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Draft Guidelines for International Trauma Training

Version 11.00

Taskforce on International Trauma Training
International Society for Traumatic Stress Studies

Download 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 professionals.

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 areas:

The values underlying international trauma training
Contextual challenges in post-conflict societies
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
Suite 400
850 W. Jackson St.
Chicago, Illinois, 60607
E-mail: smweine@uic.edu.

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 catastrophe.

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 values are:

Recognizing the legitimacy of multiple perspectives on trauma and related concerns.
Promoting an open dialogue among differing voices on trauma and related concerns.
Integrating different perspectives and positions on trauma in the quest for what is helpful.

B. Contextual Challenges in Post-Conflict Societies

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 post-conflict societies.

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 conditions.

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 process.

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 various interventions.

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 stakeholders.

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 of partisanship.

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 are considered.
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 mental health.

The potential risks of undertaking such interventions need to be carefully considered.
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 workers.

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 guidance.

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 service delivery.

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 situation.

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 participating agencies.

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 societies.

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 survivors.
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.

C. Core Curricular Elements

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 paraprofessionals.

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 essential.

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 considerations include:
(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 event);
(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 agents.

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 healing.

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.

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 of burn-out.

D. Monitoring and Evaluation

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 training.

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 confused.

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 of competencies.

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 training methods.

Evaluating the impact of training on trainees' skills.
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 services.
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 Force recommends:

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 outcome.
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 analysis.

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 time.

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 skills.

4. International trauma training initiatives should report and disseminate the results of the monitoring and evaluation. Reports should:

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.