Dr. Ofra Ayalon: Beyond Words

Beyond Words
Trauma-Healing Experience & Methods
in the wake of the Tsunami Disaster
Dr. Ofra Ayalon

The challenge
The chapter describes a post-Tsunami "Helping the Helpers" training for two hundred teachers and mental health workers from Thailand, Singapore, Malaysia and Indonesia, six months after the Tsunami disaster.
The goal of the training was to develop support systems for disaster helpers, and train them to help the local direct or indirect Tsunami victims. The training program included theory and experiential activities concerning trauma,. We have chosen to go "beyond words" in introducing our holistic "body-mind" methods of coping with trauma. As trainers, we put special emphasis on non-verbal expression, such as movement, relaxation, healing touch, guided imagery and a variety of forms of art therapy, symbol-therapy, Mandala painting, debriefing & narrating trauma stories and therapeutic-metaphoric COPE cards.
These methods helped participants access their coping resources and develop new strategies for dealing with stress and trauma. Using mostly non-verbal communication and healing methods provided culturally accepted means of assisting individuals, families, and even communities devastated by the Tsunami disaster.

Our great challenge as Israeli trainers was to consider and respect local traditional and cultural values and the variety of religious belief systems, such as Buddhism, Islam and Christianity. We learned from the participants that Southeast Asian cultures did not encourage open expression of distress. In their words, both men as women were expected to pretend that all was well, avoid expressing sorrow, refrain from discussing the disaster and endeavor to return to "life as usual." These cultural norms conflicted with our basic assumption about the importance of discharge and personal expression in healing from trauma. We had to be sensitive to the possibility of conflicting messages that could confuse our trainees.

Circles of vulnerability
In cases of a major disaster such as a Tsunami, victims and helpers are similarly exposed, and often are enmeshed with each other. This social and emotional proximity makes the helpers' task difficult, as it is impossible for the helper to create the needed neutral space of security, a "potential space" where the healing process takes place (Winnicott, 1971). Helpers in the "circles of support" find themselves as part of the "circles of vulnerability" together with their clients. This "shared fate" of being victims/survivors and helpers at the same time placed extreme demands on helpers (Ayalon, 2003). Thus, many of our participants the grieved the death of members of their family, suffered loss of homes and devastation of their villages. One group of teachers barely survived the big wavewhich flooded their school. Luckily it happened on Sunday, when the school was closed. They were still under the horror of the brush with death, expressed as: "what if it had been Monday?"…
" I often speak with the other teachers about what we’re going to do if Tsunami happened again: Who would grab which kid? In which direction we would run? What would happen to the other children that I would not be able to reach? These pictures haunt me day and night."

Such re-current post-traumatic reactions emerged when the helpers identified themselves as part of the victims' "circles of vulnerability" in the aftermath of trauma. Helpers as well as victims may experience disruption of the sense of continuity of place and time, cause and effect, social connections and professional roles as a result of the disaster. Helpers may experience shock, confusion, frustration, fear, horror, and loss of the control over their life (Omer & Alon, 1994). Many studies point out the risks of burnout and secondary traumatization for disaster helpers (Lahad, 2005). helpers often suffer from "compassion fatigue", amplified by their physical and social proximity to the affected population (Figley, 1996). "Compassion fatigue" can have deleterious effect on their work and personal lives. Indeed participants reported symptoms of trauma, such as sleep disturbances, fears, recurrent images of the destruction, guilt for having failed to rescue others and also self accusation for having been saved while others had perished. Some vacillated between their "rescue fantasies" and apparent helplessness:
" We wanted to rush to the spot of disaster for help, but were scared that Tsunami will strike again".

Post-Tsunami verbal & non-verbal training

The goals of the training were:
a. To share theory-based conceptual information on trauma and healing.
b. To establish a safe place where trauma can be faced, expressed and contained, by transforming the traumatic memories associated with the sea into feelings of reconciliation and of trust.
c. To train the participants in verbal & non-verbal supportive methods which are culturally appropriate and transferable to survivors' communities.

a. The first goal was both didactic and experiential. Our program included essential theoretical information on different aspects of trauma: anatomical and neurological aspects, psychological and social aspects of traumatic and post traumatic responses. Participants received information and techniques of our "holistic model of coping methods". They learned to recognize risk factors and to understand the traumatic and coping responses typical to children and adolescents. Through experiential learning they received psycho-educational methods of treatment and of enhancing coping skills.

b. The second goal involved the understanding that in south-East Asia the sea that was the source of livelihood became associated with fear, pain and loss. In order to reach the second goal of desensitizing the disastrous connotations and memories, we invited participants to take part in a ritual of "appeasing the sea". This ritual was inspired by cultural rituals, while at the same time it reflected a method of healing based on metaphoric and creative activities. Participants were asked to create their own "symbols of security" by choosing a personal "healing color" and painting on sheets of paper, and. All the paintings were hung on a rope between trees alongside the beachfront.

Picture no 1 – symbols of security

Then they painted personal symbols on shells and coral stones found on the beach The painted shells and corals were placed on the water line as offerings to the sea. This ritual was accompanied by silent prayer.

Picture no 2 – offering to the sea
c. To reach the training's third goal, participants took part in a series of multi-sensory expressive experiential activities, geared to help them reach the pain that was hitherto locked up in their bodies and souls. It became clear that the Tsunami victims' horror and anxiety were contagious and affected the helpers. As it often happens, exposure to trauma triggered old traumas and flooded participants with memories of pre-disaster experiences of loss and grief. We attended to this by discussing issues of loss and grief in the plenary, and also by small groups body/mind activities. Healing activities of body-work, art-work and metaphoric story-telling Cope-cards generated many painful narratives of pre-tsunami times, such as childhood losses, parents' death, separation from a mate, painful divorce and difficulties in daily life. These body/mind activities enabled processing the loss and separation and broke the dam of cultural self-restraint. Participants reacted emotionally to the "permission to cry." They paired up to create a "buddy systems" for mutual support while sharing old grief and pain with each other. The sharing and caring allowed the expression of grief, which was then contained and eventually transformed into helping attitudes. The non-verbal methods included body awareness and pain release through light massage and aromatic smells, breathing and relaxation exercises, free movement to the sounds of music and vocal singing, art expression in color and shape for creating personal archetypal symbols and Mandalas.

Picture no 3 – painting symbols of bringing light into the darkness

Verbal activities included the narrating of the personal trauma stories. These narratives were elicited by the use of a special method called "COPE metaphoric cards" (Ayalon, Lukyanova & Egetmeyer, 2000). Participants introduced to this specially designed card-deck were asked to choose cards to portray their personal manner of coping with traumatic events in their lives.


Picture no 4 – the cards' circle

Half the cards were face up, while the other half were face down. The choice of the open card allowed a feeling of control and mastery, while picking up a card at random created suspense and surprise and prompted new learning and insight. The sharing in small groups brought forward a great number of stories of pain & loss, some dating back to early childhood. It seems that the common disaster triggered previous loss and unresolved grief, that were elicited by the pictures and shared in the confidence of the group. Having unloaded the emotional burden, participants were guided to look for their inner strength and find in the card the image of their coping skills.

Pictures no 5 & 6 – COPE cards for telling the trauma story

Re-narrating trauma on the road to healing
An essential component of any treatment of traumatic experiences is the debriefing of personal narratives of the traumatic experience and bearing testimony of the untold events (Ayalon, 2005). Workshop participants were encouraged to tell their stories in small groups and to listen to one another with empathy, devoid of criticism or advice. Releasing one's personal story, the horror of which was sometimes "beyond words", was made easier through artistic, creative and metaphoric expressive methods. It was obvious that re-narrating the trauma story contributed to the gradual discharge of the emotional burden during the post-Tsunami training. Giving and hearing testimony enabled participants to cast light on the darkness of the trauma, to reinstate order in place of chaos and confusion, to fill memory gaps and to authenticate what had happened. Supportive listening lent legitimization to the most bizarre and unusual personal experiences.

Tsunami stories from afflicted areas captured everyone's attention. One participant, who in the past months had refused to talk with local psychologists about her distress ("I was afraid that they will think that I was crazy "), described the despondent search for her mother, whose body was discovered three days after the destruction of her village. Another teacher shared the devastating saga of her flight from the big wave to the nearby mountains, her feelings of anxiety and desolation, and also her gratitude for the food and shelter local residents gave her. A school counselor told of the painful disenchantment after the first "honeymoon phase of social cohesion: " The disaster brought us together and created many instances of reciprocal help, but following the donation of money from other countries, suspicion and competition tore up the social fabric and the friendly atmosphere deteriorated". A sense of hopelessness echoed in some stories: " I lost my trust in the world as a safe place." Others expressed a collective guilt: "nature punishes people for destroying the environment".

Respecting cultural diversity – pacing & leading
Our great challenge as trainers from a foreign culture was to consider traditional and cultural differences and the variety of religious belief systems, such as Buddhism, Islam and Christianity and the diversity of traditional ways of coping. Southeast Asian cultures do not encourage expression of distress. Both men and women were expected to avoid expressing sorrow and weeping, refrain from discussing the disaster and endeavor to return to "life as usual." These cultural norms conflicted with our basic (Westeran) assumption about the importance of emotional discharge and personal expression. We had to be sensitive to the possibility of conflicting messages that could confuse our trainees. Our solution to that dilemma was to employ the Eriksonian method of "pacing & leading", (Rossi, 1986). "Pacing" or "joining" is a method of effective communication that enables the therapist to meet the clients within their own frame of reference, join them in their distress and understand their perspective from within their culture and their experience. "Pacing" relies on language, tone of voice and body language to create affinity, understanding and confidence. Once this is established we start "leading," suggesting new ways of expression and conduct that help release participants from being stuck in the aftermath of their traumatic experience. The technique of "pacing and leading" employed in a cross-cultural situation demands that trainers pay special attention to participants' non-verbal expression. "Pacing & leading" serves helpers to establish supportive contacts with varied populations of victims and survivors.

Coping Resources
The central axis of our "helping the helpers" training was the theory and practice of "positive psychology" that focuses on natural resilience and coping resources was. We stress people's innate or acquired ability to manage stress and crisis and to turn distress into an opportunity for growth. We applied this approach to the Tsunami workshops, using the multi-dimensional model of coping resources called " BASIC Ph " (Ayalon and Lahad, 1991 ; 2000 ; Lahad & Ayalon , 1994) used in training helpers and therapists throughout the world ( Rosenfeld, Caye, Ayalon & Lahad, 2005). " BASIC Ph " identifies six "coping channels" that together form the spectrum of coping resources: Beliefs channel, Affect (feelings) channel , Social channel, channel of Imagination and creativity, Cognitive channel of logic and thinking & Physical channel of bodily activity. We apply this model (Ayalon, 1992; Lahad, 1993) with families, groups and communities during and in the aftermath of personal or communal trauma, in situations of uncertainty, loss, anger, aggression, and vindictiveness (Ayalon,1998).

The following are examples of the variety of coping channels emerging from responses to the question: "what helped you most during and after the disaster?"

belief in God or in supernatural powers:
"At the time of the Tsunami I was praying in the mosque. The wave arrived abruptly, flooded the street, circulated the mosque and did not touch it. A miracle happened and I was saved."
Affect and expression of their feelings:
" There was a session where I experienced an immense feeling of pain inside me. It’s hard to explain. Even after you share your feelings with your friends, at the end of the day you stay alone with your thoughts. That’s why this workshop was very important for me: It allowed me to deal with my own feelings, so later I could help other people.” It was especially valuable to help heal those who will, in turn, try to help others overcome the trauma they suffered.
social skills:
"I volunteered to help people who were hurt. Their suffering was much greater than mine. By helping others I helped myself".
"Do you want to know how I was saved from death? As I was drowning I imagined a strong rope in the water. I seized it and pulled myself up. I was saved, in spite the fact that there was no real rope in the water".
Cognitive solutions, search for information and understanding:
"Two weeks after the Tsunami I could not fall asleep. So night after night I searched for information about Tsunami on the web. Then I started visiting schools and sharing my newly acquired knowledge. That is why they sent me to this training.
physical activity:
" I had to immerse myself in the hard work of cleaning the debris of the storm. This was the only way I could manage my anxiety and sadness". Another teacher said: "working with children I succeeded in calming them down by engaging them in vigorous movements until they tired, sat quietly, breathed deeply and relaxed".

There is no one single appropriate method of coping for all situations, all people or all ages. Each person, family, and community have their specific combination of coping channels, that constitute their basic coping language. The effective way for the therapist to help is to join the victims' basic language, and then guide them in developing additional coping resources. Dr. Amporn Sornprasit of Prince Songkla University, our local partner in organizing the workshop, summed it up: “Only now we understand that we, in Thailand, need to be prepared in the event of another crisis. Here we are training the new cadre of helpers and teach them how to assist victims and their families.”


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