Mental Health Training and Debriefing for Field Workers - 4 Hour Course Content

Timeframe of the course

TOPIC ONE: Trauma and Re-trauma
20 minute lecture to all 80 fieldworkers by main teacher
Small group sessions45 minutes, led by social worker (or main teacher) for groups of 14 field workers
per group.
~ 15 minute break ~

TOPIC TWO: Identifying Persons Needing Mental Health Referral

20 minute lecture to all fieldworkers by main teacher.
Small group sessions45 minutes, led by social worker (or main teacher) for groups of 14.

~ 15 minute break ~

TOPIC THREE: Self-care for Fieldworkers

20 minute lecture to all field workers by main teacher.
Small group sessions45 minutes, led by social worker (or main teacher) for groups of 14.

~ 15 minute break ~

Author: Samah Jabr MD, Palestine Medical Director, Palestinian Medical Education Initiative; Clinical
Associate Professor of Psychiatry, George Washington University School of Medicine and Health
Sciences; Faculty, Birzeit University
Co-authors:
Saara Amri LPC, Bilingual Therapist, Program Co-Coordinator for the Program for Survivors of Torture and Severe Trauma,
Northern Virginia Family Service
Elizabeth Berger MD MPhil, US Medical Director, Palestinian Medical Education Initiative; Clinical Associate Professor of
Psychiatry, George Washington University School of Medicine and Health Sciences
Allen Dyer MD, PhD Professor of Psychiatry and Behavioral Sciences, Division of Global Mental Health, George Washington
University School of Medicine and Health Sciences
Wasseem El-Sarraj, UK Program Director, Palestinian Medical Education Initiative
Michael Morse MD MPA; Executive Director, Palestinian Medical Education Initiative; Resident Psychiatrist, Division of Global
Mental Health, George Washington University School of Medicine and Health Sciences

First Lecture: Trauma and Re-trauma

At the beginning, we must acknowledge that human rights field workers are not trained mental health
professionals and cannot be expected to function as if they were mental health professionals. We are
therefore not aiming today for a mastery of technical diagnosis of mental disorders but for something
more general. We wish to start here with the ordinary concepts of grief and psychological traumaas
these concepts are recognized the world over by almost everyone. At some point these normal human
responses to tragedy and injury become themselves needs of greater or lesser intensity; it is our hope
to discuss these human responses as needs, and to attempt to fill these needs in Gaza at this time as
best we can.
Fieldworkers will be interviewing persons who have suffered from physical injuries and losses: war,
bodily trauma, death of others and injury of others in their families or communities, loss of their homes
and loss of other things of value to them. These physical events are also psychological or emotional
injuries and losses because severe physical injuries and losses bring psychological/emotional suffering
with them. Not all physical harm causes emotional harmfor example, athletes may be proud of their
physical injuries or mothers proud of the pain of their childbirth experiences. But often physical injury or
the threat of physical injury, or witnessing such injury, overwhelms the persons psychological balance.
It is the fact that ordinary mental coping mechanisms are being overwhelmed that leads to
psychological trauma.
The emotional effects of sudden life-threatening accidental events such as automobile collisions can
lead to ongoing psychological damage. But we find that psychological injury of this kind is especially
strong when the injury is purposefully and maliciously inflicted not by chance but by other human
beings. These purposefully inflicted physical harms cause great emotional pain, anger, and humiliation.
In this context we speak of physical and emotional abuse and the resulting psychological trauma. The
emotional status of the people of Gaza at this time in addition is also deeply affected by the experience
of grief, both individually in many cases and collectively.
Field workers will be interviewing persons who have recently experienced or witnessed human rights
abuses and atrocities. Human rights abuses are inherently emotionally traumatic and we find that
victims of human rights abuses can often present the most profound kind of psychological damage of all.
The field workers job, therefore, is to pay attention to two subjects at the same time: one subject is the
factual history that the interviewee will communicate; the other subject is the emotional damage which
may be indirectly communicated. This makes the field workers job very challenging. It is likely that due
to their victimization either directly or as witnesses, these persons have experienced great fear,
helplessness, and horror. These emotions set the stage for characteristic disturbances of thinking and
emotion among trauma victims.
During the abuse, the functioning of victims mind and emotions may be altered dramatically from their
ordinary way of thinking and feeling. The victim of abuse may feel that time is altered, or that things
seem unreal, or that the person is somehow leaving his or her body, or looking at events from a great
distance.

After the abuse, the victim may experience immediate or delayed problems that are characteristic of
responses to emotional trauma: numbness, detachment, the sense of being dazed or in a fog. The victim
may report a feeling that he or she does not feel real, or that reality itself does not feel real. There are
often problems with memory and forgetting key parts of the history. The victim may have problems
remembering simple things related to everyday life as well as
The victim may also suffer from re-experiencing the trauma as if it were happening in the present: he or
she may see the events themselves or have the illusion that the events are still happening in the
corner of their eye. They may have sudden intrusive memories or flashbacks or feel they are reliving
the experience.
The victim may experience a need to avoid reminders of the abuse such as sights, sounds, or smells.
A sense of fear, anxiety, dread, distress, worry and nervousness is the hallmark of emotional disturbance
following psychological trauma. There are typically also problems with sleeping, eating, and functioning
generally and often bodily complaints such as headache, pains, shaking, and distressing physical
sensations.
These, then are the features of psychological trauma.
In a setting such as the current one in Gaza, one might observe that the entire community is
experiencing a kind of post-traumatic stress response. The reminders of the assault are everywhere and
unavoidable; the pervasive and desperate physical destruction and unmet needs cannot help but induce
a degree of psychological trauma in the community at large.
Psychological trauma becomes an important aspect of the interview itself for two key reasons: the first
reason is that the interview risks making the victim remember painful events and can thus be a source of
re-traumatization. The second reason is that the victims problems with memory and with anxiety can
make it difficult for the interview to proceed in a logical, concise, orderly, and efficient fashion. The very
abuse that the victim has suffered from gets in the way of quickly obtaining the facts about the abuse.
Principles of interviewing the trauma-victim thus are:
1. Set the framework carefully. Be patient and polite, making the interviewee as comfortable as
possible. Explain your name, your title, your role, and particularlyexplain that you are here to
help the people of Gaza to have their story told to the world so that there will be more
recognition of the truth and more justice. Explain that you want to do whatever you can do to
help them tell their story, if they are able to do it. State that the interview is a safe situation.
Acknowledge that you are asking them to do something very difficult in giving their narrative of
events and that you understand this. Indicate that the person can tell you whenever they wish
to take a break, or whenever they wish to stop. Explain that they are in charge of the interview
and that you do not want to pressure them into something that they cannot do or do not wish
to do.
2. Do not rush. Have water, food, etc. available.
3. Express ordinary human compassion when appropriate.
4. Be sensitive to the importance of avoiding any criticism of the interviewee or suggestion that he
or she might have done something differently.
5. Do not put pressure on the interviewee if you sense that a certain subject is too difficult. You
may be more successful by postponing the subject and returning to it later. Do not insist on

making the form of the interview correspond to the unfolding historical events in chronological
order.
6. Many trauma victims feel as though they cannot think clearly or as though they are losing their
minds. We will talk in the next lecture about deciding which interviewees may need referral to
mental health professionals for further evaluation and treatment. For most interviewees who do
not need such referral, it is often helpful to normalize their symptoms. Explain that it is normal
and natural for people who have been through trauma and grief to feel as if they cannot think
clearly and that they cannot bear their emotions, and that these reactions will become easier
with time. Indicate that some people may need additional services and that these are available.
7. Evaluate for family and community supports and be alert to isolated individuals who may need
more support. Enlist relatives, friends, and othersask who may have come with the victim to
the interview.
8. Be aware that the interview and perhaps the person being interviewed may be difficult to
tolerate. Trauma victims not too infrequently re-experience the trauma in the interview by
feeling suspicious of the person conducting the interview. The person you are trying to help may
appear uncooperative, angry, withholding, evasive, or oppositional. Even if the person seems to
be trying his or her best, the narrative may seem confused, confusing, meaningless, or
fragmented. It is good to remember that the fragmented and destroyed qualities of the
interview may reflect the injuries that the person has undergone. Be aware of how the interview
makes you feelthis is often an indirect clue to valuable information that the person may not
be able to communicate in any other way.
*

Break-Out session: Have small-group leaders ask group to review an outline the main points of Lecture
One:
1. Emotional trauma is the consequence of helplessness, fear, and horror in response to danger and
threat.
2. Trauma induces characteristic disturbances of feeling, memory, mood, re-experiencing, avoidance,
anxiety, and sleep.
3. Field workers can structure the interview to avoid re-traumatizing the interviewee through various
techniques.
Have the group members form pairs and interview one another for 5 minutes with the interview
focused on traumatic events. Then have them form different pairs for another 5 minutes. Have the
group of 14 then meet together to discuss their observations as interviewer and as interviewee.
____________________________________________________________________________________

Second Lecture: Identifying Persons Needing Mental Health Referral

The most urgent category of persons needing referral for mental health services are those who appear
in immediate danger of hurting themselves or hurting someone else. The interview may give the
interviewer hints that the person may be considering deciding upon such acts or is experiencing
impulses to commit them; if this is the case, it is important to tactfully inquire explicitly whether there
might be a danger of this kind. One might ask, Sometimes a person is so terribly upset that it seems
that death might be better. I am wondering whether this thought has occurred to you. If the person
indicates that this thought has occurred to him or her, the interviewer can explore whether he or she
has thought of how this might happen, or whether actual plans have been made or attempts have taken
place. If the person indicates that he or she might make such an attempt soon or unpredictably, family
members might be invited into the interview. Gaining the cooperation of the interviewee is important.
In extreme cases, it may be impossible to respect the interviewees privacy and family members must
be involved without the interviewees consent in order to prevent immediate harm or even death (this
can present a difficult situation and the field worker may call upon a supervisor if available).
Another category of persons urgently needing referral for mental health services are those who are
over-excited, agitated, combative, entirely mute, confused, or seem to have serious problems thinking
clearly; some may report that they are hearing voices speaking to them or complain of seeing things
that arent there. The interviewee may misinterpret the meaning of the interview in a suspicious way or
appear to be speaking or gesturing to someone who isnt present. Strange ideas such as my body is
poisoned or a machine is reading my thoughts can suggest that the interviewee is suffering from
unrealistic ideas. Getting background information from family members is often crucial, since some
individuals may have longstanding problems of this kind. Even if these problems are not new, the
person may need referral for mental health services if the problems are worsened in the current crisis in
Gaza. Persons in this category may inadvertently walk into traffic or otherwise create a dangerous
situation; they may fail to eat and sleep and otherwise neglect basic needs.
Children and adolescents are especially vulnerable because they require from adults a sense of security
and protection from danger. The catastrophe in Gaza has threatened the ordinary faith that children
have in their parents and families that they can be kept safe. Children and adolescents who have
experienced previous losses, disruptions, injuries, and separations are particularly at risk. Children who
demonstrate agitation, assaultiveness, screaming, or withdrawal, running away, or self-injury should be
referred for mental health services. Nightmares and sleep disturbance are commonplace among
children exposed to war conditions. Individual assessment may depend upon an evaluation of family
and social supports.
The extreme conditions at present make it impossible to refer each individual who, in more ordinary
circumstances, could benefit from mental health services. Some triage functions should be in place so
that the most severe and needy cases are seen first. Group modalities with visiting therapists making
interventions in schools, mosques, community centers, similar settings may be especially helpful in this
setting.
*

Break-Out session: Have small-group leaders ask group to review an outline the main points of Lecture
Two, the need to refer for mental health services:
1. Persons who present risk of danger to themselves or to others.
2. Persons who present disturbances of thinking or behavior
3. Children and adolescents, who are especially vulnerable.
Have the group members form pairs and interview one another for 5 minutes with the interview
focused on psychological symptoms. Then have them form different pairs for another 5 minutes. Have
the group of 14 then meet together to discuss their observations as interviewer and as interviewee.

Third Lecture: Self-Care for Field Workers

It has been recognized in many contexts that professional persons who obtain documentation from
victims of abuse and atrocities are themselves vulnerable to what has been called vicarious
traumatization. Psychotherapists who work with patients who have been tortured or who have been
victimized in extreme ways can develop themselves psychological syndromes that reflect the impact of
their patients abuse on third-parties. Trouble sleeping, obsessing about the patient, loss of interest in
other subjects, anxiety, and depression are some typical complaints.
The field workers who are documenting human rights abuses are doubly challenged in Gaza because the
total environment here is saturated with trauma, injury, and fear. The staff members who come here
share many of the outright dangers and deprivations of the citizens of Gaza, as they share the water, the
roadways, and the face of human misery that is everywhere unmistakable and unavoidable. People with
a strong sense of outrage about injustice are likely to participate as field workers. So the field workers,
like everyone in Gaza, are already bearing a burden of shared community injury before the interviews
begin. To manage this burden, we begin by acknowledging it. A burden is lightened by giving it a name.
The second burden is the pain that the individual interviewee brings to the interview. This cannot be
overestimated. The pain experienced by the victim may be communicated to the interviewer in indirect
ways. Sometimes the victim is suspicious, or even hostile, or passive-aggressive and difficult to
understand. Sometimes the victim seems to be inducing in the interviewer a state of mind as if the
interviewer were actually injuring the person, leading to feelings of frustration, anger, or impatience.
Sometimes the interviewer feels a deep sense of identification with the victimwhat mental health
people call over-identification or over-involvement. The victim may have shared with the
interviewer details that no one else knows, leading to a deep sense of intimacy. Paradoxically, there is
sometimes a sense on the part of the interviewer that he or she might drown or be swallowed up by the
victims narrative; to protect himself or herself from being engulfed by these sensations, the interviewer
may feel overly-detached from the victim or insufficiently involved. It is difficult at times to maintain a
proper distance, to be neither over-involved nor under-involved.
Some principles of self-care are:
1. Be as self-reflective and self-aware as possible. Try to name and understand ones own feelings
rather than brushing them aside, or ignoring them, or dismissing them as weak or foolish.
2. Take breaks. Stretch, drink a beverage, take a walk.
3. Find a co-worker for informal dialogue, especially for difficult situations.
4. Make use of group supervision, colleagues, and leaders for professional morale and moral
support.
5. Keep in touch with outside family, friends, and community.
6. Know your limits. Not everyone can work with every interview.

Basic CBT-like relaxation techniques

*

Break-Out session: Have small-group leaders ask group to review an outline the main points of Lecture
Three, self-care issues:
1. Field workers are vulnerable to vicarious trauma
2. Some principles of self-care: self-awareness, support from colleagues, reaching out to family and
friends.
3. Basic CBT relaxation technique
Have the group members form pairs and interview one another for 5 minutes with the interview
focused on self-care for field workers. Then have them form different pairs for another 5 minutes. Have
the group of 14 then meet together to discuss their observations as interviewer and as interviewee.