Draft Guidelines for International Trauma Training
Taskforce on International Trauma Training
International Society for Traumatic Stress Studies
the Final Published Guidelines (PDF Format - 127 KB)
The ISTSS created a Task Force on International Trauma Training in
November 1999 to address an important activity of trauma mental health
International trauma training refers to the training initiatives by
professionals with expertise in trauma mental health who travel from one
country to another in the effort to teach and train local persons to
respond better to trauma-related problems.
The overall goal of the Task Force is to advance international trauma
training as it is currently being practiced. In an effort to work
towards this goal, the Task Force began to draft Guidelines on
International Trauma Training during its meeting of July 27 to July 30,
2000, in Chicago, U.S.A.
This version of the guidelines address four specific
- The values underlying international trauma
- Contextual challenges in post-conflict
- Core curricular elements
- Monitoring and evaluation of training.
These guidelines are intended especially for professionals who are
engaged in international trauma training, such as: trainers; recipients;
designers; sponsors; funders; monitors; and evaluators.
The attached first public draft of the guidelines aims to open a
dialogue on this text with the ISTSS membership and Board, as well as
with individuals and organizations external to the ISTSS. The Task Force
believes that holding an ongoing dialogue is inherent to the pursuit of
its central concerns, and to international trauma work in general.
The task force invites your comments, criticisms, suggestions and
queries. Please submit in writing to:
Task Force on International Trauma Training
c/o Stevan M. Weine M.D.
Health Research and Policy Centers
850 W. Jackson St.
Chicago, Illinois, 60607
Stevan Weine M.D. (Chair)
Yael Danieli Ph.D. (co-Chair)
John Fairbank Ph.D.
Joop de Jong Ph.D.
Jack Saul Ph.D.
Arik Shalev M.D.
Derrick Silove M.D.
Mark Van Ornmeren Ph.D
Robert Ursano M.D.
A. The Values Underlying
International Trauma Training
The task force believes that international trauma training should be
based on a central set of values and that this set of values should be
made explicit. The literature on international trauma work demonstrates
neither a comprehensive nor a serious attempt to directly articulate the
values that should underlie international trauma training.
Engaging with these values is meant to actively enhance the
capacities of trauma mental health professionals to meet their ethical
obligations as professionals involved in training in situations of
These values should inform all aspects of the professionals' work,
from conceptualization through design, implementation, monitoring,
evaluation and reporting.
1. Values tie professionals to humanity and to
professions. These values are:
- Respecting the concerns, needs, resources and strengths of persons,
their families and communities.
- Grounding in established scientific and clinical knowledge of trauma
mental health and other related professional knowledge.
2. Values guide professionals in responding to the
dilemmas that arise from competing or conflicting obligations. These
- Recognizing the legitimacy of multiple perspectives on trauma and
- Promoting an open dialogue among differing voices on trauma and
- Integrating different perspectives and positions on trauma in the
quest for what is helpful.
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B. Contextual Challenges in
The Task Force believes that a thorough, integrative understanding of
multiple elements and dimensions of the context is needed to inform the
design and implementation of trauma training. This is especially true
when international trauma training occurs in postconflict societies or
in other societies in transition.
Understanding the context requires an analysis of the complex
interplay of multiple spheres or systems and their evolution over time.
The processes of analysis are dependent upon the recognition that each
dimension may be a subject of one or more disciplines, which may overlap
and interact, such as anthropology, economics, international development
studies, law, philosophy, political science, psychiatry, psychology,
religious studies and sociology.
Certain fundamental questions always need to be addressed: To whom is
the training directed? For what purposes? Who will be ultimate
beneficiaries? Who will train?
Below is a further articulation of contextual challenges that are
likely to arise, and suggested responses.
1. International trauma training initiatives must
address cultural dimensions.
- Training programs need to be culturally sensitive
and appropriate. A deep appreciation of the culture, its historical
roots, and the way it has shaped indigenous concepts of mental health
and healing requires an ongoing commitment to learning.
If the training team is not familiar with the culture, cultural
awareness raising programs prior to personnel entering post-conflict
societies may be helpful. The process of learning about culture should
evolve throughout the contact with the indigenous society.
- Trainers need to be aware that international trauma
training is itself an element of the process of rapid cultural change in
War and its aftermath ruptures structures. Many of the "culture bearers"
such as traditional healers may have fled or been killed in the period
of upheaval. The arrival of international agencies and their personnel
has the potential of creating irreversible cultural change.
Access to international sources of information can occur rapidly with
the introduction of computers and the Internet. A delicate balance needs
to be achieved in which training teams both endorse and promote a
genuine and deep interest in indigenous ways of approaching human
suffering while, at the same time, recognize that local professionals
will be exposed to international trends in trauma treatment methods.
Ultimately, local professionals will make their own choices in
developing an integrated model of healing that best suits the needs of
their evolving society.
2. International trauma training initiatives must
identify ways to appropriately enter complex environment under insecure
- Training programs in post-conflict societies take
place within a complex social and political context in which multiple
sectors and stakeholders seek a voice in shaping the reconstruction
The United Nations and its agencies, local political groupings,
international and local NGOs, peacekeepers, armed liberation movements,
previously warring factions, religious groups, and traditional
structures of justice and civil government may all be involved in
At the same time, the potential for tension, friction and even overt
conflict m ay continue for some time after a ceasefire. In such a
context, locating the sources of power, decision making, priority
setting and planning may be difficult because authority may shift
sequentially from one leadership structure to another.
Legitimacy and consent are likely to be of concern, since it may be
difficult to establish which sector is responsible for endorsing mental
health initiatives in general and trauma training in particular.
- Essential components to ensuring that the broader
needs of all subgroups are considered, are engagement, consultation and
ongoing feedback in partnership with all interested sectors and their
Offering training without properly understanding the ongoing political
process risks accusations of uninvited intrusion. On the other hand,
strong affiliations with a particular faction may lead to the accusation
Complete neutrality generally is unrealistic, since most outside
helpers tend to be motivated by their identification with the larger
aspirations of the society as a whole. Finding the middle ground between
identification and dispassion should be an explicit goal.
The process of engagement, consultation and ongoing mutual feedback
in partnership with all interested sectors and stakeholders is an
essential component to ensure that the broader needs of all subgroups
- Training is more likely to succeed if it is
integrated with general development efforts.
In many low-income countries, general mental health services have never
existed or have been destroyed during the conflict. Hence, the service
setting in which trainees will implement their newly acquired skills
needs to be considered carefully.
Newly acquired knowledge will be lost or diminished if a coherent
framework for practicing such skills is lacking. Further, the sense of
urgency and paucity of resources in the immediate post-conflict phase
may encourage incoming experts to take "short cuts" such as offering
very brief training courses to personnel who have no prior experience in
The potential risks of undertaking such interventions need to be
- Preparing personnel practically and psychologically
for conditions in the field and for taking active responsibility in
managing risk once they are deployed is critical.
Personnel who enter post-conflict societies inevitably are at risk of
physical injury and illness and emotional stress. Self-care activities
(physical and emotional) should be an intrinsic strategy supported by
the training agency.
Infrastructure support (adequate shelter, food, water, transport, means
of communication) can be problematic in the early phases because of
logistical and financial constraints.
Personnel need to be prepared to undertake multiple tasks, many of them
novel, to establish an optimal infrastructure that ensures their own
safety prior to concentrating on the task of training per se.
3. International trauma training must train persons
to help recipients who are facing short and long-term hardships.
- a. Trauma trainers need to be aware that providing brief training to
unsupervised persons who themselves have been subjected to severe
stressors may result in poor practices and demoralization of
The risk is greater when the trainers fly in and out for brief visits.
Training should develop the capacities of local leaders, experts and
managers, and local organizations, to provide ongoing support and
If computers and Internet hookup are made available to trainees, then
new communications technologies offer some possibilities for ongoing
supportive dialogue with trainers in other countries.
- When training personnel, their future roles in an
emerging service structure need to be considered.
If training occurs outside the mainstream planning processes, trainees
may find that their personal and professional aspirations are ultimately
thwarted since their credentials (for example, as a "trauma counselor")
may not meet the professional designations (nurse, physician, social
worker, psychologist, etc.) adopted by the public service.
Training needs to support persons' role within the emerging system of
- As potential future players and even leaders in the
field, trainees need to be drawn into a partnership with trauma trainers
in which all threats to and opportunities in the program are considered
in a transparent way.
Sustainability of the program may be difficult given the uncertainties
of funding. By discussing the broader context that influences the
program and vice versa, the training team assists trainees in developing
skills relevant to leadership, advocacy, accountability, management,
planning, problem solving and team building.
As leadership and initiative is developed in trainees, responsibility
for the sustainability of the program (such as the task of approaching
donors) can be shared, and the risk of dependency and unrealistic
expectations may be minimized.
4. International trauma training initiatives must
design curricula that fit best the realities of the local
- Although genuine debate about the emphasis of
training is important to generating new ideas and a wider synthesis of
all contributing disciplines, it needs to take place in a context of
respect, professionalism and constructive cooperation among
Even though commitment to the area of trauma mental health is growing,
mental health funding represents only a small percentage of the overall
donor contributions to relief and development aid in post-conflict
Competition for project funding amongst United Nations Agencies, NGOs,
torture and trauma services, university-based centers and other
groupings is intense and can lead to excessive rivalry.
Theoretical polarizations in the field (mental health vs. trauma
training vs. psychosocial programs) are often inappropriately
exaggerated to promote the claims of legitimacy of particular training
groups or disciplines. Such exaggerations need to be avoided.
- Depending on the context, international trauma
training is to be tailored to health care professionals and/or health
related paraprofessionals or to other professionals.
Training should be directed toward the persons who are available to
engage in service delivery. Because most low-income countries have few
mental health professionals, services in trauma programs are generally
provided by health care professionals or paraprofessionals.
The training of personnel in the justice system, the police, and
peacekeepers offers another important path for providing services to
- The actual curriculum of the trauma training needs
to fit the trauma program's design, which should be based on public
mental health programming needs assessment.
Decisions need to be made regarding: (a) which types of problems are
prevalent, (b) which types of problems are serious, (c) which types of
problems motivate people to seek help, (d) which types of problems can
feasibly be treated, (e) whether the program will be clinic-based or
community-based, (f) whether the program will focus on individuals,
families, or communities, (g) whether the program will provide both
individual and group therapy, (h) whether the program will include
prescribing psychotropic medication, (i) whether the program will focus
on both adults and children, (j) whether the program will focus on
secondary and tertiary prevention only or also on primary prevention.
(k) which local human resources are available.
- Depending on the context, trauma training needs to
be expanded to training in basic psychiatric care.
In areas with few facilities, trauma programs are likely to attract
help-seekers who have not been traumatized but who do urgently need help
(e.g., people with epilepsy, schizophrenia, and physical disease).
Because of the absence of services for these people, part of good
program development is to anticipate and to make decisions about who and
what to treat or to refer. Whatever the ultimate decision, it is
important to remember that to not consider the service needs of the
seriously mentally ill is to abandon a fundamental obligation of the
mental health professions.
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C. Core Curricular
The Task Forces' articulation of the core curricular elements of
international trauma training centers on raising trainees' professional
knowledge and skill. Thus, this articulation of core elements utilizes
the professional language and concepts of mental health. It is mainly
directed at mental health professionals, health care professionals, and
- International trauma training includes competence in
listening and other communication skills.
Helping requires good communication skills by empathic helpers. Teaching
people the ability to establish a sound helping relationship is
- International trauma training includes training of
established interventions to diminish distress.
A wide range of specific social, psychological, and biological
interventions exist in the professional literature.
- International trauma training maintains that the
full understanding of the local context determines the appropriateness
and feasibility of specific interventions.
The context may effect implementation in many ways. Important
(a) help-seeking expectations (e.g., clients socialized by traditional
healers may expect almost immediate relief);
(b) duration of treatment (which may need to be short because of limited
access to care);
(c) familiarity with the concept of trauma (In cultures where psychology
is an unknown field, it can be difficult to convince clients that it may
be helpful to try to recall and focus on the details of a traumatic
(d) attitudes toward intervention (e.g. In many cultures patients tend
to expect medication);
(e) family attitudes and involvement (many cultures emphasize the family
over the individual).
- International trauma training provides strategies
for problem solving.
Trauma training should not only be limited to treatment of
stressor-induced symptoms or distress but also cover approaches to
reducing problem situations whenever possible. Such approaches may be on
the individual level (e.g., problem-solving treatment), on the family
level (e.g., solution- focused therapy), and on the community-level.
(e.g., working with change agents).
- International trauma training addresses the
treatment of somatic expressions of psychosocial distress.
In many settings, especially in non-western contexts, help-seeking
through somatic complaints is very common. Training in treatment of
medically unexplained somatic complaints (psychosomatic complaints,
functional complaints) is essential. Feasible treatment approaches are
available. It is important to address the linking of psychosocial
services to medical services to address medical needs.
- International trauma training includes training on
collaboration with existing local human resources or change
Local human resources (e.g. clergy, teachers, traditional healers,
formal and informal leaders) may help trainers and trainees understand
indigenous perceptions of suffering, illness, loss, pain, and
Collaboration with traditional healers is important because of their
knowledge of and role in the community and the potential effectiveness
of their interventions. Local leaders may help (a) sanction programs,
(b) reach feasible solutions for problems situations, (c) provide
information on community concerns, and (d) provide referrals.
- International trauma training ensures the
establishment of an ongoing supervision structure.
Many failures and some successes in international development over the
last 50 years demonstrate that program developers need to focus on (a)
feasibility (is it possible to effectively carry out this intervention
in this situation?) and (b) sustainability (will the program last? will
the effects of the program last?).
Thus, in terms of a specific intervention by paraprofessionals, these
questions may be phrased as follows: (a) Is it possible to train
paraprofessionals to effectively carry out this intervention in a given
setting? and (b) For how long will trainees retain the knowledge and
skills obtained in the training and for how long will they be in the
situation to practice what they learned?
Paraprofessionals are likely able to master most interventions if these
interventions are socioculturally appropriate and if they receive
sufficient ongoing supervision.
However, to train in an area without setting up a structure of ongoing
supervision is likely unsustainable and may lead to harm. When competent
supervisors are not available, an expatriate mental health professional
may have to be stationed locally to function as a supervisor for as long
as it takes to train competent local supervisors.
- International trauma training includes training in
Self-care is important for two reasons. First, previous traumatization
may limit the trainees' effectiveness. Second, caring for severely
traumatized people may lead to vicarious traumatization or other forms
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D. Monitoring and
Monitoring and evaluation are necessary and potentially very useful
to improving international trauma training. Monitoring and evaluation
are increasingly required by the organizations that support the
Constructive feedback from monitoring and evaluation to trainees
tends to be both correcting and motivating. Yet there are still many
instances where monitoring and evaluation are not done or are done in a
way that does not yield practical results.
The task force believes that monitoring and evaluation can be most
useful if there is first a clarification of the values underlying the
training and an understanding of how training fits within the given
context. Evaluation that does not recognize the values or the context
may end up reinforcing or covering up positions that are misguided or
1. International trauma training initiatives should
incorporate monitoring and evaluation components. The overall aims
are as follows:
- To insure that training is not doing harm.
Harm may be manifest directly upon trainees or those they serve, or
indirectly as in the case where training contributes to an undermining
- To insure that training is beneficial.
As further discussed below, evaluation of the benefits of training
should address the questions, "To what extent, on which dimensions was
the training helpful?", and "To what extent, on which dimensions was the
training regarded as helpful?"
2. International trauma training initiatives must
identify the most appropriate indicators for monitoring and
evaluation. These include:
- Evaluating the need for training. A good
understanding of the needs for training should guide the development of
the training program. This should clarify, "What training?", "For what
persons?", "To address what needs?", "By what means?"
- Evaluating the process of training.
It is necessary to take an honest look at how training develops from
anticipation to completion. Process evaluation is concerned with issues
such as feasibility, acceptability, translation and adaptation of
- Evaluating the impact of training on trainees'
It is important to evaluate changes in the area of the transfer of
specific knowledge and skills to trainees ("building a toolbox"), but
also the broader development of capacities of the groups and
organizations where trainees work.
- Evaluating the impact of training on
It is essential to evaluate for possible changes in the provision of
services by those who have received training.
3. International trauma training initiatives must choose
appropriate approaches for assessing their indicators. The Task
- Collaborative approaches.
Involving local investigators, professionals, paraprofessionals, and
service recipients will help to keep the monitoring and evaluation
oriented toward real world concerns and hierarchies of needs. All
parties involved in the training should assess, on an ongoing basis, as
part of the evaluation, the degree of mutual agreement about whether the
objectives of the training are being met.
- Investigating multiple dimensions of
When assessing trainees or services, consideration should be given to
the Impact of training on multiple dimensions, including: (a) relief
from somatic pain; (b) diminishing psychological distress and symptoms;
(c) improvement of physical and social functioning; (d) reduction of
social isolation and reestablishment of social relatedness; (e)
successful problem solving; (f) better family processes; (g) managing
competing cultural beliefs; (h) removing obstacles to recovery however
they may be defined; (i) promoting truth, justice and reconciliation
processes; 0) and satisfaction with services.
- Mixed-method approaches of data collection and
There is a greater likelihood of useful results through combining
qualitative and quantitative methods, including surveys, individual
interviews, focus groups, and participant-observation.
- Ascertaining the impact of training over
The aim is to determine if the effects of training are maintained over
time or whether there are serious drifts in the practice of learned
4. International trauma training initiatives should
report and disseminate the results of the monitoring and evaluation.
- Incorporate the views of both providers and
recipients of training.
A balanced look at both perspectives upon the training experience is
likely to offer more than either of them alone.
- Present not just the successes but the failures and
difficulties of training.
Documenting failures and difficulties can be very helpful to those
pursuing future trainings.
- Share tools, materials and resources that will be of
value to further training initiatives.
Sharing of evaluation and training materials is a positive contribution
to the field.
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