ISIL („Islamic State)

• In July and August, 2014, fighters tore into Kurdish northern Iraq and committed a horrific genocide under the black banner of Islamic State. Much of it happened in the Sinjar district, about 120 miles west of Mosul, where one of the biggest communities of Yazidis (a Kurdish non-Muslim religious group) live. Islamic State fighters took more than 7000 people hostage, killing around 5000, mainly men.

• Captured women and girls have been subjected to sexual violence as an explicit Islamic State tactic, to break the dignity and the honour of the communities. Also because they believe that if they rape the Yazidi women they will make them Muslim.

Dehumanisation

Genocide (UN Report, 13 June 2016)

Special-Quota Project of the State Government of Baden-Württemberg

Aim of the Project

• The project aims to bringwomen and children whohave been held hostageby Islamic State toGermany for care on1100 specially issuedvisas.

Means, S.D. and ranges of PTSD, depression and self-esteem scores distributed according to group membership. 1 Theoretical range = 0-80, 2 Theoretical range = 0-54, 3 Theoretical range = 0-25

Yazidi child soldiers: Exposure to extreme situations experienced during the ISIS attack and captivity (N=81)

Event Ever (%) Before ISIS

attack (%)

During ISIS

attack (%)

During ISIS

captivity (%)

1. Have you been injured with a weapon? 50.5 1.8 17.6 31.1

1. Have you been raped? 4.2 0.0 0.0 4.2

1. Have you been trained with weapon? 100.00 0.0 15.9 100.00

1. Have you been victim of an attack or looting? 100.00 0.0 100.00 57.4

1. Have you seen dead or mutilated bodies? 80.9 9.2 87.1 80..9

1. Have you witnessed a person being beaten or tortured? 93.5 1.4 82.1 92.9

1. Have you witnessed a person being injured with a weapon? 86.8 1.4 95.3 84.7

1. Have you witnessed a person being killed? 46.5 3.5 42.5 40.5

1. Have you witnessed a massacre? 47.4 1.5 33.9 10.4

1. Have you witnessed the murder of your family members? 37.2 1.2 33.7 12.1

1. Did you believe that you yourself would die? 100.00 3.2 98.2 100.00

1. Did you have to hide under dead bodies? 5.2 0.0 5.2 0.0

1. Did you lose your mother? 15.3 2.8 10.3 6.5

1. Did you lose your father? 29.0 1.9 26.2 8.9

1. Did you lose any brothers or sisters? 90.0 11.2 23.8 60.9

Critical relationship between stressors and development (Perry, 1998; Siegel, 1999)

– neurodevelopment is a process of making and maintaining complex networks of neurons (linked by synapses), guided by experience and the responsiveness of caregivers

– stress responses include altered emotional, behavioral, cognitive, social, and physiologic functioning

– early development is critical but plasticity continues throughout life

• Types– secure-autonomous

– insecure-anxious/avoidant

– insecure-dismissing/resistant/ambivalent

– insecure-disorganized/disoriented

• Neuroendocrinological and EEG abnormalities in children and adolescents with insecure attachments and abuse

• Leads to adult attachment styles of relationality

• Peritraumatic reactions• Posttraumatic reactions

– immediate (may resolve, continue, or return) – delayed– Chronic

• Acute Stress Disorder

– 4 weeks’ duration or less

• “Simple” Posttraumatic Stress Disorder– immediate – delayed– chronic– often /usually comorbid (depression, anxiety, ED/SA/OCD

etc.)

Trauma Responses and Disorders

Complex PTSD• related to severe chronic abuse, usually in childhood;

participation in/victim of atrocities, war, terror– often/usually co-morbid

Dissociative Disorders

– associated with disorganized attachment and/or abuse in childhood, war, terror

– can develop in the aftermath of trauma that occurs any time in the lifespan

Individual psychotraumatherapy alone is not enough!

• In the case of Yazidi and another minority ethnic and religion groups that have been persecuted, excluded and forcibly converted for centuries and over generations in Iraq and Syria, we are facing a transgenerational trauma.

• Collective trauma like in Ruanda, Bosnia, and now in Iraq and Syria, impacts not only each individual separately, but the community as a whole.

• Crisis intervention and psychosocial services for victims of war in refugee camps or other locations are important, but for the long term not sufficient.

Transgenerational / historical Trauma

Historical trauma is most easily described as multigenerational trauma experienced by a specific cultural/religious group.

Historical trauma can be experienced by anyone living in families at one time marked by severe levels of trauma, poverty, dislocation, war, etc., and who are still suffering as a result and the trauma can passed from one generation to the next generation.

Historical trauma is cumulative and collective. The impact of this type of trauma manifests itself, emotionally and psychologically, in members of different cultural groups (Brave Heart, 2011).

(example on Yazidis: since 800 years 74 Genocide)

Conceptual Model of Transgenerational Trauma

Collective Mass Trauma Experience

Dominant Group/Terrorist and radical GroupsOppression

Trauma Response (Resilience, Protect Factors)

War, Flight, Refugee Camp etc.

Physical/Psychological Violence

Cultural and religion Dispossession (lost of tradition roles, language,

First Generation

Physical Response- Nutritional Stress- Compromised immune system- Biochemical impairment- Endocrine impairment- Adrenal maladaptation- Gene impairment/expression

Psychological Response - Posttraumatic Stress

Disorder- Other psychological Disorder

(Depression, anxiety, somatoform disorders etc.)

- Emotional changes (like anger, aggression, social isolation, embitterment, mistrust, shame etc.

Social Response - Poverty - Social Isolation as a group- Low Education- Family, tribe structure as a

only protection system- Marriage in a peegroup- Conserve traditional-

patriarchal rules as regulatory system

Secondary And Subsequent Generation Until Present Generation

Repeated Trauma Events- Violence

- Terror

- Genocide

- Displacement

- War

- Discrimination

- Hunger

- etc.

Imp

act of Tran

smissio

n Trau

ma fro

m G

eneratio

n to

the n

extG

eneratio

n (C

ollectively an

d In

divid

ually)

Current Beliefs, Behavior, Culture and Religion Role, Health etc.

Economic Destruction (loss of resources, legal rights

Why is Transgenerational Trauma Relevant?

As a collective phenomenon, those who never even experienced the traumatic stressor, such as children and descendants, can still exhibit signs and symptoms of trauma.

Manifestations of Historical Trauma

– Internalized Oppression

• As the result of historical trauma, traumatized people may begin to internalize the views of the oppressor and perpetuate a cycle of self-hatred that manifests itself in negative behaviors.

• Emotions such as anger, hatred, and aggression are self-inflicted, as well as inflicted on members of one’s own group.

Communities Impactedby Transgenerational Trauma

For example the Yazidi population has been exposed to generations of violent, religion conversion by force, genocide (74 times) flight, migration, assimilation policies, and general loss.

– Example of Stressor: The Islamization of Middle East since 637.

– Current Manifestations: Mistrust of Muslims; self-worth, victims of genocide, high prevalence of PTSD, domestic violence, pat iatrical structure, isolation as a group…

Transcultural Psychotraumatherapy

• Basically, the concept of post-traumatic stress disorder (PTSD) can be applied to all ethnic groups.

• Different notions of health and/or illness and cultural-traditional medical treatments when dealing with traumatic experiences requires different concepts or supplements

• The Yazidis are familiar with the practice of “narration”, speaking about disasters, and this can be used to good effect as a resource

„Culture of shame“

• High moral conceptions and limitations and internalised attitudes to “honour and the violation of honour” lead to considerable worry and the fear of collective exclusion.

• In a “shame culture” it is not so much the incident itself and the perpetration of a possible violation of the norms which plays a part but rather how one can save one’s face in front of the others.

• The role of the perpetrator is also regarded as a violation of the norm but in the collective it is of only secondary importance.

Integrative Transmission Trauma

Time1

Transgenerational

stress

Collective and

individual stress

Meanfull collective,

historical and

individual events

Time 2

Trauma Event

Individual

Collective

(Genocide, Massacre,

Torture, Hostage, War,

Migration, Refugee, etc.)

Time 3

Time after the

Trauma (ta) event

Psychosocial-

economic situation

Secure Environment

Health Service

P

Transgenerational

events passed through a

range of cultural and

religious narratives and

behaviours/cognitions/e

motions

Collective important

events

New integration of

self/identityExposure through

narration

Self observe position

Transgenerational Transmission

Does Transgenerational / Historical Trauma Have Only Negative Effects?

Not necessarily. There are positive aspects that arise fromhistorical trauma.

• Resilience

– The ability to become strong, healthy, or successful again after something bad happens

• Adaptive survival behaviors

– Increased Religious/Spiritual Coping

• Evolutionary Enhancements

• The strong survive

Treatment Approach: Principles

Stage measured in mastery of skills and healing tasks,

not time!

Therefore, often a problem for patient and for managed care; however, good stage 1 work often saves time in

the long run

• Therapeutic alliance as essential to treatment success but takes time to develop

– mistrust due to interpersonal victimization & posttraumatic responses

• Safety as essential, not to be ignored

– safety planning as needed: collaborative and ongoing problem-solving vs. time-limited contracting

• involves a hierarchy of interventions and actions, internal and external and the agree-upon use of supports including voluntary hospitalization, if indicated

– trauma work cannot be conducted without safety

• expect and plan for relapses

• Psychopharmacology

• Stress management

• Self-care/wellness

– Getting in touch w/ one’s body

– Exercise

– Nutrition

– Sleep

– Massage

• Medical management

• Somato-sensory therapy

• Movement therapy

Psychopharmacology of PTSD

• Expert consensus on PTSD treatment is psychotherapy and psychopharmacology– affirmed by growing knowledge re: psychobiology of trauma– to relieve symptoms and suffering

• Collaboration between therapist and prescribing provider is required– both need alliance with patient

• In general, the positive symptoms (re-experiencing, hyperarousal) often respond to medications, while negative symptoms (avoidance, numbing) respond poorly

• Medications have little or no effect on the dissociative defensive process

• Special techniques (empirically supported)– cognitive-behavioral protocols– hypnotherapy

• for ego strengthening and pacing, not for memory retrieval

– EMDR (Eye Movement Desensitization and Reprocessing)

• for resource installation and for memory processing

• Collateral work– with current family/significant others: often desirable at

different stages of the treatment process– mediation model w/ family of origin

• w/ cautions, preparation, training

• Development and connection with new sense of self• Existential crisis and spirituality• Ongoing meaning-making

– may involve a survivor mission

• Current life stage issues• Career/vocational issues, as applicable• Continued development of a support network and

restitutive relationships with others– intimacy

– sexuality

– family

– friendships

Institute for Psychotherapy and Psychotraumatology at the University Duhok /Northern Iraq

45

• The Master provides a broad understanding of theories and practices of cognitive behavioural psychotherapy (CBT) and psychotraumatology necessary for safe and effective clinical and scientific work. To enter the Master studies students require a bachelor degree in Psychology, Medicine, Sociology or Nursing.

• The official vocational regulations of the MASPP program are based on the vocational regulations of specializations in Psychological Psychotherapy in Germany (PsychTh-APrV).

• The MASPP comprises of theoretical trainings, individual and group supervision sessions, intervision, personal experience and practical work (individual treatments, clinical internships).