping when areaccompanied generally a parentin children applicable isby arrested. uncertainty of male to It situations politicalis about a time the prisoners ofwhere extremefuture, a parent confusionin emotional the isPhilippines." detained. over stress, events, fear,The These firstlossand greaterofUnited post-traumatic States if the relationshiphave sequelae" observedTreatment between thatThey themust thealso intensity victimbe have related and foundof the the to exposurethat the post-traumaticchild's to traumadevelopmental is an stage and perception child was close." sequelae are indicator of of control,what occurred and helplessness. and whatThe will secondCommon happen stage behaviors and is attempts one includeof adjustment. to locateseeking and Becauseexplanations visit the a parent.parent about is absent, the internal thebein behavior reinforced. trauma.possibility mustFactors Whenthat be the such addressed.treating survivor's as loss, adults Internal grieving, perception who motivationwere guilt, traumatizedof stigma, his and or heremotionalnightmares, as trauma children, has not strengths must and changes be alert to been visitingschool;mustdynamics adjust the of detained moodinessto the changed family parent; and economic changingthe and roles a circumstances mixture oftemperaments family of joy,members orsadness, aof new their change. house, andparents; bewilderment Often neighborhood, boredom the children when or therelatingaltered survivor byto thematuration, must trauma be helped thatand arethat toTreatment expected thereexamine adult inmethodssurvivor athe child trauma may butmust notharbor from be in appropriate anan thoughts adult.adult Inperspective. and tothese the casessurvivor's age. Among methods feelings chooseexperiences,political tend prisoners to the be childrenmaladaptive otherThe than have third theand few stage parent aggravate coping is arecharacterized alternatives; emotionalreleased. distress. Because bythe vigorous coping these devices attempts are newthey to secure the detained informationchildrencoloringthat have orbook been abouttheir coupled used parents,the relative." are with directed group discussions Treatment therapy, and undirected may about and also efforts it,involve drawings, informational to psychotherapeutical obtain a trauma-specific release booklets of for orly- withwiderasparent's in the the latitude frustration release.second of stage,copingThe they stresses butfeel alternatives. becausewhen experienced attempts they The have children'sto by press adjustedthe children for greatest the to the detainedare situation, stressessentially parent's is theyassociated the releasehave same a orienteddissociation?'reenactment,frustration play tolerance, therapy andIn children encouragement with encouragement an of emphasistraumatized of ofrepression on verbalization parents, reality testing,instead the as untangling an ofattempts alternativedenial, of to their increase to physicalexperi- projection, or 75 are ignored or rejectedaroundperspectives IGJivingby the them government. ais in satisfactoryalways life have difficult As not explanationProtacio-Marcelino yetto do been to a warpedpointto the that fact bywrites: they ofthe detentioncan inequities fully comprehend. to and children injustices Andwhose orstrengtheningences other from therapeutic those the ofresources their Othermethods, parents helpful and group copingmust therapeutic activities be mechanisms accomplished. techniquesthat help of the to includefamilycreate using newfamily cognitive therapy that focuses on bonds of continuedin the final detention analysis, of political there can prisoners really isbe no convincing answer because the . . unjust . . . ." Wheneverfriendship, possible,and education refer theof parents family toin serviceschild care that and can post-traumatic help them restore sequelae. their I OM NM IMIN I= MI NM III MB MN living154 and material conditions to approximate the pre-traumaticServing period. Survivors of Torture Victims of Violence, in Ochberg, Frank, Editor, New York: Brunner/Mazel, p. 201. Children and Traumatic Human Rights Abuse Post-Traumatic Therapy and Victims 155 tionalleviate to the post-traumatic next. Successful interventions with child survivors and children of survivors can both sequelae and prevent their transmission from one genera- 11. Robinson, S., (1979) Late Effectsof Violence,(n=31),214.Adolescentsof Persecution The had subjects been Survived in Persons detained were Nazi patients Who in Occupation concentration as in Children a psychiatric in Europe, orcamps hospital (n=44) whoor labor had camps lived in (n=35), the ghetto had Isr Ann Psychics: Ret Disc 17: 209- Young REFERENCESI. War and AND extreme NOTES civil strifeadolescents can have and adverse can disrupt psychological their normal effects development. on children Arroyo, and William; Eth, Spencer, 12. Bridgingcontrols.patientsbeen in hidingin OnlyCultures: the study,five(r26), survivorsSocial orof whomwho Work hadhad some with carriedpsychological were Southeast false exposed identity problemsAsian to multiple papers Refugees, that stressors.(n=24). predated There There persecution. were were 106 28 Los Angeles: Social 2. Id.,AmericanRobert(1985) ChildrenS., Psychiatric Editors, Traumatized Press, pp. by Central103-120.p.103. American Warfare, in Eth, Spencer; Pynoos, Post-Traumatic Stress Disorder in Children, Washington, D.C.: 14.13. Eitinger,Mowbray, Leo, (1987) personal communication.Services for Groups (1983), p. 265. supra, n.10, p. 202. Summary of common victim reactions by age grouping. 3. See, Chodoff, P., (1975) Survivors,AcuteHandbookPsychiatric and Chronicofin Aspects Psychiatry, Psychiatric of the Nazi and Persecution, Psychosomatic in Reactions in Concentration Camp Society, Stress and Disease, Vol. 6., ch. 41. New York: Basic Books; Eitinger, Leo, (1971) Vol. 1, London: Oxford University Press; American 16.15. BerkeleyThe following Planning studies Associates, have investigated (1977)supra,Projects n.children 1974-1977,6. who were physically abused. Some of Hyattsville: National Center for Health Sciences Research; Green, A.H., Evaluation of Child Abuse and Neglect Demonstration Holocaust:MedicalcalHemisphere;Dimsdale, Stress, Effects A ResearchJoel, Chodoff,of Editor,Concentration Bibliography, Paul, (1980)Survivors, (1970) Camps The and German Victims Related Concentration Persecutions Camp on Survivors as a Psychologi- of the Arch Gen Psychiatry 22: 78; Eitinger, Leo, Vancouver:(1985) University of British Columbia Press. and Perpetrators, PsychologicalWashington, and D.C.: Morse,(1967)mightchildrenthese childrenbe DevelopmentalCarol who expected were W.;were Sahler, subjected alsoto occur Characteristics neglected. 011e into Jane childwar These trauma.Z.;survivors. of Friedman, papersAbused Their Elmer,do Children, results Stanfordnot investigateElizabeth; are B., only (1970) refugeeGregg,indicators A Three-Year childrenGrace of what S., or Pediatrics 40: 596-601; 4. Kempe,5. Martin, C.H.; H.P.; Silverman, Beezley, The P.;F.N.;Developmental Conway,Battered E.F.;Child Characteristics Kempe,Syndrome, C.H., (1974) of Abused The Children,Development of JAMASteele, 181:B.F; Droegemueller,105-112; Elmer, W.; E.; Gregg, G.S., (1976) Pediatrics 40: 596-602.Silver, H.K., (1962) 129-134.John,KempeFollow-Up (1981) Study Neurological of Abused Impairment and Neglected in Maltreated Children, Children, et al., supra, n. 4; Green, Arthur H.; Voeller, Kytia; Gaines, Richard; Kubie, Am J Dis Child Child Abuse Neglect 120: 439-446; 5: Three-Year439-446;MedicalAbused Children, Publishers, Follow-upSandgrund, in StudySchulman, 21: A.; 25-73; of Abused I., Morse, Editor, and C.W.; Neglected Sahler, Children, J.Z.; Friedman, S., (1978) A Gaines, R.W.; Green, A.H., (1974) Child Abuse and Mental Advances in Pediatrics, AmChicago: J Dis YearChild Book 120: 19.18.17. Mobray,Epstein, Helen, (1979) DaughtersId. of Survivors, supra, n. 10, p. 197. NewChildren York: of G.P. the Putnam's Holocaust: Sons, Conversations p. 298. with Sons and 6. Green, A.H., (1983) ChildChildren,(1984)Retardation: Abuse:150. Personality Dimension A Problem Development of of Psychological Cause Afterand Effect,Physical Trauma Child in Abused Abuse, Am J Men: Defic Arch Dis3: 327-330; Childh Oates, R.K., 59: 147- 21.20. Phillips, Russell E., (1978) Impact ofPsychotherapyId., Nazi Holocaust on Children of Survivors,pp. 1, 4-5. 32: 370-378. Am J 7. DSM-III-R, p. 250. TherecollectionsAmRevisited: former J Psychiatry mayThe of Effects take the event the of Psychicplace (criterion of Trauma recurrent B1), whileFour and Yearsthe distressing latter After occur a School-bus instead ofKidnapping, markedly .1 Am Acad Child Psychiatry 140: 1543-1550. 22: 231-237; Ten, Lenore C., (1983) Chowchilla 22. Danieli, Yael, (1988) Treating SurvivorsandaHolocaust, form "hencepresent) of and time inlive simultaneously." ChildrenOchberg,distortion in different ofin thatplacesSurvivors they (Europe may of identifythe and America) with images and differentof relatives time who zones perished (1942 supra, n. 10, pp. 282-283. Survivors' children may also exhibit Nazi. 7 9. Frederick,8. Ten, Lenore Calvin, C., (1985) (1985) Children Childrenpp.diminished 47-70. Traumatized Traumatized interest in inSmall by significant Catastrophic Groups, activities in Eth Situations, and (criterion Pynoos, in Eth C4). and supra, n. 1, 23. See Rosencheck, Robert; Nathan, Pramila,psychodynamicsHolocaust(1980)dren of Difficulties Vietnam(1985) Survivors, Secondary Veterans, and in Separation-IndividuationAm issues J Traumatizationin of guilt, anger, in depression,Chil- as Experienced and acceptance by Offspring of authorityof Nazi t..1 Orthopsychicury Hosp Commun Psychiatry 50: 87-95. For a further discussion of the 36: 538-539; Freyburg, 10. trauma.traumaticof thePynoos, Id.adults Mobray, sequelae (n=350). Carol among But T., other children(1988) research Post-Traumaticis higherSeventy-seven has notthan confirmed among Therapy percent adults that for of the subjectedtheChildren incidence children Whoto hadof similar post- Are PTSD supra,(n=150), compared to 57 percent n. 1, p. 85. 24. Children of war veterans and formerdivorce,transgenerationalaffecting prisoners maritalthe of children war conflict, witheffects of PTSD survivors, andseen also domestic in childrenexperiencesee Phillips, violence of Holocaustthe in these survivors. homes isThe great. incidence Mothers of supra, n. 21. I OM I= MO 11 OM MI MI I= =II MI I= 156 Veteranstraditionalfrequently who do paternalwitnessed most of rolethe the parenting becausekillingServing or maimingbecause of Survivors irritability, ofthe children offather Torturepoor is tendphysical absent health, to be overprotectiveor unable to orassume a or fatigue. Hunter,absencedepression,overdemanding Ednahas behavioralbeen J.; of Segal, related their problems, children.Zelda, to the degree(1976) Children and ofproblemsUniversal his in childrens'these atConsequences familiesschool. psychopathology. Thehave length beenof Captivity: ofnotedSegal, the father's to haveJulius;Stress SocemotionalReactions Sci J 28: lives;among593-609.Children high Divergent levels of veterans of Populations guilt, with anxiety, PTSD of Prisoners and tend aggressiveness; to haveof War an and intense Their and involvement conscious Families, in their fathers' andAm 25. Cohn, Jorgen; Danielsen, Lis; Holzer,fantasies.Theyunconsciousimitation Kirsten; also Rosencheck tend andInger, preoccupation toidentification fantasizeMygind; and Nathan, Koch, withabout with specific theLone; supra,the father, events events n. 23. these their that children fathers internalize their were traumatic to their fathers. went through. Through frightening 26. Allodi, Federico, (1980) The Psychiatricof PoliticalinBirgit; Denmark,Effects Thogersen, Persecution in ChildrenLancet Steen; II:and and 437-438. Torture,Aalung, DanishOle, (1985) Med ABull Study 27: Of229-232. Chilean Refugee Families of Victims ChildrenSeverin, abuses11. is that their Prevention trauma andThe suffering most tragic could aspect have been of working prevented. with Although survivors this of traumatic human rights 29.28.27. ProId. tacio-M arcelino, Elizabeth, Stress and Coping Among Children of Political Prison- otheroccurred,book traumatic has thefocused event greatest from on needways occurring,Prevention isto to help preventsecondary survivors takes such three prevention abusesonce forms: torture from directedprimary occurring preventionat early interven- aimed at preventing the or other abuses have at all. torture or 31.30. Newman,Id. Janet C., (1976) Childrenlished,ers of in Disaster: the undated). Philippines, Clinical Department Observations of Psychology University of the Philippines (unpub- at reducingtion before post-traumatic the impact of sequelae traumatic once sequelae those has sequelae occurred, are andpresent. tertiary prevention aimed Stress,ConferenceChildrenCreek, Am Baltimore, and J Psychiatryof Violence: Society Md., 133:Tape forDimensions Traumatic 306-312; Nos. W-71A, ofPynoos, Stress Victimization W-71B. Studies:Robert (1987)and A World Treatment Presented View ofImplications, Traumatic at workshop, at Buffalo thinkbecausePRIMARY of as it distinctinvolves fromPREVENTION political the provision activismPrimary ofwhich healthprevention most care.' North is Health the American most professionals difficult health for professionals North American health professionals living outside 34.33.32. Pynoos,Green,Frederick, A.H., supra, supra, supra, n. n.31. 9,n. pp.6, p. 90-94. 152. preventiondistantof countries events of where traumatic over traumaticwhich humanGovernments they human rights can haveabuses rights that no abusesviolateis influence. a vitally the important rightsYet becoming of theirpublic citizens involvedhealth occur commonly regard them as activity. in the nationalgovernmentsprotest,not omnipotent. or and sanctions, internationalin many In the theyeffective face musthuman of ways. relentsufficient rights You or andthey can domestic medicalwillparticipate crumble. and in international Youcampaigns initiated criticism, by may be powerfulor scientific but they areorganizations can pressure such 73 aimedHumantions at to stopping supportRights Watch rightstheir work. abuses periodicallyInternational or make publicize financial human the contributions rights organizations such cases of persons whoas are Amnesty perse- International and to such organiza- concernedTheypoliticalcuted call because killing,on demanding individuals orof theirother thatto political violationssend mistreatment letters opposition of internationally or telegrams to the authorities of the countrycease and that the person be accordedor outspoken criticism of torture, recognized human rights. 80 I us NI as No Ns EN I= No NW i mu um Is um me No .aPPEHDE it

81 The Psychiatric Effects of Massive Trauma on Cambodian Children: I. The Children J. DAVID KINZIE, M.D., WILLIAM H. SACK, M.D., RICHARD H. ANGELL, M.D., SPERO MANSON, PH.D., AND BEN RATH

This report, which uses standardized interviews by psychiatrists, describes the psychiatric effects on 40 Cambodian high school students in the United States who suffered massive trauma from 1975 to 1979. They endured separation from family, forced labor and starvation, and witnessed many deaths because of the Pol Pot regime. After 2 years of living in refugee camps, they immigrated to the United States at about age 14. Four years after leaving Cambodia, 20 (50%) developed posttraumatic stress disorder; mild, but prolonged depressive symptoms were also common. Psychiatric effects were more common and more severe when the students did not reside with a family member. Journal of the American Academy of Child Psychiatry, 25, 3:370-376, 1986.

Since the studies of the Nazi concentration camp anxiety was inconsistent, and was probably modified victims after World War II it has been known that by the presence of adults and other factors. massive trauma causes serious and long-term psychi- A few clinicians have reported on the effects of atric effects (Chadoff, 1975; Eitinger, 1961). Such massive psychic trauma of a concentration camp on trauma has often fostered a unique group of symptoms children (Krystal, 1978; Sterba, 1949). When such referred to as the concentration camp syndrome. Most massive trauma has occurred in Southeast Asian ref- of the symptoms are similar to those included under ugee children, a group already vulnerable to stress and the posttraumatic stress disorder (PTSD) diagnosis of psychiatric disorder (Tobin and Friedman, 1984; Wil- DSM-III. Studies indicate, however, that concentra- liams and Westermeyer, 1983), significant psycholog- tion camp experiences affect not only prisoners but ical and behavioral disturbances have not been unex- their families as well; the symptoms are long-lasting pected. and often resistive to traditional psychotherapy treat- This report describes adolescent children who lived ment. through 4 years of severe concentration camp-like Psychological or behavioral effects of traumatic ex- experiences in Cambodia from 1975 to 1979. The 40 periences on children and adolescents followed a cy- students studied are compared to 6 Cambodian stu- clone disaster (Milne, 1977), a severe winter storm dents who escaped internment. We will further de- (Burke et al., 1982), and the Buffalo Creek flood scribe the psychiatric disorders among the affected (Newman, 1976). Terr's (1983) work with school bus group and relate them to both the traumatic expen' kidnapping victims indicated multiple posttraumatic ence itself and posttraumatic and immigration exile' symptoms were present even 4 years after the incident. riences. The effects of war on children noted by A. Freud and To our knowledge this is the first report, using Burlingham (1943) during World War II and others operationally defined diagnostic criteria of mental di during Middle East conflicts (Milgram and Milgram, orders, of the psychiatric effects of massive trauma n 1976; Ziv and Isreali, 1973) indicated that increased children. Received Dec. 17, 1984; revised March 25, 1985; accepted April Background 16, 1985. Dr Kinzie is Professor of Psychiatry, Dr. Sack is Professor of One of the more tragic outcomes of the Indochineat Psychiatry and Director of Child Psychiatry, Dr. Angell is Assistant the Professor of Psychiatry, Dr. Mason is Associate Professor of Psychia- conflict was the takeover of Cambodia in 1975 by try, and B. Roth is a Cambodian Mental Health Counselor, all Pol Pot radical Marxist regime. By following a stncl associated with the Department of Psychiatry, Oregon Health Science simplistic communist philosophy there was an at University, Portland, Oregon. urbar Reprint request should be sent to Dr. Kinzie, Department of tempt to divest Cambodia of any western or Psychiatry. Oregon Health Sciences University, Portland, OR 97201. influence and return it to an agrarian communal 1' Presented at the Annual Meeting of the American Academy of ciety. As a result, city people were sent to work vigil* Child Psychiatry, Toronto, Canada, 1984. and 0002-7138/86/2503-0370 $02.00/01986 by the American Acad- throughout the country. Families were separated emy of Child Psychiatry. most children and adolescent children were put In"' 370 82 BEST COPY AVALAgil 371 MASSIVE TRAUMAON CAMBODIAN CHILDREN. I These led to a according to age groups with little or nocontact panic disorder, phobia, and anxiety. camps Research Diagnostic Criteria (RDC)diagnosis of these with their parents.Adults with western educationand government respective disorders. PTSD questions fromthe Diag- westerninfluence or contact, as well as led to a DSM-III officials, and Buddhist monks, were nostic Interview Schedule (DIS) officials, military 1982). Mental of mismanagement thousands diagnosis of PTSD (Robbins et al., executed. As a result orientation, calculation, died of starvation orfamine. Itis estimated that, status examinations included execution, starvation, and disease, and recall. Any leads from thequestions and any through deaths by noted and one-third to one-fourthof Cambodia's 7 million pop- ambiguities or nonverbal reactions were followed up during the interview. An originalinterview ulation perishedin 4 years of nightmare (Hawk,1982). only in 1979 when the Vietnameseinvaded was taped by onepsychiatrist (J. D. K.) and observed It ended psychiatrists (W. S. Cambodia. Subsequently manyCambodians were able and discussed by the other two smaller and R. A.) to ensure a standardizedapproach to the to escape asrefugees to Thailand and, later, a the United States. interviews. With the presence of the sameCambodian group came to interviews, further For 6 years theDepartment of Psychiatry of the mental health interpreter in all standardization was assured. After each interview a Oregon HealthSciences University has sponsored an Indochinese refugee clinic(Kinzie and Manson, 1983). narrative psychiatric history was dictated. Recently the clinic staff became awareof the severe After each psychiatrist had completedseveral cases, and dis- difficulties adult patients werehaving as a result of each case was presented by the interviewer experiences. We ultimately identified cussed in detail to ensure feedback onthe approaches their Pol Pot the Childhood the PTSD amongthese patients (Kinzie et al., 1984). and standardization. At this time This report adds anonclinical population of high Global Assessment Scale Score (CGAS)(Shaffer et school students originally fromCambodia who also al., 1983) was assigned by the interviewers.Subse- endured 4 years of this massivetrauma. quently the primary interviewer gave adiagnosis on a basis of RDC criteria. Each protocol wasalso evalu- Method ated independently by a second evaluator.The inter- Teachers in an Oregon high schoolbecame con- rater reliability of the diagnosisof PTSD was 85%; cerned about the unusual behaviorof some Cambodian and the presence of depressive disorder,88%. refugee students, noticingstartle reactions and at All students participating in the interviewheard the i1 timesthe pressure of the students to tellhorrible purpose of the interviewexplained in both English events of their past. Whenteachers approached our and Cambodian; they signed a written consentform department about these observations, aresearch proj- as did their legal guardians.The interviews were usu- ect was organizedinvolving 3 members of our depart- ally done about half in English and halfin Cambodian, ment, a Cambodian mentalhealth worker, and teach- but varied from 100% English to100% Cambodian. ers and counselors atthe school. The school, having The interviews often were emotionallycharged for the 52 Cambodian students, offered anopportunity to student, interpreter, and psychiatrist, asthe questions Iinterview these students and toobtain home and involved memories of severe trauma andlosses. Nev- classroom observations on theirbehavior. The inter- ertheless, 46 of the school's total of 52Cambodian views were done by one psychiatrist(J. D. K.), who students agreed to participate in the project. ilhas worked with Southeast Asiansfor 6 years, and two child psychiatrists(W. S. and R. A.) from the Results department of psychiatry. All interviews weredone in Life Experiences and Effect of Pol PotRegime on the the presence of a trained Cambodianmental health Students worker (B. R.) who had American universityexperi- the Pol American mental health Six of the 46 refugees interviewed escaped 4ence and 5 years of training in Pot experiencethey either came to theUnited States and psychiatric clinics. during that time. IThe semistructured interviews includedspecific in 1975 or were in another country school These 6 (2 males and 4 females) with an average age questions related to current family life, health, refugees, although experience, life in Cambodia before Pol Pot,the ex- of 17 years, who served as "normal" experi- not considered as an adequatecontrol group, has been periences during Pol Pot, the refugee camp All lived with States. This inquiry was in Oregon an average of 45 months. ences and life in the United separated from their guided in part by Terr's (1979) work on psychic some family members, but 3 were parents. They reported very few symptoms; nodiag- trauma. and noses were made. Their averagechildhood global as- IFrom the Schedule of Affective Disorder of 75-92. In Schizophrenia (SADS) (Spitzer and Endicott, 1979) sessment rating was 84 with a range specific questions were asked on affective disorder, general, they were performing in the good tosuperior MON F 83 BEST COPY 372 KINZIE ET AL. range of functioning and by all accounts were adjust- 15 hours a day, 7 days a week. Thirty-three went ing well to American culture. without adequate food for long periods and 27 starved The other 40 students lived 4 years under the Pol to the point where they described themselves as "look- Pot regime in Cambodia and comprised the focus for ing like a skeleton"; 17 had edema in their legs. Sev- this paper. These students all were raised, until Pol enteen students saw people killed and 7 saw their own Pot, in traditional Cambodian homes emphasizing the family members killed. Fifteen described themselves cultural values of a strong family identity, respect for or their families as being beaten. All had seen corpses. ancestors and the past, a need for smooth interper- Twenty-seven had members of their group killed while sonal relationships (nonconfrontation in cases of dis- trying to escape to Thailand and 20 still felt their life agreement), tolerance for ambiguity, and willingness was in danger in Thailand. to accept things the way they are. Traditionally, high The number of "lost," killed, or missing family status was accorded to scholars. The predominant members of this group was extremely high. Eighteen faith was Buddhism and with a belief in reincarnation. of the 40 knew their fathers had died; 7 knew their Current success or failure depended upon deeds done fathers were missing (63% without fathers). Eleven in a previous life. The Pol Pot's ideology struck at the mothers were dead and 4 were missing (38% without heart of traditional Cambodian beliefs, especially their mothers). Sixteen had at least 1 sister and 15 at least respect for family, the past, and the Buddhist religion. 1 brother dead or missing. Thirty-two of the 40 (80%) The 40 students included 25 males and 15 females, lost at least 1 family member; the average number with an average age of 17 and a range of ages of 14- lost, either dead or missing, was 3 members of the 20. Three females and 5 males had not yet reached nuclear family. puberty. In Cambodia, their fathers were generally employed in the military, government or business, or Symptoms were farmers. Twenty-eight of these lived in cities, Although the interview was primarily designed to while the others lived in rural areas. Thirty-one went identify a psychiatric diagnosis, the major symptom to school in Cambodia and 33 could read Cambodian. patterns are of interest (Table 3). Twenty-six of the Only 4 spoke English when they came to the United students reported headaches and 15 had some concern States. Currently 11 were living with their natural about their health. Other health symptoms, however, fathers, 20 with their natural mothers and 15 had were not reported to a large extent. The major symp- some siblings. Overall, 26 were living with some family toms of posttraumatic stress as reported by a large members while 14 were living in either American or number of students included nightmares, recurring Cambodian foster homes or alone. dreams, being easily startled, feeling ashamed of being The "average" childhood experience could be de- alive (intrusive mental states) and avoiding memories scribed as follows (Table 1): Born in a Cambodian city of Cambodia or completely avoiding discussion of the in 1967; began school in 1973; terminated schooling traumatic events (avoidance behavior). abruptly in 1975 (not to be resumed until reaching the Trouble sleeping and trouble concentrating are United States); endured 4 years of the Pol Pot con- posttraumatic and depressive disorders. Additionally, centration camp experience from 1975 to 1979; es- there were a number of depressive symptoms reported, caped to Thailand and became refugees for about 27 including some appetite or weight changes, loss of months. The students came to the United States in energy and interest, a sense of feeling guilty, a pessi- 1982 and had been in this country (attending high mistic outlook, and brooding. A number of the stu- school) an average of 2 years. dents felt inadequate and resentful, and expressed The shared traumatic experiences of the 40 students self-pity. Only 6 reported suicidal thoughts. Eight are summarized in Table 2. Thirty-six lived entirely students described some type of panic attacks, but in age-related segregated camps for the 4-year period. only a few described the whole symptom complex of Thirty-three were separated from their families during panic disorder. Generalized anxiety also occurred in a that time. Almost all (39) endured forced laboroften small number of students.

TABLE 1 "Average' Life Experiences of 40 Cambodian Students Year 1967 1973 1975 1979 1982 1984 Age 0 6 8 12 15 17 Early family life in 2 years of school 4 years of Pol Pot Refugee in Thailand in United States Present study Cambodian city "concentration camp"

84 BEST COPY LE MASSIVE TRAUMA ON CAMBODIAN CHILDREN. I 373

TABLE 2 TABLE 4 Four Years of Pol Pot "Work Camp' Experience (N = 40) Current Diagnosis by RDC Criteria (N = 40) v Percent Experiences N Percent

16 90 Lived in age-segregated camps 20 50 PostTraumtic Stress Disorder (DSM-III)

:1:1 83 Separated from family 21 53 Depressive Disorder, all types 39 98 Endured forced laboroften 15 hours a day, 7 days a 5 Major Depressive Disorder week 1 Minor Depressive Disorder 33 83 Went without enough food for long time 15 Intermittent Depressive Disorder 27 68 Described themselves as looking like skeleton" 17 of 20 PTSD also had a depressive diagnosis 17 43 Described swelling in legs (edema) 3 8 Panic disorder 17 43 Saw people killed 7 18 Generalized anxiety disorder 7 18 Saw family members killed 27 had at least one diagnosis

15 38 Described themselves or family beaten; all saw corpses No cases of schizophrenia, drug or alcohol abuse, antisocial or 27 68 Had members of their group escaping to Thailand conduct disorders killed Others 2 mild mental retardation 20 50 Felt life still endangered in Thailand 1 Organic brain syndrome with oppositional person- ality disorder TABLE 3 1 schizoid personality Current Major Symptoms (N = 40) Medical 2 blindness of one eye (one also amputation of arm) :V Percent Symptom 6 inactive tuberculosis Health 1 unknown atrophy of leg 26 65 Headaches Concerned about health 15 38 years. Additional students suffered from a major de- PTSD Symptoms pressive disorder but because of poor recall or diffi- 22 55 Nightmares culty in recalling the duration did not technically meet Recurring dreams 20 50 the criteria. 20 50 Easily startled 28 70 Felt ashamed of being alive We were impressed that depressive symptoms from 23 58 Avoided memories of Cambodia a mild to moderate degree were quite common in this 17 43 Never discussed Cambodian events before group. Overall, 21 students met some diagnosis for PTSD and Depressive Symptoms depressive disorder. Depressive disorder and posttrau- 22 55 Trouble concentrating matic stress are closely related and 17 of the 20 per- 16 40 Trouble sleeping sons with posttraumatic stress also had a depressive 17 43 Appetite or weight change disorder. Three met the diagnosis for panic disorder, Depressive Symptoms and 7 for anxiety disorder. Twenty-seven students had 53 Loss of energy at least 1 diagnosis while 13 had none. Significantly, 19 48 Loss of interest no case of schizophrenia, drug or alcohol abuse or 19 48 Feeling guilty 17 43 Pessimistic outlook antisocial conduct was found. Other diagnoses in- 17 43 Brooding cluded mild mental retardation (2 students), organic 21 53 Feeling inadequate brain syndrome plus an oppositional personality dis- 55 Feeling resentful order (1 student), and schizoid personality of adoles- 24 60 Self-pity cence (1 student). Medical problems in this group 14 35 Restless, unable to sit still 6 15 Suicidal thoughts included inactive tuberculosis (6 students). Two peo- 14 35 Feeling depressed some of time over 2 years ple, 1 with an amputation of the left arm as a result Other of a traumatic injury, were blind in 1 eye; both had 20 Described some type of panic attacks; few described stepped on mines while escaping to Thailand. specific panic symptoms Childhood Global Assessment Scale Diagnosis Compared with the 6 "normal" Cambodian refugees By DSM-III criteria 20 students met the diagnosis whose average CGAS score was 84, the CGAS average for current PTSD (Table 4) and 5 met the diagnosis score of the 40 students who lived under Pol Pot was for major depressive disorder (RDC). (An additional 62 with a range of 43-75. Ten, or 25%, of the 40 5 would have made the latter diagnosis but the dura- students who lived under Pol Pot had a score higher tion of 2 weeks was not met.) One met the diagnosis than 71, which equals no more than slightly impaired of minor depressive disorder, and 15 met the diagnosis functioning. Twelve, or 30%, rated some difficulty in of intermittent depressive disorderthat is, they had a single area but generally were functioning well some depressive symptoms much of the time for 2 they had a score of 61-70. Thirty-five percent, or 14,

8 5 BEST COPYAVAiLABLF

- 374 KINZIE ET AL. scored 51-60 either with variable functioning with killings, being beaten, going without food, having leg sporadic difficulties or with symptoms in several but swelling, or starved to the point of looking like a not all social areas. Four, or 10%, scored below 50 and skeleton. Also, none of these factors related to receiv- had a moderate degree of interference in most social ing a lower CGAS score. areas or severe impairment in a single area. In no case However, there was a strong relationship between did the Pol Pot students score higher than the non- the current living situation and a psychiatric diagno- Pol Pot Cambodian refugees (Table 5). Since the sis. This is shown in Table 7. Twenty-six of the 40 childhood global assessments were made by the same lived with 1 or more nuclear family members, while psychiatrists who did the interviews and were partly 14 lived in a Cambodian or American foster home, or based upon symptoms, it is not surprising that the alone. (Thirteen of the 14 received a psychiatric di- CGAS score strongly related to the current diagnosis agnosis while only 12 of 26 living with a nuclear family as shown in Table 6. member received a diagnosis.) The nuclear family In other words, the presence of a psychiatric diag- members could be any combination of a natural father, nosis related at a significant level with receiving a a natural mother, or siblings. Similarly, as shown in lower CGAS score. Table 8, there was a strong relationship between the CGAS and not living with nuclear family members. Correlates of Receiving a Psychiatric Diagnosis or a One-way analysis of variance on the means of these Low CGAS Score scores shows this relationship. In other words, al- Not all of the 40 students received a psychiatric though diagnosis of a disorder and low CGAS scores diagnosis, althoughallexperienced a significant are common, it is more common to have a diagnosis amount of trauma over a prolonged period of time. or lower CGAS score in those students who live in a We found no relationship between the experience in foster family or alone. Cambodia, age and sex and the presence or absence of a diagnosis. There also was no simple or direct rela- Discussion tionship with specific reported experiences in Cam- At an early age these young Cambodian refugees of bodia such as the death of family members, seeing our report were separated from their families for 4 years, endured forced labor and starvation, and TABLE 5 watched many deaths, in some cases of their own Childhood Global Assessment Scores (N = 40) family members. Their traditional cultural values and Score* Assessment N Percent belief systems were discredited or destroyed. They 71 No more than slight impair- 10 25 spent 2 more years in a refugee camp and then began ment in functioning high school in a foreign country without knowing the 61-70 Some difficulty in single area 12 30 but generallyfunctioning TABLE 7 well Presence of Current Psychiatric Diagnosis StronglyRelated to 51-60 Variable functioning with spo- 14 35 Living without Any Family Members° radic difficulties or symp- toms in several but not all Presence of social areas Home Life Diagnosis Total 50 Moderate degree of interfer- 4 10 No Yes ence in most social areas or severe impairment in a sin- Live with a nuclear family 12 14 26 gle area member" LiveinCambodianor 1 13 14 ° Mean = 62; range = 43-75; "normal" Cambodian refugee aver- American foster family age CGA = 84. or alone TABLE 6 X 2 test df = 1, p < 0.0309. The relationship holds if natural father, natural mother, or CGA Score Strongly Related to Current Psychiatric Diagnosis° siblings in home. Presence of Score Diagnosis TABLE 8 CGA Scores Related to Living without Any Nuclear Family Member No Yes Home Life CGA Score (Mean) 71 3 61-70 5 7 Live with member nuclear family' (N = 26) 64.6 51-60 1 13 Live with foster family or alone (N = 14) 56.3 50 0 4 One-way analysis of variance p < 0.0095 Total 13 27 ' The relationship holds true if father, mother or sibling is In ° Corrected x2 test, df = 3, p <0.0049. home. 86 BEST COPY AMIABLE MASSIVE TRAUMA ON CAMBODIAN CHILDREN. I 375 language and often without family. Even 4 years later, due to the presence of a family member, otherfactors after leaving the most severe of the traumatic experi- must be taken into consideration. The traditional encesbehind, half of the 40 students still experienced Cambodian and Buddhist values ofacceptance of one's major symptoms considered as PTSD. Twenty-one life, the importance of education, and the belief that students also had symptoms of an on-going depressive present events are influenced by past actionsmay disorder. Although usually mild, the disorder was pres- have helped shape a coping style characterized by ent some of the time with some symptoms for 2 years suppression of feelings and avoidant behavior. This or more.Both of these diagnoses represented enduring was indicated by the students' frequent denial of dis- profound effects of this experience. tress and their avoidance of memories or events which Additionally, the group in general had low scores on would remind them of past events. This avoidant the CGAS, corresponding to some degree of impair- behavior seemed to minimize symptoms and the social ment and functioning, especially compared to the consequences of the symptoms. Avoiding intrusive other Cambodian students. No student told of or by thoughts and memories perhaps balances the distress other evidence was described as having social acting- that they feel. out behavior, truancy, or other disruptive behavior in To the extent that this mechanism has prevented school, a significant finding. Neither alcohol nor other socially disruptive behavior, symptom formation,or drug abuse was reported in this group. In general, their poor school performance, it has been successful. How- symptoms were private, subjective, and characterized ever, it has also left many students somewhat isolated by denial and avoidance of thinking about their prob- and with subjective suffering. Such traditionalCam- lems or their symptoms. American adolescents expe- bodian values as passive acceptancemay provide a riencing trauma or stress are stereotyped as acting out more useful means of coping with this disorder than in antisocial or drug-seeking behavior. This is exactly western values which emphasize talking about the opposite of what the Cambodian students demon- problem and expecting or excusing disruptive behavior strated. Their problems were internal and much of because of the trauma. The lack of school disruption their behavior and thought served to avoid or deny may also have both cultural and immediate determi- the significance of their past. nants. School is viewed positively by the students, Of particular interest is that the amount of trauma perhaps because of the traditional Cambodian value per se, or the experience in Pol Pot Cambodia as placed upon the status of the scholar. Also,at least in reported by the students, by age orsex, were not this setting, school is a secure place ofacceptance and related to the current diagnosis or global functioning. social interaction (see Part II; Sack et al. (1986)). However, not living with a nuclear family member The Pol Pot regime attempted to destroy theroots predicted the diagnosis of a major illness as wellas of the Cambodian past and values. However,these lower global assessment scores. Indeed, 13 out of 14 same values may have helped the students tocope people living in foster homes or alone hada psychiatric with the brutality of Pol Pot. Further long-termstud- diagnosis. Although the students in general had lost ies are needed to determine whether these mechanisms members of their family, averaging 3 members of the will continue to be effectiveor whether in the future nuclear family, those who had been able to reestablish there will be further disruptionor symptom formation family contact with any family member and live with at other times of stress. them did much better than those withoutsome con- References tact. It may be that those without any family contact BURKE, J. D., BORUS, J. F. & BURNS, B. J. (1982), Changesin thatis,they lost their entire familyhadmore children's behavior after a natural disaster. Amer. J. Psychiat., trauma. But it seems more likely that having reestab- 139:1010-1014. CHADOFF, P. (1975), Psychiatric aspects of the Nazipersecutions. lished some contact with family members in thisset- In: American Handbook of Psychiatry, ed. S. Arieti. NewYork: ting mitigated some of the symptoms of thesevere Basic Books. EITINGER, L. (1961), Pathology of the concentrationcamp syn- trauma, while being alone or in a foster familyexac- drome. Arch. Gen. Psychiat., 5:371-379. erbated the disorder. The role of the familycontinued FREUD, A. & BURLINGHAM, D. (1943), Children and War.New to be extremely important in modifying thesedisrup- York: Ernst Willard. HAWK, D. (1982), The killings of Cambodia. New Republic,187:17- tive symptoms (see Part II; Sacket al. (1986)). 21. Although our rates of psychiatric disorderswere KINZIE, J. D. & MANSON, S. (1983), Five-year'sexperience with high, not every student hada diagnosis or was severely Indochinese refugee psychiatric patients. J. Opnl. Psychiat., 14:105-111. impaired by the profoundly disturbingtrauma. Indeed the lack of KINZIE, J. D., FREDRICKSON, R. H., RATH, B.,ET AL. (1984), Post- more social impairment or antisocial be- traumatic stress disorder among survivors of Cambodianconcen- havior in thisgroup was remarkable. Although some tration camps. Amer. J. Psychiat., 141:645-650. KRYSTAL, H. (1978), Trauma and affects. The PsychoanalyticStudy of the successful copingand adjustment was obviously of the Child, 33:81-116.

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i4;ke .; 376 KINZIE ET AL. M1LGRAM, R. M. & MILGRAM, N. A. (1976), The effects of the Yom Disorders and Schizophrenia-Lifetime Version, Ed. 3. New York: Kippur war on anxiety levels in Israeli children. J. PsychoL, New York Biometric Research Division, New York Psychiatric 94:107-113. Institute. MILNE, G. (1977), Cyclone Tracy; II. The effects on Darwin chil- STERBA, E. (1949), Emotional problems of displaced children. J. Soc. Casework, 30:175-181. dren. Aust. Psychologist, 12:55-62. TERR, L. C. (1979), Children of Chowchilla, a study of psychic NEWMAN, C. J. (1976), Children of disaster: clinical observations trauma. The Psychoanalytic Study of the Child, 34:552-623. at Buffalo Creek. Amer. J. Psychiat., 133:306-312. (1983), Chowchilla revisited: the effects of psychic trauma four ROBBINS. L. N., HELZER, J. F., CRAUGHAM, J., El' AL. (1982), years after a school-bus kidnapping. Amer. J. Psychiat., 140:1542- NIMH Diagnostic Interview Schedule (DIS) Wave II. St. Louis: 1550. Washington University School of Medicine. TOBIN, J. J. & FRIEDMAN, J. (1984), Intercultural and developmen- SACK, W. H., ANGELL, R. .H., KINZIE, J. D. & RATH, B. (1986), tal stresses confronting Southeast Asian refugee adolescents. J. The psychiatric effects of massive trauma on Cambodian children; Opnl. Psychiat., 15:39-45. II. The family, the home, and the school. This Journal, 25:377- WILLIAMS, C. & WESTERMEYER, J. (1983), Psychiatric problems 383. among adolescent Southeast Asian refugees. J. Nero. Ment. Dis., SHAFFER, D., GOULD, M. S., BRAS1C, J., ET AL. (1983), A Children's 171:79-85. Global Assessment Scale (CGAS). Arch. Gen. Psychiat., 40:1228- Z1v, A. & ISREALI, R. (1973), Effects of bombardment on the 1231. manifest anxiety level of children living in kibbutzim. J. Consult SPITZER, R. L. & ENDicorr, J. (1979), Schedule for Affective Clin. Psychol., 40:187-291.

88 BEST COPYAMU r LE The Psychiatric Effects of MassiveTrauma on Cambodian Children: II. The Family, the Home, and the School WILLIAM H. SACK, M.D., RICHARD H. ANGELL, M.D., J. DAVID KINZIE, M.D., AND BEN RATH

Forty Cambodian high school students who survived 4 years under the Pol Pot regime (1975-1979) and 6 Cambodian students who escaped their homeland prior to Pol Pot were studied by means of home interviews and school teacher ratings. In these findings, compared to psychiatric interview data on the same subjects, students reported more distress with school grades, peers and themselves than was observed by their caretakers. Many of their family members exhibited similar posttraumatic stress and depressive symptoms. In school, students receiving a psychiatric diagnosis were more likely to be rated by their classroom teachers as withdrawn or daydreaming than as disruptive. The crucial role of the school as a cultural agent of change became strongly evident. Journal of the American Academy of Child Psychiatry, 25, 3:377-383, 1986.

In Part I of our study of Cambodian adolescent reactions had more of an effect on children than the refugees (Kinzie et al., 1986), we described the psy- children's own reactions to the bombings per se. Burke chiatric status of these students, obtained from a et al. (1982), in their investigation of the effects of a standardized semistructured clinical interview. In this natural disaster, found that the parents' denial re- report we present findings on the families of these sulted in their minimizing their children's distress. students, obtained from a home interview, and on Aleksandrowicz (1973) described an "affective defi- their school performance and adjustment, obtained ciency syndrome" with associated hyper-repression in from teacher ratings and school records. a study of 34 Holocaust families. Other authors (Dan- The extreme suffering these students endured as iele, 1980; Freyburg, 1980) focused on survivor par- children under the Pol Pot regime in Cambodia (1975- ents' tendency to create family relationships charac- 1979) could not be isolated from that of family mem- terized by extreme cohesion and loyalty. As a result bers. After the horrors of Pol Pot, when the entire of their own fears of separation, these parents became traditional fabric of family life was targeted for de- overly protective and blurred boundaries between struction, Cambodians felt new uncertainty about themselves and their children. Adolescents in such family survivors, and apprehension about migration families were thought to have special difficulty when to a strange land. The accumulated stress on families their strivings for independence and autonomy came was therefore enormous. into conflict with their parents' desire to keep the The role of the family has long been recognized as family intact. They subsequently manifested this con- an important variable in the adaptation of children flict by disruptive and antisocial behavior. Zlotogor- ski's (1983) investigations of holocaust families did during disasters. A. Freud and Burlingham (1942) not, however, support this inevitable portrayal of ex- found, for example, that in World War II maternal treme cohesiveness and disturbed affective communi- Received Dec. 17, 1984; revised March 25, 1985; accepted April cation. He found instead a wide variation of family :6. 1985. functioning often quite similar to the control families. Dr: Sack is Director of Child Psychiatry and Professor of Psychia- As described in Part I of this study, family relation- .-.. Dr. Angell is Director of Residency Training, Child Psychiatry, IndAssistant Professor of Psychiatry, Dr. Kinzie is Director of ships served well as buffers against the massive :aural Services and Professor of Psychiatry, B. Rath is Cambodian trauma suffered earlier in Cambodia. Those living ksearch Assistant, all in the Department of Psychiatry, Oregon with family members did better than those without a H.Ith Sciences University, Portland, Oregon. Requests for reprints should be sent to Dr. Sack, Department of natural family. The school also played a crucial, mul- P.yrhiatry, Oregon Health Sciences University, Portland, OR 97201. tifaceted role in aiding accommodation to a new coun- Presented at the Annual Meeting of the American Academy of rhild Psychiatry, Toronto, Canada, 1984. try, a new language, and new cultural demands. The authors wish to acknowledge the special assistance of Karen In compiling our data, compared with self-reports Mug, M.A., and Dan Dickason, M.A., English-as-a-Second-Lan- from the psychiatric interview (Kinzie et al., 1986), zuage (ESL) teachers, throughout all phases of this project. 0002-7138/86/2503-0377 S02.00/0 © 1986 by the American Acad- we relied on home interviews of the students and on emy of Child Psychiatry. family observations. The school inquiry followed much 377

BEST COPY AVA.A.A.90: 378 SACK El' AL. the same format: teacher ratings of classroom per- study was an overall exploration into the many psy- formance and behavior, plus the school records. chosocial and psychoeducational variables of these students. Because of the small sample size, findings of statistically significant differences were interpreted Method as tentative. For the sake of brevity, the two-way comparisons will be presented with their x2 values The semistructured psychiatric interview, the Chil- and p value in parentheses. dren's Global Assessment Scale (CGAS) (Shaffer et al., 1983), and the consent form have been described Results of Home Assessment (Kinzie et al., 1986). The structured interview for the home study consisted of 110 items, plus a 25-item Family Characteristics art home observation inventory, and was administered by Twenty-six of the 40 "Pol Pot" students were in a trained Cambodian mental health professional (B. homes of members of the nuclear family, that is, with R.) to a natural or foster parent. The family question- parents or siblings. The remainder were in foster naire covered the student's health, the parents' as- homes or, in the case of one, living alone. Ten stu- sessment of the student's school and social function- dents' foster parents were Cambodian and four were ing, and family relationships, rules of behavior, and American. A wide variety of family configuration was finances. The parents were asked about the possible found ranging from two-parent to all-sibling families. presence of postraumatic stress disorder (PTSD) and Physically the homes were crowded by Western stand- depressive symptoms. A multiplicity of observations ards (as many as 12 people lived in one home). Two- were made about family configuration, fluency in Eng- thirds of the families lived in apartments. In all the lish and social class status, the physical characteristics non-American homes, the language spoken was Cam- of the home, and an estimate of acculturation. bodian (Khmer). The information obtained from the cooperating Or- Over one-half of the families received public assist- egon high school came from three main sources: (1) a ance, and only about one-third included a parent who classroom teacher checklist (already in use by the was steadily employed. Most families were living school), (2) global ratings by two English-as-a-second- either at a poverty or working-class level. Three- language (ESL) teachers, and (3) official school rec- quarters of the adults interviewed felt that their finan- ords. Items pertaining to the PTSD were added. The cial assistance was inadequate. A third of the students checklist was divided into two main sections: academic earned extra money by part-time jobs. ratings and behavior ratings. Each student received at In appearance, homes of 32 of the students blended least two ratings by two different teachers at various Cambodian and American cultures; statues, pictures. times from January to June 1984. In analyzing this baskets, evidence of Buddhist religious practice, and information, scores from these two ratings were av- other ethnic possessions were observed along with eraged. American furnishings. All but one home had a televi- These global academic assessments were designed sion. In all of the Cambodian homes, even those that to gain an overall impression of each student's aca- appeared more American, interest in Cambodian cul- demic skills, motivation to learn, and sociability in ture seemed high. school. Two ESL instructors who had personal knowl- It was difficult to assess the degree of marital and edge of these students rated each separately at the family discord in these homes given the Cambodian s end of the term, June 1984. Their interrater reliability concern about propriety. Basing his impressions on was 91%. observations of disagreements and nonverbal inter- Even though the psychiatric interviews were con- actions, the interviewer found that two-thirds of the ducted in the school, the teachers were "blind" to the parents got along well with each other and of these. psychiatric assessments until after the study. The half got along very well. No overt marital discord was psychiatrists were also blind to the teacher ratings seen. and home interviews throughout the data collection Relationships between siblings were also described which ran from January to June 1984. with only 4 of the 40 subjects reporting difficulties. The formal school record yielded days absent, a Almost all homes had rules about curfew time record of any disciplinary incidents, grades, and choice of friends and activities, and watching TV. The achievement test results. These data were then used parents, furthermore, thought that these rules were in making two-way comparisons against psychiatric well tolerated by their children. All but four of the assessment ratings, using the chi square (x2) test. The parents thought they got along well with their children

9 0 BEST COPYAVAiLARLF 379 CHILDREN.II MASSIVE TRAUMAON CAMBODIAN this particularsymptom. in the homewho was having reported theyenjoyed might admit to it aswell. In summary, and themajority of the parents Later, he/she not con- their children. and parent reports were the timespent with student self-reports Cambodians are significant associationcomparing fam- sistent. This is notsurprising as We found no status. Fosterchildren not to burdenothers. ily variableswith economic taught to bearpain silently and much highereconomic status lived inhomes with a those studentsliving with their Results of theSchool Assessment than inthe homes of students family (x2 = 8.23, p =0.0060). However, own psychiatric General Description homes had a muchhigher rate of study could in foster It is important toemphasize that this diagnosis (Kinzieet al., 1986). undertaken withoutthe active support not have been school administration. of the ESLfaculty and its Parents'Symptoms welfare of this three-quarters of allthe Their concernfor the psychological We foundthat more than students led to aninitial request forassist- Cambodia underPol Pot. This group of Oregon parentshad lived in of Psychiatry, included bothCambodian foster par- ance fromthe Department subsequent phases of high percentage Health SciencesUniversity. All and natural parents. carried out jointlywith the partici- ents inquired about thelevel of stress parents this project were When we than one-half of the ESLstaff. The student experiencing, wefound that more pation and consent done at the school. were following symptoms(some- interviews, forinstance, were all respondents had the students were listed assophomores of the sleeping, troubleconcentrat- Most of these times oroften): trouble "feeling register. Their prioreducation irritability, and sad or or juniorsin the school less than 3 years ing,anxiety, fatigue, admitted to four disrupted: 50% had Two-thirds of theparents who had been severely only blue." had lived throughthe Pol before enteringthe United States; of these symptoms of schooling schooling. Twenty-five or more 6% had morethan 4 years of Pot years. percent had noschooling. Student composed of both aca- between Parent and The teacherchecklist was Comparisons questions. Thenumber of stu- Observations demic and behavioral were run onmultiple vari- "below average" or"having difficulty" Numerous comparisons dents scoring items weretabulated. attempt to findpatterns ofconsistency on two or moreof the academic ables in an the home inter- scored deviantly ontwo or more from the two sourcesof information, Likewise, those who We found that interview. Wecompared the behavioral items werealso counted. views andthe clinical be seen as behav- with the parents'report of these more likely to students' symptoms these students were academically deviant Comparisons of apsychiatric diag- iorally deviant(25%) than same symptoms. were alsodone. Like- with the teachers'overall assess- nosis andparental perceptions (15%). This agreed diligent and con- reports of theirchild's school func- students as generally wise, the parents' and ment of these only 7 of the 46 compared withstudents' reports scientious learners.For instance, tioning were yielded statistically for more than 5days during the grade point average.None of these students were absent 9 disciplinaryincidents, all minor Significant relationships. school year. Only logged in parents thoughttheir children got drugs or alcohol, were When asked how thought to have and none involving only four were the school recordduring the year. along with their peers, one-half of the behaviorally deviant onthe teacher difficulty. However,in our interview If rated as with- that they did nothave many friends. checklist, they were morelikely to be rated as students reported students said that On the whole, but one of the drawn or daydreamingthan disruptive. The parents of all about their experi- rebellious students. they had talkedwith the student these were notoppositional or But when weasked would be flashesof hostility be- ences duringthe Pol Pot regime. Occasionally there (tra- question, the answerdiffered: less Cambodian andVietnamese students students this same tween the specific had discussedPol Pot with their antagonists). The more than 50% said they whether having a ditional cultural reactions or parents. We alsowanted to know symptoms of thePTSD (such as startle parent predisposedthe students to dramatic examplesof suffering, more symptomatic significant asso- flashbacks), while be more symptomatic.There was no were not commonclassroom occurrences. the number or typeof symptom students received aGrade Point ciation between either The students Ten of the 46 academic year of reported by the parentand the student. for the 1983-1984 symptoms. For Average (GPA) school grades oftentook were not unawareof their parents' 2.0 or below.The pattern of semistructured interview wefound students movedfrom the instance, in the a noticeabledecline as these occasionally initiallydeny having the mainstreamof the high school that a student would another person ESL program into a symptom himself,but would identify LAN _F 91 BESTCOPY MA utS 380 SACK ET AL. curriculum. Despite their hard effort, at the end of the between these two ratings (x2 = 8.54, p = 0.003). d st 1983-1984 academic year, less than a quarter of the There was also a strong relationship between the get students could pass the high school graduation stand- students' GPA score and the classroom teachers' rat- cau ards tests of Oregon high schools (a test comparable ing on academic items ( x2 = 4.95, p = 0.02). These 'KJ a to roughly the 7th grade achievement in reading, lan- independent measures served as a validity check for yes guage, and mathematics). the teacher assessments. is C The global ratings of overall student sociability did oplt Comparisons between School Observations and not show a significant relationship with other aca- DUI Student Self-reports demic or behavioral measures. In attempting to obtain mn- As noted before, those 40 students who were Pol some overall measure of these students' peer contacts iv( Pot survivors were more likely to receive one or more and involvement, the ratings did show that most of ted: psychiatric diagnoses ( x2 = 7.22, p = 0.007) than the the students maintained friendships within their eth- ct t. 6 "non-Pol Pot" students. Yet, when we compared nic group. Only a few had developed comfortable, close ap' these two groups on academic classroom measures or relationships with American students. r is GPA averages, we found no significant differences. In summary, students who had received a psychi- gt Likewise the Pol Pot group was not significantly ab- atric diagnosis and were rated as functioning low on Tht sent more frequently, nor did they show significantly the CGAS were more likely to be seen by the classroom more disciplinary incidents than the non-Pol Pot stu- teacher as emotionally withdrawn and daydreaming. M dents. However, when we compared these two groups Case Vignette e d on the teacher behavioral portion of the checklist, we On did find some significant differences: the Pol Pot Illustrating the kinds of information obtained from adolescents were more likely to be rated as deviant on the psychiatric interview, and school and home rat- I. ch two or more behavioral items than the non-Pol Pot ings, we present the following case example: group (x2 = 5.66, p = 0.01). A 16-year-old Cambodian female student became When we compared the two groups on one particular very upset in the classroom of one of the ESL teachers itembeing emotionally withdrawnwe also found a in October 1983. A classroom film on China evoked h significant difference (x2 = 4.82, p = 0.02). Other several symptoms of acute posttraumatic stress in this behavioral items did not by themselves yield signifi- girl who later explained that certain pictures of China cant differences. recalled a past experience in which she again wit- Next, we examined only the 40 Pol Pot students nessed the execution of 200 people. 47 and divided them into two groups: those who had Most of her psychiatric interview required an inter- r1 received one or more psychiatric diagnoses, and those preter. We learned that she had been in this country not receiving a psychiatric diagnosis. We then com- about 15 months, and was currently living in an Amer- pared these two groups of students on the same school ican foster home with a younger sister. For the first 6 variables. Again, no differences were found in terms months of her school experience, she did well. The of the GPAs of either group or in the teacher's aca- following 6 months, however, were different. She be- demic ratings between the 27 students who had re- gan to miss school and complain of headaches. Very ceived a diagnosis and the 13 who had not. When we depressed and suicidal, she finally sought help and compared these same groups against those who had had been seen in psychotherapy by another profes- received a deviant score on two or more teacher-rated sional at the time of our interview. She stated she was behavioral items, we again found a significant differ- feeling better and confessed that the reason she had ence (x2 = 6.41, p = 0.01). earlier felt suicidal was that she was "thinking too When the CGAS was used instead of psychiatric much." She was not able to sleep well and could not 0 diagnosis, a similar difference was found. Dividing concentrate on her studies. -a students into those who scored 60 and above versus She was 9 years old and living in Phnom Penh with those scoring below 60, we found the teacher's rating her family of 6 siblings when Pol Pot came to power. dt of behavioral deviance in the latter to be significantly Her father, a military officer, was stationed in another related ( x2 = 4.94, p = 0.026). This time the particular country and had earlier urged the family to leavethe behavior of being emotionally withdrawn in class, as country, but they had refused. He finally returned well as daydreaming, also appeared related to the home to his family, but had to change his name and

CGAS of below 60 (x2 = 6.71, p = 0.01). identity to survive. t We had two independent teacher ratings of stu- Shortly the family was separated and sent to differ dents' academic skills: those on the teacher checklist ent work camps. The preadolescent girl was sentwith and those from the year-end global ratings of the two her mother to one of the worst of these which was in ESL teachers. There was a significant relationship essence a starvation camp. Her mother waspregnant

92 BEST C PY AWAKE MASSIVE TRAUMA ON CAMBODIAN CHILDREN.II 381 and starving during this time. The daughter attempted Discussion to getextra food for her, but was afraid to steal food In general, these Cambodian adolescent survivors because of an automatic death penalty. Her mother seemed to be experiencing a greater amount of suffer- died after childbirth, but the child survived and now ing than their caretakers realized. They were more lives withher sister in Portland. Over the 4 years of anxious about their school work, had worries about this camp's existence, only 700 of the original 2,000 friends, and complained of symptoms of depression at people survived. a higher rate than that reported by their parents. During the ordeal of the work camps, her father While we did not do formal psychiatric assessments committed suicide; one sister and one brother died of starvation; one brother-in-law, a surgeon, was exe- on the parents, the frequency of their reported symp- cuted; both grandparents died. She had to hide the toms during the home interview revealed much PTSD fact that she had 4 years of formal schooling. When and depressive symptoms. The suffering of the stu- escaping to Thailand with her sister, in order to hide dents was manifest in the classroom by the predomi- nant symptoms of daydreaming and emotional with- her identityshe changed her name. In the Thailand refugee camp she found a sister and brother. drawal rather than by verbal complaints or disruptive behavior. The review of her present and past symptoms elic- ited sufficient disturbance to qualify her for both the Irrespective of the economic and physical conditions DSM-III diagnoses of the PTSD and a major depres- of the homes, all of the families were successful in sive disorder. maintaining traditional child-rearing practices with One of the more striking aspects of her symptoms high expectations for conformity. This was true even was her declaration that she had ceased to care as in families where older siblings functioned as an adult much about other people as she used to. She also figure. Clear adult-child boundaries were maintained noted that she avoided getting involved in school with a high level of filial piety. This high degree of activities, homework, and friendships. When we asked interdependency and compliance is not simply the her how long she might live, she smiled ruefully and result of the extreme trauma these families endured. said, "Maybe I'll die tomorrow." It is important to emphasize that all these children After we reviewed the interview material, she was completed approximately the first 8 years of their assigned an overall score of 47 on the CGAS. A score development before Pol Pot. Cambodian children are of 47 is in the category of 41-50: "Moderate degree of thought to be independent at birth and then are wooed interference in functioning in most social areas or into a sense of interdependency by attentive, indulgent severe impairment of function in one area, such as child rearing from multiple parenting persons. Parents might result from, for example, suicidal preoccupation, become increasingly strict in their expectations for school refusal, etc." (Shaffer et al., 1983). conformity and responsibility after their children In the several teacher ratings made over the last 6 reach age 7. Compliance is based less on emotional months, there was one consistent pattern: she fre- relationships between child and parents and more on quently daydreamed, was emotionally withdrawn, and respect for authority. Responsibility for honoring the did not participate in class discussions. Less consist- family name is learned early. Adolescence in tradi- ent were the ratings she received on academic issues, tional Cambodian families is usually not accompanied such as completing assignments. Two ESL teachers by overt emancipation struggles. Respect for elders' cored her as below average on their global ratings in authority is undiminished even as the children are overall academic skills and in motivation to learn. In apprenticed into adult status by work or marriage her overall sociability, she was noted to remain close both of which may come during teenage years (Tobin to a small group of Cambodian students. Her GPA and Friedman, 1984). After years of living alone, the had dropped from a 3.0 the previous 6 months, to a teenagers in our study who now lived with natural 1.1 during the following 6 months. family members exhibited none of the rebellious, pre- She now lives in an American foster home with delinquent behavior that has been described in some several other Cambodian youths and American foster survivors of other disasters (Newman, 1976). children. She was described by the foster mother in Foster children were not so fortunate. Bereft of their he home interview as havingmany worries about her own families, most had been living independently for health, but not as posingany behavioral problems. several years before living in their foster homes. They Her troubles in schoolwere recognized, but she was occasionally complained that family supervision was seen by the foster mother as being reasonably sociable. too strict. One student complained in terms that were She had sharedsome of her Pol Pot experiences with suggestive of work camp experiences under the Pol her foster mother. Pot cadre. He quoted the foster mother as saying to

9 3 BEST COPYAVAILABLE 382 SACK ET AL. gwm the family, "If anyone says anything, I'll beat his head their traditional one of imparting knowledge: (1) They atB in. often were assigned by the students to be counselors The issue is more complicated than being "strict." and friends, listening to concerns, answering ques- B. (: than For example, one foster boy who complained about tions, and correcting misconceptions. (2) They became F the strict curfew rules later admitted that he did not case finders for both physical health and mental health ob: go out at night because he was afraid. This same boy concerns in the refugee students. Seven of these 46 1231 said that he did not think his family liked him, con- students had been referred for psychiatric services in sequently he felt isolated. For him the close supervi- the Southeast Asian Psychiatric Clinic at the Oregon sion was not embedded in shared loyalty and respect Health Sciences University. (3) They were advocates. for a common family name. Even good relationships They helped students find part-time and full-time with the foster parents could not easily replace his jobs. They interpreted their needs and vulnerabilities own family identity. At the same time, this student to other teachers. (4) They were both students of and stated clearly his need for having traditional family endorsers of the Cambodian culture. For instance, they support and his unreadiness to move out and live arranged all school assemblies in which Southeast independently. A typical comment was, "There is no- Asian students could perform traditional dances. They body to help me if I leave home." These findings occasionally attended community traditional ceremo- should not minimize the tremendous dedication and nies and tried to learn bits of the Cambodian language. commitment of the foster parents we met in this study. (5) Finally, they were the main "bearers" of American They were uniformly compassionate people. culture to these students, in helping them to under- We did find clear-cut connections between the class- stand American customs and traditions. Because of room behavior of this group of Cambodian refugee their good relationships with these students, 46 out of students and the information they gave in a single 54 available students participated in this study. psychiatric assessment. Despite their past suffering, We feel that such students, new to the United 111 and family and educational disruptions, these students States, should be allowed to remain in school as long performed relatively well in academic classroom as- as necessary to make the major and difficult transition

I!' sessments. That is, they performed academic tasks to our culture. The move to individual independence reliably. Yet, manifestations of their suffering showed may be a formidable one for these students, coming up in certain classroom behaviors. We found that from a country where family solidarity is more highly classroom behavioral items correlated with our psy- prized than personal autonomy. As representatives of chiatric assessment while academic items did not. This a culture that has been largely ignorant of the Pol Pot was a consistent finding, whether we used presence or atrocities (or has tried to ignore them), we present absence of any psychiatric diagnosis, or the CGAS as this family and psychoeducational data in the hope our independent variable. that all who work with such students can be increas- Of the classroom behaviors that might suggest suf- ingly sensitive to their past traumas and future needs. fering in such a refugee group as this, emotional with- It is important to determine how these students adjust drawal, daydreaming, and nonparticipation in class to the major life changes involved in leaving school would seem to be the most consistent and sensitive and their families and weeking work or other educa- clues to inner psychological turmoil. In contrast to the tion away from home. We intend to follow up these American adolescent who might be more likely to act students in 2 years to determine the effects of the out problems by disruptive or oppositional behavior, changes on psychiatric symptoms and social adjust- the Cambodian adolescent seemed to withdraw as a ment. way of coping. This disparity between school perform- References ance and behavior was also found by Ten (1983) in ALEKSANDROWICZ, D. (1973), Children of concentration camp stir" her study of 25 "Chowchilla children." Despite their vivors. in: The Child and His Family, Vol. 2, ed. E. J. Anthony extensive inner turmoil, only 4 of the 25 children of New York: John Wiley & Sons. the Chowchilla kidnapping exhibited problems in ac- BURKE, J. D., BURNS, J. F., BURNS, B. J., MILLSTEINK, H. 6: BEASLEY, M. C. (1982), Changes in children's behavior after ademic performance. natural disaster. Amer. J. Psychiat., 139:1010-1014. Because the Cambodian student brings to the Amer- 'DANIELE, Y. (1980), Families of survivors of the Nazi holocaust; ican educational experience a deep commitment to some long and short term effects. In: Psychological Stress Oro Adjustment in Time of War and Peace, ed. N. Milgram. Washig learning and a respect for the teacher as a revered ton. D.C.: Hemisphere Press. authority figure, responsibilities and opportunities for FREUD, A. & BURLINGHAM, D. (1943), War and Children. Neg. ESL teachers are of great significance. During the York: Ernst Willard. FREYBURG, J. (1980), Difficulties in separation-individuation as course of this study we noted the skill with which experienced by offspring of Nazi Holocaust survivors. Amer. these teachers played a variety of roles in addition to Orthopsychiat., 50:87-95.

94 BEST COPY AVAILABLE MASSIVE TRAUMA ON CAMBODIAN CHILDREN. II 383

N;F,wmAN. C. J. (1976), Childrenof disaster: clinical observations trauma four years after a school-bus kidnapping. Amer. J. Psy- at BuffaloCreek. Amer. J. Psychiat., 133:306-312. chiat., 140:1543-1550. KISZIE, J. D..SACK, W. FL, ANGELL, R. H., MANSON, S. & RATH, TOBIN, J. J. & FRIEDMAN, J. (1984), Intercultural and developmen- B. i 1986), The psychiatric effects of massive trauma onCambo- tal stress confronting southeast asian refugee adolescents. J. OpnL dian children;I. The children. This Journal, 25:370-376. Psychiat., 15:39-45. .0,4A FITE.D., GOULD, M. S.. BRASIC, J., ET AL. (1983I, A children's ZLOTOGORSKI, Z. (1983), Offspring of concentration camp survi- global assessment scale (CGAS). Arch.Gen. Psychiat., 40:1228- vors: the relationship of perceptions of family cohesion and adapt- 1231. ability to levels of ego functioning. Compr. Psychiat., 24:345-353. TERE. L.C. (1983), Chowchilla revisited: the effects of psychic

SIXTEENTH EUROPEAN CONFERENCEATHENS, GREECE September 6-11, 1986 "Psychosomatic MedicinePast and Future" For information, write: Prof.-G. N. Christodoulou Athens University Department of Psychiatry Eginition Hospital Vasilissis Sofias 74 GREECE

BEST COPY AMIABLE 95 'D PEHDEK

96 Children of HolocaustSurvivors

Shirley Ann Segal,M.S.

Purdue University Dept. of ChildDevelopment and Family Studies

Child Developmentand Family Studies Building West Lafayette, Indiana47907

-PERMISSION TO REPRODUCETHIS INIANTINIINT OP 101/CATION Sr NATIONAL IMIIITTTUTI OP /DUCATION MATERIAL HAS SEEN °PAWED po.prT.oNt. p!noNctoarowyTION CINTIP ,FAIC, )1( IksAntruene.1 .04 Men 11fOriA reOA IS 14 00 wens IV nr(panill,nn 4.4644.. 6444/0 10.404 t'ON.4 LOS.p04 In4n,444 444,n4.4fin. 4.4..V TO THE EDUCATIONALRESOURCES ,..01,0 gam n14.nnil OW./"". 4." INFORMATION CENTER (ERIC1." nP!'w rl NI .4.nt4n m14 nay16444 .440,4 11.11.10.ov for*/

BEST COPYAMAMI 9? 2 Abstract

many survivorsdeveloped As a resultof the Holocaust, impairement known asthe Poet-Traumatic long-termpsychosocial individuate Due to theirinability to Stress Disorder(PTSD). adolescence, manyoffspring of from theirparents, by The purpose to exhibitPTSD symptoms. Holocaustsurvivors began the literature onchildren of of this paperis to review of my findingsfrom Holocaust survivorsand present some the symptomsexhibited interviews withthem. I will describe children, explainthe by Holocaustsurvivors and their offer suggestionto clinicans transmission porcess,and finally of anycatastrophe. working withchildren of survivors

98 and the children'steeth "The fathers haveeaten a sour grape,

are set onedge." Jeremiah 31:291

,Introduction

of catastroph Social supportersclearly benefit victims heavily on too few (Burge, 1983). When victims rely too develop supporters, however,these drained supporters can An psychosocial impairmentthemselves (Kishur,1983). is example of drained supporterswho develop impairment

children of Holocaustsurvivors. In this paper I will present review the literature onHolocaust survivors'-clii*dremilind I will some of my findingsfrom interviews with tbem. describe the symptomsexhibited by Holocaustsurvivors and and finally their children, explainthe transmission process, offer some suggestions toclinicians working withoffspring of survivors of anycatastrophe.

Symptoms

Although the Holocaustoccurred over forty years ago, many survivors and theirchildren are still exhibiting psychosocial impairment. Although not all survivors exhibit impairment, it is impossible toknow the incidence of those who do, since there are fewstatistics on Holocaust survivors in the general population. In 1956 the Concentration Camp

Syndrome (Niederland, 1968) was the specific name givento 2

Holocaust survivors. These the symptomsexhibited by inability concentrate.depress ton. symptoms includeinability to psychosomatic illnessand to express anger.anxiety. nightmares, insomnia.obsessive thoughts hypocondriasis, guilt, mistrusts_and estrangement about theHolocaust, survivor Eitenger, 1980;Koenig, 1964; from others(Daniels, 1981;1982; III (An,1980) characterized Niederland, 1968). In 1980 the DSM in offspringof any catastrophe most of thesesymptoms occurring Disorder (PTSD). as thePost-Traumatic Stress of Holocaustsurvivors By adolescencemany offspring as theirparents, and began exhibitingthe same symptoms The symptomstheyexhibited were some soughtpsychotherapy. to express andcontrol inability toconcentrate, inability psychosomatic illness,lack of individuality, anger,depressions guilt, (Barocas,1975; mistrust, estrangementfrom others, Phillips, 1978; Russell, Daniell, 1981;1982;Epstein, 1979; Sigal, Silver,Rakoff, & 1980; Rustin &Lipepig, 1972; 1975; Timmick,1981), Ellin, 1973;Steinitz & Szony, 1978; Timmick,1981). nightmares and drugabuse (Scheider,

their parents'traumatic . Thus, withouthaving experienced same symptoms astheir event, thesechildren exhibited the interivewed Holocaust survivorparents. In 1980, I All of these eleven offspring ofHolocaust survivors. I just mentioned. eleven reported someof these symptoms twenty-one. One example is myinterview with Marc W., age Marc began (Marc W. is apseudonym). In grammar school, passages collecting books on theHolocaust. He read and re-read BEST COPY AMIABLE 5 100 3

and became annoyedthat they of these booksto his friends, seriously as hedid. In did not takethe Holocaust as threatened suicide,and at age grammarschool, he often by throwinghimself eleven, he made anunsuccessful attempt By junior highschool, Marc in front of amoving schoolbus. drug dealer.He became the became a heavydrug abuser and sold drugs forhim and stolefor leader of a cohesivegang who shoplifting. Althoughhe him by robbinghouses and high school, he wasunclear overdosed on drugsseveral times in a suicideattempt. Marc whether any ofthese overdoses was and was admittedto college. managed to graduatehigh school father died. Marc During his first yearin college, his death, and reportsmaking blamed himself forhis father's his lifestyle. He quit a consciouseffort to change began to take hisstudies drugs, disbandedhis gang, and his last year oflaw school, seriously. Presently he is in international law.Although and plans ontaking aMaaters in problems in adulthood,I am Marc seems to overcome his impairment ends byadulthood. not implying.thatin all:cases

process of PTSDTransmission

that the effects of the The literatureclearly documents transgenerational, and this casestudy is an Holocaust are second illustration of the prooefts. In order to prevent other catastrophes, generation effectsfrom occurring in but how we need toknow not only thatthe transmission occurs, 6 101 4

1 consensus in theHolocaust it occurs. There is _growing from parents tochildren literature thatthe transmission from one's parents occurs bythe inabilityto individuate (Barooas, 1975; Daniels.1981; and establishone's own identity 1980; Steinits &Szony, 1975; 1982; Phillips,1978; Russell, from parents Wanderman, 1975). In transmitting traumatization of identificationis impaired. to children, thenormative process establish their own Instead of allowingthe children to identities into identities, the parentstry to hammer their their children assymbols their children. The parents view lost and suffered,and the children to compensatefor all they have 1975; Danieli, readily assume thisresponsibility (Barocas, & Stony, 1975; 1981;1982; Epstein, 1979;Russell, 1980; Steinits author of a book Wanderman, 1975). Helen Epstein (1979) an quotes this perceptionof on childrenof Holocaust survivors responsibility from asurvivor child who says: 1 and that each of I knew my parentshad crossed a chasm, them had crossed italone. I was their first companion, a new life,and I knew this lifehad to

be pure life. This life was asdifferent from death as good was fromevil, and the present wasfrom

the past(p. 30). Rather than blamingHolocaust survivors forexpecting lost, we their children tocompensate for all they have Every need to keep in mindthe impact of tbeirlosses. their lives was person, possession,value, and belief in

102 7 5 redefined their world as destroyed in theHolocaust, and they hostile others (Bergmann evil and dangerousand populated by 1981;1982; Eitenger, 1980; & Jucovy,1982; Danieli,

Niederland,1968). married, but Aftsr the war, Holocaustsurvivors hastily Because they almost always otherHolocaust survivors. hostile, they preceived all othernonHolocaust survivors as friends (Danieli,1982; chose mostly othersurvivors as their their only substantial Epstein, 1979). Their children became too heavily link to the outsideworld. Thus suvivors relied Often the on too fewsupporters (ie. theirchildren). audience to recount parents used theirchildren as a captive For many children graphic details of theHolocaust experience. of being their parents of survivors, the responsibility chief social supporter wastoo great to endure. their lives Thus, in expectingtheir children to provide but they also with meaning, survivorstook from their children, children gave. They desperately wantedto insure that their wiuld be safe in a worldin which Holocausts can occur. world To insure safety,they taught their children that the was hostile, andthat they must always be ongaurd (Barocas, 1975; Daniels, 1981;1982;Epstein, 1979; Sigal et al., 1973; Steinitz & Szony, 1975;Wanderman, 1975; Timmick,1981). Although the children'sexperience did not fit their parents' woridview, they were taught tobe mistrustful enough of outsiders and guilt-riddentowards their parents that they accepted their parents'woridview. Apparently they

BEST COPY AVALABLE 103 8 6 closely, thatlike their identified withtheir parents so symptoms. parents, theydeveloped PTSD Erikson'e theoryof identity Although thecomponents of to explain thesymptoms formation areused consistently of the Holocaustresearchers of childrenof survivors, none explainthe survivor's explicitly usesErikson's theory to briefly explaintheir child's difficulties. I will therefore framework. identity formationusing Erikson's survivors' attempt First of all,children of Holocaust problematic, since it wasdifferent from to individuatewas to Erikson'stheory, that of their peers. Normally, according out of allformer identity formationinvolves a sorting of others are identifications in whichthe influences identity (Erikson,1968). resynthesized into theadolescent's unique their parentsdemanded In.the case ofchildren of survivors, identities, so that noselecting total conformityto their own 1981;1982; Russell,1980). was possible(Barocas, 1975; Daniels, prepared to Moreover, theseadolescents were not developmental stages havenot individuate, since their previous the childhood tasks been mastered. According to Erikson, and industry(Erikson, 1968). are trust,autonomy, initiative, impairment rather than If these tasks arenot mastered, identity formationwill result. completed From the onset,children of survivors never They were taught tomistrust the initial truststage. al., 1973; (Daniell, 1981;1982;Epstein, 1979; Sigal et Timmick, 1981). Steinitz P, Szony,1975; Wanderman, 1975;

104 9 7 allowed to develop. Consequently none of theother stages were taught shame and guilt In place ofautonomy, children were 1978; Rustin (Barocas, 1975;Epstein, 1979; Phillips, Industry was encouraged & Lipsig, 1972;Sigel & Rakoff,1971). achievement in school but inconsistently. On one hand, high felt:guilty for surpassing was encouraged,yet the adolescent (Daniell, 1981; 1982; the accomplishmentsof his/her parents

Epstein, 1979;Phillips, 1978). children could Also, according toErikson (1968), these initiative, and not possibly havelearned trust, autonomy, qualities industry, if their parentsdid not possess these (1964) as a result of the themselves. According to Koenig and thus had not Holocaust, survivorssuffered ego regression mastered any of thesetasks themselves. Thus, unlike their peers,children of Holocaustsurviors and in were unable toindividuate from their parents PTSD symptoms. their struggle toindividuate, they developed According to Bergmannand Jucovy (1982) the taskof adolscents in this way: of survivors wasdifferent from that of their peers The task of survivors'children who are becoming adults is to understand theirparents' past experience without degrading oridealizing them.

In one sense, this taskis not different from that of other young adults growinginto adulthood. Yet, it is different in that it concursa reality that defies trust in human nature and createsobstacles to the young person's need tounderstand history as a basis for the present and the future(p.61). BEST COPY AVA6LABLE 105 10 8

Suggestions for Clinicians

children of Holocaustsurvivors By lateadolescence, many Clinicans who have sought psychotherapyfor PTSD symptoms. written of their worked with childrenof survivors bave (Russell, 1980; Rustin & difficulty in workingwith them blame the clientfoy Lipsig, 1972). Therapists tend to expereince instead not understandingtheir parents' traumatic of the Holocaust aswell. of viewing theclient as a victim successful for The type of therapywhich seems to be with fellow survivors and theirchildren is group therapy 1980). DanielLhas survivors(DaniVIA, 1982; Russell, A group tried support groupsinvolving both generations. each other to of fellow survivorsand children can help restore a sense of recognize their lossesand then attenpt to One of the strategies continuity, belonging,and rootedness. goals to is have groupmembers Daniels usesto reach these construct a threegenerational family tree. Conclusions Thus we know that notonly survivors, but theirchildren Prom this we can as well aretraumatized by the Holocaust. hypothesize that childrenof survivors of othercatastrophes victims, etc. such as Vietnamveterans, burn victims, rape that they develop may identify withtheir parents to the extent the same symptoms. Perhaps we can use thisinformation to determine assess parent-childinteraction of such groups to whether the transmission ofPTSD is occurring anddevelop BEST COPY MAIM-, 10 6 11 intervention programs tocounteract this. Finally, I went toemphasize that for mostpeople, the

Holocaust is simply history. We need to bereminded, therefore, catastrophes such that for some survivorsand their children, their as the Holocaust arenot history; They are a part of everyday lives. 106 a 6.. 6.. 111 S .1 SurvivorsAn Intergenerational and Their Children Program Designed for Holocaust NewGroupDirectorDr. Yael York, Projects Danieli New Yorkfor Holocaust Survivors and Their Children L 0 --II - - *- - 41 z tionsdeeplyperspectiveI by my haswork been withhave minesurvivors travelledfrom ofbirth. the through Holocaust, five continents.contribu- to treatment of the Aborigines I've been touched very in A multi-culturalAustralia, and 110 MIE 111111 BEST COPY MUM NM OM MN _99 MN MI makeevents.earthquake the world victims a better and survivors place. This of other ultimately dramatically propels terrible Hopefully, I help, and, hopefully, I do a little bit to me. I victims,peoplesion, andsurvivors' to listendenial to warof or their accountsbelieve. Holocaust Similar were experiences. too to otherhorrifying victims for who most are Like other connectedothermywant work toprojects shareto whether them. withbecause These it'syou my theareI own actualthe wordsproject feeling of because Eli that Wiesel: propels I hear of them or I'm in some way built it, or me in foughtslaughter."ticipatedvasivelyblamed and held infor thattheir their myth they ownvictimization, that shoulddestiny they hadhave survivorsby actively"going been were likepreparedor passivelyfaced sheep with for to par- athethe per- This myth implied not only that they could have hasAfteroflittle been Thethe the that blacklearned.balancereckoning, only years one Auschwitzsheet hasconclusionone is begotten feelsdisheartening. is notdiscouragement is yetevenpossible. another served Society Mainly, failure. and has theshame. changedNothing failure warning. so them,theyassumedHolocaust chose which that as towas iftheescape anyone clearly Holocaust and notwas thatthe victimsor case.couldthe rest had have of somewhere the been. world But wantedto it goalso if beingspointdeterminedNow that'sof from view from Inwhat and light the evilfrom of perpetrator's mydoes, the life lessons we that can from point wemake thecan of theservice-providing view.learn world as a as humanI'm quitea better onvivorsAdditionally,immoral to the as survivorspointing act by in standards, order an the accusing tosuspicion survive. guilt fingerlead that Like many theyat other them hadto victims, regard andperformed to theythe project sur- werean place. theMayThe heavens in sun 1944. made were The a helpless sundesperate is warming on effortthat day.in to May. shine A force It heals. But on the last day of so evil ruled even derstandthattheirlives.also nobodytoldHolocaust tothem let cared bygones unlessexperience. to listen they be bygonesandhad thatgone nobodyand through to get could the on samewithreally their ex-un- These reactions insured the survivors' silence about They were forced to conclude smoke-filledburningoutuniverse.heaven of my Mother.and Andskyvision earth of the Auschwitz.for heartthat forty it of alteredyears my 1 have mother now, the tried naturalbut was to my rub floating eyesorderthe smoke are ofin still the ingsurvivors'Holocaustperiences. the already familial survivors profound and andsocietal sensesociety cultural of proved isolation, integration detrimental loneliness, by intensify- to and the The resulting conspiracy of silence between theaLater, projectwhile: in thatAmerica, we built, Isabella, tellsIn ofa who wayher is mother,she one didn't of who the really livedparticipants die, for she just simply in became smoke. whenhavemourninginteracting,mistrust alsosurvivors of theirtypicallysociety. integration, massive mentioned Thisparticipated lossesfurtherand or healing recountedimpossible.impeded in the and conspiracy the themade Psychotherapists possibility Holocaust their of silencetask of ex-the of goodbye.MotherinHow the dots sky? I'm one tryingHow bury doesto smoke? say one goodbye How bring does toflowers you. I one place headstones am trying toto saythe clouds? Inresearchaminedperiences. analyzing psychotherapists' discovered In the one sources study, 49 such ofI've counter-transference these reactions.Identified reactions, and systematicallywhat reactions. I discovered ex-My 1 ufylvors of the Nazi Holocaust.9b,%aciescomprisedwar,Her poignant survivors which of questionshaveobtuseness, were confronted victims articulate indifference, of asurvivors perversive but avoidance, and societal children reactiondepres- of After liberation, as during the a few of the numerous Andthetherapistis that therapistsurvivors I it is has the blind aboutorHolocaust their and whatever children. deaf, rather wanting the than Holocaust thenot actualto hear was encounter or that not rendersto see.with strongly believe that therapists' difficulties in treating It is the imagination that the 112 I IMI 100 MEI WM NM MEI IMO MI MIA LE111111 INS NM 10111 MN NM MIN MO WIN =I 101 thevictimizations.otheronlyphrase survivors' victimssurvivors option may silenceleft Assimilarly toI said survivors about andbefore,have their refugees othertheir suchHolocaust rootsthan reactions included totalIn experiences. the solitude havenature under insured or of that Theshar- their Americasimultaneouslytheiranniversaries.manifest Identities theseand In thelivedHolocaust-derived different images in different time of those zones, places, behaviors who such like perished in as particularly Europe in 1942and and have and on in Moreover, some have internalized as part of withdrawbitsparents'Childrening ofand the completely andpieces, Holocaust lost attended families' Into experience the warto newlythe histories, psychological withestablished aseach they other presence say,families. wasonly oftoin of such families, although remembering their thewethat.ferent1988. world.can When onlyThereligions you betherapist, talkfull that ofabout wondermentmay therefore, different coincide must souls,about with be bringing theit'sable sowisdom to similar goodnessencompass of that dif- to healthyrodeofbally.the silence Holocaust their "normal becauseown atlives homeAmericans". of and their at prevent all fear times, Wethat their touchedboththeir children verballymemories yesterday from and wouldbecoming non in cor-ver-the In contrast, other survivors welcomed the conspiracy ly.naturaldeprivedMost The families Holocaustdeath. the normal of Survivors survivors took cycle six on areyearsof a the wholeextremely ofgenerations their die fivelivessmall. years andwith The agesallpremature- Holocaust their and los- of come?andwhatgroups what that In does.otherdoes itdiscussionsAnd call what upon does usabout to "normal be the or need become American" to belong or notmean, and be- steepedthaningsurvivedses, physical andthe inbyrest also death anotherillness of reduced the and andpopulation,five losses, suicide.years.the length yet They as its well. offspringof die their of all lives are causes, expectedwhen includ- they to They're more physically ill Each family tree is tonorneitherBut have theirthe understood childrenconsciouslyown sense grew the of and 'inexplicableguilt.up inunconsciously The painful children terror bewilderment. within of absorbed survivors their families seemtheir They againstdoa newgrandparentsre-root so, and the that healthyNazis tree and andand generational relatives; againstre-establish humankind. they cycle. the have extendedThey been They are cheatedhave family,expected not startingof had nor-to despite conscious and unconscious resentment Thus,thethemsurvivors'parents' life how one condition Holocaust V::$findsparents, survive, children under inexperiences theand of which attemptsurvivorsin the they process,into to who hadtheirgive psychologically transmittedsurvived theirlives. best, the to taught themwar. and Holocaust theirmeanandmal parentsisolated; own potential parents and they loss. a fearsay,normal another"You childhood. are Holocaust. the onlyThey oneFor have Ithem, have," felt differentlove this will is They deeply comprehend that when tities.orfromescapesometimes country commitment Yet or others continuouslyor literally another. adopt to live a career, aSomein runresigned hiding. from keepor fromOthers pacificatoryrelationships split one orare placedouble always as with oftheir fakeresidence readypeople, motive iden- to person'sparents.Manywhenoften literallysurvivorsAmericans reality. true. approach will call this old aage. neurotic manipulation by the However, These feelingsit are particularly poignantis quite different when this This is very important. is the scamp. theyWebe in see do a worldaretireless resistent that manipulators they fighters. experienced and those at thein whom concentration whatever These modes of being are wasTheA Program Groupestablished ProjectModel to forcounteract Holocaust the Survivors profound and sense Their of isolationChildren 114 MN /Ili UVdreams. manifestedAM WM UM MI Ilia Many childrenIn of survivors, their language, behavior, fantasy like their parents, life and uml at gip andFormally alienation established among Holocaust in 1975 bysurvivors volunteer and therapists their children. in the ma 11110:31110 withinception.izedtanceNew theonYork of group projectself-help City and area, are towards community themselves the project reaching therapeutic survivorsrecognized its goals modalitiesor and thechildren hasvital capital-from impor-of sur- its In fact, most professionals who have remained possiblyyouoriginaldoThis do not isnot theprovidevery trauma. help next important people the generation right rightbecause kind after will of what help,thealso victimization webethe have diseasednext learnedgeneration and with ifis you thethat and if vivorsvivors,andperiences.By participating werecomprehendunderscoring able They at in were lastthe groups, toself-helpHolocaust's also talk survivors ableabout orientation. to long-termtheir explore and memories the with childrenconsequences each and of otherex- sur- theThisnaryofInto case humanproject's one's everyday of victimizationexistence lifethat central life. is, guiding that confronting means are principle not integrating normally and is Incorporatingintegration, encounteredthe extraordinary which aspects in ordi-in In extreme cases, such as massive wereofmentpriorion approach theirmost designdeveloped liveshelpful. existedand and graduallyfeedback share for the their throughfromproject. feelings survivors trialFormal andand andmethods error. concerns. their offspringof treat No a- While acknowledging the long-term ef- Flexibility ingspiracyalsosuchcatastrophes the destroyedas victimof yours, silence survivors of victimizationall theexasperated of theNazi of individual potentialHolocaust not the only situation existing support.ruptured and other bysupports. continually, further holocausts depriv-A con- but Especially, the Survivors'ganizesurvivorsfects of andthe andresistance Holocaustview their these children, toand individualsInstitutions, post-Holocaust at no aspoint their sick didfear experience or the pathological.of beingproject on stig- or-its ing.maltorupture unrealizable.normal." society" of victimization This or returningMoreover, Is true rarely both to clinging prior inhas terms ways the to such meaningof of re-adoptingbeing hope of and may "going function- torepresent "nor- backIn fact, the hope of resurrecting their previous lives is course,makingcallygassingmatized, damaged theythe labeled sickprojectare bynotandcrazy the crazy.part mentally (stemmingvictimization of the ill), mental orfrom considered specifically the health Nazi facility. practicespsychologi- precluded of All of the suffering makes perfect Of feelingsa denialIn contrast, of of grief, their Integration shame, victimization hurt, and and recovery experiences, guilt. in our which formulation includes invol- Thetocessense make ofproject accordingfears our todayprojectthat couldto provides parttheir beof history. anlabeled. individual existing They We mentalfamily alsochose, have grouphealth therefore, many andfacility. inter-sour- not thetivevesnotit victimizationhappenedtheof underwhat victim happenedhis survivor's the oroccurred, wayher andcontrol it ability did. so to theyIdentifyFor andto develop example, thenwhat by accept couldwhom a realisticwhat thenot and was realitybe perspec-to andandwhom that whywas theirthereparative,tionalgenerational integration lives settings. and are community awareness predicatedof Holocaust assistance ofon the experiencestwo meaning major in a variety assumptions: ofinto post-Holocaust ofthe non-institu- totality of Its goals, which are preventive as well as one, onetainedquentlyremovesare explored.from Image guilt theconstructing Inneed Acceptingof false the to events responsibility.attribute a view the of impersonalityof personal victimizationoneself andcausality of ofpotentially the humanity andevents conse- freessole- also An educated and con- succeedingprocessesing;dictatorial and two,115 styleswill generations. that inhibit will awareness be transmission liberating of transmitted and of pathological potentially Inter-generational self-actualiz- behavior to theaimsly helpon short arethe people run. notbasis just get of to better.these "make events.On people a whole, We feel havenot better." just learned to We feel intend that better our to for 116 I 111111104 MIR IMO MI INK MN MI tat MIR ow rot tam UN am 1.1. Importance of Mutual Support for Healing orcause express many both survivors the events say they and do what not theyhave feel. words The to group describe as mutualI would likesupport to elaborate In counteracting further on thethe survivors'reparative andvalue the of ora whole whatever, puts tothe do words express together. something. We find words, even songs It also is a safe place I perhapsasmurder.vivorschildren a healing rarely Thatofonly survivors' modality.say collectivelyis Important "I". Theysense can tosay of recognizethey Isolation"we". find It a was inandmeaningful what aalienation. massive you responsepropose group These modalities acknowledge that Sur- Nazis,viteforhow exploring also theyas the well, feel. fantasies,souls by the of theway, imagining family. if somebody and inviting needs relatives. to tell them In fantasies you can do so much work. They Sometimes we invite the in- responsessible,multiplebestto their work task horrific meanings. through of to mourning thehistory theirvictimizers They of experiencestheir victimization.have massive aand necessary, toof thelosses.survivors' world although They guiltthat blocked andImpos-let the its Collectively they can Anothertakeusingbehaviorssignificance on rolestheaspect peer andof is murdered group tohelp identify forgroup confrontation.relatives and members observe or victims otherrecognize examiningvictim-derived their the own in the identity of the survivor or offspring. boundlessnessTheymillionNazis experiencesystematicallyof whom ofwere evil a sense children.andmurder the of fall 6shame million of civilization about of their witnessing and people-1-1/2 review the Thepowerfulstory,member group and confrontsthanmay it therapistsrecognize the member, alone.that reaction The and groups then in somebody next can timesafely else'sthe test is very helpful. Peer groups are much more sinceaboutHolocaust.meaning it religionis suchof being anwith Important a their Jew patients. and part their of identity. We belief try into Godreturn after to that the Psychotherapists customarily would not talk worldWeothers.out wherenewprovide That's behaviors you individual cana safe beand laboratory, knockedtherapy receive andfeedback rather feelfamily rejectedthan about therapy. out the again. there impact in the on Family is TheweretoGroups help group's lost rebuild and during therapistscommunities the the sense Holocaust may of established feelextended overwhelmed and familyalso by the help community projectsby thethese therapy. servedstories which groupveryEveryother.have important therapy multiple two months and familyin thegroup on groups,context atherapy Sunday where of asrelatedness. from awarenessone family1 p.m. learnsWegroups. to 4 provide p.m., from thewe We have inter-generational community meetings. We canhorrorlesstherebut have becomeburdened, who alone. eight may Thatenabled other beand isable theyverysurvivors to to provide doimportantlisten. not or Theyhavewhatchildren because helptowe deal ofcall the survivorstherapists with atherapist holding all ofsitting alone feelthisen- neighbors.ofeveryonehold survivors is Theinvited.who project are We participating invitecompensates the survivorsin the for project. the and loss theWe of children include family an Inter-generational community meeting, where inggroupvironment.interaction to some,may compensate othersInvoked do by provide formemories that. the While mayholding any prove particularreactions. too overwhelm- intense Thus, It is so needed for the sense of belonging. The andforanybodyhope people extendedbad of news ever whois sick family havingofno andmembers. longer and needsone. community. have We volunteer beginone at Weit help allby buildand sharing to visitwhoa community goodthem gave innews up the We begin by finding out if 11 'Wisebalizing,multiplicitypressionthe experienced group ofand functions emotions,of modulating optionsas un-containable. as especially for an them.expressing ideal negative absorbedThe feelings,group ones entity also that naming, offersfor are our other- a ver- ex- This Is very important be- asthehospital Iworld. shared because We yesterday. do allsome kinds people,We of havecombinations as grandparentsI in the community,adopted by said, are totally alone in 112, I Sr arm am am as am ins 13ES COPY MALAWI 11/21 MI IN ail MI beganForIt example,ishelpchildren not by each onlysinging without lastother. during meeting the parents the and meeting that we do somebody wrote a without grandparents, a lot of sharing. song, and we and they bypoemeightcommunity another. books I read He writtenat from theexpressed beginning, bywithin the is members.song. Isabella, We thepromote creativity that If he started cryingcommunity. he We have a member that was inspired woman whose at least wouldin the amongdevelopexpresswholenever family throughituniverse.stop. in members. sculpture Or projects. if So he andstarted in people try to put it In writing. I am a grandmother forWe have had marriagesscreamingpaintings. he would We shake have had They try to happen films the I wantmunitythelittle onlytobabies emphasizethat one. Inspiresand So a theGodmother and that we have a community. We is inspired by itself.for a few, as well, and I have a com- quite a few am not roundingcommunity,butresources volunteer communities. between and spirits on the volunteerwithin work importanceIt isof very communityreliance healing andthe the community rest of the and outside not just professional work to see volunteers on community of the sur- peoplethemselves.work as to healers, be Yougood cannot and create only to thecreate receiver, something but good. a very wonderful opportunity for very often to 120 1 lip 1111111 Mill Olt MINI 1110 MI SIMI 'Ot MS 1111111 ern NMI =II us as au MRSADEI d STO JE NORMALNA REAKCIJA? momentalneragirajurazlitito.U traumatskim naCak razlieite reakcije, i u situacijama sklopu nadine. dok iste drugi situacije reagiraju Ijudi kasnije t esto Ijudi Neki Ijudi imaju ragiraju vrlo RATNA kojenava§thiskustva).(ponekad veoma smatramo bli2njih, te§ketakAko nekolikozapamiite normalnim.vassituacije brine godina da (kao yak postoji storeakcije nakon su cijeli ratne traumatskog titniz strahote)reakcije reakcija TRAUMA I javitizabrinutivecVa2no kod su bilijeIjudi zanapomenuti svjedoci vlastitukoji nisu sigurnostnasilja, bilida sedirektno reakcijekao ill isigurnost kodizlo takodjer Ijudieni nasiljubli2njih. koji mogu su Dvamu§karcima, bro§uratarima; je 2enama, iznamijenjena gradova djeci; i sela; svima mladima svima vama: vama kojiOPORAVAK i pomotiRazumijevanje u procesu vlastitih oporavka. i tudjih reakcija mote biti od ;teitradanjimaVarna;vjedoci;voje bili domove koji ili nasilja; ste i livotno biliijo§ svu izlo±eni vamauvijek imovinu; opasnim koji izloieninasilju vama situacijama.ste iii izgubili kojiratnim ste biliste Prve reakcije u traumatskim situacijama obi no KAKO LJUDI REAGIRAJU? ;travienimarijateljia.zg-ubilivama koji drage iskustvima; i bliinje u all ovom i vama ratu; koji svima ste i elanoviste raseljeni; vama eiji obitelji i bili izloieni su razdra2enostbijes,idogadja,uldjutuju negiranje. strait, potpuni 6ok, tugu, kao i gubitak zbunienost,cijeli niz svih drugih ulas, osjetaja, osjeeaja. osjetaj povlatenje krivnje,Iako se Kasnije osoba mole osjetati Ijutnju,nevjerovanje da se to stvarno vjerojatnosamovrlokoje vjerojatnoniste sluali nebili o znate ratnimpripremljeni proiivljavate kako strahotama. izaeirazlieitim osjeeaje na kraj. Svi situacijamaZazavi okolnostimai s kojima dugotrajnomseodredjenreakcije tipitno rasponrazlikuju javlja i ponhvljanom uobitajera kod od Ijudi osobe reakcija nasilju.koji do su osobe, ibili osjecaja izIo/Eni postoji koji mnogeuvijekUpravopoenete traju odvoditi zato, vas i trajat brigu vrlotraumatska eeoje svim va2nojos nekoovim iskustva da vrijeme.temama, odmah jo§ Traumatskoreakcijamedjuljudskeponatanje,podrutja koje iskustvo se odnose. obitno mote javljajuNavodirno utjecati kod na djelomitnuIjudi gotovo koji svasu listu bili 2ivota: tjelesno na zdravlje, razmAlkule, duhovnost osjeeaje, i 123 ipopoktgarakcijayam ne sebi. dekate ipomoei reakcija da se u svevamarazumijevanju dovr§i bliskih i sredi Ijudi vlastitih samo te da predtoli Svrha ove broure je da yam naeine za uspje§nije 122 granicamaBibizloteni koja nasiljunormalnog. kombinacija i slienim ovih traumatskim iskustvima. reakcija je u BEST COPY AVAILABLE Iprebrodjivanje ove te§ke situacije. INN INN MI NIN INt 11111 NS- MB NMI NEI INN NMI INI INN NII NEKE UOBItAJENE REAKCIJE SilovanjczbogPOSEBNI karakteristienth i tortura SLUCAJEVI zahtijevaju problem : SILOVANJE posebnu koji se I pozornost javijajuTORTURA kao Osjetaji Tjeksne silovanjuiskustvodrugtva.potpunostiposlijedice. tortureOsim sudjelujeIskustvo osjeciaja ili silovanja silovanjau ugrotenostitivotu mote obitelji,all ugroziti i vlastitogsamo zajednice iii prisustvo uni§titi2ivota, i torturi mogu onemogueiti osobu da u OsjeeajOsjeeajWas,PotpuniTuga nernoeistrah, krivice gubitak briga beznadnosti osjetaja za vlastitu i bespomoenosti sigumost ZelubanePovratanje,ProblemiPoteskoeeUmor smetnje proljevs sa apetitom snom/spavanjem i hranom osoba.bitiosjeeajpovjerenja naroeito ljudskog unarukno druge dostojanstva, Ijude. ako Povjerenjeje viastite napadae vrijednosti u drugepoznata mote i Osjee.ajNoeneNagleBijes,Osjeeaj ljutnja imore ranjivostiekstremnebezvrijednosti i promjeneovisnosti raspolo2enja BoloviVrtoglavice,Znojenje, u ledjimaprsima ubrzani glavobolje tit puts vratu zlouptrebepaneNasuprot veze uobieajenomemusite sa i je seksom.mod glavni nad vjerovanju, cilj drugom silovatelja silovanjeosobom da ponizi, nemapri osramoti, Silovanje je primjer StrahOsjetajOsjeeajOsjetaj od prljavosti toga izoliranosti gubitka kontrole nad vlastitim 2ivotom to drugi Ijudi misle PonaffanjeCeste prehlade i gripe uslijed2stve§irompravilukontrolira, silovanjasvijeta, osjeeaja jedan zastra§ii odueesto srama ratnim se i ocllueujuistraha. u mirnodopskim U neratnim prijaviti uvjetima,uvjetima. zloein najrjedje prijavljivanihi degradira txtvu. zlodna To je u MgljenjeStrah od trajne izlotenosti nasilju Razdratljivost,PretjeranaPovlaeenjeZloupotreba ovisnost od alkohola, Ijudinestrpljivost o drugim droga iIjudima tableta dapitanjeobziromprijava nakonli odlueite jesilovanja da takokome vojnici prijaviti te§kog uopee test° imaju traumatskogsilovanje prijaviti djeluje "dozvolu zloein?jo§di ne,iskustvaza besmislenije silovanje"vrlo Bez je toobzira vain° prije a si TegkoeeZbunjenostTetkoeePrevige pri uu misli prisjetanjuodrtavanju donogenju odjednom i pozornostiodlukapameenju Sna2neNarugenjeNemoguenost reakdje dnevne na obavljanja male rutineobavljali promjene(zvukove, zadataka bez uIjude) poteskota okolini koje ste ranije poduzmete korake za vlastiti oporavak. IskrivljenStalnoRazmigljanjeIznenadne razmigljanje do2ivljaj Mikeo samoubojstvu traumatskogvremena o traumatskom do2ivljaja dogadjaju Medjuljudski odnosi traume,Jedna a koju od Ijudi najeekih Zesto nereakcija razumiju, nakon je osjeeaj pro2ivljeneOSJECAJ KRIV10E : CESTA REAKCIJA GubitakDuhovne vjere sumnje SumnjanjeTeskoeePogretnaPromjene u vjerovanjuu di uemocionalne sek.sualnimiskrivljena IjudimaIjudima uopeavanjavezeaktivnostima o drugim katastrofe,prepoznaliblitnjedogodilo,krivnje: na Osjeeaj zbog primjerenosjeeaj i toga krivnje krivnje to naein, niste zbog zagtititilizbog toga toga sebe i svoje reagirali na znakove priblitavanja zato to ste pretivjeli, to vam se to niste [24 OsjetajSumnjeOeaPrestanakPovlaeenje j dau prijagnja je prakticiranjasvijet iz crkvene promijenjenvjerovanja zajednice vjere "naglavaeke" OsjeeajUdaljavanjeOsjetaj usarnljenostikritienosti od obitelji, pram"ne prijatelja drugim razumiju" Ijudimai kolega koji vas toVrloosjetaj ito je yam vain()odgovornosti se dogodilo.da upamtite za to da vi niste odgovorni za to vam se dogodilo. I NM 1E11 In Mt MI OM MI IBM MI NM ION MI all BEST COPY MUM EMI ubrzanIviedjutim, oporavak od pretrpljene tratime to biti i olakkn vagim aktivnim pristupom, Najbolje je poeceli s Pustitcreakcijamausporcdba vrerncnu drugih da Ijudi zalijeei je potpuno yak rane. beskorisna. vlastitih trauma tskih reakcija Budite s to inemogutese pripremati prirodno ih seje pojavljivatizaizbjeti. njih. Bilo bi u korisno vakm oeekivatitivolu ih i aktivnornsprcmnogtuRazlititinajvige odgovara.brigompristupi i odlutnostu. zapomatu sebe, ritzlititimbirajuti ono ljudima. gto yarn Num formula i recepata. sebe"nekogaosjetatestrpljivi ne stvarnosamibijes, znati sa na dasobom.povrijediti. primjer, stvarno ne nemate Ako -mora Prihva se znaeiti kontroluosjetate tile svoje da "van fetenad osjetaje takve kakvi jesu. Ako mogutisvjcstannakon tekogrutin napor i traumatskogto u na svrhu svint brige ptxtruejima iskustva- Io na sebi kraju, najesttivota. najva2nijenajbolji to mo2ete utiniti za sebe ulotili naPotnite osobnom s rnalim planu. promjenama Na primjer, koje vrlo to je yam vatan porno& svaki L-TO MO2ETE UCINM ZA SEBE? stresnimdesituacijom. aliste pokolebani stvarno i kriznim Ako bespornotni. alise situacijama. osjetateniste bespomotni. Motda bespomotni,- Pokugajte ste obeshrabrcni se ne sjetiti znati to yam je ranije pomoglo u Upotrijebite to i ostvaritiiskustvanekiNakonUnatot naein tekog zauspijevaju tome, postatisebc traumatskog mnogi smislene pretjerano nakon Ijudi iskustvativote. odredjenog koji oprezni su Za motdaprotivjeli oporavak uvremena tivotu.tete slitna na je uspostavljanjernogute,tivotom.pokugaj uspostavljanjaDonoknje vlastitih odluka kad god je to bitno osjetaja jc za vlastitogkontrole nad vlastitimjatanje dostojanstva,i ponovno sada.pomoti,kojima kaose osjetate gto su pomogli bliski mnogirn- ljudima koji suKontakti s obitelji, prijateljima i sigurni mogu yam i Ijudima s potrebno vrijeme ali je mogul, uz prikladnu pornot. samopogtovanja,oblikaprocesuudonogenje getriju ponaganja i smalih kim ponosa tete kojaodluka popiti su kaopomogla kavu, to su: mogudrugim kada pomotitete ljudima otiti u oporavka. Navodimo listu i integriteta. razlieitih Cak i fetesvojestepretivjeli motda stalno instinkte. osjetatiokrulenitegka traumatska potrebu ljudima da i iskustva.- budete-to Traumatska je u redu.sami Slijediteiii iskustva da mogu djelovati na yak Povremcno StrueniLosFrederick,InstitutePripremila Angeles, konzultanti: for Ph.D., Victims CA; UCLA/VALeila Mary of Trauma,F. Harvey, Dane, Medical McLeanPh.D., Ph.D., Center, Director, VA;Director, WestC. J. i napisala Irena Sarovit, psiholog. u slitnim situacijama.Vodite Motda brigu- pomognuObavite o velesnom lijeeniekii vama. zdroviju pregled ako je to ikako reakcijamaprihvadjivapartneromseksualne zanao tomeoboje. njih eestokoja su korisni.- Razgovori o traumatskim iskustvirna i vagim potrebe. Razgovarajte razina intimnosti je sa Razmijena svojim Program,Program;UCLAKathleenVictims Trauma, of Physicians Nader,Shana Violence Violence Swiss, DS.W., forProgram, Human M.D., and Director SuddenCambridge Rights,Director, of Bereavement Boston,Evaluation, Women'sHospital; MA; . zatra2itemogute. ju. - Upamtite da trauma i dugotrajan stres mogu Ako zdraystvena njcga nije osigurana iskustavanutnoiskustva das motedrugim razgovarate yam Ijudima pomoti. o koji svim Cesto, su protivjelidetaljima medjutim, slitna vageg nije State,JanetInitial Yassen,County, printing MS.W.,and donated Municipal Boston, by Employees,American MA. Federation AFL-CIO. of djelovatividIjive" Poku§njte na povrede. vale uspostaviti zdravljc Brinite bezo dncvnu svorn obzira zdravlju. rutinu da li imate razgovorarazgovortegkimtraumatskog iskustvima. mote s iskustva.drugima bit; Nekivrlo motete koristan,Ijudi- PatIjivo znajuosjetati dok slugatibirajtc jog se nakongore is sam kim i razgovarate o svojim 2607Coordinator,USA.Project Connecticut U coordinated 1993 Psychologists PsySR.Ave., NWby forAnne Washington, Social Anderson, Responsibility, DC 20008,National kbntrolirajteigrajte Sc skonzuniaciju djecom, idite alkohola. u etnju- PokugajteJedite- - (izitke redovilo, Sc aktivnosti odmarati koliko jeredovito.Bavite to moglite; se tjelesnim smanjite aktivnostima. i Vjetbajtc, moguvasegdokusamijenije. to traumatskogpru2iti drugi Neki potrebnumoti Ijudiiskustva. podnijeti pornotto moti Slijedite -samo nekimmirno svojeneke Ijudima.saslugati instinkte.dijelove Caksve,Struenjaci iz podrueja mentalnog zdravlja akosmanjuju se razlikuje utjecnj odstresa. yak uobieajenc.- Uspostavite neku vrstu dnevne rutine, eak i traumatskograzumijevanjestruenjakomi dogadjaja, moteyak situacije. yarn sarnoznaeajni pruliti- jedan datumiokvir odlazak za u vakm na Neke situacije kao razgovor to su godignjices takvim tx.)lje 1 2 123 irazlikujc yak traumatske od osobeVodite rcakcije.do osobe. brigu Vi- o Za stesvojim oporavak jedinstveni osictajana je kao potrebno vrijeme, Upravo ztxtg toga, i to se iskustvoaliuspomene.tivotu, mote Televizijska izazvati slieneernisija,bilo rcakcije. gtoelanak drugo Teu novinama situacijegto vas p

PANEL #1

WAR TRAUMA AND RECOVERY This brochure is for all of you, men, women, and children, old Ind young, from town and village, who have been exposed to ongoing raumatic war experiences and life-threatening situations: For all of you have been exposed to, or witnessed violence; for those of you who ave lost your homes and all your belongings; for you who have lost oved ones in this war; for displaced people, but also for those of you whose family and friends have had terrible experiences or you who have nly listened to them. You may be experiencing feelings that you have of been prepared for and don't know how to deal with. For many of you raumatic experiences are continuing and will continue for some time. Because of this,it is very important that you begin to take care of Ithese issues immeidately and don't wait for everything to get resolved n its own. The purpose of this brochure is to help you understand your reactions and the reactions of your loved ones, and to suggest ays for successfully overcoming this difficult situation.

BEST COPY LE 123 ANEL #2

WHAT IS A NORMAL REACTION?

People respond to traumatic experiences in a variety of different ilays. They may respond differently even to the same traumatic event. ome people will have immediate reactions; others, delayed responses perhaps even years after the experience). If you are concerned about your reactions or reactions of your loved ones, remember that there is whole range of responses to very difficult situations (such as the I/orros of war) that is considered to be normal. It is important to stress that reactions may appear even among the yewitnesses of violence, and those who worry about their safety or the afety of others. Understanding reactions can be helpful in the rocess of recovery from traumatic experiences.

il HOW DO PEOPLE RESPOND? Initial reaction to a traumatic event can include shock, 111isbe lief, numbness, withdrawal and denial. Later, a person may xperience anger, rage, fear, grief, confusion, guilt., terror, rustration and a variety of other feelings. Even though these 11eactions are individual., there is a wide range of common feelings and reactions that occur among victims of violence, especially repetitive Ilr ongoing violence.

Experiencing trauma can affect almost every aspect of your life: ognitive, emotional, behavioral, physical, spiritual and relational.

ere is a partial list of common reactions to violence and other . 11rauamtic events. Any combination of these or similar reactions is still within normal range.

11

II

II

1

11

II

II SUABLE 123 BEST COPY il IFANELS #3 & 4 SOME COMMON REACTIONS

IFognitive Physical

difficulty remembering things fatigue and time making decisions change in sleep habits onfusion eating/appetite problems distortion of time stomach problems Ififficulty concentrating vomiting/diarrhea oo many thoughts at once sweating, rapid pulse thinking about suicide chest pains "flashbacks dizziness, headaches eplaying the event back or neck pain catch colds or flus

1piritual Relational

loss of faith difficulty trusting IIpiritual doubts changes in sexual activity ithdrawal from church community false or distorted apses in spiritual practice generalizations about others uestioning old beliefs doubts about relationship 11 ense of the world being feeling critical of others changed, out of kilter alienation from family, friends despair and co-workers who "don't understand" sense of aloneness

Behavioral

11busing alcohol, drugs and medication clinging to people withdrawing from people disruption of daily activities Irritability, impatience inability to perform skills eacting strongly to small that you could do before changes in environment (sounds, visitors, etc.)

Emotional

Ileeling helpless,' hopeless or emotional rollercoaster powerless nightmares grief feeling worthless Ilumbness feeling of isolation Ilread /fear /safety concerns feeling lack of control over guilt own life eeling vulnerable and feeling of uncleanliness dependent fear of what other people think 11nger, rage fear of ongoing victimization 1

BEST COPY AWARE 130 PANEL # 5

THE SPECIAL CASES OF RAPE AND TORTURE

Rape and torture require special attention because of specific issues related to them. Witnessing or experiencing rape and/or torture can impair a person's ability to participate fully in family life, ILommunity and society. In addition to threatening one's physical ealth, torture and rape can destroy one's feeling of human dignity, self-worth and trust in others. Trust in others may be particularly haken if you have been assaulted by someone you know.

Contrary to belief, rape has little to do with sex. It is an buse of power and control in which the rapist seeks to humiliate, hame, embarrass, degrade and terrify the victim.Rape is among the (ost undereported crimes worldwide, both during peacetime and war. Victims of rape often ch000se not to report the crime out of shame and 1rear. In wartime, it often seems even less menaingful to report the ape since there is no one to report to, and soldiers may have license to rape. Regardless of whether you decide to report being raped or tot,it is important that, after such a difficult traumatic experience, ou take steps towards your own recovery.

GUILT: A COMMON REACTION One of the most common reactions after experiencing trauma, one hat people often don't understand, is the feeling of guilt: Guilt boutbout what happened to you, about not protecting yourself or your loved ones adequately, about not recognizing and responding to the signs of pproaching catastrophe, guilt because of surviving, feeling esponsible for what has happened to you. It is very important to I(emember that you are not repsonsible for what has happened to you.

BEST COPYMIME 131 /ANEL #6 & 7 However, recovery from trauma will be facilitated andsped up with IIour active approach,readiness and determination. You can start with elf-care, choosing what feels best for you. There are no formulas or prescriptions. Different strategies work for different people.

WHAT YOU CAN DO FOR YOURSELF 1 You can begin to do things on a personallevel that assist the recovery process. For example, any effort you make toward eestablishing a sense of control over your life is veryimportant. aking your own decisions whenever possible can be abasis for 1/enhancing or restoring a sense of dignity, self-respect,pride and .ntegrity. Even taking charge of the small decisions such aswhen to ake a walk or with whom you will share coffee ishelpful for some have helped 11eople. Here is a list of different types of behavior that other people in similar situraiton. They may help you too.

II* Take care of your physical health. Have a physical examination, if at all possible. If medical attention is not available, ask for it. II Trauma and ongoing stress can affect your physical health, whether or not you have visible injuries. Care for your II health. ** Make an effort to establish daily habits. Eat regularly as much as possible; reduce 11 and/or control intake of alcohol. Try to get enough rest, preferably on a regular schedule. Engage in physical activity it reduces stress. Exercise, play with children or just go for a walk regularly. II Establish some kind of daily routine, even if it differs from your usual one. * Take care of your emotional needs. Healing takes time and it varies from 11 person to person. You are unique and so are individual traumatic reactions. Judging the length or nature of your 11 traumatic reaction in comparison to others is not helpful. Allow your own time for recovery. Be patient with II yourself. Accept your feelings the way they are. Feeling rage, for example, does not mean you will hurt someone. Feeling out of II control, for example, doesn't mean that you will lose control. Feeling helpless EST COPY AVAILABLE

132 doesn't mean that you are helpless. You may be discouraged or faltering but not helpless. Remember what has worked for you in the past in times of crisis or distress. Use those tools where they apply. Contacts with family, friends or people with whom you feel safe or close has been beneficial to other people who have been through traumatic experiences. Occasionally, you may feel you want to be alone, or you may want to be with others all the time, and that's okay. Follow your own instincts. Traumatic experiences can influence your sexual needs. Talk to your partner about what level of intimacy feels comfortable for both of you. Talking about the traumatic experience and your reponses to it can be important. It can help to share your experiences and what you learned from them with other people who have had similar experiences. It is not necessary to talk about all the deatils of your experience with others. Choose carefully who you talk with about your difficult experiences. There are people who can be of help when they listen to you and others who may make you feel more alone or more distraught. You may find that some poeple can hear everything while others can comfortably listen only to parts of your experience. Follow your instincts. Trained professionals can be very helpful to some people. Even one session with a skilled professional may be of assistance and may offer a frame for better understanding of your situation. Some situations, like anniversaries, significant dates in your life, or people may trigger painful memories. That can also be caused by media coverage or anything that reminds you of a traumatic event. Those situations will naturally occur in your life and it is

LEST COPY AV[WOLE 13E 'PANEL #8

impossible to avoid them. It would be useful to expect them and prepare for htem Finally, the most important thing you can do for yourself after experiencing trauma is to make a conscious effort towards taking care of yourself in the best possible way in all areas of your life.

After severe traumatic experiences, you may 1 always remain cautious in some ways. Even so, many people who went thorugh similar experience manage to create 1 meaningful lives after some time. Recovery takes time, but it can take place with adequate support.

* * *

repared and written by Irena Sarovic, M.Ed. onsultants: Leila F. Dane, Ph.D., Director, Institute for Victims of rauma, McLean, VA; C. J. Frederick, Ph.D., UCLA/VA Medical Center, West Los Angeles, CA; Mary Harvey, Ph.D., Director, Victims of Violence rogram, Cambridge Hospital; Kathleen Nader, D.S.W., Directorof valuation, UCLA Trauma, Violence and Sudden Bereavment Program; Shana Swiss, M.D., Director, Women's Program, Physicians for Human Rights, ioston, MA; Janet Yassen, M.S.W. nitial printing provided by the American Federation of State, County and Municipal Employees, AFL-CIO. lirroject coordinated by Anne Anderson, National Coordinator, sychologists for Social Responsibility, 2607 Connecticut Ave., NW, Washington., DC 20008, USA. Copyright, 1993, PsySR.

i3 4h BEST COPY AM LAMS ,,PPaffE Presentation, "Educating Educators"

Special issues of Newly Arrived Refugee Groups

Theme: Bosnian Survivors by Amer Smajkic M.D., and Stevan Weane M.D.,

Specifically, my approach to this issue is discuss the processes which affect Bosnian refugees abilities to learn English as a second language.It is necessary to look beyond the simple act of learning itself and to see how learning English takes place within the context of key historical, cultural, social, Political, and psychological dynamics.It is my objective to share with you some of my thoughts on how these complexities impact the teaching of English expecially to recent

Bosnian Refugees.

The specific unique elements of Bosnia and an independent nation go back since before the birth of Christopher Columbus.Bosnia was an independent country since the twelfth century with all factors that define a Country. We had our own Kings, flags, language, crypts, heros and folk songs specificly for Bosnia. Bosnians are Slays.Bosnian Muslims are centuries old citizens of Europe.. The only difference between them and other Europeans is their religion. The cultural or social habits are European. History says that the first Muslims immigrated to Bosnia in the

10th century from Asia after wars there and through trade routes between the east and the west which passed through Bosnia. The Turkish "Ottoman" empire entered the Balkan area in 1371. Bogumils had been the biggest percentage of Bosnian citizens and we can say the were the "

native Bosnians"Islam was accepted by the Bogumils as a very compatable religion to their special brand of Christian religion.Muslims in Bosnia are not, as often stated, left over Turks from the ottoman empire. They are the peoples with a history which predates the Ottoman

Empire. Their practices of culture are mainly European.

Later migrations that happened after war in Spain in 1492 between Queen Isabel and Spain's

Muslims who were called Moors. The Moors had been in Spain since the 8th Century. They migrated from Granada to Bosnia and further defined the culture of the Bosnian Muslims.

Spanish Jews also migrated to Bosnia at this time.

Most ,bu not all, of the Bosnians in Chicago are Muslims. the USA government gives priority to Bosnian Muslims because this group is the most threatened group in the Bosnian War.

Language Differences

Bosnian was a distinct Slavic language.

After the Second World War, the communist goverment defined the official language of

Yugoslavia as Serbo-Croatian. Bosnian,Chroatian,Montenegrian and Serbian languages are basically the same languages, however, there are differences in pronunciation and idiom.

Bosnian is, however, separate and distinct from the commonly considered "Serbo-Croatian". .

For examplecoffeewill bekahvain Bosniankafain Serbian andkavain Croatian. Also softly is mehkoin Bosnianmekoin Serbian andmekanoin Croatian.

The English language has 26 symbols (letters) for 44 sounds or combinations, This makes

English especially hard for pronouncing and using with transcription of each term.The sounds 'W' and "th" present special problems.

13? The Bosnian alphabet has 30 symbols (letters) for 30 sounds it is functionally a phonetic alphabet. This challenge is emense for the aged and poorly educated Bosnians who try to learn

English.

The Article which is so common in English, does not exist in Bosnian. In fact, I asked my friend to add the appropriate a's, the's, an's and so on to this text.In English nouns are not changed in number and gender or case with the exception of the Saxon genitive. In Bosnian nouns are changed in number, gender and seven cases. This, I understand makes Bosnian especially difficult for Americans with good educations to learn. In English adjectives are unchangeable, in

Bosnian adjectives are changeable in number, gender and seven cases. English verbs present

special problems.In Bosnian there are two auxiliary verbs, "to be" and to "want". English verbs, including do, might, culd,should,would, are difficult.

Learning English

Most Bosnian people in Chicago go to Truman College.

There are seven levels and people may go during the day or night. We found that survivors who are highly motivated and those individuals who will add some extra effort will be more than successful in these and other colleges.

We also have volunteers that work under the umbrella of churches and refugee organizations.They work at refugees homes. Their success is open for discussion. This is not because they are not good teachers.It is only because their students are primarily wounded or other Bosnian groups which are handicapped by age, or other physical or mental problems.

Educational and intellectual differences are issues that make have significant impact on the process of learning English as second language. Clearly Bosnians with higher educational level are able to learn with less perplexity than those who are not highly educated.It is only a question of training and experience. People who are trained and experienced in learning, will do it more easily than those who are not.However, anumber of other factors are involved.

138 Financial problems may complicate and confound the learning of English. Refugees are very limited with finance. They are not always able to get money for transportation, which means they will not be able to get to the school or college. For example,. in Chicago we have excellent public transportation. If someone wants to go by train or bus he must spend 1.5 $ each way.

Round trip would $3.00 .For a family with four members, two adults and two adolescents or children, the monthly income from Public Aid is around 420 $ plus food stamps.

A one bedroom apartment in Chicago costs from $380 to $500 minimum. One only needs to do basic math to understand that daily English classes would cost over $60.00 a month and there is no money left for rent, toothpaste or toilet paper.

Financial problem also bring more problems. Refugees without money try to find a job as early as it is possible. If they get something it will be a very low salary because they do not speak

English. It will force them to do physical and hard jobs. Working eight hours or more a day, they are often very tired and find study difficult let alone sitting for three hours in a class.

The Bosnian population in Chicago varies in age from 1 to 90 years. Bosnian children and adolescents learn English much easier and faster than other ages.

Bosnians from 22 to 30 are also more than successful learning English.Bosnians over 30 are not as successful but many master the language with some difficulty. Many of this age group also give up and accept a future with limited language ability. People over 50 have serious problems learning English as second language. Most of them do not study English.

I3 Genocide

I am certain you are familiar with those problems. In addition, what you must understand are the horrible experiences the Bosnian cannot leave behind them.

The mileau of learning is often emphasized as a major factor in education. The education of Bosnian refugees must include an understanding of the mileau which caused them to be in your classes.

The reason we are here today talking about Bosnians in America is that they were resettled after a forced relocation from their homes and cities in Bosnia as a result of the Serbian nationalist's initiative in "ethnic cleansing". Ethnic cleansing was the official Serbian policy to create a Greater Serbia that included the historical real estate of Bosnia but did not include the historic majority of the Bosnian population, the Bosnian Muslims.

The significance of the founding of the new Republic of Bosnia and Herzegovina was the concept that people of various religious and ethnic history could live together in harmony. Many orthodox Bosnians have ethnic roots in Serbia but choose to remain as Bosnians, not Serbs,

Croats or Muslims. These persons are included in the cleansings. They and all those who opposed the Serb Ethnic Cleansing were considered disposable and, in many areas were forced to move or die. Serb forces attacked Bosnian civilians and used genocidal methodology including concentration camps, human atrocities, snipers, unopposed heavy weapon fire, and mass rapes to kill over 200,000 people and to terrorize another 1,000,000 into leaving their homes and relinquishing their participation in dream of a Bosnian multi-ethnic society.

The fact of Bosnians having endured genocide must be not be forgotten if one wants to understand their current dilemmas, especially those of learning English. Genocide attacks a person's cultural identity and their sense of participating in life.

140 Their efforts to build a new cultural identity as Americans or to achieve cultural and linguistic competency in America with English takes place in the wake of the severe trauma to their cultural identity which genocide.

Two thirds of Bosnia are completely "ethnically cleansed". In two thirds of Bosnia there are no any Muslims remaining alive.. In the rest of Bosnia we have cities such as Sarajevo or

Gorazde and others that are surrounded by the serbs chetniks forces and isolated from the outer world. The civilians in these areas are the most threaten population, even today. They are surviving without elementary necessities. With out water, food, electricity, heat, and exposed almost every day to shrapnels and sniper's bullets. The genocide in Bosnia is, from the beginning of the war been directed against civilians irrespective of the region of Bosnia. In areas like Prijedor and its surrounding communities, serbian criminals organized the raping of Bosnian woman, they arrested every one who had a Muslim name and imprisoned them at Concentration

Camps. In these camps they performed the worst barbaric crimes immaginaable. Many of these crimes are only recently being described to the rest of the world.

After the initial efforts of the Serbs, the Croatians also made an attempt to "grab land" using many of the same techniques. They were only a pale copy of the Serbs in their efforts to be barbarians.

Genocide is something which describes almost all important happenings in Bosnia.

Genocide is something which affects our very souls and something with which we must always live. Genocide is an experience of Bosniacs and it is part of our past, present and future.

One study found that the average Bosnian survivor was exposed to 17-en types of traumatic experiences.

142 Let me discribe what I mean by genocide. It is when your town is attacked by an army, when those who are attacked did not even think it was necessary to organize a defense let alone organize and arm an army. You must try to survive while, in front of you, people are dying: your parents or brothers or friends, or neighbors.

Your home is being destroyed, you are without of food, water or energy. After that they rape your sister or mother or you in front of those you most love and respect.

After exposure to traumatic events, survivors continue to experience considerable distress as a result of the trauma. The current psychiatric diagnosis that best addresses the psychological distress experienced by survivors is refereed to be PTSD. Posttraumatic Stress

Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stress involving direct personal experience of an event that involves death, injury, or a threat to the physical integrity: or witnessing an event that involves death, injury, or a threat to the physical integrity of another person: or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.

Symptoms of post-traumatic stress disorder may appear immediately after trauma or even months or years later. PTSD can be an acute, time limited, condition or it can become a chronic life long condition. We try to intervene as early as possible to prevent the development of chronic conditions similar to those documented in holocaust survivors, Cambodian refugees, and

Vietnam veterans.

142 The symptoms of PTSD can be divided in to three groups.

Group 1

Rexperencining traumatic memories: recurrent and intrusive distressing recollections of the

event, including images, thoughts, or perceptions. In young children repetitive play may occur in

which themes or aspects of the trauma are expressed. Recurrent distressing dreams of the

event. In children, they may be frightening dreams without recognizable content. Acting or feeling

as if the traumatic event were recurring (includes sense of reliving the experience, illusions,

hallucinations, and dissociative flashback episodes. For example a patient may say: "I am sitting

in my apartment and I think and feel like I am in Bosnia and I am seeing everything which

happened to me there" These are referred to commonly as "Flashbacks"

Group 2

Persistent avoidance of stimuli associated with the trauma and numbing of general

responsiveness not present before the trauma:

Symptoms include:

-efforts to avoid thoughts, feelings, or conversations associated with the trauma.

-Efforts to avoid activities, places or people that arouse recollections of the trauma.

- Inability to recall an important aspect of the trauma.

- Markedly diminished interest or participation in significant activities.

- Feelings of detachment or estrangement from others.

-Restricted range of affect (like unable to have loving feelings).

- Sense of foreshortened future like does not aspect to have a carrier, marriage,

children, or a normal life span.

14, Group 3

Persistent symptoms of increased arousal, not present before the trauma:

-difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating,

hypervigilance, exaggerated startle response

Associated descriptive features and mental disorders. Individuals with Posttraumatic Stress

Disorder may describe painful guilt feelings about surviving when others did not survive or about

the things they had to do to survive. Phobic avoidance of situations or activities that resemble or

symbolize the original trauma may interfere with interpersonal relationships and lead to marital

conflicts, divorce, or loss of job. They may be increased risk of Panic disorder, Agoraphobia,

Obsessive-Compulsive Disorder, Social Phobia, Specific Phobia, Major Depressive Disorder,

Somatisation Disorder, Substance-Related Disorders, Insomnia.

Treatment for survivors of genocide is a complicated, multi-dimensional, and long-term prospect -- but it works. Survivors can get help from medications, from psychotherapy, from supportive relationships, and from work and other productive involvement's in their community.

Symptoms of PTSD will come and go. They may be silent for decades and then return in the context of a new life stress or life change. At one point onetime a survivor may want to remain silent about their memories, and at anotherpoint onetime it may be very important for them to talk with another. Professionals working with survivors try to meet them where there at-- not to hurry them, or force them lest they risk retraumatizing the survivor. You who are not mental health professionals, but who are nonetheless, involved with survivors, must learn to appreciate the nuances of the survivor's mentality -- when they need silence and space, and when they need support and listening. Survivors will also look to you as an authority figure and try to sense how you feel about them and about mental health care. Here it is important to remember that most

144 Bosnians have no history of a good helping involvement with mental health professionals

and the idea of PTSD is essentially foreign to them.

They often rely on folk concepts or terms such as "prolupao" that is a slang term for what

you would say about your car when it is revving up but not going anywhere, or "puko" that is a

slang term for something that is broken. You can do a real service for survivors by helping them

to positively reframe what it means to have PTSD and to seek mental health services. As we say

to them, you are having an expectable reaction to extrpme circumstances. You are not crazy

and its nothing to feel ashamed about.

How do these emotional and mental disturbances affect daily functions or especially learning

English?

For example, I am studying for my medical boards and I have noticed that it's completely different to study now compared to before the war.I cannot memorize, study, concentrate, and focus like before.Survivors with PTSD can have serious problems in memorizing new data. For him or her is very difficult to adapt to anything what is new.It is very difficult to understand

cultural shades. It is hard to learn how to deal with bills, medical system,public aid and other necesssary but complicated normal living activities.

How does one learn a new language? PTSD interferes with the normal cognitive processes of learning. Learning may be very hard if the patient is is reexperiencing trauma through nightmares or flashbacks, if the patient has intrusive thoughts, if the patient has numbing of responsivnes, if the patient avoids thoughts or acts related to his or her past trauma.

We may ask how many of Bosnian refugees have symptoms of PTSD.?I know I have some of them.I further believe almost every body who has experienced the trauma of Bosnia under the siege of Genocide would expectably have some sort of changes in his mental status.

There is only question, how dominant are these symptoms? and will it affect somebody's ability to experience normal functioning.

LL) We also must say that we can not make a model. We can not say that everybody

responds in the same way to trauma. We have many internal defense mechanisms that are different from person to person. The effects of trauma will also depend on the age of the attacked person. It will depend on intellectual abilities and education, it will depend on the time of exposition and the etiology of the trauma.

Genocide, torture, and rape are a part of the experience of Bosnians. These criminal acts require special attention be given to the victims. Regarding thisitis not only a sense of life threatening occurances. In situations such as torture or rape, patients may have serious problems with feelings of their honor, self confidence and trusting other people.

It is also important to consider how Bosnians think about their future. This genocide has struck at the very heart of the cultural identity of Bosnians. What will their cultural identity be?

As multi-ethnic Bosnians? As Muslims? As Americans? Some would say that its necessary to choose between being Bosnian and being American.I suggest that we think with the biculturalism model that says that one can achieve cultural competence in the ways of the host country, while maintaining the integrity of one's original cultural identity. We need to find ways to think about this that is not all or none. This is clearly going to be an issue that we are going to have to struggle with for a long time.

Contemplating the future for Bosnian people raises many more questions then it provides answers. The future of Bosnia and the possibility of whether Bosnian refugees in this country will be able return to Bosnian is very much uncertain. Some wish never to go back, while many would return the instant it were possible. This lingering uncertainty prevents the Bosnian refugee from committing to establishing a new life in America. It as if they were believing that to learn

English and make a life in America was to acknowledge that which they refused to acknowledge

- that the Bosnia that they knew has been irrevocably changed by genocide.

146 And precisely because this genocide and war is still going on even as we speak here in

this pleasant setting today, and the Bosnian refugee knows that their loved ones and family

members are still there and in danger, their hearts and minds are to a large extent still in Bosnia.

For many, they are just existing here. These are not the best conditions for learning English.

But if it is your professional job to teach them English, you have no choice but to except these realities.

147 MG)MIM L Problem Is It? Crisis Intervention forthe ESL Teacher: Whose cat Anh Quan :,enior Associate, Sprang Institute forInternational Studies

Working with a student fromanother culturalbackground has motivational factor forall ESL teachers. !peen a challenge and a something most of us Working with multi-levelrefugee students is However, dealingwith a crisis, have learnt to thrive on. issue is simply especially one precipitatedby a mental health training background, norsomething that most neither part of our within the space ofthe of us would visualizebeing confronted ESL classroom. there, lest we chooseto ignore them. The statistics are outof twc) nurbaut(1984) discoveredthat almost every one country will facedepression within their refugees entering this mainstream ratio of one lifetime, this compared tothe American Starr(1978) reviewed stressorsfaced by the refugee out of ten. general public on communities and find nocomparable item for the scale:loss of country,loss of culture,loss of the mainstream of life, all these family member(s), lossof status, loss of way the advent ofculture shock thrust upon losses compounded by resettlement groups of peoplewho are coming tothe country of expectations and minimaltraining and employment with very high by the School of A University ofHawaii study conducted skills. that the Vietnamesesuicide rate in the Social Work revealed 100,000, five-year period,1978-1982, was 24.6 per state for the 11.9 per 100,000reported for over twice thenational average of Weekly Reporter(5/21/85),this in 1980 in Morbidityand Mortality community supportsystem. a state with anextensive Asian review the stressorsconfronting the This article will fills for focus on the role(s)the ESL teacher refugee student, series of guidelinesfor the his(her) students,and outline a teacher's usage in acrisis interventionsituation.

Stressors in refugeeresettlement and Health CareNeeds of In the "Special.Report: Physical Court Robinsonlisted the problems IndochineseRefugees"(1980), health task forcein order of identified by anational mental conflict, depression, anxietyreactions, marital frequency: adjustmentproblems, intergenerationalconflict, school loss, including fatigue,dizziness, weight psychosomatic symptoms The frequencyand headaches, chest painand insomnia. nausea, beenrepeatedly reported ofthese problemshave of health severity in terms ofrisino incidences throughout theSII011610/ country i.100 'OETOOTES101 TO WOODLICE 1 ICS MATERIAL PTAS SUN GRANTEDYr All 01111a0so I . 1.00.6. al %CLAUSMoil 4c, A-. ihr .1.8 *OS Ow. 11610* ft ..e4/ ft.** 1.11~ I .41,410,1 BEST COPYAMIABLE 1110, 4.0.010 *We 1100. MOPal .1.6.0.

11-4 SIOSOURGOO oftwilloOmemparimMMIammedmor TO THE EOLICATIONAt ONO ID r -'111.1111M 0111. MOIONEMATIOM CONOTIO ONO syrrtoratolocy with nc cryhnic basis, anecdotesof severe and unresolved yriof reacticrs, post-traumaticdelayed stress and high rates of far...ily conflict and break-up.

First and foremost amongst.thestressors the refugees encounter is the flight process itself. For almost all refugees it is a lona, arduous,dangerous,complex and frequently hazardous process. The United Nations Higher Commissionerfor Refugees, working through the assistance ofhost governments and donor countries, is mainly responsible forthe welfare of thesegroups from the flight from their homelandand subsequent arrival to holding camps to their eventualassignment to a country of resettlement.": Once in the country ofresettlement, the process is even further impacted by cultureshock and displacement. Just the overflow of new information andresources can become another source of confusion, difficulty andtrauma. Improved federal policy and local input into theservice deliveryprocess have minimized the isolationprocess which once was prevalent with policy of dispersion. the ": However, the stress on "employment first" have exerted additionalpressure on local and state systems,which are continually experiencing frustrationin finding employment for theirown indigenous clients. In a mental health needs assessmentconducted with serviceproviders in eight Southeastern U.S.states, respondents indicated that "rental health" problems, per se, did not surface howeverduring this initial period ofarrival. Rather, in a Maslowian hierarchical structure, psychosomaticsymptoms, depression and other indicators of stressare exhibited in the context ofthe emergency room most often after thefirst year, when basic such as finding suitable needs housing, putting children intoschool, securing the first job havealready been met andthings are expected to get better. These developmental andsituational crises seem to cropup again around permanentresidence status application and thennaturalization applicationtimes.

Table I: AcculturationTimeline

6 mths 1-2 yrs. 3 yrs. 2-3 yrs x- xx xxx------xxxx------xxxxx rlightEncampmentPrimary Permanent Citizenship Resettlement Residence

; significant amount of secondary after the primary migration has occured resettlement for a numberof differentreasons: reunification with extendedfamily members andfriends, dissatisfaction with climateor community,lack of employment,

EST COPY AWAKE 150 NM

breakdown of spensvi relatic,nship and ensuingloss of face with ethnic community. Secondary migration usually resultedin continuing "problem" resettlement, becausethe "problems" have simply been transferred to a different geographiclocation. As a rule, they tend to occur ininner city neighborhoods with low cost rental housing, availahility of low levelemployment, and proximity to members of the same ethniccommunity.

Rumbaut pointed out that the 6 month - l year after initial resettlement period is typicallya period of toil and physical hardship as well as one of discoveryand new learning. The mood of the newcomer during this phaseis one of elation and joy. Subsequently however, depressionsets in after the first basic needs are met. He went on to ascertain thatalthough most refugees manage tocope with the ensuing depressionand difficulties, very few willreturn to the elation period of those first six months. Researchers, keying on the differentS.E. Asian refugee waves in terms of their ethnic origin, socioeconomic status, degree ofurbanization, prior education and employment, have hypothesized thatdepression coincides for the 1975 group with their citizenshipand the graduation oftheir children from high school,approximately 7 to 9 years aftertheir arrival. For the subsequentwaves, the time frame is much shorter, anywhere from 3to 5 years, due to the increasing hardship of their flightexperience coupled withrising expectations concerning family reunification and life in theU.S.

Who do refugees go to when they need help? Cross-cultural 11/factors play a key role in theexpectations of the h.:,lp and the perceived person seeking helper. Table II looks at thethree different modalities of interventionthrough time. It has become IIincreasingly clear that inthe spiritual and thebio-chernical modalities, the emphasis isplaced on the ability ofthe helper, be that person a physicianor an elder member of the Ifamily system, to provide extended immediate solution andguidance. In the psycho-social modality,the focus is on the ability individualto "do for self" through of the verbalization. ventilation and

Ilihis is further exacerbated for both helper and clientwhen one considers the language andculture barriers that Ito overcome to both sides have arrive at an accurate diagnosisand an effective "treatment plan. Service providers have working through told us repeatedlythat a translator is not the idealsituation, _specially if the translatoris untrained. s to note here that the bilingual It is essential for paraprofessional, servingas (ranslator, playsa dual role. For the client and the this person explains community, linguistically and culturally"how" things 11

151 REST COPY MIAMI Table I]: Modalities of Intervention

Mode Hulper Expectation 1. Spiritual Extended Family Advice Clergy, Monk!. Solutions Shaman, Soul Callers 2. Physical Herbalist Diagnosis/Treatment (Pio-chemical) Physician Medication Nurse Injection

Psycho-social Psychologist Ventilation Counselor Feelings Social worker Self-concept

get done. For the agency, h /she hasto explain "what"the perceived problem is. This same person isan "American" for his/her ethnic group anda "refugee" for the mainstream. position of risk and compromise It is a for which few peopleeither has the training or the abilityto fulfill.

IIThe Role of the Teacher

when we asked translatorsto literally define "mental their language, they health" in cannot cone up with a termfor it. A Mental Health Center becomesa "crazy hospital". Depression becomes "extreme sadness" or "sicknessof the nerves",or of "the heart", or of "the liver" dependingon the ethnicity of the translator. Labeling the problem alienatesthe refugee client further any support system they from may have had.This is anotherreason why a refugee may sometimeappear quite resistant to talk from their own ethnic to someone group about their problem forfear of ostracism and rejectionfrom the group. In their country of origin, the teacher has alwaysplayed a key role. The teacher controls thegates of knowledge in where literacy is a structure more the exception than therule. In the old randarin structure,and to a greatextent, under colonialist rule, the teacher isalways at the top ofthe caste system (Si, tong, Cong, Thuong:Teacher, Farmer, Laborer, initial experience with Trader). Their the new society reinforcesthat belief: when you havea problem, the PSI, teacher or show you how to get the can frequently helpyou problem taken care of. Teachers have identified forus the numerous roles theytake on within their

152 BEST COPY AVAiLABLE Instructional copacity: cultural tranlatoy,surrogate parent, driver, appointment keeper, "lathe: confessor", advocate, counselor, friend, mediatoy, explainer ofrules and explainer of "how to qet around tulvn".

Guidelines for Crisis Intervention

When the "oift" ofa problem is offered to thehelper, it is crucial to us as a helperto assess the severity of theproblem at hand. If the expectation is forus to solve the problem, solving it may help meet therefugee's expectations, also create a dependency but it may pattern. If the situation isone involving danger for the clientto self and others,we may not have the choice but tostep in and take action. an appropriate course of Following are seven proceduralsteps outlining a crisis intervention:

1. Pre-planning 2. Physical support 3. Assessment 4. Resources utilizedto date Treatment plan 5. Referral 6. Follow-up 7. Closure

In addition to these crisisintervention steps, there some cross-cultural treatment are also considerations we havefound very useful in our clinicalsetting. These would fit well kinds of background into the cross-cultural informationand student data teachers usually look forin the context ofa classroom: 1. What are the issues?problems? people involved? 2. Would this have been a problem in culture oforigin? Or is it a result of theexperience of flight? culture shock? or of 3.If this had been a problem in culture oforigin, who would have been thenatural helpers? Are they available here? Ensuing expectations?Outcomes? 4. What resources have been utilized todate? Natural consequences of situation? ofintervention? 5. What course of action couldyou take that wouldmost likely create a WorseOutcome? Finally, these are some cultural tipsdealing with non-verbal behavior,attitudes, values and behaviorsthat haveproven helpful to teachers,counselors and professionals with. We have separated them we have worked into "passive" and"active"

BEST COPYAVAiLABLE a_ 53 iiny mole Ltx,..teyies, not that theactivestrategies reguiit "uoany" than the passive ones,Lutth,lt an teams of timarg, you with a new student withthe flit choose as a teacher to start which cow, pos!.ave steps firstbefore movinyon t0 the active, lter within the change processand as students becorbe more farm liar and comfortablewiththe new cultures"direct" corilLunication/confrontation style:

PASSIVE ACTIVE

1.Encourage these, even 1. Observe patterns ofinteraction (work, play, lunchroom,etc...) if they do not conform to mainstreambehavior 4atch non-verbal behaviorin dif- 2. Show "American" charac- ferent contexts (within sameethnic teristics through role 9ioup, with other LEPstudents, with modeling American friends) 3. Encourage new roles !. lay attentionto any sudden change ("gradual adaptation") of behavior (socialinteraction, apputite, work, etc...) 4. Seek parentparticipation and reaction to school activities/functions 5.Encourage all studentsin their interest/interaction with each other'scultural background. working with therefugee In the final outcome,the challenge of own reward.Students come back &tudent is frequently its very continuously about the to visit yearafter year,and talk teacher has made intheir acculturation dift rence that the ESL support that theyprovided. to tnis new countryand the trust and definition of "mentalhealth" servicedelivery That is the best provided without anylabeling that we can thinkof, which is Global Village, we canonly point to involved. In the age of the pivotal role of theESL classroomteacher.in the central and but a sense ofhope and providing not onlylanguage and culture, faith in the humanability to learn and grow.

Annaheim, California March 1986

154 BEST COPY AVMLA91,F Stressors in the refugee resettlementprocess

Within the family system

Role changes: adult child male female elderly

Values, attitudes E. behaviors: extended vs. nuclear close vs. open group vs. self cooperative vs. competitive

With the old culture:focus on thepast

Survivor's guilt &post-traumatic delayedstress Self-identity & marginality Generation gap

Within the mainstreamsociety: focuson the present The institution of theschool Work

Language barriers

Cultural barriers(time,communication interpersonal relationships) patterns,

Aspirations: focuson the future Education

Careers

Family

Special considerations:High Risk Groups Single male adolescents UmR's Ex-military Single parents(homehound women with children) Clergy 7,mrasians Elderly

BEST COPYMORE 155 156 DOCUMENT RESUME II ED 204 471 UD 021 557 AUTHOR Cohon, J. Donald, Jr. II TITLE Can TESOL Teachers Address the Mental HealthConcerns of the IndochineseRefugees? Draft. PUB DATE 8 Mar 80 NOT! I/ 26p.: Draft of paperpresented at the Spring Convention of the Teachersof English to Speakers of Other Languages (SanFrancisco, CA, March 8, For a related document, 1980). 1/ see UD 021 558. EDE! PRICr MF01/PCO2 Plus Postage. DESCRIPTORS *Acculturation; *Adiustment(to Environment); Asian II Americars; *EnglishInstruction; *Indochinese: Language Teachers: MentalDisorders; *mental Health: Refugees; Student Teacher Pole Relationship; *Teacher II ABSTRACT This paper examines researchin the fields of psychology, anthropology, 11 and the Teaching of Englishto Speakers of Other Languages (TESOL1as it relates to the mental health the Indochinese refugees. needs of It is arcued that TESOLinstructors are in a key position to influencethe adaptation process of their classes. Cultural refugees in II values of the Indochineseare explored, and methods that TESOL instructorsmight use to facilitate and improve mental health acculturation are outlined. Teachers are urgedto remain. IIaware and responsive to chances in their students, behavior. (APMI

*** NOTE: Portions of this paper discuss government fundingfor special mental health projects for refugees andthe use of TESOL classes in theseefforts.

* ipipsillsmarnipipipssip****** Reproductions supplied by EDRSare he best that can be made from the oricinal document. ******* ***** *********************wfw***** .1",..4,104.411.1...**4..**Ip******

157 19

the numerous human problems associates with acculturation

and to research and revise these alternatives as they are proven inefficient or as they become obsolete. Hopefully, these efforts will be carried out sensitively and with re- spect for other cultures.

A final comment about TESOL and refugees' mental health

related to the level of secondary prevention of mental

illness which involves early detection and treatment of

pr,,blems. Most teachers don't have formal training in

evaluation and diagnosis of mental disorders. Because

teachers are in daily contact with their students, changes

in students' demeanor or behavior become important cues.

Teachers need particular awareness of thes! changes with

their Indochinese students because the value placed on

repression and denial of affect contribute to making overt

symptoms more subtle. Experience with other refugee and minority groups indicates that frequent complaints about

headaches or other physical symptoms sometimes suggest a psychologically based problem. The teacher must be cautious not to put a student in an embarrassingsituation by call-

ing this to the student's attention in frontof others.

If there are doubts about the existence of a problem,call- ing in a consultant is adviseable. If this service is not available, a private conversation with the studentshould

153 3EST COPY MAIMS 20

be offered. Any referral ought to he done on a personal basis with a formal introductory meeting convened by the

referring TESOL teacher. Tertiary prevention of mental illness is the elimination or reduction (i.e, treatment) of existing problems. As with secondary prevention, most

teachers are not equipped with training to address this

area of concern, particularly in a culturally appropriate

manner. Many persons in the United States have come to

view psychotherapy as a cure for various problems but there is little agreement on what psychotherapy involves or on

its efficacy in helping people. Brown (1975) notes that

current definitions of the term mental health are so am-

biguous that they describe "a human ecology that encom-

.11 passes at least the earth, if not the universe .

(p. 2324). Rather than impose this ambiguity on refugees whose needs for structure and stability are more like those of a newborn child (Weinberg, 1955), it would be better

to call English instruction what it is and not confuse the task. The effect of English instruction on assimila- tion, adaptation, and acculturation will occur regardless, and by clearly delineating its aims it will be more accept- able to the Indochinese.

BEST COPYMIME 15 ,/,,PIPSIBE H

16 0 ACANADIAN CENTRE FOR VICTIMS OFTORTURE /IPquarterly - t,ue September 1 994 # 9 An Overview: ESL for Survivors

In considering the settlement process for newcomers both directly and indirectly affect the learning of a second to Canada who have suffered torture,arguably the most language are: memory impairments, depression, loss of daunting challenge is learning English. It is a goal that is self esteem, disruption of normal sleep patterns, recurrent at once the most illusive anddifficult to attain, yet the nightmares, a re-experiencing of traumatic events and an single most important tool required by any newcomer. inability to trust other individuals, particularly those Fluency in the language of the society one settles in allows holding positions of authority. Overcoming these obstacles for more freedom and control over one's life, Without as best as possible must be apriority in any English language, the simplest of tasks such as making a telephone language instruction programme for survivors. call or asking for directions pose insurmountable barriers. The ESL programme at the Canadian Centre for There are considerable differences in how individuals Victims of Torture (CCVT) has attempted to meet the progress in second language acquisition.While some needs of victims of torture in the classroom through several learners manage to achieve complete bilingualism, others strategies. Most notable is the integrative approach. All never advance beymtlialow level ofproficiency. Linguistic classes are held on site at the CCVT with intake research suggests that there is a significant number of counsellors present. In this way a support system for both factors which impact the learning of a second language, students and instructors is established. If a student including age, aptitude, personality, and cognitive style. experiences a crisis while in class (i.e. a flashback of a Social-psychological factors such as self esteem, attitudes traumatic event, or a more mild form of trauma such as towards the new society and its language, and the depression), seasoned counsellors with background in the psychological well-being of the learner also come into play. client's history can step in. Counsellors can also provide advice to instructors regarding specific students' behaviour Survivors of torture typically suffer what the American in the classroom. Psychiatric Association has identified as Post Traumatic Stress Disorder (PTSD), whose main cause is "a Within the ESL programme the mandate is as much psychologically traumatic event that is outside the range about rebuilding self-esteem in the learner as it is about of usual human experiencc."1 Symptoms of PTSD that language instruction. A positive self-image is an

16L BEST COPY MUSH indispensable ingredient for carrying out almost any The ideas outlined above represent only a small portion cognitive activity. For second language acquisition, it is of what can be done in an ESL class for torture survivors. crucial. The learner must always be prepared to take risks The guiding principle for the ESL instructor must always with the new language, knowing s/he will inevitably make be that individuals have survived torture, to some extent, mistakes, particularly in the early stages of instruction. at the expense of her/his self esteem. Making the ESL This can be difficult for survivors, since torture by its very classroom a place where learners can feel positive about nature is an implicit attack on the personalityand self- themselves is a big step down the road to second language image of the individual. acquisition, as well as personal well-being.

A good beginning in helping survivors feel more Lorena Bekar confident about learning English is to make the classroom ESL Programme Coordinator situation as informal and comfortable as possible. Students are not prohibited from coming and going within the 1. Report of the Canadian Task Force on Mental Health Issues period of instruction if they feel they need a break. Affecting Immigrants and Refugees, After the Door has been Learning activities are of a non - academic nature and food Opened (Ottawa, 1988) 85. is often shared during class hours.

Once students establish themselves in the class after an initial period of adjustment., noticeable differences are often observed. Even the most reserved students begin to form relationships with others and participate in classroom activities. Attendance tends to be quite good (75 to 80 per cent class averages), with many students remaining after class hours to socialize and take advantage of other services offered by the CCVT.

It has also been our experience that the comfort level of students is higher when class size is small. A ratio of 10 to 12 students to every instructor works well. When this is ct, not possible, volunteers an indispensable asset to the 1:$41010.1i ESL programme -;_iaLk.with students in small groups Pixer be that help to break up a large class and/or work with learners te:Meluptigebremeskel who require special attention. S41.1

An important means of establishing confidence in students is to use the ESL classroom as a bridge into the Crisp community. Frequent class outings is one way to lilt Wucatfoti:Corri. accomplish this. These trips can be ofan academic nature, Dietermege.10. such as visiting a museum, but more often they should Eiat' Massolleinitia attempt to familiarize students with their new community '40on Sirrialehik Examples include going to the post office to purchase :Mulugeta Gebrameskel stamps, shopping for cookies for break time, or going to a Kathy Nice cafe for conversation.

162 BEST COPYMOUE aPPEHDE © PRIMARY PRUE TIO \ A \ D THE PROMOTION OF MENTAL HEALTH A. THE ROLE OF THEThe teacherESL TEACHER in the ESL IN classroom PRIMARY plays a crucial part in the promotion of PREVENTIONi\ THE ESL CLASSROOM men- PRIMARY PREVENTION AND THE PROMOTION OF MENTALexample.heating HEALTH taking problem IN THE on ESL orthe a responsibilityneighborhood to crime directly situation resolve is probably a refugee's home CLASSROOMnot within withrefugeeTotal health.begin the student. teacherwith, the enhancementthe Southeastin ESL a highly teacher Asians. ofrespected copinghas for skills. position. and a very special and unique relationship Withexample, the place great value on education. the socialIn fact, well-being according of refugees. to tradition. duplicateindividualthe job description other client efforts, level, or theandifTeachers not expertise in appropriately other assuming ways of a beteacher. done.roles counterproductive. in couldIn primary fact. complicate involvement prevention should: matters. at an refugeewouldquestioning consider. student the has Theauthnrit regular ESLAs of teacherandthe a teacher teacher-studentextensive is relationship develops. ma also he the one American with whom the contact. not something a Southeast Asian adult and along with it. an increasing experiencesRecognizeUnderstand nor theythat over they arewhat parthave a refugee of no a control network faces: over of the"helpers" emotional who pain are working a refugee directlytionmands.amount that or Duringofindirectly. there trust. ahas it teaching naturallyabout been stressful noactivity follows heat social,inthat his the her teacher who on housing. for example. a student might men- environmental.apartment and institutional for over a de-week. Or, a listens will begin to hear. AdvocatesibilitiesAdvocatetoward other forsimilar foradequate than further goals: teaching supporttraining are forandexpected both staff teachers development. to be carried and students: especially if out: respon- lems.onstudent the It subway. ismight also apologize likely or fear that of forthebeingIt having isstudents probable robbed missed have on that the atkiapted the neighborhood ESL teacher is not the only "helper" aware of suchclass prob- because of fear of traveling alone to resolve problems with the streets. limitations.EstablishtimeAvoid off. "burn-out" and realistic sharing bygoals. frustrationsjoining recognizing local with professional peers: their organizations. own strengths. skills. and taking tionof thishelp in help-seekingthe of theirclassroom ow n system. supportby assuming and networks. will the be role The of: ESL A good listener, allowing students to most effective in the area of primaryexpress preven- and vent feelings and share prior teacher does, however, become part 2. Refugee Students ExpectationsA refugee student Stressful in theLife process Situations of social adaptation is coping with the loss behindAexperiences mediator social. betweenwith environmental, each cultures, other: and helping institutional students demands: to understand the meanings classlookbyand newto traumato do thesocial this ESL of andeffectively.forced class environmental migrationas a place and that demands. facing the It innumerable it can facilitate this process. For an ESL is not surprising that refugees stressors created andAful thefacilitator,provider events rehearsal and of allowing informationdirect of coping students for skills:a whoclassroom to will community conducive prepare students for possible future stress- resources for help: to sharing. problem-solving. 3. The Classroom teachers assess the needs of students as a is essential that programs and individual group. (See Chapter B. Section II). Before adopting teachingdifferences. strategiesA model orandshaped representative to draw conclusions of a culture, about allowing aroundthese these differences. general principles of students to observe cultural enhancement of coping skillsA classroom is one that: that is most conduciveFostersHas a loss feelings to anxiety the ofpromotion helongingnesslevel: of and success: mental health and andtoprimary examine feasibility prevention the in context the in curriculum.the inclassroom.I. which The an teachers ESLfollowing program functions, to determineand scopeor programelements administrators should be considered: need ReducesIs responsivereceptive isolation to to student theb encouraging learning issues styles and cultural of individuals traditions: in a class; 165 16,4 guagein primarESL needs Teacher's prevention of the Strength refugee involsThe and esstudent primary considering Limitations together. task of ESLAs ESL instructors is to teachthe English.social. psychological, Assuming a roleand lan- teachers become more canences,Recognizes serve feelings. as a thatbridge and the opinions: to prior new knowledge learning: and experiences peer support and sharing of experi- of refugee students I. am ow al. ow am ever,assumeconscious teachers responsibility of cannotthe stress-producing allow for functionstheir roles demands not to expandappropriate in for urn me on their refugee students. how- No such a way that they their position. For BEST COPYwe awn MAME No am owBringsProvidesEncourages the ammaximum real students world opportunitymu intoto participate the classroom. esfor actively rehearsal: am and us to assume responsibility: No PRIMARY PREVENTION AND THE4. PROMOTION Curriculum OF Materials MENTAL HEALTH Teaching IX THE Approach ESL CLASSROOM Curriculum. materials. and teaching approaches will vary widely, depend- PRIMARY PREVENTION AND THE PROMOTION OF MENTAL. HEALTHtheless IN existingTHE familiar). ESL CLASSROOMhost (See community this Handbook. and its Chaptersocial structures C. Section with II.) which Second. the refugeethere is materialsamininganding on community a theseparticular and methods areas resources. program's in mayrelation and be goals. required.theto primaryteaching level Inof prevention, the students.style adaptation of each availability adaptation teacher. process of Whenofa teaching teacherexisting ex- employers,bemay resource still locallack people basicgovernment such familiarity.Coordination as officials, housing understanding. oradvocates.with day and care inclusion lawyers.workers.and information. ofpolice. information job These developers. about could social service sys- should ask him herself the following questions: DopositiveHow I do ones?I help to change self-defeating attitudes of refugee studentsuse strategies to that help students to gain confidence, both in and taxonomiesgeelumtems andstudent and staff other that needsdevelopment community categorize to learn activities. supporttheto interact world networksThis differently. with is essentialhost has Thisinstitutions to bebecause is anpart educational andof the ESL toadult usecurricu- refu- new pro- learning?outDoes of the my classroom? teaching enable students to feel successful with their language shouldrefugeecessinformation that view students leads themselves about to to accessing develop community and strategiesstrive "mainstream" toresources be for viewed coping services. in by theand others classroom self Using as-help. and ESLis drawing teachers on part of the larger one was for -refugee'sTo Do what they extent world?drawtake into ondo prior theconsiderati'.'m materials knowledge and the and curriculum cultural experience? and mirror socio-economic the reality of con- the change.andprimarycommunity activities. playing prevention of Finally. a helpers. vital roleefforts ESL This in teacherssanctioning byshould linking increase must themuse view of to the help-givers a themselves likelihoodlarger community by of refugees. success of peoplefor their as agents of HowwellDo the as do emotionalmaterials I combine andneeds?ditions ESL curriculum subjectof the refugee?focus areas on (e.g.. students' transportation) day-to-day needswith stu- as mation?HowDodents' I allow do emotions. I promotefor cultural feelings, critical differences and thinking. anxieties to be inquiry, (e.g..examined fear and ofin thetakingthe gainingclassroom? the subway)? of infor- theirstressors?DoAre lis I studentses?teach Language language asked that tothat goes develop will beyond enable their identifying students own strategies and to takeaccepting? formore addressing control of 166 skillsArcDoHow communit in I doreal-life I ensure resources situations? that rehearsal a regular opportunities part of classroom occur activities? regularly?use actin tiles that allow students to apply newly-learned coping 5. ties,Local their Community support networks. AgencyESL programsRelationships and the resources should he refugeesreiv.ved in access relation or to could their own local communi- withinsors.portaccess. systems temples. the This ethnic can and Mutual he groupnetworks viewed Assistance tit is atwith this two whichnetwork levels. Associations the First. with student therewhich (MAAs). is are familiar,ESL refugee-specific teachersand such role as maymodels spon- sup- be BEST COPY AVAILABLE NM MIN 14 1.11 =I NIP MI Is NMI NM MI e U.S. DEPARTMENT OF EDUCATION Office of Educational Research and improvement (OERI) Educational Resources information Center (ERIC) ERIC

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