The TSR programme consists of a series of pilot projects conducted in more than 10 countries. Evaluative research is key in this pilot phase for purposes of local validation and project adjustment.

TSR has been designed to create a pool of available organized personnel to serve as frontline para-and allied professionals confident and able to relieve traumatic stress in others, going beyond offering Psychological First Aid (PFA), thus becoming an integral part of an expanded mental health referral system. Task-shifting in health is part of a worldwide phenomenon over the past 50 years of sharing simpler functions with para- and allied professionals while reserving more complex technical tasks and leadership roles to professionals, thus increasing workforces and optimizing available skills to deal with the increasing workload (e.g., paralegals, paraeducators, paramedics, paramilitary, parapolice).

While the focus is on the delivery of TSR to unreached traumatized populations, the knowledge and skills provided will also enable those trained to care for themselves and to support their colleagues in highly stressful and humanitarian situations.

The TSR curriculum introduces selected techniques and approaches in a simplified and protocolized form for the purpose of delegating certain routine activities to carefully prepared para- and allied professionals. This is also known as task-shifting to para- and allied professionals.  The techniques and approaches are selected for their effectiveness, safety, and efficiency. They have been empirically validated and are widely used by professional therapists. The TSR curriculum is informed by the Adaptive Information Processing (PDF version) model; the principles of early intervention protocolised interventions; and the latest insights from adult learning pedagogy (experiential learning, hands-on methods, learning through reflection and doing).

The training is conceived in two parts, to be delivered over a minimum of four days. Part I includes a necessary minimum of psychoeducation (theory) while prioritizing exercises for stabilization and working in communities. Part II prepares frontline workers to deliver two simplified group protocols.

The curriculum also defines pre-requisites for organizing such TSR training. These include selection criteria for trainees; professional support being ‘on-call’; and systems in place for referrals, supportive supervision, and evaluative research. Safety is a paramount consideration.

Proposed pathways to scaling up Traumatic Stress Relief

The need now is to accelerate rolling-out the TSR trainings and field applications, and to carefully monitor processes and evaluate outcomes.

• Using an already-identified core team of international academic and clinical experts to oversee training, implementation, supervision, monitoring and evaluation (GIST-T team)
• The GIST-T team will broaden the existing network of EMDR therapists to act as specialist support supervisors and to receive professional referrals by training them in the two TSR protocols.
• Given its pilot nature a strong evaluative research component is essential.
• The GIST-T team will train an initial cohort of allied professionals as TSR Providers (selected from individuals who are working in direct contact with the population in a recognized organizational structure that supports and supervises their work
• TSR Providers will initially be allied health professionals, specifically mental health clinically licensed professionals, not trained in EMDR, but working in NGOs and alongside other organizations.
• These TSR providers will administer the TSR group protocols to Beneficiaries as a kind of Psychological Second Aid.
• The GIST-T team will train a select number of the above allied health TSR Providers as TSR Facilitators (Trainers) who will in the future train and supervise TSR Providers selected from a range of frontline personnel (MH professionals, para and allied professionals).

In other words:

TSR training project locations are:

• Afghanistan
• Angola
• Bosnia
• Brazil
• Burkina Faso
• DR Congo
• Iraq
• Jordan
• Rwanda
• Saudi Arabia
• Uganda
• USA (Vermont)

Existing translations of protocols and/or complete TSR curriculum:

• Arabic
• Bosnian – all modules
• Brazilian
• French
• Kinyarwanda
• Kurmanji
• Pashto
• Swahili
• Ukrainian – module 6 only

Types of para- and allied professionals trained:

• Counsellors
• Faith-based Counsellors
• Junior Psychologists (not EMDR trained)
• Medical Doctors
• Midwives
• MHPSS service delivery personnel
• Mountain Technical Rescue personnel
• Nurses
• Police personnel
• Psychosocial workers/assistants
• Social Workers
• Teachers
• Yezidi Women (Harikara)

TSR – Programme Evaluation:

A recent publication by Pupat et al., (2022) evaluated TSR training sessions for both para- and allied professionals and mental health professionals from DRC, Rwanda, Uganda and Burkina Faso.

They found:

• That TSR programme acceptability and feasibility were good.
• The tools and the training are sensitive to the culture and can be adapted when needed.
• The trainees understanding of traumatic stress, of when to intervene or when to refer, how and when to conduct grounding or stabilizing practises, how to communicate with traumatized individuals, was found helpful and useful.

A follow-up impact study by Pupat et al., is in progress:

• Preliminarily results suggest that there is a significant reduction of traumatic stress levels and increase of resilience after 1 to 3 sessions of TSR conducted by para- and allied professionals.

A Summary of TSR programme evaluation findings of several ongoing projects:

• Increase in knowledge was found in all data gathered based on entry and exit questionnaire data.
• Self-efficacy was increased after TSR training.
• Traumatic Stress levels decreased after training.
• Traumatic Stress levels were found high in all project reports, with significant risk of clinical PTSD pre-training in some individuals.
• Many of the projects experienced some cultural challenges to implement TSR training materials.
• Overall, the TSR training package were found feasible and acceptable.

Recommendations for future research proposed for TSR:

• Group protocols and evaluation tools need to be culturally adapted and translated to answer to the needs of largely illiterate populations, from different cultural backgrounds.
• Incorporating body movement techniques, less pen and paper and integrating treatments existing in the communities to address trauma.
• New exercises which comply with the AIP model (PDF version) and are culturally acceptable could be designed to improve the acceptability and wider use of TSR.
• To add the use of biometrics in efficacy research, e.g. heart rate variability as a biomarker of stress.

New Initiatives for TSR

• COVID19 Pandemic has resulted in TSR moving online in the form of a self-help intervention. This supports frontline workers remotely
• An official, first of its kind TSR Training of Trainers is planned for March 2023 in Paris with 40 participants recruited through several institutions.

Following the issuance of an EI White Paper and the EI Boston Conference call in early 2018 for the design of an appropriate curriculum, GIST-T convened a workshop in December 2018 at which 25 participants from 13 countries contributed their expertise. Building on Psychological First Aid (PFA) the purpose was to design an innovative four-day curriculum to train frontline, non-therapist personnel to provide Traumatic Stress Relief (TSR) following natural disasters and violent conflicts in low- and middle-income countries (LMICs).

Experts participating in Dec 2018

After further consultation and elaboration, the training materials were tested with a few volunteers in June 2019. A refined package of Facilitators’ Notes, Power Point slides and Participants’ Guide was then prepared, and a first Training of Trainers (ToT) was held in August/September 2019. This ToT brought together experienced professional psychotherapist trainers from Brazil, Cambodia, Canada, France, India, Iraq, Netherlands, Saudi Arabia, Spain, Turkey, Uganda, UK and USA for a seven-day learning programme. Almost all had first-hand experience in crisis situations, and some were already experienced trainers. Several of them are now piloting the use of the TSR materials with organized frontline, para- and allied professionals in emergency and disaster situations. Rigorous evaluation and research are an integral part of the projects.

Despite the enormous worldwide prevalence of trauma and trauma-based diseases and disorders, it remains largely hidden—unrecognized, undiagnosed and untreated—especially in the developing world. Many traumatized people initially seek out medical care for physical ailments (for example, chronic pain or addiction) that may actually be rooted in earlier psychological trauma (Adverse Childhood Experience or ACE). For this reason, physicians and other medical personnel are in a unique position to help recognize, diagnose, intervene, and support those who have experienced psychological trauma. But they need the necessary knowledge and skills to do so.

Medical personnel all over the world are organized through professional associations, many of which run courses aimed at updating knowledge and skills. However, as far as GIST-T knows, none focus on trauma detection, or specifically on non-pharmacological approaches to treatment, or the two WHO-approved, evidence-based trauma therapies.

Using the GIST-T Resource Kit and TSR curriculum, GIST-T plans to promote a series of online webinars and courses, aimed at doctors, nurses and other medical personnel, on the assessment, diagnosis and treatment of acute and chronic trauma symptoms. Also included in these courses will be simple self-care techniques for traumatized patients, and how to implement early intervention protocols, and where to refer patients for further trauma care. Training medical personnel to recognize the signs and symptoms of trauma, and to intervene appropriately, can ultimately result in hundreds of thousands of patients worldwide getting the care they need and deserve.

Additional online training projects are currently being explored for several other groups including nursing staff (non-mental health focussed primary and secondary care institutions and outpatient facilities), students at the applied sciences institutes in the Netherlands (social work, nursing, education, paramedics) and medical professionals from LMICs.

One of GIST-T’s stated goals, formulated in 2016, is to ‘Engage with humanitarian and protection agencies, dealing with violent conflicts and natural disasters, to better understand whether and how trauma is dealt with among their personnel and the vulnerable communities they serve.’

The Listening Exercise was proposed as a means to open informed dialogue and initiate relationships with organizations that might become users of products created from the Confronting Stress and Trauma Resource Kit. Conducting the Listening Exercise would also deepen GIST-T’s understanding of what individuals and organizations have found to be both effective and challenging in regard to the prevention, monitoring and treatment of stress, burnout and trauma.

The first step in achieving this goal was foreseen as a two-pronged approach: (i) to enquire about staff’s current level of trauma, burnout and stress symptoms through a written questionnaire, and then (ii) through interviews, to listen to staff recounting their experiences in regard to stress and trauma, within their respective agencies.

The Listening Exercise does not claim to offer statistically representative information but aims to get a ‘feel’ for the range of stress and trauma experiences and responses, and the organizations’ perception of the adequacy of their policies and practices.

GIST-T advocates for all organizations to allocate adequate resources to fulfil their ‘duty of care’.