By Their Side E-Book

Barbara Preitler

• Herausgeber: StudienVerlag
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 219

Veröffentlichungsjahr: 2022

Beschreibung

'I want to help!' It's a thought that goes through many people's minds when they see refugees forced to seek safety in other countries. Some might find themselves asking further questions: What's the best way to talk to someone dealing with trauma? How can I establish a foundation of trust? How will our relationship function? The answers are contained within these pages. A handbook for volunteers, By Their Side offers a solid foundation for people supporting and working with refugees. In clear, comprehensible sections, Barbara Preitler discusses trauma and forced displacement from a psychological point of view, imparting advice and background knowledge, and illustrating ways in which we can deepen our understanding of others and work to build good interpersonal relationships. She encourages us to seek out opportunities for new encounters, helping people with different cultural backgrounds and experiences to build strong relationships.

Leseprobe

Barbara Preitler

By Their Side

Barbara Preitler

By Their Side

Psychosocial Support for Traumatized Refugees

Translated by Eleanor Updegraff

Contents

Foreword to the 2016 Edition

Introduction

1. Forced Displacement – Psychological Wounds, Psychological Strengths

Healthy, Healing Relationships

Post-Traumatic Stress Disorder

Critical Remarks on PTSD

The Latency Stage – a Period of Inner Peace

Painful Memories – Listening Helps

Ways of Creating Distance

Creating Distance from Nightmares

Internal Helpers

Calming Strategies

Difficulty Concentrating or Remembering

Traumatic Experiences Can Have a Lifelong Impact

The Sense of Coherence

2. Ten Consequences of Trauma and How We Can Respond in Psychosocial Support

2.1 Chaos – Security

Chaos – The Total Collapse of Security

Safe Encounters

Information Provides Security

Secure Relationships

Trusting in a Safe Place

Safe Environments

Re-establishing Safety Within Oneself

Internal and External Security

2.2 Losing Control – Regaining Control

Losing Control in Traumatic Situations

Information Helps to Control Situations

Making Good Use of Available Space

Communicating with Relatives

Controlling the Body

Sports

Managing Pain and Insomnia

2.3 Violated Boundaries – Reclaiming Good Boundaries

Trauma and Boundaries

The Consequences of Violating Boundaries

Re-establishing Boundaries

Clear Parameters

Self-Reflection for Support Workers

Cultural Differences – Finding a Good Middle Ground

Preventing Relationship Breakdowns

2.4 Speechlessness – Regaining Communication

How Trauma Fragments Language

Naming the Nameless

Losing Language

Finding Associations in Fragments

The Importance of Talking

Understanding and Naming Revisited Traumas

How Imagination Can Help, or: What Is Objective Reality?

What If Traumatic Events Have to Be Discussed?

Using a New Language as a New Mode of Expression

2.5 Pain – Understanding and Developing Strategies for Managing Pain

Pain in War and Forced Displacement

Pain as a Result of Human Rights Violations

Pain and Control

Permission to Talk

Pain Without Medical Evidence

Pain as a Symbol of Suffering

Acknowledgement Is Essential in Healing Emotional Wounds

Self-Harm as a Means of Feeling

Pain and Communication

2.6 Aggression – Acknowledging, Attributing and Managing Aggression

Acknowledging Aggression

Where Does Aggression Belong?

Strategies for Managing Aggression

External Self-Control

Boundaries Provide Safety

Transformation

2.7 Guilt and Feelings of Guilt – Understanding, Accepting, Grieving

Feelings of Guilt

Managing Guilt and Feelings of Guilt

Religious Rituals

Other Rituals

2.8 Injured Self-Esteem – Strengthening Self-Worth

Injured Self-Esteem

Purification Rituals

Self-Defence

Artistic Expression

Acknowledgement and Positive Feedback

Safe Spaces for Regression to Restore Self-Esteem

2.9 Loss – Grief

Grief – a Vital Reaction to Loss

Successfully Integrating Grief

Avoiding Grief

Grieving Requires Rituals

Belated Rituals

Modifying Rituals

Reimagining Rituals

Supporting the Grieving Process

Relatives of the ‘Disappeared’: A Difficult Situation

2.10 Regression – Supporting the Return to Age-Appropriate Coping

Regression as a Response to Violence and Displacement

Meeting on an Equal Footing

Recovering Age-Appropriate Ways of Living

The Subsidiarity Principle

Transitional Objects

Integration in a New Linguistic and Cultural Environment

2.11 Summary: Helplessness – Empowerment

Additional Chapters

3. The Third Side of the Triangle – Communicating Through an Interpreter

Interaction Between Clients and Support Workers

Interaction Between Interpreters and Support Workers

Interaction Between Interpreters and Clients

Interaction Between Clients, Interpreters and Support Workers

A Thank-You to All Our Interpreters

4. Guidelines for Outdoor Activities with Refugees

Empowerment as a Response to Helplessness

Being Active, Being a Winner!

The Risk of Repeating Trauma

How to Avoid Re-traumatizing Experiences

What to Do if Someone Experiences a Traumatic Flashback

Boosting Self-Esteem – Trusting One Another

5. Hurt Children – Strong Children

Traumatic Burdens

Trauma and Grief

Safe Places and Relationships

6. Concluding Remarks

Bibliography

Foreword to the 2016 Edition

The book you hold in your hands is one of which we are in urgent need. It is a book we require right now: in exactly this format and clear, understandable tone. To write such a book – one that is so readable, practice-oriented and emotionally effective – requires decades of experience working with severely traumatized people from all over the world, not to mention a comprehensive overview of international research in this field.

‘Emotionally effective’ means that this book has succeeded – in as far as it is possible for practitioners and other people interested in studying severe trauma to succeed – in empathizing with the real-life horrors and nightmarish experiences that refugees have to go through. The stories and vignette-style case studies that Barbara Preitler has built into her explanations and guidelines come in ‘exactly the right dose’ for readers: here, we are not at risk of the paralysing fear that could so easily be brought on by an overdose, or the wrong choice of words with respect to trauma. For, sadly, this paralysing fear can lead to resistance or even the denial of trauma, of nightmares made real and of ‘rock-bottom’ experiences – an avoidance of which we are all (even the professionals) capable if we find ourselves unable to cope with the horror with which we are confronted. It was precisely this kind of avoidance we saw so suddenly emerge following the events of New Year’s Eve 2015/2016 in Cologne – almost as though it had been hiding within us all along, patiently waiting to put an end to our exhausting attempts to empathize with the unspeakable suffering of refugees from Syria, Iraq, Afghanistan and other countries. After the summer and autumn of 2015, when many people learned first-hand how good it can feel to do something, to allow themselves to be guided by their superego, or conscience – an experience hitherto largely unknown in consumer capitalist societies – the new year saw ‘do-gooder’ resume its status as a derogatory term. Just as we’d seen twenty years earlier, at the peak of the refugee crisis perpetuated by the Yugoslav Wars, it was once again voted the ‘ugliest word of the year’.

The way in which language has changed to reflect how we have recently hardened – even begun ignoring – our collective conscience can seem, at times, rather Orwellian. The ‘Australian solution’ (which would effectively imprison refugees on an island in the Mediterranean) is viewed in some quarters as a humane measure to prevent yet more suffering and deaths by drowning. Military preparedness and ‘admitting’ to having purchased weapons can now pass as preparation for the challenges ahead. Politicians seem to be trying to train us in a new kind of heroism, in which we will have to be ready to see terrible pictures of children crying at border fences and still not allow ourselves to be moved. In reality, this rhetoric aims at resisting our conscience – something almost everyone still does possess.

When a series of aid projects was launched under the motto ‘We’ve got this’, it was predicted they would fail in many ways. The balance, it was said, was bound to ‘tip’ soon. But the failure and mass burnout never materialized. If voluntary support workers become tired, they simply take a break. Some will stop for good. But others will come to take their place. New professional and voluntary support workers can be inducted and receive supervision and training from experts such as Barbara Preitler, for example. Many are grateful to be allowed to do such important work. Particularly in light of the summer of 2016, in which we saw an accumulation of killing sprees and Islamist attacks involving individual refugees and young second-generation migrants, we have no choice but to provide effective support and further development for psychosocial aid projects designed for war refugees and torture survivors. Their patient efforts to provide empathy and reassurance, and to work towards restoring individual self-esteem in the wake of the traumatic experiences many refugees have been through, can also contribute to preventing violence. Explosive acts of revenge against an environment perceived as ‘unhurt’ can be an attempt to cure untreated trauma and personal grievances – a kind of ‘twisted healing’.

As readers will soon see, the tone Barbara Preitler adopts in this book is reassuringly calm and shows us all that it is possible to ‘do something’. Lamenting the situation won’t help. Nor do we need to pack traumatized refugees off to distant psycho-experts – something that has often happened in the past, and which can also be a form of resistance to trauma. Our knowledge of trauma psychology and trauma therapy is now so well founded and based on so much experience that other professional fields and voluntary groups can also put it to creative use. Of course, there are some things that only trained trauma therapists can do, such as so-called exposure therapy, or trauma confrontation, which aims carefully and methodically to reintegrate horrific experiences back into a traumatized patient’s life story. (They have usually had good reason to split off, or block, these terrible experiences from the rest of their memories.) But strengthening people’s resources, providing comfort and praise, understanding the mechanisms of trauma and simply ‘bearing up’ someone who has gone through hell – all these are things that many other people are capable of doing, provided they are interested in having this kind of personal encounter. It is important to be prepared for setbacks. But nowadays, it is almost always possible to seek professional advice. There is, for example, a dedicated field of trauma-informed education, which is based on the results of psychological and psychotherapeutic trauma research but functions independently. Countless organizations use trauma-sensitive approaches to help refugees reach a new level of self-confidence.

I had – and still do have – the good fortune to work with Barbara Preitler over a number of years. Even in times of crisis, she never gives up. I hope this book will find its way into the hands of as many readers as possible.

Klaus Ottomeyer

Introduction

For many years, the work we did with traumatized refugees received hardly any public attention. All this changed abruptly in 2015, when large numbers of people fleeing war and crisis on the Asian and African continents arrived in Central Europe in search of safety and asylum.

What was at first a generally friendly attitude towards these new arrivals turned sour after just a few months, and the media began to present as a threat people who were seeking protection against war and human rights abuses. And yet – though they were no longer in the limelight – we still saw many people who were willing to help: the ‘support workers’ mentioned throughout this book.

In 2022, large numbers of people had to flee war and violence once again. This time, though, they were Europeans. This emergency was far closer and more threatening, and again we saw an enormous willingness to help.

We have learned a lot over the course of the past few years. As a psychotherapist and psychologist, I have used this book to compile my knowledge and practical experience working with the psychological consequences of trauma, as well as ways in which we can offer to help our fellow human beings.

The psychological burdens that traumatized refugees have carried with them, and which they have to face even in their new surroundings, need to be seen and understood if we want to manage them properly. Help is also needed to support healthy cooperation between the people who have had to flee their homes and the people standing by to welcome them, so that neither side feels overburdened.

Refugees are completely normal people with individual characters shaped by their language, culture, education … One thing they have in common is that they have all experienced existential stress, and in many ways continue to do so. Likewise, they have all faced extreme aggression and violence. Almost all will find the culture and way of life in their country of exile confusing, and will struggle to find their feet in such a different everyday world. But the ways in which they will deal with these experiences, and their hopes and expectations of their new home, will be as various as human beings themselves.

This was and certainly still is a challenge – but perhaps what we need is a more realistic picture of refugees, as well as more knowledge about what might be causing certain behavioural patterns.

And so, what can we say about the characteristics common to people who have had to flee their homeland? In this book, which builds on many years of experience as a psychotherapist working with severely traumatized refugees and in crisis zones across Asia, as well as academic study of this topic, I hope to provide a concise overview of the biggest problem areas we face, to offer explanatory models for how to understand them, and to present various possible ways in which to actively approach them.

The word ‘trauma’ comes from the Ancient Greek and means wound, or injury. It is a medical term that has found its way into psychology and can be used in many other contexts as well.

And, just as a person who has broken their leg will be exactly the same person to talk to as they were before their accident, despite their new injury, so too will people who have been psychologically wounded – or traumatized – be the same. The friend with the broken leg might not be such a good hiking companion, however. And, in the same way, we need to establish which situations a psychologically wounded person might have to ‘sit out’ for a while. This, of course, is rather more difficult: a broken leg is clearly visible in its plaster cast, but a psychological wound less so. This kind of injury first needs to be understood – by outsiders, but also by the wounded person themselves.

Trauma doesn’t automatically mean that people affected by it need to be treated differently to people who haven’t been traumatized. What is important is listening closely and treating them with respect. This book hopes to encourage people to seek opportunities to come into contact with one another – respectfully and open-mindedly. While I can’t offer any readymade solutions, I can provide background knowledge, examples and ideas based on things that have worked in the past and which may well be helpful in other cases.

This book is dedicated to all those who continue to believe in and champion humanity and human dignity.

Barbara Preitler, March 2022

1. Forced Displacement – Psychological Wounds, Psychological Strengths

Healthy, Healing Relationships

People who have been badly hurt by other people need one thing above all else: healing relationships. And these can be found in any situation that brings people together.

In post-traumatic stress disorder, we encounter the avoidance of ‘activities and situations reminiscent of the trauma’ (ICD 10). To explain this phenomenon, it is easier to switch briefly to other triggers of traumatic experiences, such as natural disasters. In the wake of the huge tsunami of 2004, everyone knew that the people who had survived such a horrific event would be afraid of the sea or large bodies of water. It didn’t require an expert to explain what was happening psychologically – it is innate human knowledge that we will seek to avoid the very thing that has hurt us. In the case of the tsunami, that thing was the sea. We could understand, too, that the survivors wouldn’t just be afraid of the Indian Ocean off the coast of Thailand, Indonesia or Sri Lanka, but that this avoidance behaviour could be extended to the Atlantic, the Mediterranean, perhaps even a nearby lake.

But what happens when it isn’t the movement of tectonic plates and seawater that has caused deep psychological harm, but other people? It’s astonishing that we have far more difficulty understanding avoidance behaviour in this context. But in fact, fear of other people who in one way or another recall the perpetrators of that hurt is a phenomenon commonly experienced in the wake of a traumatic event. These people might wear uniform, speak a certain language, or belong to a specific ethnicity or gender. In the worst case, a survivor might become afraid of people in general.

Let’s go back to the natural disaster: the tsunami. Any Central European tourist who survived it would find it relatively easy to maintain this avoidance behaviour. It is entirely possible to live a fulfilling life without going anywhere near the sea ever again. Daily life can take place inland, while holidays can be spent in the mountains, the countryside or cities. But for families who live in coastal regions and earn their living by fishing, things look quite different: avoiding the sea would rob them of their income, house and homeland. They require strategies in order to be able to live by the ocean again.

A similar situation arises when people have been the cause of severe trauma: strategies are required in order for the survivors to be able to live among people again, or else they face being forced into social isolation.

The image of a set of balancing scales can be helpful here: an acutely traumatic event is a very heavy weight on one side, while everyday experiences are lighter weights that stack up on the other. A very high number of normal, everyday experiences are therefore required to regain balance. Among these, positive encounters weigh more. And so healthy, healing relationships with other people, in whatever situation they may occur, can become important building blocks for establishing a good life in the aftermath of trauma.

Psychotherapy is, by definition, the meeting of two people with this kind of healing relationship at its heart. But healing relationships or encounters can be found in any situation that brings people together.

Sometimes, it might be merely a brief encounter that provides a source of strength in difficult times. I felt very moved when several of my clients told me how kindly they were received by Austrian military conscripts during the period in which the Austrian army was helping out on the rural border between Austria and Hungary. Even years down the line, many of them continued to remember and describe the friendly reception they had received from those young soldiers as a special moment. For a few hours, they had felt welcome and taken seriously as human beings who had needs. This positive experience was something they could draw on as a source of strength when things became difficult and stressful again later on.

Newly arrived refugees often describe how awful it was to feel themselves just one part of an enormous crowd, and to sense that they no longer counted as an individual. How good it was, then, when someone there to help them was friendly, asked their name and how they were, or took their painful feet seriously and didn’t simply tell them they were causing a hold-up.

Brief encounters of this sort are like oases that safeguard people’s psychological survival and can still be remembered positively even many years later.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is the chief psychiatric/psychological diagnosis given to traumatized refugees. The term first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) published by the American Psychiatric Association (APA) in 1980 and most recently in the revised fifth edition of the manual published in 2013 (DSM-V, APA, 2013).

In almost all our clients, we see symptoms from the four main symptom groups:

1. Intrusive or recurrent memories of the trauma (day and night)

2. Avoidance of painful reminders of the trauma and anything that might trigger them

3. Feeling on edge, jittery or agitated (hyperarousal)

4. Negative emotions such as profound sadness, despair, numbness, difficulty thinking about the future

This diagnosis gives us a common language that isn’t just used within the attending medical/psychological team, but also represents a consensus with authorities, NGOs and, perhaps most importantly, the clients themselves.

Many survivors are unable to attribute their psychological symptoms, so are afraid that they have been dealt another blow of fate and now will have live with a mental illness as well. Having a diagnosis of PTSD explained can therefore come as a relief: there is a name for what they are experiencing; it isn’t a discrete event, but a reaction to what they have already gone through. It’s an injury, not an illness! The violence to which this person has been subjected was so great that it left them wounded – even if the associated symptoms and pain have only become noticeable after a delay.

Psychoeducation, in the sense of explaining what post-traumatic stress disorder is and how it manifests, can thus significantly ease the burden on people affected in this way.

Critical Remarks on PTSD

There are, however, many critical remarks to make about this diagnosis, beginning with the name. The fourth letter, the ‘D’ in PTSD, stands for ‘disorder’. Thus, to diagnose someone in this way is to tell them that they have a disorder. In my opinion, this both strips them of their worth and shifts the focus away from the perpetrator to the victim. Yes, there was a disorder – a disruption to the order of things. But, as is always the case when human rights are violated, this disorder lies with the perpetrators and not with the people who were injured by the violence meted out against them! Trauma reactions are normal reactions to abnormal, disturbed violence.

The ‘P’ for ‘post’ also needs to be questioned when working with refugees: post – after – suggests that the traumatic situation is over and done with. But refugees especially don’t know whether they will have to return to a crisis zone, whether they will once again be exposed to the same or similar situations they have fled. Their living situation is marked by hugely acute stress. They don’t have enough energy to work through the traumatic experiences that caused them to flee. Should their relatives still be living in the crisis zone, their trauma will be continually revisited. It is often merely wishful thinking to presume that our clients’ trauma is over, and they can now turn their attention to overcoming the past. Any form of therapy or psychosocial work to process their traumatic past will continually be complicated by acute stress situations.

The Latency Stage – a Period of Inner Peace

In the immediate aftermath of traumatic events, we may experience acute stress reactions. It is theoretically possible to diagnose these as such, though almost never necessary. In human terms, it is perfectly clear and comprehensible that people’s immediate reaction to stress will often include trembling, crying, the inability to move, etc.

Following acute stress, many people experience a period in which they can handle the situation with relative psychological stability – particularly when they have a lot to do and need to focus their full attention on everyday life. This period without symptoms of post-traumatic stress disorder is known as the latency stage. Of course, this also applies to refugees fleeing their home. Each new day requires them to adapt to a new situation; they have little space and no energy for thinking about the past. But after some time – and this may be a very long period – old traumatic experiences take centre stage again: as memories and attempts to avoid those memories. Nervousness, sadness and difficulty concentrating or remembering things can all develop and have a negative impact on everyday life. The latency stage is over, replaced by post-traumatic stress and suffering.

The latency stage can differ vastly from individual to individual. When the survivors of the Holocaust began to reach old age, it became abundantly clear – if it hadn’t already been so – that this phase can even last for decades. Many of those who survived the Shoah as teenagers or young adults and afterwards appeared to have ‘both feet planted firmly on the ground’ went on to develop PTSD with the onset of old age. Often, a milestone such as reaching retirement or their youngest child leaving home cast them back to unresolved traumatic experiences.

‘We worked so much and in the evenings, I was always so tired I fell asleep before my head even hit the pillow,’ one client described the active life she pursued for decades after surviving a concentration camp. But with old age came many physical ailments that forced her into being less active. Scenes from her extremely difficult childhood and youth began to emerge in tandem with this new physical inactivity. She felt that these old memories – of severe human rights violations, her father’s murder, her mother’s desperation, their hunger and fear – had her … at their mercy. Symptoms such as painful memories, avoidance behaviours and jitteriness were manifesting even all those years later.

The therapeutic process was, however, completely different in cases like this compared to the process required for people whose trauma lies mere weeks or months in the past. Time and again, it required going back over a survivor’s entire life story and recognizing that despite those severely traumatic experiences, they had achieved an awful lot of good in the years that followed. Listening closely and showing interest in a person’s entire story are key factors here.

Painful Memories – Listening Helps

Memories of severely traumatic experiences can be very intrusive and have an enormous impact on daily life, despite intensive attempts to suppress them. This can take the form of painful memories. People affected describe them as being ‘like a veil drawn right across life’, or scenes from the past as ‘burned on to my retinas’.

The ambivalence involved in trying to avoid traumatic subjects but simultaneously wanting to talk about them can use a lot of energy. It is important to provide people in this situation with space and time. If their desire to talk grows stronger, it is good if someone else can be there to listen to them. Often, it is a trusted person who will be ‘chosen’ for this. For refugees, this might be trusted person with whom they feel safe enough to talk.

Initial approaches and attempts to discuss the past can sometimes still be informed by these conflicting inclinations. The client might only mention a bad experience shortly before the end of an appointment. This is a small trial run: How will the person I want to entrust with my story react? Immediate retreat is still a possibility. At this juncture, it is good to extend an invitation to talk further. Even if it isn’t possible at that very moment, the conversation could take place soon.

Listening to someone means engaging. It means that what gets voiced might be deeply upsetting. Some severely traumatized people have considerable misgivings because of this very thing: is what they themselves have experienced perhaps too great a burden for their listener even in its retelling?