Clinician's Digest


Clinician's Digest

Therapists without Borders

July/August 2015


Fifteen years ago, psychotherapist Jeffrey Kottler never imagined he’d be stuffing nine duffel bags full of antibiotics and suture kits for a return trip to Nepal. Or that he’d become so familiar with the long, arduous journey through dozens of trips after what was supposed to be a one-time visit to study maternal mortality rates in one of the country’s poorest regions. But this time, as the plane descended into Kathmandu, the scene was startlingly different from anything Kottler had ever seen before. Hundreds of makeshift tents peppered the ground below. “Holy crap,” he remembers thinking. “It looks like a nuclear bomb just went off.”

On his first visit, Kottler had trekked through southern Nepal’s thick jungles, mustard fields, and ramshackle villages, many of which had never been visited by a psychotherapist. Along the way, a chance encounter with a young Nepali girl changed the trajectory of Kottler’s life forever. During his visit to a remote school, the principal pointed to one of the female students, barely a teenager, and matter-of-factly explained to Kottler that, like dozens of other girls in her class, she was destined to be sold by her impoverished family into a life of sex slavery in neighboring India. Kottler was speechless. A paltry 50 dollars—which the girl’s parents would have otherwise received for selling her—was all it took, he recalls, to set her free.

In order to sustain his anti-trafficking efforts, Kottler founded Empower Nepali Girls (ENG) to provide scholarships to at-risk children, returning to the country several times each year since then with a small team. The organization now monitors nearly 300 girls in more than a dozen villages, using mentoring programs to stave off alternatives that might otherwise swallow them up: backbreaking labor, early marriages, and sex slavery. But Kottler’s program goes a step further in preparing these girls for a different life, priming them for careers in medicine, engineering, and teaching. “This is the single greatest thing I’ve ever done in my life,” he says. “Nothing comes close to this.”

As a psychology professor at California State University at Fullerton, Kottler has brought along hundreds of students on these trips—everyone from aspiring medics to pharmacists and hospital administrators. Meeting his cadre of female clinicians is an especially eye-opening experience for the girls, he adds. Many have never seen a career-oriented woman before. But Kottler’s manner of interacting with the locals is the real driving force behind ENG’s success, and a far cry from the daily routine most clinicians know, an uncommon blend of therapy, relief work, and social justice advocacy.

A crucial component of Kottler’s work involves visits to homes and schools. After following leads about struggling families—many with single-parent households, whose fathers either died or abandoned the family altogether—he interviews principals, teachers, and mothers to determine girls’ scholarship eligibility. After evaluating overall household stability and a girl’s academic talent, Kottler collaborates with her guardians on a game plan for the prospective journey through school and legitimate work. “So many of us work with middle-class people dealing with middle-class issues,” Kottler says. “These are life-and-death issues.”

But Kottler’s work in Nepal took a sharp turn on May 12. The day he returned, a magnitude 7.3 earthquake struck outside the capital of Kathmandu, nearly two weeks after a magnitude 7.8 earthquake had killed nearly 8,800, injured almost 23,000, and left more than two million homeless. Lacking earthquake-proof infrastructure, many of the country’s buildings—including half a dozen schools Kottler had been assisting—simply crumbled. With roads obstructed by rubble, UNICEF put out a special request for desperately needed resources: clean drinking water, temporary shelter, and psychological support.

As dozens of aftershocks rumbled in the following days, Kottler provided psychological first aid in brief sessions with traumatized Nepalis, again relying on his ability to bridge cultural divides with uncommon rapport. Sometimes, his help amounted to holding clients’ hands and looking into their eyes, as he did with one trembling 96-year-old man. In another instance, he simply held a 3-year-old in his lap, bracing the girl for the news that her parents hadn’t survived. Time and again, he bandaged wounds and treated respiratory infections, as lines hundreds of people deep coiled around the tent cities, seeking whatever help they could find.

“There is no training for this,” Kottler says, recalling the scene of infants crushed by buildings and headless bodies being tossed into ambulances. “The work becomes a matter of taking care of basic needs where there’s no hospitalization, no drugs, and no clean water. It’s not even third world. It’s fourth world.”

For nearly two weeks, Kottler slept with his clothes on and a flashlight in his pocket, the hypervigilance that his team had treated in so many clients slowly affecting him as well. But sharing his own traumatization, he adds, became a mutually healing process connecting him with those he helped. “I told people about my own terrifying experiences,” he says. “This resonated with them. It showed that I understood what they were feeling and enabled us to hold each other.”

So what separates therapists like Kottler from those who’d never think of subjecting themselves to the hardships of service in far-flung impoverished countries? What keeps them going back, even in the face of enormous difficulties and risk?

Like Kottler, Elaine Karas, executive director of the Trauma Resource Institute in Claremont, California, believes that what therapists can offer isn’t so much standard-issue therapy, but their skills at human connection. Her work is grounded in helping distressed people learn to reregulate their nervous system by having them tap into and articulate bodily sensations—which she says isn’t dependent on cultural upbringing.

Karas remembers some of her most formative career moments being in her work as a Lamaze teacher and doula, nearly 30 years ago. It was here she learned about the body’s resilience and the psyche’s vulnerability. But when two of her clients’ babies died, Karas’s focus shifted to understanding psychological resilience. “Our childhood education courses didn’t prepare us for this,” she says. “They prepared us for the joy of birth, not the suffering of losing a child.”

She decided to open a clinic for grieving mothers shortly afterward, and eventually decided that many of the approaches she’d learned to help mothers cope could also be applied in countries recovering from war and natural disasters. In 2006, she founded TRI, taking small teams everywhere from China to Darfur to Turkey. In traveling, Karas also learned how to communicate with people of widely varying cultural backgrounds by using common human experiences as her reference point. Working with Mayan migrants during a 2013 trip to Guatemala, she and her team used the country’s natural landscape as a metaphor to help people articulate their emotions and understand the activity of their own nervous system. First, the migrants sketched drawings of Lake Atitlan, the body of water central to their village. Then, they used the glasslike stillness of the lake and the storms that whipped up the water to convey the high and low points of emotion Karas had taught them about. At the migrants’ behest, these drawings were pasted in a floral pattern on the wall. The Tree of Life, they called it. “How beautiful is it to take the concept of nature and apply it to neuroscience teachings?” Karas says. In the end, the act of drawing not only became a source of deep comfort, but a means of building a sense of community.

Like Kottler, Karas is quick to point out that work with traumatized people isn’t for the faint of heart, and recalls feeling personally shaken, even years into her trips abroad. Visiting Haiti after the January 2010 earthquake, she admits feeling unprepared to handle the scope of the devastation, living among locals who’d been so severely retraumatized by aftershocks that they looked as if they were in a trance. “They weren’t in their bodies,” she recalls. “It was almost like those old zombie movies.”

By using mind–body techniques, including guided imagery to help access internal and external positive experiences—thoughts of loved ones, music, dance, and spiritual beliefs—Karas saw many of the people she worked with in Haiti rebound. Slowly, bit by bit, they were able to digest traumatic experiences, replacing negative emotions and sensations with positive ones. And for Karas, seeing these breakthrough moments had a restorative effect on her, too. “When these people shared stories of others who’d helped them survive, you saw them take a deep breath, their muscles relaxed, and they began to talk about their strength-based story of survival,” she says. “That’s what keeps me so involved in this work, so hopeful.”

While seeing a client break through the fog of trauma is in itself a reward, the fact remains that doing this type of work requires immense emotional fortitude, a quality that wavers in even the most skilled therapist. So who protects the protectors?

“Our philosophy is that we’re all in this together,” says Jim Gordon, who directs Washington DC’s Center for Mind–Body Medicine (CMBM) and does relief work abroad several times a year, including teaching mind–body skills to thousands of traumatized Gaza residents, victims of the recurrent conflicts between Hamas and Israel. Gordon’s ongoing involvement in Gaza was recently featured on 60 Minutes. He underscores that doing work of this magnitude requires a deep attunement to the needs of the healer, as well as to those of the target population. That’s why members of his team of 160 traveling clinicians, including surgeons, internists, and teachers, take an 18-month course where they not only learn mind–body techniques, like mindful meditation, deep belly breathing, and even dancing and drawing, but focus on small group work. Gordon says this group format—with a ratio of one clinician for every twelve patients—keeps everyone involved from biting off more than they can chew. Like Kottler, Gordon sees something primal in this type of work. “We’re speaking a universal language,” he says. “These small group circles are how human beings have gathered to help and heal each other since time immemorial.”

An integral part of the CMBM repertoire is peer counseling. Regardless of whether the team is in Haiti, Gaza, or Turkey, each day ends the same: the therapists gather together and talk about anything that might have personally triggered them. This, Gordon says, is an experience that separates the work his team does from that of most private practitioners back home, providing regular access to camaraderie and a sense of shared purpose. “People come on these trips looking for something more,” he says. “They’re looking for a new way to practice.”

Amy Shinal, CMBM’s clinical director, echoes Gordon’s sentiments about the importance of peer support in helping therapists work through their own triggers. “As a group,” she says, “we connect not just around what we’re teaching, but around what’s happening within ourselves. This work utilizes every single part of you. As a therapist and a human being, it stretches you in ways nothing else ever will.”

So what sets these therapists apart? Perhaps it’s their willingness to commit to a job that’s never truly finished. Later this year, Gordon and Shinal plan to work with Tibetan refugees in India, and again with displaced Palestinians in Gaza. This summer, Karas plans to travel to Nepal to assist with earthquake recovery efforts. Kottler plans to return there in December.

Going back to some of the world’s most devastated regions time and again doesn’t make this work any easier. And many say it’s easy to view your own efforts as insignificant when the scope of devastation and suffering seems so immense. But it’s the sense of a higher calling—an even addictive urge to meet the world’s neediest where they are and experience the healing relationship in its most fundamental form—that keeps them steadfast. To keep doing this kind of work requires a basic belief that in the midst of devastation and need lies the potential for recovery and resurrection. “If we can help with healing on individual levels, then it eventually ripples outward,” says Shinal. “Maybe we heal a family and then it ripples into a community. I’ve seen it happen. Once you’ve experienced this, it shifts your thinking about what’s possible.”

—Chris Lyford




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