THE PHILIPPINES-January 2014 and April 2014
UPDATE: The CRM Skills Trainers in Cebu have created a nonprofit to spread CRM skills throughout the Philippines. The organization is called Phillipines-CRM Skills Trainer. Tess Hernandez, a leader in domestic violence awareness will be its President. Elaine Miller-Karas skyped with the organizers as the new group was being formed. TRI will offer educational support and there are plans to return to the Philippines in the winter of 2014-15.
TRI conducted two trainings on Guimaras Island for individuals from social service agencies, religious and community organizations. This project is co-sponsored by ADRA International, the Unitarian Universalist Service Committee and Loma Linda University. Approximately 80 people were trained to be CRM Skills Trainers. The participants were enthusiastic and completed their student teaching in villages on the Island of IloIlo.
The Philippine Typhoon Yolanda Project (PTYP) was initiated by the Unitarian Universalist Committee and TRI as a result of Typhoon Yolanda that devastated a large part of the Philippines on November 8, 2013. Typhoon Haiyan, known as Typhoon Yolanda in the Philippines, was an exceptionally powerful tropic cyclone that devastated portions of Southeast Asia particularly the Philippines, in November 8, 2013. It is the deadliest Philippine typhoon on record, killing at least 6,201 people in that country alone. Haiyan is also the strongest storm recorded at landfall, and unofficially the strongest typhoon ever recorded in terms of wind speed. More than 1.9 million were left homeless and more than 6,000,000 displaced. In Tacloban alone, ninety percent of the structures are either destroyed or damaged while other cities, such as Ormoc, are reporting similar damage. Casualties have been reported as a result of the lack of aid in affected areas and the number of dead is likely to rise. Psychological reactions as a result of this natural disaster can be expected. The Philippines had many typhoons in 2013 and a major earthquake in Bohol (7.2). It is reported that the extreme weather is becoming more problematic and climate change is of concern.
Elaine Miller-Karas, the Executive Director of TRI and the creator of the CRM Train the Trainer program for the Philippines headed the team to Cebu City. Michael Sapp, PhD, Kim Cookson, PhD, and Lovelyn Santos, B.S.W. rounded off the team from TRI. Ms. Santos has been a trainer since 2008 and she brought a special expertise of the culture as she grew up in Manila. Dr. Sapp and Dr. Cookson are both psychologists experienced in facilitating and training in the Community Resiliency Model skills. Rainero Lucero, UUSC’s Philippine Coordinator was an excellent organizer. She had prepared the trainees before our arrival with information about CRM.
The training groups were called Batch 1 and Batch 2. Batch 1 was trained on January 14, 15, 18, 24, 25 and Batch 2 was held on January 16, 17, 18, 20, 21. The trainees were brought together for one training day on Saturday, the 18th to learn the children’s exercises. We ended early on January 18th as it was the first day of the Festival of Santo Nino in Cebu where literally millions of people attend throughout the Philippines. Santo Nino (the baby Jesus) is the patron saint of Cebu. There are 171 different dialects in the Philippines. Everyone in the training had a working knowledge of English except for one, who understood but could not speak with proficiency.
The dialects included Tagalog and Cebuana. We encouraged the student trainers to give their presentations in their most comfortable dialect. Participants acted as interpreters when this occurred. The participants came from a wide variety of NGOs throughout the Philippines and many from the most impacted areas. We were fortunate to have a vital group of leaders who attended from many NGOs already working with individuals at risk within the Philippines before typhoon Yolanda hit in November. The participants have been providing services to the individuals in the impacted areas. We witnessed a high degree of commitment to bring CRM skills to their people. There were a wide variety of activities that included traditional songs and dancing that were interwoven within the training. TRI has found asking participants to share a song and/or dance is a way to join in a positive way with other cultures and a way to develop communal resourcing.
Community Organizing Plan
The last portion of training was spent brainstorming with the groups about the next steps. All trainees described the importance of using the skills for self-care. The following additional items came out of the discussion.
- As the trainees, for the most part, are seasoned community organizers and a lively discussion was held in both groups about plans to role out the CRM Skills Training
- Some participants felt that the CRM skills could be folded into what they are already doing to help individuals and communities. More than one person stated the skills, especially tracking was the missing piece from many models that had learned.
- Each organization spent time discussing how they would share the CRM information with their staff and then more broadly in the community.
- Some trainees felt it was important to reach out to governmental officials to explain the wellness aspect of CRM.
- Many members who worked with a cross section of ages felt that the skills could be modified to bring into all the groups.
- The CRM trainers will act as mentors once they have taught others the skills.
- Both groups felt it was important to translate the materials into different dialects.
- Some groups wanted to designate a point person in the areas affected and then train the point person in the CRM Skills. The CRM Trainers from Cebu would act as mentors.
- The participants felt that they could help each other and wanted email information to make contact with others in the training.
Since the trainings ended less than a week ago at this writing, many of the participants are expanding their visions about how to bring CRM skills forward to help survivors of the typhoon and their community in general and sharing how they are integrating the skills. Since returning from the training, I have received many emails regarding going forward with teaching the CRM Skills. Here are some highlights:
1. From Irish Ramirez “…I was able to share the basic 3 skills of CRM to 10 Community Health Workers … At first, they were a little bit uncomfortable since we are not use to share what we usually sense in our body but as we go on.. they found out the importance of it, appreciating how it works on themselves. I’m happy too that they said they going to share it with the members of the organization before their meeting starts and also with their patients who are from their communities too. I still have my schedule there so I can have my follow up.. I will be sharing it to you next time.
I will be sharing the CRM also in Bohol in a student organization composed of nursing and psychology students. this will happen Feb 4-5, 2014 since we integrate the CRM in our psychosocial module so we will be sharing it our volunteers too.”
2. From Tish Vito Cruz “Missing everyone since we left Cebu. I will share CRM to 10 SARILAYA members in Northern Samar (Catarman) on Feb. 1-2. One member who happens to be a college faculty member there will also bring her 15 students on community development to listen to the sharing. Then I will proceed to Eastern Samar for a courtesy call to two Mayors & 8 Barangay Captains in relation to SARILAYA’s project on gender-based violence prevention in their respective municipalities, all Yolanda-affected areas. Will conduct CRM TOT in both municipalities after we pick the dates. Will update you on the CRM sharing after my return to Manila on Feb 8.”
3. Catherine Roden thanked another participant for finding additional information about one of the skills, “Grounding” and she wrote the following: “…Thank you very much for this resource…it has strengthened my resolve about the health benefits of grounding. I am also happy to tell everyone how I was able to help a co-worker through Help Now (pushing against the wall) get back to her resilient zone when she faced a stressful situation. I pushed the wall with her and used Tracking to let her be aware of what’s happening to her body. The quick exercise helped her calm down and get her breathing and heartbeat steady. The amazing sensation of warmth inside after knowing that the skills can really help us and other people has become a great reason to continue teaching the skills to others. God bless you all!
There were many comments made by the trainees about the usefulness of CRM. However, the comment that had great meaning to TRI that expresses our intentions as we bring the Community Resiliency Model to our world community was expressed by one the trainees in Cebu, the Philippines, “The conduct and demeanor was very open and non judgmental that hastened my learning process and served as a living inspiration to pay it forward.”
TRI will continue to provide more information as we go forward and receive feedback from the new CRM Skills Trainers of the Philippines. I will end with a poem that was written by Tess Fernandez, the leader of LIHOK and shared the last day of the training in Cebu:
We are body mind and spirit
The body houses the mind and spirit so…
Listen to your body
Trust your senses
Feel your gut
Imagine if everyone is in their best self – the Resilient Zone
Here and now
It would be a beautiful world!
TRI is working in association with the Nichi Bei Care Network, a group of dedicated Japanese-American clinicians and others, who are creating a network of trained clinicians to bring culturally-sensitive information about the Community Resiliency Model to the area impacted by the tsunami and earthquake of 2011. Satsuki Ina, PhD, is heading up the network and Nobuko Noni Hattori, PhD is the coordinator for this project with TRI.
THE CHINA EARTHQUAKE RELIEF PROJECT (CHERP)
The China Earthquake Relief Project (CHERP) was co-sponsored by the World Health Organization, the Foundation for Human Enrichment, the United Foundation for Chinese Orphans and the Trauma Resource Institute. This project began in July of 2008 and was initiated by Robert Blinn, PhD, Director, Psychological Health Center Beijing United Family Hospitals and Clinics, after the the May 12, 2008 earthquake in Sichuan Province.
The project was implemented collaboratively by the Foundation for Human Enrichment and the Trauma Resource Institute (TRI). The Foundation provided two teams and TRI coordinated 5 teams into China. The goal of this project was to bring biological based interventions to the Chinese people impacted by the earthquake. The project trained health providers, mental health providers and community members in the skills of the Trauma Resiliency Model(TRM) and Somatic Experiencing(SE). Individual and group sessions were offered as well as didactic trainings. The overreaching goal was to increase capacity within the Seichuan province with regard to education and skills that were trauma-informed and resiliency-informed.
The TRI teams were welcomed wherever we were asked to deliver the trainings. Roberta Lipson, CEO of Chindex and Rob Blinn, PhD helped create a welcoming environment that expedited our ability to conduct trainings and create capacity within the Seichuan province. Team members were supported by the extraordinary students from Beijing who spoke excellent English and became very proficient in the skills.
Research was conducted and results of training evaluations received from approximately 350-367 trainees indicated 97% of the respondents believe that the biological-based training would be very to moderately relevant or useful for their work with earthquake survivors, and about 88% said they thought they will use the skills very to moderately frequently during the two weeks following the training. An Additional 60% of the trainees reported they would be able to use the skills they learned from the training for their own self-care.
The following is a report by Elaine Miller-Karas and a description of one of her sessions in one of the camps:
The Beichuan Hospital, the City of Beichuan & the Resettlement Camp
We were told we would train at the Beichuan Hospital and the next day work in the Resettlement Camp providing sessions. Each day, we gather for the hour or so ride in the ambulance for the trip. The seats are hard but the conversations are lively and at times, we sing songs from the 60’s and songs from our favorite show tunes. It is warm and humid and the smoke from our driver’s cigarettes permeates the air. Rita, Harriet and Rhine, our translators, sing Chinese songs. They giggle and we are touched by the rhythmic sounds of their sweet, clear voices.
As we ride through the roads toward Beichuan, we are confronted with the ruins of the damaged buildings. We understand much has been cleared away but there is enormous damage; it will take months or years to remove the debris. There are also the vistas of new life. The crimson red of the bricks of rebuilding is threaded through the roadside alongside the blue tents of recovery. The color yellow of corncobs splashes the landscape of the roadsides, as they hang to dry in front of the blue tents. The roadways are full of life, children laughing and playing, people talking, riding their scooters and bicycles, and building new homes. Yet as we drive closer to Beichuan Hospital, the mood changes within the ambulance as the damage from the earthquake becomes more vivid and more global. The carcasses of ruined buildings floods us; there is a pallor in the air; the day is smoky from the fires of rebuilding; the mountains loom, surrounding the ruins, framing the damage making the images more discrete.
We arrive at the hospital, and are guided to a medium size room, full of computers and two or three people working. An officer of public health greets us. They tell us that most of the medical personnel today are taking a mandatory exam and only a few people will be available to teach.
The room slowly fills with doctors and nurses and the noise from the building distorts our voices as we try to speak. There is a sound of a chain saw, then a bullhorn and over a short period of time, 5 or 6 cell phones blast through the room; the room is like a tin can and each time someone moves a chair and steps outside, the sounds of movement vibrate and ricochet off the walls. The translators have difficulty hearing us through the commotion. The participants are clearly in a high state of activation. The staff is short-handed because of the exam. Also, half of the health care providers were killed in the earthquake. Because of the activation of the doctors and nurses, we decide to shorten the training and work the second part of the day providing sessions for them. Flexibility and change is as important as the air we breathe when we are in a disaster area.
Later in the day before we return to Mianyang, Dr. Zhau, from Mianyang, our host in the field, takes us to the vista site, high on a mountaintop, so that we can see the City of Beichuan. The Chinese government has put a huge barbed wire fence around the parameters of the city, which is down in a valley. The barbed wire fence can be seen for miles. The local residents have set up food stands and concessions selling incense and photos from the destruction.
It is the most sobering vista I have ever experienced. Cars drive up and citizens quietly leave their cars and with a solemn reverence look out into the valley that is now a tomb for literally thousands upon thousands of people. We were silent and many of us had tears in our eyes. The enormity of the loss was omnipresent.
Next, we visit the ruins of Mianyang Middle School where 2000 children and teachers lost their lives. There is a skeleton of two stories of what was a 5-story building and a pile a rubble that runs wide and high. Within the rubble, vestiges of happier times are visible – school desks, notebooks and children’s shoes are strewn throughout the rubble.
Parents of the dead children have left flowers, bowls of fruit, poems, and colorful umbrellas at the site in memory of their children. We stand on the basketball court that was unscathed, our team of 12 and stare in silence, transfixed by the ruble and the loss. Our young translators are overcome with grief and those of us from America stand next to them with our arms around them as they shed tears for the innocence and the lost potential of each one of those little lives that will never grow up and who will be encased in this cement tomb for eternity. As we stand there in our grief, we are suddenly reminded of the resiliency of life when all of a sudden children’s voices laughing echo through the school site, as they play on a nearby hillside.
When we arrived to the hotel, we had our team meeting and we are exhausted.
The Resettlement Camp
We have learned to have a plan but not to be tied to any plan because arrival to our destination may present us with a different challenge. Our team members work well together and we have developed a nice collaboration with our translators. The shared experience and our intention to the group process have created a strong bond between the 12 of us.
When we arrive, we are escorted to a large community room. Bookshelves of children’s books line one wall. There are desks at one end and many chairs in front of the desks. An elderly woman of 72 years of age arrives first and she tells us how she and her husband survived the earthquake and that the land for the resettlement camp used to be where her home stood. She is very talkative and tells us she is doing fine since the earthquake and is glad to be alive when so many have lost their lives.
Within a few minutes, the room quickly fills with adults and children. There are about 40 people in the room and there is the rustling of anticipation, children are laughing and crying and they are waiting for us to speak. We begin by talking to the group about who we are and why we have come. I relate a short story about being in many earthquakes in California and how unsettling it is after always to feel like the earth is shaking when it isn’t and feeling shaky in my legs. The people responded to this personal experience and when I asked if anyone had had an experience like mine, the whole room practically stood up and shouted in agreement.
We then share that we are going to show them some simple skills that might help them feel better. So we introduce grounding. Many people respond that they feel their breathing slowing down and then one women raises her hand and says she felt her heart rate go up when she pushed her feet into the ground. So, I ask her for permission to work with her. She answers in the affirmative and we begin to work. Soon after, each TRI team member is working in a corner of the room. Friends and family surround their family member who we are working with to give added support. There is also a great curiosity. Brenda Williams and Ellen Elgart play the games with the children. TRI’s children’s games vary dependent upon the culture. We researched the games common to the children of China. Our translators shared with us their favorite games of childhood. Culturally sensitive games we have found can become another positive resource. Also, most children’s games have some degree of sympathetic activation where we can track the children during the game and after the completion of the game to see whether or not the children can regulate back into their resilient zone. In China, they have a version of a “tisket a tasket” called “drop the handkerchief” and “tug of war” that is called “pull the river”.
We also have sheets and play parachute games that we have expanded upon from our research into Jane Ayre’s Sensory Integration Theory. Sensory Integration Therapists have used many parachute games since the early 1970s. Also, the book 465 Parachute Games is a very helpful book that describes many ways to use parachutes in healing play. We like to use sheets because our trainees can easily replicate the parachute games once we leave the area.
Pat Kouwabunpat, MD, is a family physician, from the United States. He did his senior thesis for his family practice residency program on how to use somatic-based therapies in primary care medicine. He is a great help on the team. He introduces the TRM training by talking from a physician’s perspective on the importance of somatic-based therapy. He illustrates his presentation with stories from his medical practice from the United States. The doctors and medical students have been very interested in his perspective.
The Resettlement Camp-Case Report
The young woman was identified when during the group grounding exercise she became more activated. Her left foot and leg started to shake uncontrollably. She said that her legs always shake when she sits quietly. While walking, she reports that her leg is fine.
Explanation: Shaking could be a discharge from the injury she experienced at the time of the earthquake or something else.
Intervention: The decision was made to bring her attention to the sensation of shaking to see whether or not the shaking would lessen. Her leg’s movement lessened in intensity and the client took a deeper breath. The change was brought to her attention and she was asked to notice the difference. She activated her parasympathetic nervous system and a relaxation response resulted and her leg stopped shaking.
Explanation: Grounding with the feet can result in some individuals feeling more activated and resulting in sympathetic hyperarousal. This is true especially if there is an injury to the legs or if there is an implicit memory capsule of bracing from past experiences. She recounted that she was pinned from her waist done by a large stone. As she recounted the story of being pinned, her leg began to shake again. As a result of her injuries, she was in the hospital for several weeks and she lost the toes of her right foot.
Intervention: She was asked if we could try a different form of grounding that might help her. She said, “yes”. She was invited to draw her attention to how her back was being supported by the chair. When she did that she immediately took a deeper breath and her face muscles relaxed. Her leg temporarily stopped shaking as strongly. She smiled and reported that she felt more relaxed and she was invited to notice the changes inside.
Explanation: The next treatment task is to establish resources. We wanted the client to experience once again her body’s ability to self-regulate to further anchor positive sensations within her nervous system.
Intervention: The client was asked about what gave her strength or pleasure in her life. She responded “my children”. She was asked to tell us about her children who were part of the group and her older daughter was by her side and her smaller daughter was tugging at her shirt. She smiled warmly and told us how much she loved and cared about her children. As she described her children, she was asked to notice what was happening inside her body. Her body again went into a deeper sense of relaxation and she was invited to keep noticing it.
Explanation: In the beginning phases of treatment, it is important to evaluate the client’s ability to experience the resiliency within the nervous system. The client had been very traumatized from the earthquake, hospitalization and separation from her children. She, however, could sense her body and access her parasympathetic nervous system. In trauma, people often lose the ability to sense their own healing capacity. The knowledge of her body’s ability to self-regulate can be another new resource for the client. She then began telling us about the earthquake. She recounted that she felt pressure and pain from her waist down to her feet when she thought of the earthquake. Her leg began to shake once again.
Intervention: When asked if there was anywhere in her body where she did not feel the pressure and pain, she said, “my left hand.” She was invited to draw her attention to the left hand and to notice what happened next. She brought her awareness to the inside and said that she did not feel the pain and pressure in the same way; it was less. We invited her to notice the difference inside the body. This skill called “pendulation” was at first directive and then a spontaneous pendulation occurred which evidenced the body’s own capacity to heal. She was surprised to feel less pressure.
Explanation: When working somatically, there are therapeutic decision points. In the above scenario we can:
1. Use the skill of Titration and ask her to image the pain on the inside (does it have a shape? color, size? and then titrate it by, for example, sensing an “edge”.
2. Use the skill of Pendulation that was used, or
3. Restore defensive responses by asking her if there “is an impulse” of what her body wants to do at this moment as she thinks about the pressure on her body.
It was decided to use option number 2 to give her an internal experience of spontaneous pendulation so she would gain more confidence in her body’s ability to self-regulate.
Intervention: She wanted to tell me the story of the earthquake. She was respectfully interrupted so as not to overwhelm her nervous system. She told us about the injury to her leg. Her leg began to shake again. She was then asked if she would allow me to hold her left foot. She said, “yes” and she was asked if she would push her left foot against my hand. As she did that, she experienced a big release; she felt heat, tingling and trembling. She was asked to draw her attention to the release sensations. She then spontaneously said, “My leg feels safe for the first time since the earthquake.” I invited her to notice that and she felt a deep sense of relaxation and calm.
Explanation: Sensing the large muscles of the body can help regulate the nervous system, whether someone is “Stuck on Low or Stuck on High”. In her case it pendulated her from a state of hyperarousal and brought her back to her resilient zone. She suddenly, had a traumatic flashback and she shut her eyes and said she felt like the ground was shaking and everything was happening again. Her foot went back to the ground.
Intervention: Deactivation strategies were immediately used. The client was asked to open her eyes and look around the room. As she did this, a deeper breath was noticed, she opened her eyes and reported that the sensations lessened. She was again invited to notice the changes.
Explanation: Sometimes, if the parasympathetic nervous system response is sensed too deeply and not sensed more laterally, the person will flip into traumatic activation. Although this was not the intention, it happened in this case. It is important that the practitioner know deactivation strategies just in case this happens. Strategies including touch can be used to bring the client’s awareness back to the present moment.
Intervention: Dr. Robert Scaer’s metaphor of “memory capsule” is an easily understood concept for most people. This is a simple way to explain implicit memory. Psychoeducation was threaded into the session. Memory capsules were explained.
Explanation: Psychoeducation is an important way to normalize and depathologize distorted or misinformed beliefs about symptoms related to traumatic experiences.
Intervention: She again went into a more balanced internal rhythm, and she was asked to tell us more about the moment she knew she was going to survive. She related the day she was released from the hospital and saw her children for the first time. They all cried and she felt like everything was better. As she told us about this, she was again invited to notice what happened on the inside. She again activated her parasympathetic nervous system, which was evidenced by a deeper breath. She also reported warmth, tingling and her face was released of tension. These changes were brought to her attention and she noticed the changes.
Explanation: This intervention of bringing out the end of the story when the client can sense into the survival energy is another way to establish resources within the body. The client had many pendulations into resources and she was able to sense sensations of survival, happiness and release. When we have knowledge that the client can access positive resources and the client can pendulate out of traumatic material and back into the window of tolerance, we can move into helping the client restore the defensive responses.
Intervention: She then started talking spontaneously about being pinned by the earthquake and as she did so she moved her hands as if she was pushing away the stones. She was asked to repeat the movement and then to notice what was happening inside. As she did so, her hands went into fists. She was asked what she wanted to do with the fists. She said, “I want to run. “ She was then asked if she could imagine that she was running and let her hands move in the way they wanted to move. She then moved her hands and feet in a way that looked like she was running. She was instructed to slow down and asked to notice what was happening inside as she was running. As she completed the defensive response, she experienced tingling, heat and trembling. She felt a sense a relief and brought her right hand to her heart and her left hand to her belly. As she went into this soothing position, she was invited to bring her attention to that. She again took a deeper breath and she said that she felt calmer inside like she really did run away from the earthquake. As she said that, she smiled and we could track that something had shifted.
She then reported that she has had difficulty going to sleep since the earthquake. The images of the earthquake kept coming to her head. She shared with us that she could place herself in the position of her hands on her heart and stomach when she was going to bed. She thought this would help her sleep better and maybe remove the images from her head. As she was reflecting on this new thought, we invited her to sense her whole body and to notice the changes she had experienced since we started. As we ended the session, the woman smiled and she appeared more peaceful, her heart rate was in normal range, her breathing was even and her leg had stopped shaking.
She was also instructed to repeat the spontaneous gesture of healing that had emerged at the end of the session and to sense into the posture at night and during the day to help her continue to sense into her internal balance. She was also encouraged to think about the shaking of her leg in a different way. We reminded her that when she allowed the shaking of her leg and noticed the release, she felt better in the session. So, if she allowed this to happen in the course of her daily living, we hoped for the same result for her.
Explanation: At the end of the session, it is important to bring the client’s will help her body remember the changes. New neuronal pathways can be created that are now about her resiliency and her body’s ability to release the traumatic energy. This can also can establish another resource.
She then invited me to her resettlement home. So, the translator, Rita, the woman, her two children, a host of other smaller children and I, walked back to her home. The children loved the digital cameras and I took many photos of them and they wanted to see them all. Her home consisted of two small rooms with bunk beds and one full size bed. There were two small coaches, a TV and a table. She insisted that we sit down and have a snack with her and her family. She brought raw peanuts for us to eat. She asked me about my children and I showed her photos of my kids. We then told her we had to leave and she brought us a bag of peanuts as a gift. It was clear that this gift to us meant a great deal to her. She gave me a hug and we took photos of her, her children and mother in front of the house. She thanked me for coming such a long way to help her.