Current projects include:
SCALING UP WITH TRAUMATIC STRESS RELIEF (TSR)
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:
The ‘Facilitator’ trains
…‘Participants’ selected from among existing ‘Frontline personnel’
…who, once trained, serve as ‘TSR providers’
… offering traumatic stress relief to ‘Beneficiaries’ in the community – and to their own colleagues – while continuing to operate in their normal organizational roles
TSR NEWS & NOTEWORTHY
TSR training project locations are:
- Burkina Faso
- DR Congo
- Saudi Arabia
- USA (Vermont)
Existing translations of protocols and/or complete TSR curriculum:
- Bosnian – all modules
- Ukrainian – module 6 only
Types of para- and allied professionals trained:
- Faith-based Counsellors
- Junior Psychologists (not EMDR trained)
- Medical Doctors
- MHPSS service delivery personnel
- Mountain Technical Rescue personnel
- Police personnel
- Psychosocial workers/assistants
- Social Workers
- 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.
- 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.
BRIEF HISTORY OF TSR
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).
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.
USE OF GIST-T RESOURCE KIT & ONLINE TRAUMA COURSES FOR MEDICAL PERSONNEL
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’.
In the period before GIST-T’s formal constitution as a legal entity, and since then, it has been involved with several significant international NGOs in efforts to initiate projects that would promote capacity building and scaling up of trauma relief action, especially in LMICs. Thus, GIST-T engaged with the following organizations:
- Free Yezidi Foundation (FYF) in the design and start-up of its trauma care project for women and girls in Northern Iraq and helped to secure funding from UN Women and the Oak Foundation. The project successfully treated hundreds of women and girls who had been victims of ISIS’ genocidal action beginning in 2014. Some of them were subsequently employed in an all-female Yezidi brigade (Harikaras) to provide PFA in the IDP camps in Dohuk and to promote reluctant women (and men) to seek professional help. Follow-up funding has been obtained from USAID.
- Action Contre la Faim (ACF) in the design of a research project comparing the relative cost-effectiveness of CBT- and EMDR-based group interventions using its field staff in Central African Republic and Iraq as lay counsellors. The positive research findings will shortly be published.
- World Organization of the Scout Movement (WOSM), an organization with over 40 million young members serving communities worldwide, considered to get involve in PFA and the use of more advanced psychosocial methods of trauma care, and GIST-T offered several proposals. Preoccupation with other humanitarian interventions relegated the GIST-T proposals to a lower priority.
- World Bank staff suggested GIST-T field a needs assessment mission to Marawi, Mindanao, Philippines to gauge the psychological damage inflicted on the local population by ISIS-affiliated groups in 2017, and to propose a whole-systems approach to deal with the trauma in that city and province. Together with other local actors (Philippines Psychiatric Association, Nonviolence Peaceforce and EMDR Philippines) a project was designed and costed (see GIST-T final report). Unfortunately, the World Bank was unable to set aside or secure follow-up funding.
- Caring for the Carers was a GIST-T initiative aimed at providing a rapid response to Grenfell Tower Disaster Support Organizations in the form of a series of workshops in 2017. Lack of adequate coordination resulted in the offer not being taken up.
- Paraprofessional training in Sri Lanka was a GIST-T response to a request from several Tamil individuals in the diaspora to offer a workable formula to scale up trauma relief services to their war-traumatized compatriots in the North, but our proposals remained unfunded.
Original project write-ups can be found in the Archives. The first two projects have been successful and are ongoing: one a small NGO, the other a very big one. For the other projects it was mostly the lack of funding for project proposals, however promising and favourable their benefit/cost ratios, leading to them being abandoned. For GIST-T as a start-up itself, this was a steep learning curve, and even to this day, sustainable funding or income generation remains its biggest challenge, followed by ‘staff’, people available and willing to help manage or run projects, often on a pro bono basis. Which explains the list of future project opportunities, below.
Future project opportunities
Future project opportunities include:
TACKLING PHANTOM LIMB PAIN (PLP)
Promoting EMDR to Organizations Dealing with PLP
Millions of people worldwide suffer from phantom limb pain, which is a debilitating and psychologically disturbing condition. Causes of limb loss range from wounds of war (landmines, infected bullets) to medical conditions (diabetes) to torture and accidents. Conventional treatment modalities for amputees are many, including various types of pain medication as well as non-medical treatments (e.g., acupuncture, massage, biofeedback, imagery, etc.).
EMDR’s Adaptive Information Processing Model (AIP) posits that PLP is the result of unprocessed memories of the event (together with its physical sensation) that necessitated the amputation. This is a different paradigm than those underlying conventional treatments. EMDR Therapy offers an effective PLP treatment, namely one that targets and reprocesses the traumatic memories associated with limb damage. Success (defined as complete or substantial reduction of experienced pain) was on average obtained with 80% of the cases after 2 to 9 sessions.
GIST-T seeks to promote and broker arrangements that connect victims of PLP (mainly through their special interest organizations) with licensed providers of EMDR therapy (mainly through their professional associations). While the evidence cited earlier is very promising, only six case studies have been published. More field research using randomly controlled trials would provide a stronger evidence base, and for that reason, GIST-T is also interested in identifying interested researchers to connect them with organizations representing victims. Finally, GIST-T is keen to bring together EMDR trainers with organizations (of nurses, doctors, physical therapists and others) that are potentially interested in building up their own capacity in the area of PLP reduction.
RAPID TRAUMA MAPPING
Using Mobile Telephone Technology to Gauge Prevalence
Most countries have never undertaken a nationwide PTSD/trauma prevalence survey, which requires costly and time-consuming research. Lack of prevalence data is one reason why trauma remains unrecognized, undiagnosed and untreated: you cannot manage what you cannot measure.
This is where the ubiquitous mobile telephone technology may come to the rescue. If it is possible to communicate with very large numbers of people (‘social monitors’) within a country through an SMS-based programme, asking one or more specific questions, then the very large number of respondents easily com-pensates for the lower quality or accuracy of responses.
This is precisely what UNICEF has done, initially in Uganda and Kenya, and now elsewhere. Recently it sent a carefully phrased question to three million social monitors about their experience with violence against children. Those who responded ‘yes’ can again be contacted with one or more follow-up questions. UNICEF has rolled out such free and open programmes, called U-Report, in over 50 developing countries to interact with social monitors (or U-Reporters) on a whole range of issues.
Results are then tabulated and shared with the respondents, but at the same time they are shared with government offices, politicians, newspapers, and TV and radio programmes. Suddenly the voice of ‘nobody’ becomes the voice influencing national discourse—real power to the people. This method is ‘quick, cheap and ballpark’ rather than ‘very time-consuming, expensive and accurate’. It helps to raise the profile of an issue.
GIST-T seeks resources to develop, validate and apply one or more appropriate methodologies to assess the magnitude of the trauma problem in countries. This type of study lends itself well for one or more PhD students to conduct. Initial validation of methodology, using statistical analysis and scientific study, will first be undertaken in a developed country setting, with already well-established and accurate data on trauma and PTSD. The next phase will be to develop one key question (for example: “Have you seen or experienced any mental trauma in the past 3 or 6 months?”, &/or “Have you experienced chronic sleeplessness?” &/or “Do you want some help in dealing with this?”), the answer to which would be the best proxy indicator for PTSD or trauma (and then more questions, asked sequentially). This phase requires a deep understanding of the phenomenon of trauma in the cultural setting where it occurs and the language in which it is expressed. Information on available treatments would be shared, targeted at those who gave a positive response.
A breakthrough in this area of measurement of PTSD/trauma could dramatically help in getting trauma onto national and global agendas and become a driving force in demanding improved mental health services. Repeat surveys could easily be carried out over time, and more targeted in-depth surveys could then fol-low to serve as baselines.
TOWARDS AN INTERNATIONAL TRAUMA AWARENESS DAY
Focus on Trauma Suffering, Trauma Treatments and Post-Traumatic Growth
Almost every day the international community recognizes an issue of significant concern, such as AIDS, disability, poverty, cancer and autism. Many are widely known—for example World AIDS Day on 1 December. There are even days focusing on mountains, toilets and jazz. Yet, surprisingly, there is no International Trauma Awareness Day. This is all the more curious since many of the issues addressed by the existing international days are related to trauma, although that is not explicitly stated.
There may be as many as 500 million people worldwide who suffer from trauma and trauma-based diseases and disorders and yet there is no day in the year when the world stops to consider the insidious individual, and far-reaching social, consequences of stress and trauma. The closest we come to that is World Mental Health Day on 10 October.
GIST-T seeks to increase awareness about trauma and the effective treatments that are now available by setting up a campaign to declare an International Trauma Awareness Day. We will be approaching many stakeholders and liaising with key organisations, including the UN, about the mechanics and logistics of doing so. As a way of supporting those efforts, we are planning on launching a social media campaign to mobilise public support, including on-line petitions, both in the UK and in other countries. We also plan to use our social media profile to disseminate information about the latest developments relating to the causes, symptoms and, crucially, the effective treatments of trauma, as well as to inform the public about how best to help people in the aftermath of an overwhelming event so as to minimize their chances of becoming traumatized. Our aim is that the social media framework supporting International Trauma Aware-ness Day will become a portal for public information about all aspects of trauma.
We believe our message is ultimately very positive. Trauma can be healed. Moreover, we also want to highlight—indeed celebrate—the fact that treatment of trauma can lead to significant personal, and even spiritual, growth. To this end, we hope to produce and publish a companion publication coinciding with the declaration of the International Trauma Awareness Day based on interviews with inspirational people who have managed to overcome trauma in ways that have restored their health and enabled them to live more fully and to connect more deeply with others. This is an important part of our campaign because, although we wish to highlight the devastating effects of unresolved trauma, we also want the message to be hopeful, which we very much believe it to be.
Over the next year we foresee a period of intensive lobbying of governments and UN delegates in favor of a UN resolution creating an International Trauma Awareness Day, perhaps as early as 20 September 2018. This date is significant as it precedes the International Day of Peace on 21 September. By choosing this date, we also wish to highlight the fact that trauma is the root cause of much of the violence and abusive behaviour in the world and therefore treatment of trauma should become an integral part of conflict resolution, civilian protection and peace building efforts. Ultimately, the message we wish to communicate through this campaign is that healing trauma is essential, not only because the health, wellbeing and future of our species depends upon it, but also because it provides us one of the best opportunities to realise our great potential as human beings.
INCORPORATING TRAUMA EXPERTISE IN RAPID RESPONSE ACTION
Strengthening the UN’s Standby Capacity
The Protection Standby Capacity Project (ProCap)—an inter-agency initiative created in 2005 in collaboration with the Norwegian Refugee Council (NRC)—seeks to build capacity of relevant actors to enhance the humanitarian protection response. Protection Capacity Advisers support the strategic and operational humanitarian protection response for IDPs and other vulnerable populations.
ProCap deploys senior personnel with proven protection expertise to field, regional and global operations and trains mid-level protection staff from Standby Partners and UN Agencies. ProCap Advisers are an inter-agency resource deployed to the Humanitarian Coordinator, UN agencies, and integrated missions. ProCap Advisers work in humanitarian emergencies caused either by disaster or conflict, in the immediate aftermath or at a later stage, and to protracted or neglected crises. ProCap can also respond in transitional contexts.
GIST-T seeks to identify experienced EMDR therapists with a public health background and expertise in rapid needs assessments, and to nominate them for addition to PROCAP’s standing roster of experts.
EXECUTIVE DIRECTOR A.I
c/o Rolf C. Carriere
Van Ommerenpark 164
2243 EW WASSENAAR
GLOBAL INITIATIVE FOR STRESS AND TRAUMA TREATMENT - GREATER GENEVA