Waves of Healing — Group Therapy With Tsunami Survivors
By David Surface
Social Work Today
Vol. 6 No. 6 P. 30

Emphasis on the importance of relationships and community is helping survivors of the tsunami ease some of the pain of loss.

Human disasters are always difficult to grasp. When the scale of disaster is overwhelming, we often try to contain them in a few isolated, representative images. The distraught fireman carrying an unconscious child in his arms. The stunned businessmen coated in gray dust staggering from the rubble of the World Trade Center.

For Joan Hoeberichts, MSW, there is one image of the tsunami of December 2004 that will not go away. It’s the one she saw with her own eyes when she arrived in Sri Lanka five weeks after the crushing wall of water had done its deadly work. “It was a palm tree,” Hoeberichts says, “Fifty feet high. It was hung with saris.” Hoeberichts pauses, perhaps remembering the sight of all those colorful garments 50 feet above the ground, moving back and forth in the ocean breeze.

Hoeberichts had come to Sri Lanka on the first part of an ambitious mission: to train counselors to do group therapy with tsunami survivors. There were already teams of counselors and therapists at work in survivor camps and disaster relief centers. But Hoeberichts believed she and her coworkers had something special to offer.

Hoeberichts is a social worker and certified group psychotherapist. She is also an ordained Zen Buddhist priest. These two aspects of Hoeberichts’ life had always complemented and supported each other, but that connection had perhaps never been as important as when she stepped off that plane and into the devastation the tsunami left behind.

“What compelled me initially was that Sri Lanka is a Buddhist country,” says Hoeberichts. “And there aren’t too many of those left.”

It was her Buddhist practice that led Hoeberichts into a career in social work. After a successful career as a corporate executive, Hoeberichts left the corporate world in 1992 to lead a program for homeless people that her Zen teacher had established in Yonkers, NY. After two years of running the homeless program, Hoeberichts returned to school to earn a master’s degree in social work. Her primary practice is in family and relationships. As Hoeberichts says, “I look at the world through a relationship-lens.”

The Self as Community
While the importance of human relationships in emotional healing was something Hoeberichts had always understood, it was scientific research on relationships and the development of the human brain that had a powerful impact on her.

Two books by Daniel J. Siegel, Healing Trauma: Attachment, Mind, Body, and Brain and The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are, collected a body of research about the brain that confirmed much of what Hoeberichts found in the precepts of Buddhism.

“If you look at it through a Buddhist eye, he’s confirming scientifically the notion of no-self, that the mind is formed in relationship,” says Hoeberichts. “The relationship between mother and child is what forms the child’s sense of self. That sense of self continues to expand through school and community and is a never-ending process. Furthermore, these studies show that the mind changes moment by moment, which reinforces the Buddhist notion of impermanence.”

This view of community-as-self has strong implications for the use of group therapy in the treatment of disaster survivors. “There’s been a great deal of new research in neurobiology on the importance of relationships in healing trauma and psychic pain,” says Hoeberichts. “The foundation of the work we’re doing in Sri Lanka is based on that research. The reason we focused on group therapy in the first year [was] to help survivors reconnect with community. There was so much loss that the family structure was in disarray; all the support systems were damaged.”

Seeing the Damage
Hoeberichts witnessed firsthand the kind of destruction wrought by the tsunami during her first visit to Sri Lanka, and, during her second visit, the slow pace of repair.

“There was a train full of bodies,” says Hoeberichts. “The heat was very bad and the bodies rotted. In the end, they burned the train with the bodies on it.” When she returned to Sri Lanka in September, the blackened and charred train was still there. “Everybody I met had some level of connection to the disaster,” says Hoeberichts. “Everybody had lost someone.”

People affected by large-scale disasters such as the attack on the World Trade Center or Oklahoma City bombing are often diagnosed with postdisaster psychiatric disorder, which can manifest itself in an array of symptoms. The most common is major depression, along with substance abuse and suicide. “Suicide rates often rise after a disaster,” says Hoeberichts. The enormity of the tsunami disaster, the number of people who had lost everything—their homes, their livelihood, their friends, and their families—made a skyrocketing suicide rate a real possibility.

Another thing that was compelling to Hoeberichts was research about how trauma can be passed from one generation to the next. “Many of these parents had their children literally ripped out of their arms,” says Hoeberichts. “Holding that kind of grief inside and not being able to process it in any kind of contained way leads them to parent the remaining children very poorly, and in that way, the trauma is passed on to that next generation.” The counselors attempt to break this cycle of “inherited” trauma by holding mother and child healing workshops in which mothers who are deeply depressed from losing children or spouses are helped to find the strength to raise their remaining children.

Healing the Mind of the Community
Working as the Heart Circle Sangha, a group of experienced therapists and social workers who share a background in meditation and spiritual concerns, Hoeberichts and her coworkers set out to train the team of 22 Sri Lankan counselors and trainees who had already been assembled as the Sarvodaya Psycho-Spiritual Healing Programs. The counselors faced formidable challenges, traveling from their homes by bus to villages along the coast and meeting with villagers in groups. In a series of visits, the Heart Circle Sangha teams led four-day intensive programs for the counselors to train them in integrating meditation and spiritual practice with group therapy methods for grief and trauma.

No matter how much experience and preparation went into their mission, Hoeberichts and her partners understood that not only would they be dealing with the after-effects of one of the worst natural disasters of human history, they would also be struggling with enormous cultural differences.

“It was very hard to know what was realistic, how difficult it would be to communicate, how many cultural issues there would be,” says Mary Cattan, MDiv. “Personally, I went with a lot of trepidation about bringing western psychotherapy into an eastern culture. The colonial culture was part of their background, so we wanted to be wary of that whole cultural backdrop. To be a missionary was not what I wanted to do. I wanted to learn as much from them about what they needed and to hope that some of the things that we were bringing would turn out to be helpful, and it turned out that was the case.”

The American team took external steps to blend into Sri Lankan culture as unobtrusively as possible. They joined their Sri Lankan partners in their morning and evening Buddhist rituals, assumed their way of greeting each other with hands joined together in front, shared their food and their way of eating with fingers rather than utensils, even dressing in traditional Sri Lankan long skirts and shedding their shoes when not on the street. But the most important steps the team took to respect Sri Lankan culture were internal.

“The biggest things we did to guard against letting our cultural beliefs interfere with theirs was to work on our own self-awareness,” says Cattan. “Using my own meditation practice, I just tried to stay very much aware and awake when it came to how we were interacting.”

But despite their best efforts at not being perceived as authoritarian figures, a certain amount of that was unavoidable, due to certain elements of the Sri Lankan culture itself.

“We had to work all the time at saying to them, ‘We want to know what you’re feeling, what you need,’ but it was difficult to do that because their tendency was to say, ‘We like everything you’re doing,’” explains Cattan. “To say anything negative to an authority figure was very countercultural for them. They’re very used to listening respectfully to teachers and reciting chapter and verse what they’re told to do.”

While verbal criticism and feedback was not forthcoming from their Sri Lankan partners, the American team was able to pick up on how their work was being received by attending to nonverbal cues.

“In the early stages when things weren’t going well, when they weren’t taking things in or we were perhaps going too long on a given subject, we’d be aware of the energy going down in the room, or maybe somebody would nod off,” Cattan remembers. “On the other hand, at other times, they’d be so engaged and enthusiastic. When we saw how they were reacting positively and enter into the more experiential things we were doing, we began to see and feel that what they needed was not didactic learning, but experiential work.”

In addition to all the theoretical foundation for using group therapy in disaster situations, Hoeberichts points out a more mundane but no less important reason. “First of all, it was obviously more efficient,” she says. “We were working with a limited number of counselors. We had nowhere near enough people. And only a couple of the people we were training had any previous training at all.”

Tools for Listening
Counselors were trained to deal with other preexisting family issues such as ongoing sexual abuse that are often uncovered during family therapy. But initially, it was the most basic counseling skills that posed the greatest challenge. “The hardest thing to teach them in the beginning was learning to listen instead of giving advice,” says Hoeberichts.

“Even though they were of a Buddhist background, the counselors didn’t have that much experience with meditation and were not particularly self-aware,” says Cattan. “They were so brimming with pain themselves that their listening skills were not very good. Sri Lankan culture is very solution-oriented, like ‘Let’s fix it,’ so the counselors were very reactive. To be in a group was quite difficult for them, and we found ourselves struggling with how to help them listen to the others.”

While learning to listen can be challenging in any counseling situation, it can be particularly difficult for a counselor working with people suffering trauma in disaster situations, simply because the stories can be so difficult to hear. To develop their capacity to listen to these difficult stories, the counselors were taught Imago counseling techniques and practiced role playing in which one counselor pretended to be her most difficult client while the other counselor practiced being in the helping role.

But the most effective technique the counselors used for helping people tell their stories was an ancient one.

“The method we used came out of a Native American practice called council, where the peace pipe was passed around to each member,” explains Hoeberichts. “We used a stone instead. We passed the stone around and each person spoke only when they were holding the stone. That kept the whole process a very simple structure for the counselors to implement and facilitate.” During the counsel experience of passing the stone, counselors chose appropriate and effective times to pause for group meditation. In addition to its simplicity, this technique had a symbolic-spiritual aspect that made it a powerful experience for those involved. “Many of the villagers commented on how the weight of the stone in their hand felt like the heaviness of their own grief,” says Hoeberichts.

It was the more experiential, tactile elements of group therapy that seemed to have the most positive effects. “Having them express what they were feeling in working with clay or drawing or art, then sharing it within the group seemed to be where they could focus,” says Cattan. “If they had something in their hand to help them focus, to share the meaning of, they seemed to be able to engage more and listen more and respond to the others in a way that they couldn’t otherwise.”

Trauma victims in disaster situations may not actively seek mental health services for various reasons; some may be in denial or simply not aware of the extent to which they’ve been traumatized, while others may not seek out therapy because of social or cultural stigmas associated with it. Therefore, the goal of many disaster mental health workers is to have therapy be a seamless, integrated part of an overall disaster effort, and, whenever possible, incorporate familiar community settings and rituals. Hoeberichts’ program is an excellent example of this approach with its strong focus on Buddhist practices and concepts such as meditation and mindfulness. According to Hoeberichts, the program’s spiritual dimension is the key to its success. “The thing that was unique was that the therapy we were doing was wrapped up in a spiritual process,” says Hoeberichts. “That made the whole process acceptable to the Sri Lankans.”

While fundamental concepts and practices of Buddhism helped inform the program, the team remained mindful of the presence of other religions in Sri Lanka, and the uneasy relationship between them. “All the different religious groups were wary of each other—the Muslims, the Hindus, the Buddhists, the Christians,” says Hoeberichts. “We tried to stay focused on all religions, on making recovery a spiritual process regardless of what your religion was.”

Future Challenges
For the next round of training visits, scheduled to take place this fall, Hoeberichts and her team plan to respond to some needs expressed by their Sri Lankan partners.

“They had requested more work with genograms, sharing their own family dynamics, beginning to understand about family systems,” says Cattan. “There are many family issues in Sri Lanka. Typically the men do not come to the group sessions, so it was incumbent on the women to bring what they’d learned back into the home, so we want to give them ways to dialogue with their families.”

While Hoeberichts and her team have made progress, they also face a number of serious challenges. “Now we’re dealing with a civil war, which is making the work we do more dangerous,” says Hoeberichts.

The project also faces fund-raising challenges. Of the 22 counselors trained by Hoeberichts and her team, only five are paid. The rest of the counselors are attempting to support their families by working other jobs as well. “We are faced with the task of finding therapists with a spiritual orientation,” says Hoeberichts, “ones who are willing to travel to a disaster site and do this intensive work.”

Despite these challenges, Hoeberichts and her team remain positive about the impact they have made in an impossible situation and the impact their work will have in the future.

“The workshops for the counselors have been enthusiastically received,” says Hoeberichts. “They have been very grateful for the opportunity to learn how to work with the terrible trauma and grief of the survivors, while teaching the Americans about the culture and traditions of Sri Lanka. We are committed to continuing this work for three years. Our hope is that the Sarvodaya counselors will then be able to teach this material to other Sri Lankan counselors so that the recovery efforts will continue for many years.”

— David Surface is a freelance writer and editor based in Brooklyn, NY.

Previous assessments among survivors of natural disasters have shown that PTSD and other mental health problems are common. Thailand does not have a history of natural disasters and the prevalence of PTSD among individuals exposed to traumatic events has not been assessed previously. Understanding posttsunami mental health indicators is essential for identifying vulnerable populations and developing culturally specific mental health interventions.

Frits van Griensven, PhD, MPH, of the Thailand Ministry of Public Health - U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand, and colleagues with the Thailand Post-Tsunami Mental Health Study Group, assessed the prevalence of symptoms of PTSD, anxiety, and depression and associated factors among random samples of displaced and nondisplaced persons in the three Thai provinces of Phang Nga, Krabi, and Phuket, which were the most severely affected by the tsunami.

The researchers found that symptoms of PTSD were reported by 12% of displaced and 7% of nondisplaced persons in Phang Nga and 3% of nondisplaced persons in Krabi and Phuket. Anxiety symptoms were reported by 37% of displaced and 30% of nondisplaced persons in Phang Nga and 22% of nondisplaced persons in Krabi and Phuket. Depression symptoms were reported by 30% of displaced and 21% of nondisplaced persons in Phang Nga and 10% of nondisplaced persons in Krabi and Phuket. Loss of livelihood was independently and significantly associated with symptoms of all three mental health outcomes (PTSD, anxiety, and depression).

In the nine-month follow-up survey of 73% of displaced participants and 80% of nondisplaced participants in Phang Nga, prevalence rates of symptoms of PTSD, anxiety, and depression decreased among displaced and nondisplaced persons, but remained elevated.

“This decrease may be due to spontaneous recovery under improved social and environmental conditions, such as more permanent housing for displaced persons, continued mental health support and occupational training, and restoration of livelihood programs, which were implemented in Phang Nga province by multiple governmental and nongovernmental organizations,” the researcher adds.

— Source: American Medical Association