PHILIP G. MONROE AND DIANE LANGBERG
Tsunamis in Asia; earthquakes in Central and South America; genocides in Bosnia, Rwanda, and Syria; child soldiers fighting wars around the world; failed states and religious wars leading to massive refugee crises in the Middle East and Europe; human trafficking for sex and servitude; relentless, systemic violence in the world’s inner cities—all of these events produce traumatized individuals and communities. In addition to these news-making stories we have the hidden daily scourge of gender-based violence. The United Nations Statistics Division (2015) reports that one out of three females is a victim of beatings, rape, or coerced sex or is otherwise abused in their lifetime. But this oft-quoted global statistic mutes the daily experience of vast numbers of girls and women who face the threat of rape and other forms of sexual violence. Sadly, many threats to their personhood—incest, child marriage, genital mutilation—are approved by the local community. Violence is a major health and development issue for girls and boys worldwide, and only a fraction obtain help from law and justice systems (United Nations Statistics Division, 2015).
The epidemic of psychosocial trauma around the world numbs the minds of both the victim and the onlooker. Symptoms include, but are not limited to, the minimum diagnostic criteria for posttraumatic stress disorder. Many individuals experience life-altering subclinical symptoms even when they do not meet criteria for a diagnosis. Trauma, by definition, overwhelms the individual. However, it also tends to overwhelm entire systems, including those who hear about such traumas. The usual response to atrocity is to try to remove it from the mind, to flee the memory. Those who hear about atrocities also wish to flee by way of distraction and forgetfulness. Such stories threaten comfort, social status, and the integrity of a social or organizational system. They disrupt and demand attention, and so individuals, communities, and nations find it tempting to deny these stories or their life-altering consequences.
Yet “silence is no virtue; it is vice twice-compounded: indifference toward the victims, complicity with the executioners” (Brown, 1989, p. 36). Thus, both victim and onlooker experience a dialectic tension between the need to forget trauma and the need to speak about trauma so that it is acknowledged and validated.
Trauma is the mission field of the twenty-first century, in need of well-trained mental health professionals prepared to deploy around the world. In this chapter we explore the personal, cultural, clinical, theological, and ethical requisites for those desiring to initiate trauma care work in developing nations. We conclude with a case study of an extended partnership between American Christian counselors and Rwandan counselors and caregivers highlighting lessons learned over a seven-year period.
Despite the primal urge to forget trauma, many missional Christian counselors find themselves moved by their faith to use their expertise through direct care experiences in international settings. These caregivers believe that they are called to follow Jesus Christ into his suffering for the world in order to bear witness to his character and participate in the work of healing and reconciling the world to God. For many counselors, trauma care is a place of service and mission (Langberg, 2015).
But are counselors ready for such a mission? As with any mission, the work of trauma care is neither simple nor efficient since much of the work unfolds little by little. One helper helps another who, in turn, helps another. Thus it is essential that there exists an army of well-trained, competent mental health practitioners able to respond to the need. Yet compassion and calling are not enough. Good intentions will not protect vulnerable populations from cultural missteps by counselors that undermine local leadership, create economic dependency, and ultimately lead to inoculating victims against future hope and efforts to recover from their injuries.
Those filled with a sense of calling to “bind up the brokenhearted” (Is 61:1) need to be equipped to serve in settings outside their own if they are going to provide help and avoid harm to self and others. Competencies must extend beyond knowledge about psychosocial trauma and effective clinical interventions.
If more than training in trauma intervention is necessary to be effective in doing crosscultural education and clinical care, what is required to ensure that work completed is actually helpful and not harmful? In this section we will discuss the necessary character and cultural competencies, as well as competencies in treatment intervention.
Character competencies. The Christian virtue of humility is an essential foundation for any mental health practitioner but is even more crucial in crosscultural contexts. We obey the first and second greatest commandments (love of God and love of neighbor as self) when we approach others with the recognition that our neighbors whom we want to help may have much to teach us about loving God. One of the great dangers of the helping professions is the capacity to seduce the helper into thinking he or she is somehow above or better than the helped. Even when aware of this temptation, the helper can easily see himself or herself as the one with more and the helped as the one with less, resulting in a sense of superiority or greater value. This attitude leads to seeing the giving of help as a one-way street where practitioners unintentionally expect that their dispensed services will fill up oppressed and needy victims who lack what they have to offer (Friere, 2000). Valuing Western mental health resources, clinicians are often blinded from seeing a wealth of relational and intellectual capital within an indigenous community (Smith et al., 2011). This blindness can make it difficult to listen first, to receive from them, and to walk together as partners.
In contrast, genuine humility leads to assuming the posture of a student—that of listener and learner. We often think of listening as a basic skill in any helping relationship. And while it is a learned skill, listening across and through cultures (including one’s own) requires a maturing interpersonal “I-Thou” capacity where others become more than stereotypes or bit characters in one’s own narrative (Buber, 1958). This attitude of listening and learning emanates from a deep motivation to understand the person and their rich, enculturated story (Goh, Koch, & Sanger, 2008).
The true student also possesses a desire to study culture, family and community norms, rituals, faith traditions, power structures, and social and historical contexts. Such drive often emanates from a strong belief that God’s creational and missional character is more deeply understood in strengths-based assessments than in merely looking for what appears to be the result of the fall. Exploring strengths in individuals, society, churches, and culture helps outsiders notice what God is doing within local communities through the resources divinely given to them. In addition, acknowledging strengths within other cultures and communities provides the opportunity for personal growth. Entering another culture with eyes open invites a student to see his or her own failings (as well as his or her embedded societal failings—materialism, entitlement, lack of community, busyness, and self-absorption) more clearly. In short, if God is already at work in every community, then it is the mental health practitioner’s job to see what God is already doing in that region and join in to note, encourage, and build on that foundation (Smith et al., 2015).
Time and economic pressures work against this listening and learning posture. The outside expert is sometimes present for only a short time and is encouraged to deliver as much content as possible so as to justify the expenses incurred. If one does not resist them, these pressures will curtail some of the most important learnings that happen during quiet conversations when answers to the following questions can potentially emerge:
How are psychological issues dealt with?
How are emotions held, understood, and experienced?
Is there a psychological vocabulary?
What does healing look like?
How do people grieve?
What is daily life like?
What resources exist for dealing with trauma?
What are the roots of faith in the culture?
How are “outsiders” viewed?
What other causes of trauma exist in the country?
What is the role of the church in the country?
How are gender roles understood?
What cultural norms govern family, church, village, and nation?
How is suffering understood?
This student-learner position enables an outsider to pause to learn these important truths before diagnosing problems or offering solutions, thereby avoiding simplistic translations of mainstream, Western, mental health diagnoses and interventions into other settings. The result of creating learning space prepares local and international partners to find flexible, creative, and strengths-oriented responses rather than canned and poorly contextualized interventions.
Consider the following short vignette. A Christian therapist travels to a developing nation to provide trauma care for those widowed after a genocide. There she meets one widow. She hears the woman’s story of seeing her husband and three children brutally murdered by two men in the village. The widow had known these men all her life. She had attended school and church with them. Her husband had helped one of the men build his house. Now, after the genocide, she encounters them daily as she goes to a nearby lake for water. The perpetrators were briefly imprisoned for their crimes, but the country is not able to punish all who murdered; thus she must meet them on the street and in the markets each day. She notices that their families are intact.
Such a complex story must be well understood before any intervention is suggested to help the widow deal with her insomnia, racing heart, and deep despair. She cannot leave her situation. Her trauma is ongoing and continuous. The social pressure to simply accept her reality and forget is massive. In addition, the meaning behind her symptoms runs counter to common Western mental health depictions (e.g., Hagengimana & Hinton, 2009).
Many of the current mental health interventions utilized in the West assume the presence of certain societal infrastructures (e.g., justice, privacy, adequate policing, access to medical and mental health services) and the capacity to remove oneself from daily reminders of trauma. The therapist will serve the widow best by first understanding not only the extent of her trauma experiences but also what local and natural resources are being used to help her survive, even if she does not thrive. Most important, the student-listener will incarnate (put flesh on) God providing an opportunity for both listener and widow to connect to the one who creates and sustains them.
Cultural competencies. Effective trauma care in international settings requires more than good character. It also requires a set of cultural intelligence competencies that flesh out the meaning of being incarnational (Elmer, 2006; Livermore, 2011). Goh, Koch, and Sanger (2008) summarize these competencies in four types of cultural intelligence: metacognitive (the ability to monitor self regarding assumptions, thoughts, and reactions), cognitive (cultural knowledge base), motivational (developed intrinsic satisfaction in crosscultural interactions), and behavioral (capacity for flexible responses as an outsider). Of these four types, it appears that drive (motivation) and self-awareness (metacognition) form the basis of being able to acquire knowledge of cultural complexities as well as develop strategies of engagement. The culturally competent Christian counselor engages in an endless loop of observation, action, and reappraisal in order to avoid foreclosed (premature) assumptions about a particular community.
Cultural competencies naturally lead therapists to consider how to best contextualize trauma knowledge and practices into the culture of a local community (Dawson, 2007). For example, therapists seeking to provide counseling services in a cooperative community would likely seek group-oriented rather than individual-oriented interventions (e.g., corporate lament expressions). In addition, technical clinical language (e.g., flashbacks) would not be merely transliterated into the local language; rather, existing words would be chosen to convey the core meaning (e.g., nightmare while awake). Optimal contextualization requires the presence and leadership of a cultural bridge person—someone with local knowledge, expertise, and respect, as well as courage to understand and teach outsiders.
Cultural adaptation takes time and is rarely linear in process. However, mental health practitioners who invite “pushback” can avoid common cultural errors. According to Shah (2012), “pushback describes the modes (active or passive, noticeable or covert) by which a group expresses its resistance and/or provides redirection to any intervention” (p. 444). Inviting pushback is necessary, argues Shah, given the power (i.e., social, cultural, economic, educational) asymmetries between helper and the helped. Trauma therapists recognize the importance of encouraging resistance as part of the recovery process where traumatized individuals begin to reclaim God-given agency—dominion and voice. In the act of resistance, outside helpers need not feel rejected but rather enriched by new perspectives of human flourishing. Where history and culture make overt pushback difficult, outsiders can encourage forms of resistance and collaboration by creative third person questions such as “If someone from outside were causing unintended problems, how would the community respond?”
Sometimes pushback comes in unexpected moments. In one situation, a Western clinician wishing to avoid the appearance of colonialism refused to allow an African peer to carry his bag from the car to the guesthouse. The African initially felt that he was not trusted. But what could have been a relational breach was avoided when the peer explained that carrying the bag was an important act of honor in that particular society. The ensuing discussion between the two new friends resulted in deepening mutual understanding and prepared both to resolve training challenges the next week.
Dialogue education or participatory learning is one powerful intervention known to be useful in ensuring that training done by external helpers is of use (culturally and practically) to participants. Dialogue education (Vella, 2002) has as its primary principle the engagement of learner and teacher in developing mutually agreed-on learning content and outcomes. For example, a group of Western educators planned domestic-violence training in a developing country. Prior to the group’s arrival, leaders from both countries met via web conference to discuss desired training activities. While the Western leaders had initially filled most of the training with content delivery and subsequent discussion, the local leaders noted the need for small-group discussion as well as the use of traditional means of learning new material. In addition, singing and time for games were seen not as fillers but as integral to the development of new knowledge and skills.
Trauma intervention competencies. Competent Christian mental health professionals ensure that the trauma interventions they teach to local caregivers are supported in the current psychological and religious literatures. While creativity, adaptation, and contextualization are necessary in crosscultural applications of mental health interventions, therapists must begin their preparation on a solid knowledge base. Typical understandings of posttraumatic stress disorder and complex trauma reactions can be found in the works of Herman (1997) and Langberg (2003). More recent work by Gingrich (2013) provides a Christian perspective on complex trauma and dissociation. These publications offer information on the three-part trajectory of recovery—safety/stabilization, memory processing, and reconnection—that is the current standard of care in the West.
When working with complex trauma crossculturally, it is necessary to build on this base, especially in settings where trauma is ongoing and continuous and where few trained providers exist. In recent years there has been a proliferation of interventions designed to be delivered in such settings where providers, time, and costs are of primary concern. Perusing the literature, a Christian counselor might begin examining those interventions with empirical support (Schauer & Schauer, 2010). For example, those interested in the region of sub-Saharan Africa would do well to start with Smigelsky et al.’s (2014) review of the causes, costs, and interventions that have been employed in that region. Those interested in lay-led interventions used in refugee and asylum-seeking populations might explore the data regarding narrative exposure therapy (Neuner, Onyut, Ertl, Odenwald, Schauer, & Elbert, 2008). Still others may wish to start with the well-known trauma-focused cognitive behavior therapy modified for regions of continuous trauma exposure (Kira, Ashby, Omidy, & Lewandowski, 2015).
Other forms of brief interventions (psychoeducation, ritual, movement, art, resilience training, etc.) have a nascent literature as well. These are used widely but lack robust empirical evidence to date—usually due to being utilized by individuals and institutions not yet prepared to undertake the rigors of a scientific study.
For example, Healing the Wounds of Trauma (Hill, Hill, Bagge, & Miersma, 2014) has been widely used for more than a decade around the globe with strong anecdotal support. This training program utilizes a “train-the-trainer” model to expose participants (often clergy and lay leaders) to new understandings of faith and trauma through story and Scripture engagement. The experiential program, described in more detail later in this chapter, seeks not only to educate attendees but also to provide them with skills to pass on their understanding to others. Only now is this model receiving attention from those able to complete effectiveness research.
Early adoption of untested interventions should not be viewed entirely in a suspicious light. After consulting in more than a dozen countries, it is clear to us that interventions that bring together communities by means of integrating facts (past and present traumas and resiliencies) and faith (communal worship through lament practices) with a future hope orientation lead the way in positive reception over interventions that focus only on education and coping skills.
It is important to keep in mind that we clinicians bear the responsibility to ensure the safety of those who receive treatment from us. Quality clinical practice includes informing partners of intervention limitations and possible negative outcomes (e.g., increasing trauma symptoms, increasing social rejection or physical attack after disclosing sexual trauma in a group setting). From our own experience, much harm has been done when counselors become wedded to one particular model over others, promise results beyond what is possible, and resist the use of other interventions. As an example, once at a conference, one of us was confronted by a clinician who insisted that any clinical work in Rwanda not using eye movement desensitization and reprocessing (EMDR) was a waste of time and money. Such an opinion reveals an unhealthy allegiance to one model and a failure to adopt local healing practices known to help with recovery.
Theological competencies. When natural disasters occur and people are traumatized, there are many questions and struggles related to God, his sovereignty, and his protection. These questions grow exponentially in response to human-caused traumas such as war, genocide, or rape. Trauma of any kind challenges and sometimes distorts faith. The competent Christian mental health practitioner understands the complex relationship between trauma and faith, as well as best practices to encourage reestablishing faith practices that support recovery. The competent therapist chooses to be a student of a theology of trauma (Ganzevoort, 2008).
Why does God allow evil acts and suffering? What does suffering say about God and me? Such questions during and after trauma illustrate a common response—discontent with previously embraced beliefs and experiences (Wortmann, Park, & Edmondson, 2011). As one Rwandan said, “I used to think God was the God of the Hutus; then I decided he was the God of the Tutsis. Now when I look at my devastated family and country I am not certain he exists at all.” Another voiced a similar loss: “I used to see the church as a healing place, a sanctuary; now I see it as a cemetery.” When, as in the case of Rwanda, leaders of faith communities conspire to do evil, moral injury occurs, leaving victims with no place to ask their questions. In addition, those who have been involved in combat or those forced to commit atrocities may also experience intense shame and thus greater spiritual struggle (Currier, Drescher, & Harris, 2014).
As with Job, theodicy experiences almost universally lead to reappraising what we formerly thought about ourselves, the world, and God. The competent counselor recognizes that a verbalized lament (especially in corporate worship) provides opportunity for intimacy with God and community to be strengthened (Snow, 2012). Such acts of worship have the possibility of building resiliency, improving hope, and reestablishing purpose and meaning (Walker, Reid, O’Neill, & Brown, 2009). A Rwandan caregiver once said, “My faith is stronger. Surviving itself is a sign that God exists. God is the father of the fatherless and husband of the widows. When your brother is no longer there, God sends other brothers—visibly, practically. I am being that to my fellow Rwandans.”
Unfortunately, religion can be used to abuse, to support evil, to teach lies about the character of God, and to further crush those who have been battered and oppressed by their trauma. Victims are blamed and ostracized for their own rapes; those with trauma symptoms are accused of demon possession or evil and are told they are being punished by God. Scripture texts have been used in the service of domestic abuse, clergy sexual abuse, child sexual abuse, and oppression of many kinds.
Since faith has the potential to raise hard questions and difficult struggles, to strengthen and build up as well as confuse and oppress, it is critically important to understand the ways in which Scripture is distorted by faith communities in a given culture and used to support ongoing traumas such as the battering of women and children, sexual assault, mutilation of bodies, and crushing of spirits.
Speaking truth into such deceptions requires carefulness, respect, and gentleness with local ministry leaders just as it does with victims. The competent therapist uses the previously discussed contextualization skills to talk to pastors and leaders in language they understand. For example, instead of using sociological data to convince a pastor that female rape victims are not responsible for their condition, a therapist might follow theologian Steven Tracy’s (2013) lead and explore biblical texts supporting the care and protection of women.
Ethical competencies. Those desiring to engage in trauma recovery in developing nations, without causing harm, need to consider a special set of ethical concerns and ideals in addition to what has previously been discussed.
Over the last 15 years the psychological community has paid increasing attention to the need for guidelines for those providing global mental health services and education. Weine et al. (2002) identified a significant deficit in most trauma-related training curricula, stating that “the literature on international trauma work demonstrates neither a comprehensive nor serious attempt to address the values, framework, techniques, challenges and outcomes of international training” (p. 157). While their essay encouraged trauma-education trainers to pay attention to values and contextualization, almost nothing was said about local faith and spiritual values other than an exhortation to respect clergy as essential community gatekeepers.
In 2007 the World Health Organization’s Inter-Agency Standing Committee produced a valuable set of guidelines for trauma and disaster responders. These guidelines pointed to preparatory work to ensure that any mental health service provided would avoid harm, protect human rights, avoid discrimination, ensure local participation in delivery of services, and be integrated into other humanitarian and economic supports. This document encouraged outsiders to “facilitate conditions for appropriate communal, cultural, spiritual, and religious healing practices” (p. 25).
While both of the preceding documents had as their core the goal of “do no harm,” international trauma facilitators can easily do harm without knowing it. Wessells (2009) examined a number of subtle forms of harm to avoid: approaching others with a deficits orientation, parachuting in without consideration of entrance and exit, lack of sensitivity to culture, failing to consider holistic interventions, and, possibly the worst, creating a dependency culture unable to continue care without outside help.
Finally, and most recently, the American Psychological Association (APA, 2015) has adopted a set of competencies (formerly known as the New Haven Competencies for Trauma Psychology Training and Practice) designed to articulate the minimal requirements for those providing international trauma education. These guidelines emphasize the need to know the current scientific literature regarding the diagnosis, assessment, and intervention of trauma along with trauma-informed professionalism and understanding of relationships and systems.
Each of these documents gives ample opportunity for interested therapists to do the necessary preparation to “do no harm” and to pursue capacity building in developing nations. For example, the international trauma literature points to using cost-effective intervention strategies utilizing trained lay counselors with refugees rather than attempting to replicate professional therapy models (e.g., Lambert & Alhassoon, 2015). Or consider another more potent example. Rather than continuing to provide psychological debriefing services to an entire community after a disaster, the competent therapist recognizes that such an intervention may harm individuals or undermine natural defenses that could protect against chronic trauma (APA, n.d.).
If the above competencies are pursued, partnerships between international mental health professionals, local institutions, and lay counselors will naturally (though not always easily) occur. Strengths among partners can be shared, weaknesses can be supported, and solutions can emerge when different perspectives and ideas are brought to bear on a problem (Aten et al., 2013). Learning takes place for both groups. Clinicians go to help and find they are also helped. They go to teach and are taught. They go to give but receive in abundance. The following is a brief case study that describes such a partnership formed in Rwanda between American Christian therapists and Rwandan church leaders, local professionals, and lay counselors.
A brief history of Rwanda. Most of the world is aware that in 1994 Rwanda suffered a cataclysm of human tragedy while much of the world watched from a safe distance. For most outsiders, this genocide seemed to appear out of nowhere. In reality the genocide had its roots as far back as European colonial manipulation of tribal and class differences to promote disunity and retain power. For a chronology and an extensive report of the 100 days of genocide, see PBS (1999). In short, upward of one million Tutsis and moderate Hutus lost their lives, many at the hands of their neighbors. After the genocide stopped, approximately 1.5 million people fled to neighboring countries, mingling victims and genocidaires in massive refugee camps. Now, some 22 years later, the country appears to be stable and prospering, in large part because of Rwandan leadership supported by international donors.
Step one: listening and learning. This case study begins some years ago when one of us (Diane) had a providential meeting with a Rwandan master’s level counselor at a conference. Later, on a trip to Rwanda, they met again and began a friendship shaped by mutual learning. Not long afterward, a small group of Christian clinicians were invited by Anglican clergy to “come over and help us.” During this trip, no formal teaching was provided; rather, the trip consisted of meetings with ministries of the government, clergy, institutions (e.g., hospitals and schools), humanitarian organizations, along with victims and perpetrators—all designed to identify resources and challenges to addressing the massive trauma needs in the country. Conversations and discussions continued after the trip, including in-depth reading to better understand the history, culture, and traditions of the region. The result of this engagement concluded with a memorandum of understanding signed by the American Association of Christian Counselors (AACC) and the Rwandan government to work on building up local professional and lay counselors already deeply involved in trauma work, many of whom were dealing with personal as well as secondary trauma histories. All parties involved believed strongly that while international resources existed that could advance local counseling capacity, the best use of resources would not include direct trauma care to Rwandan clients.
Step two: establishing bridge persons. During Dr. Langberg’s initial trip to Rwanda and the later initial “listening and learning” tour, two key Rwandan women provided important insights into the state of the country vis-à-vis counseling, trauma needs, and current local resources. Over and over again these individuals sacrificed time and energy to help outsiders understand the country’s history and cultural complexities. Conversations took place during trips, on their visits to the United States, and via teleconferences. Learning gained from previous intervention efforts by other organizations was a primary focus. Through the collaborate work, dreams and ideas turned into plans for an initial training in late 2011.
Step three: initial training and dialogue conferences. Funded by AACC members, a team of four Americans and two Rwandans led a conference of approximately 45 lay and professional counselors representing 11 humanitarian organizations. Participants represented religious and secular service organizations, ranging in age and experience from recent university graduates to those who had been involved in caring ministries for decades. Didactic presentations on trauma symptoms and interventions and core listening skills were made in English and Kinyarwandan languages. One of the presentations exploring “talking, tears, and time” can be found in chapter nine of Langberg (2015). However, the bulk of the conference was set aside for discussion, skill observation and practice, and other forms of experiential learning (e.g., group art, music, and the recitation of local proverbs) appreciated by nonindividualistic cultures.
Using dialogue education principles, the participants voiced their strong desire for (a) the creation of an ongoing association of counselors for support and (b) more training with specific trauma counseling interventions. One seasoned Rwandan counselor reported that it was the first time anyone had taken the time to hear her story, while another experienced counselor reported that it was the first time she had observed counseling done by others. Communication and learning continued after the training by way of email and teleconference once the American team returned home.
One and half years later, a larger group of American mental health practitioners met again with many of the same participants to continue participatory learning of additional trauma-related topics such as domestic abuse, child sexual abuse, and rape. In a country such as Rwanda, all traumas tend to be viewed through the lens of genocide, thereby minimizing the more common experiences of abuse in daily life. Participants engaged in lively discussions of whether marital rape is even possible (in a country where a dowry is paid for the wife) while considering biblical texts. Those returning noted how much growth had taken place among the Rwandan caregivers, in their own trauma processing and their clinical skills.
In each of the first two trainings, as well as the trainings that followed, emphasis was placed on care for the caregiver. As in most contexts, these resilient caregivers had been afforded little time to grieve personal and corporate losses. Together local and international participants utilized songs, symbols, drawings, rituals, and dance to grieve, lament, and seek comfort, thus deepening bonds and building resilience.
Step four: assessing and responding to challenges. As with any new venture, roadblocks and challenges were present. Following the 2013 trip, the Rwandan/American leadership team noted that three important issues needed to be addressed: deficient cultural training of international mental health trainers, minimal consultations between American and local caregivers in between the short-term trips, and lack of partnership with a stable Rwandan organization with deep roots in the country, able to reach lay and ministry leaders.
Training mental health practitioners. Highly qualified mental health practitioners capable of advanced clinical skills may not necessarily have the competency in treating trauma in order to effectively train counseling providers in developing nations. Most clinicians receive only a cursory understanding of posttraumatic stress disorder, and even fewer have been trained to engage others in diverse cultural settings as co-learners.
To address this problem, Biblical Seminary launched the Global Trauma Recovery Institute (GTRI), a 140-clock-hour, postgraduate continuing education training program to enhance competencies in the areas of neurobiology of psychosocial trauma, advanced crosscultural listening skills, strengths-based clinical and spiritual interventions, global mental health ethics, faith and trauma, and dialogue education principles. Content and engagement components are delivered in four hybrid courses culminating in a final immersion experience for those desiring it. A group of 24 clinicians began the training program with 10 choosing to travel to Rwanda for a joint learning experience in 2014. This trip culminated in the official launch of the Rwandan Association of Christian Counselors. The GTRI program continues at present with participants from Europe, Africa, India, and Australia.
Ongoing consultations. On several occasions Rwandan counselors asked for support, encouragement, and advice in between the annual trips. Such engagement had happened in the past between key leaders, but local counselors rarely had the opportunity to engage at this level. Following the 2014 trip, several of the immersion students began weekly text and voice communications with Rwandan participants. These interactions served to advance the American understanding of Rwandan life as well as to improve the Rwandans’ counseling intervention skills. The connections built during 2014 led several Americans to return again in 2015 and 2016 to train and observe Rwandan clinical practice in action.
Partnership with Rwandan institutions. Financing trips and trainings is one of the central challenges of work in developing nations. Donors and nongovernmental organizations come and go even if the need remains. As a result, local service providers may bounce from organization to organization, following the grant money, in order to support their families. Even strong humanitarian organizations may either change their focus or leave altogether when they have changes in leadership. In contrast, a partnership with an indigenous institution provides the possibility of a more stable foundation for long-term engagement as outsiders.
Soon after the 2013 training trip, we engaged in conversations with both the American and the Rwandan Bible societies regarding their Scripture-engaged trauma healing programs. The Bible Society in Rwanda serves all denominations and is well respected by Roman Catholics and Protestants alike. As mentioned earlier, one of the society’s core programs trains trauma-healing facilitators to lead healing groups using a contextualized version of Healing the Wounds of Trauma, a story-based curriculum produced by the Trauma Healing Institute of the American Bible Society (http://thi.americanbible.org/; see also Hill et al., 2014). This curriculum is being used in many language groups around the world. The program establishes training facilitators throughout the country, often embedded in existing churches, thereby offering greater stability of resources over time.
During the summers of 2014 through 2016, GTRI-trained clinicians joined with Bible society facilitators and the newly birthed Rwandan Association of Christian Counselors for a community of practice conference designed to improve the knowledge and skill base of both groups, as well as to advance local and international collaborations. Evidence of success included reports of new collaborations between counselors and Bible society staff, joint trainings on the topic of domestic abuse, plus ongoing supervision regarding difficult cases. Most recently, GTRI fellows and Rwandan leaders discussed possibilities of providing joint trainings for another Bible society in a nearby country.
The cycle continues with incremental growth. The process of listening, learning, planning, assessing, and taking action continues. New challenges and opportunities must be faced. Several GTRI graduates have begun their own partnering ministries in Rwanda, expanding ministry outreach possibilities. One such graduate partnered with the Bible Society of Rwanda to support a “three-legged stool” of recovery in a United Nations camp housing 18,000 Congolese refugees (Evans, Gatwaza, & King, 2016). With funds from American Christians, the Bible society provided holistic support: faith (Bibles in their own language), trauma healing programs, and financial stability (sewing machines and training in order to be able to make a living). Recent plans have led another GTRI graduate, at the request of the Rwandan Bible Society, to embark on a research program assessing the effectiveness of Healing the Wounds of Trauma.
Trauma is a vast mission field. It is the mission field of the twenty-first century. In this field, as in every other field of service, Jesus calls helpers to follow him into “the fellowship of His sufferings” (Phil 3:10 NASB). In doing so we hallow—honor or make holy—the name of God. To hallow the name of God is to reverence his character, defend his honor, and obey his authority. One of the major tests of hallowing the divine name is Christ-followers’ attitudes toward fellow human beings. Injustice on the part of human beings toward other human beings profanes the name of God. Complicity—silence—is the most common form of profanation. Workers in the trauma mission field begin by finding ways to bear witness to the pain of the oppressed. In the words of Wiesel (1986), the first line of help is to “never be silent wherever and whenever human beings endure suffering and humiliation. We must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Sometimes we must interfere” (para. 8).
While bearing witness is the clinician’s greatest tool in the process of recovery, competent trauma care providers and educators recognize that actions completed on behalf of others without their consent, approval, and planning may not deliver the desired result. Historically, the Western world has gone to the rest of the world as the knowers, teachers, and doers. We have often assumed the superior position with our resources, knowledge, skills, and the supposed right understanding of problems. We have assumed that if we can just instruct and give what we have, then everything will get better. Such approaches have been both arrogant and ignorant.
A better model, one seasoned with great respect, mutuality, and assumption of personal need, is required. Such work, if done well and respectfully, is far more like putting a multicultural group of people in a kitchen to cook a large meal. Each will bring something different in terms of knowledge and skill, each will bring creative ideas and traditions, and each will end up ultimately bringing something unique to the table. As a result, a fine, diverse, and creative meal will be presented; respect and understanding will have grown; joy will be shared; and we daresay some laughter will have occurred along the way.
Thus, the first lesson learned is that of being a student from the outset. Those who want to provide trauma care and training in developing-nation settings must be willing to maintain the role of a student, bearing witness to the rich tapestry of local life and experiences. Further, they must be more interested in listening to local leaders express their own assessments of local opportunities and challenges. Failure to take a learning stance on the part of the individuals delivering trainings can result in well-intentioned mental health practitioners being more likely to harm than to help.
In addition to taking on the role of a student, the most successful help offered comes in the form of mutually beneficial partnerships. Too often our partnerships look more like agreements where outsiders get permission from key gatekeepers to control the decisions made and deliver the services. This is not a partnership. Western mental health professionals schooled in individualism and scientism have much to learn from much less educated caregivers. We benefit greatly from learning community-based care founded on rich faith practices.
Navigating true partnerships takes time and is rather expensive and inefficient because true relationships are not born overnight. It takes time to find and engage locally respected stakeholders, to listen, and to consider solutions as well as a plan for implementation that does not create dependency, neuter the power structures of local leadership, or always require outside resources. Plans drawn with good intentions will frequently change. Temptations abound to move quickly in order to circumvent the time it takes to contextualize materials or obtain stakeholder agreements. However, it is wise to remember an African proverb often quoted in Rwanda: “If you want to go fast, go alone, but if you want to go far, go together.”
American Psychological Association. (2015). Guidelines on trauma competencies for education and training. Retrieved from www.apa.org/ed/resources/trauma-competencies-training.pdf
American Psychological Association, Society of Clinical Psychology. (n.d.). Psychological debriefing for post-traumatic stress disorder. Status: No research support/treatment is potentially harmful. Retrieved from www.div12.org/psychological-treatments/treatments/psychological-debriefing-for-post-traumatic-stress-disorder/
Aten, J. D., Boan, D. M., Hosey, J. M., Topping, S., Graham, A., & Im, H. (2013). Building capacity for responding to disaster emotional and spiritual needs: A clergy, academic, and mental health partnership model (CAMP). Psychological Trauma: Theory, Research, Practice, and Policy, 5, 591-600.
Brown, R. M. (1989). Elie Wiesel: Messenger to all humanity (Rev. ed.). Notre Dame, IN: University of Notre Dame Press.
Buber, M. (1958). I and thou. New York, NY: Scribner.
Currier, J. M., Drescher, K. D., & Harris, J. (2014). Spiritual functioning among veterans seeking residential treatment for PTSD: A matched control group study. Spirituality in Clinical Practice, 1(1), 3-15.
Dawson, J. (2007). African conceptualizations of posttraumatic stress disorder and the impact of introducing Western concepts. Psychology, Psychiatry, and Mental Health Monographs, 2, 101-12.
Elmer, D. (2006). Cross-cultural servanthood: Serving the world in Christlike humility. Downers Grove, IL: InterVarsity Press.
Evans, H., Gatwaza, Z. C., & King, C. (2016, March). Voices of refugees in Africa: Case studies in Rwanda and Louisville, Kentucky: Three-part model supporting refugees. Presentation made at the 2016 Global Community of Practice, Philadelphia, PA.
Friere, P. (2000). Pedagogy of the oppressed (30th anniversary ed.). New York, NY: Continuum.
Ganzevoort, R. R. (2008). Teaching that matters: A course on trauma and theology. Journal of Adult Theological Education, 5(1), 8-19.
Gingrich, H. D. (2013). Restoring the shattered self: A Christian counselor’s guide to complex trauma. Downers Grove, IL: IVP Academic.
Goh, M., Koch, J. M., & Sanger, S. (2008). Cultural intelligence in counseling psychology: Applications for multicultural competence. In S. Ang & L. N. Dyne (Eds.), Handbook of cultural intelligence: Theory, meaning, and application (pp. 257-70). New York, NY: M. E. Sharpe.
Hagengimana, A., & Hinton, D. E. (2009). “Ihahamuka,” a Rwandan syndrome of response to the genocide: Blocked flow, spirit assault, and shortness of breath. In D. E. Hinton & B. J. Good (Eds.), Culture and panic disorder (pp. 205-29). Stanford, CA: Stanford University Press.
Herman, J. (1997). Trauma and recovery: The aftermath of violence: From domestic violence to political terror. New York, NY: Basic Books.
Hill, H., Hill, M., Bagge, R., & Miersma, P. (2014). Healing the wounds of trauma: How the church can help. New York, NY: American Bible Society.
Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva, Switzerland. Retrieved from www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psycho social_june_2007.pdf
Kira, I. A., Ashby, J. S., Omidy, A. Z., & Lewandowski, L. (2015). Current, continuous, and cumulative Trauma-Focused Cognitive Behavior Therapy: A new model for trauma counseling. Journal of Mental Health Counseling, 37, 323-40.
Lambert, J. E., & Alhassoon, O. M. (2015). Trauma-focused therapy for refugees: Meta-analytic findings. Journal of Counseling Psychology, 62, 28-37.
Langberg, D. M. (2003). Counseling survivors of sexual abuse. Maitland, FL: Xulon Press.
Langberg, D. M. (2015). Suffering and the heart of God: How trauma destroys and Christ restores. Greensboro, NC: New Growth Press.
Livermore, D. (2011). The cultural intelligence difference: Master the one skill you can’t do without in today’s global economy. New York, NY: ANACOM.
Neuner, F., Onyut, P., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 686-94.
PBS (1999, March). The triumph of evil: 100 days of slaughter. A chronology of U.S./U.N. actions. Frontline. Retrieved from www.pbs.org/wgbh/pages/frontline/shows/evil/etc/slaughter.html
Schauer, M., & Schauer, E. (2010). Trauma-focused public mental-health interventions: A paradigm shift in humanitarian assistance and aid work. In E. Martz (Ed.), Trauma rehabilitation after war and conflict: Community and individual perspectives. New York, NY: Springer.
Shah, S. A. (2012). Ethical standards for transnational mental health and psychosocial support (MHPSS): Do no harm, preventing cross-cultural errors and inviting pushback. Clinical Social Work Journal, 40, 438-49.
Smigelsky, M. A., Aten, J. D., Gerberich, S., Sanders, M., Post, R., Hook, K., . . . Monroe, P. (2014). Trauma in sub-Saharan Africa: Review of cost, estimation methods, and interventions. International Journal of Emergency Mental Health, 16(2), 127-36.
Smith, B., Collins, G. R., Cruz, E., Cruz, P., Cruz, S., Cruz S., Jr., . . . Warlow, J. (2011). The Cape Town declaration on care and counsel as mission. Retrieved from www.belhaven.edu/careandcounsel/declaration.htm
Snow, K. N. (2012). Resolving anger toward God: Lament as an avenue toward attachment. Dissertation Abstracts International, 73, 1269.
Tracy, S. R. (2013). Concepts of gender and the global abuse of women. Cultural Encounters 9(1), 4-22. Retrieved from www.joomag.com/magazine/mag/0019233001475705277?feature=archive
United Nations Statistics Division (2015). The world’s women 2015: Trends and statistics. Retrieved from http://unstats.un.org/unsd/gender/worldswomen.html
Vella, J. K. (2002). Learning to listen, learning to teach: The power of dialogue in educating adults (Rev. ed.). New York, NY: Jossey Bass.
Walker, D., Reid, H. W., O’Neill, T., & Brown, L. (2009). Changes in personal religion/spirituality during and after childhood abuse: A review and synthesis. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 130-45.
Weine, S., Danieli, Y., Silove, D., Van Ommeren, M., Fairbank, J. A., & Saul, J. (2002). Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry: Interpersonal and Biological Processes, 65(2), 156-64.
Wessells, M. G. (2009). Do no harm: Toward contextually appropriate psychosocial support in international emergencies. American Psychologist, 64(8), 842-54.
Wiesel, E. (1986, December 10). Nobel Peace Prize Acceptance Speech. Oslo, Norway. Retrieved from www.nobelprize.org/nobel_prizes/peace/laureates/1986/wiesel-acceptance_en.html
Wortmann, J. H., Park, C. L., & Edmondson, D. (2011). Trauma and PTSD symptoms: Does spiritual struggle mediate the link? Psychological Trauma: Theory, Research, Practice, and Policy, 3(4), 442-52.