Project presentation: “Multidisciplinary Group Treatment for Refugee Patients with PTSD /CPTSD and Psychosomatic Comorbidity”

Introduction

For many years, Sweden has been a destination for refugees from various countries seeking a safe place to resettle and begin a new life. Some of them are traumatized people that seek help at the “Crisis and Trauma Unit” in Gothenburg, Sweden, a public health outpatient service founded in 1994. The center delivers clinical treatment to adult refugees with torture-and-war trauma-related mental health issues. Many of our patients are dealing with extreme forms of traumatization, in many cases, meant to dehumanize the whole person also through the violation of their bodies and their human rights. War-and-torture trauma involves an ethical and a political dimension that frames our work.

The majority of those who are referred to us are diagnosed with Post traumatic stress disorder (PTSD) or complex – PTSD (CPTSD), depression and other anxiety disorders (World Health Organization, 2018). Anyway, focusing only on diagnostic terms implies a risk to underestimate essential aspects of their suffering, including the experience of forced exile. Thus, we adhere to the description of traumatization as given by professor, psychoanalyst Sverre Varvin: A biopsychosocial process that compromises the whole existence (Varvin, 2017). Some patients struggle with somatic and /or psychosomatic co-morbidity, and they who present a more complex picture of suffering have generally been more difficult to help. The unit provides various forms for trauma-focused, and trauma-informed treatments, primarily through individual psychotherapy. This conforms to evidence-based requirements, and the individualistic culture in Sweden. We believe that this not always suffices in our clinical work with refugees from collectivist societies, where the healing of traumas often occurs within a group context. We contend that employing an integrative, culturally sensitive, group-based intervention with this population could potentially yield efficacy. Therefore, we aimed at developing a group therapeutic model where two different professional perspectives, and their practical approaches to trauma treatment, could purposefully complement and support each other trying to meet these patients’ needs.

Searching for our subject in scientific databases and literature we found models or proposal that, although interesting, were based on different theoretical frames, or did not implement the concept of co-therapy as we mean i.e., two therapists in the same clinical setting integrating their interventions. (Kira et al., 2010) (Bunn et al., 2016).

In this text, our intention is to describe and reflect upon the structure of a case study that explores the potential of working in a group setting, integrating two different professions—psychologist and physiotherapist in co-therapy. This approach questions and challenges a dualistic perspective in trauma treatment. The material and vignettes here presented are illustrations, and do not aim to show any evidence. We selected them from a very consistent number of clinical notes and personal memories.

The objective was to create an innovative group treatment framework within our clinic. Thus, we conceived, planned and implemented a Multidisciplinary, time-limited, clinical treatment model for patients severely traumatized by war and/ or torture, living in exile, and who suffer from PTSD /CPTSD, and psychosomatic comorbidity. The primary aim of the group was communicated to the patients as an effort to shed light to and process how post-traumatic distress impacts on self-perception and interpersonal interactions. Hopefully contributing to positive change and enhance well-being by addressing issues concerning emotion regulation, negative self-perceptions associated with shame, guilt, trust, difficulties with interpersonal relationships, as well as exploring how these aspects manifest within the physical body.

Theoretical approach

Clinically we integrate and adapted a psychodynamic process-oriented group therapy approach, with Norwegian Psychomotor Physiotherapy [NPMP] (Bunkan, 2001) (Garland, Hume, & Majid, 2002), (Garland, 2009), (Sandhal et al., 2014). The model’s overarching theoretical frame of reference is phenomenology, since we think it can purposefully harbor our theoretical and clinical approaches. In phenomenology the subject of “body” has been a relevant subject for reflections, especially in the work of Maurice Merleau-Ponty (Merleau Ponty, 2014). Having a phenomenological perspective on the body means not reducing it to its mere biological functioning and conceived it as a “bearer of meaning”, “filled” with lived experiences, a perspective that can be summarized in the concept of “embodiment” (Kirkengen & Thornquist, 2012).

Norwegian psychomotor physiotherapy is a clinical treatment developed in the 40-50’s of the past century by physiotherapist Aadel Bülow-Hansen, and psychiatrist, psychoanalyst Trygve Braatøy (Bunkan, 2010). Springing from clinical practice it became an established treatment in the Norwegian public health system, and an academic specialization at Master level. Grounded in a phenomenological understanding of the body, it’s electively administered for the treatment of clinical conditions that can benefit from a body-oriented approach, often presenting with a complexity of somatic and psychic comorbidities like chronic pain, and functional syndromes combined with psychic symptoms, traumatic and post-traumatic outcomes, and even more severe psychiatric conditions (Bunkan, 2001; Gretland, 2007). NPMP is a person-centred, and process-oriented method, grounded on a phenomenological understanding of the body (Gretland, 2007). Originally conceived for individual treatment, it was further adapted to fit group treatments, and multi-professional contexts. For all these reasons we argued that NPMP could fit well in the design, in combination with a similarly process-oriented psychotherapeutic-psychodynamic approach.

Trauma, the body and psychoanalysis

“Trauma” is a central and controversial concept in psychoanalysis, (Freud, 1920). We will here only shortly try to describe our understanding of war related trauma and torture. Sverre Varvin, describes the central feature of the post-traumatic condition as the inability to sustain a sense of basic trust and the loss of the internal empathic other. (Varvin., 2003). Traumatic experiences tend to corrode the dialogue with internalized safe others, necessary for developing the capacity for self-reflection and processing. Language falters, leading often to silence and avoidance as mechanisms to cope with anxiety and intrusive memories.

Boulanger (2005) describes the effects of terror and annihilating experiences in adulthood as a collapse of the self both as a neurobiological and a psychological/symbolic experience. Basic experiences of being a subject, a whole body, an active agent in life, are shattered. The self’s ability to identify, interpret, and self-regulate cracks, as well as parallel deterioration of the capacity to identify the feelings and emotions of others, thereby disrupting shared intersubjective encounters. Anxiety and the inflow of excitation, whether of external or internal origin becomes unmanageable. Traumatization can be conceptualized as a breakdown of symbolic functioning and bodily perception. The term “body” in this context, must be understood both as a somatic body, and “psychosomatic” body, laden of symptoms and meaning.

The traumatized individual often withdraws emotionally from the world around him/her, reinforcing personal boundaries as a defence against potential and imaginary threats, becoming self-centred and self-preoccupied. Traumatization must be understood as a subjective experience with a direct impact on an individual’s intertwined psychic and somatic functioning, as well as a collective experience influencing intersubjective processes, family dynamics, identities, and broader social and cultural issues.

The model

There are various guidelines and models available for trauma-informed group therapeutic interventions, as well as body-oriented treatments for trauma patients. (Kira., 2010) However, none of them aligned with our institutional context, specific treatment goal, patient group, and our professional knowledge.

Drawing upon adapted group dynamic principles and our aspiration to find NPMP body interventions to enhance and support the therapeutic process, we carefully considered the group’s committed goals, and we defined a roadmap to guide our journey.

The group started on February 2022 and met for one and a half hours, every Tuesday until June 2023, spanning one and a half years, with just three breaks for holidays of different duration. In total, the group met for 59 sessions. The predetermined time limit of 1,5 years was established from the very beginning. While we could dedicate an entire presentation theorizing and reflecting on this matter, let us limit here to acknowledge it as intrinsically tied to the issues of separation, loss, and disillusionment—themes strongly associated with exile—that we needed to address throughout the process. Giving a time limit for the treatment can be seen as a symbolic way to try to set an end to the internalized war still carrying on in our patients’ minds and bodies.

The group

Recruiting was conducted through the routine assessment process at the unit. The group comprised four women and three men between 39-56 years old. Both Christian, Muslims and non-religious. Ethnicity was unexpectedly quite homogeneous since five patients were from the Balkans and two were Arabic men. Exclusion criteria comprise diagnosed and untreated orthopedic injuries or organic diseases as primary problems, psychosis, severe dissociation, antisocial personality disorder and a residence permit with a duration of less than two years. A short presentation of the members follows, in anonymized form.

Patient 1. Man born with a congenital malformation of an internal organ, potentially life-threatening. He experienced war, was severely tortured and sexually abused in prison as a young man. He came to Sweden in the 90s, and he’s married and has adult children. Disabled and workless for the last 6 years, he has feelings of shame, inferiority, and presents with strong evasive defenses and a somewhat immature personality. Extremely anxious, he complains compulsively about physical symptoms, and worries constantly about the breakdown of his health.

Patient 2. Woman who experienced war as a young mother and witnessed the rape of a friend. She accepted to take a vow of silence, and years later her friend committed suicide. This led the patient to seek for psychological help. Emotionally very restrained and silent, she presents with a rigid body, and controlled pattern of movement. She has been on sick leave for 50% of the last years.

Patient 3. Woman exposed to extreme trauma as a young mother during the whole period of war. After her exile to Scandinavia, she developed severe psychological problems that required inpatient care. Eventually integrating to society, overworking for many years thus developing chronic pain problems which she overlooked, resulting at last in a herniated lumbar disc. She presents with a rigid pattern of movement, with symptoms of depression, and feelings of shame. Married with adult children, she has a very strong bond with them.

Patient 4. Woman traumatized during war. Her parents were from different ethnic and religious backgrounds, and questions about identity and belonging are central to her. She suffers from generalized pain problems, high anxiety, and recurrent depression. On sick leave 50% after she got cancer, she’s now in follow-up treatment. Side effects causes neuropathic symptoms, with loss of peripheral sensitivity in the lower extremities.

Patient 5. Man with traumatic war-related experiences during childhood. Furthermore, a dysfunctional attachment to his father, bullying experience at school, and sexually abused. Despite all this, he managed to build a successful career in a Middle East country, before moving to Sweden a few years ago. The death of a close friend during the pandemic triggered trauma related symptoms in form of severe panic attacks, and psychosomatic chest pain.

Patient 6. Woman who has mild experiences of war as a child and no traumatic memories of it. Moved to Sweden as a child with her family, both parents had severe mental illnesses and could not provide secure attachment to her. Physically abused by the mother, and neglected by both parents, she was raped at 18 years old. Currently on sick leave because of mental exhaustion. Preoccupied with diagnostic issues, she shows a clinical picture with symptoms of strong anxiety, psychosomatic pain, complex PTSD, and traits of personality disorder. The difficulty to establish a sound relationship with a man is part of her complaints.

Patient 7. Man, now seeking treatment for re-activation of PTSD problems. Bearing extreme trauma experiences of torture in two concentration camps during the war, he testified in the Hague Court. Previously treated at our unit in the 90s, he was symptom-free for 10-15 years. Symptoms reappeared when his son ended up in addiction and crime and threatened to kill him. Patient presents dissociative symptoms and a high level of arousal with murderous thoughts against his son. He also developed diffuse somatic pain but keeps a good level of function and is currently working full-time.

All the group members except for one had previously received individual psychological therapy either at our unit or in other services. Common to all of them, the “identified traumatic experiences” had taken place at least 25-30 years ago.

The process

During the whole process there has been good attendance and compliance from all participants. One patient ended treatment after six months, and one after one year. They were the youngest of the group and had experienced war trauma in childhood, not as adults. Both of them stated as a reason for ending the treatment that they felt significantly recovered and felt they did not need more therapy. Both patients left the group in an orderly way, and could anchor their desition with the rest of the group. More could be said about their individual process, but we will instead focus on the group process and other methodological implications.

The group members met in the waiting room before the session and sat together, often chatting, sometimes in their language, sometimes in Swedish. All group members have been living in Sweden for many years and are proficient in the language. The therapy room was spacious enough to allow for movement if needed. The basic setting was sitting in a circle. We regularly had body activities at each session, sitting, and in some periods, we also had activities like lying on mats (still in a circle), standing, or moving around in the room.

Every session followed a predetermined structure, which included a ten-to-twenty minute at the start for body exercises or activities facilitated by the physiotherapist. Here the psychologist primarily took on the role of the observer, occasionally intervening verbally or actively participating in the work. After that, the session continued with the psychologist embracing a more active conductor’s role fostering communication and administrating the dynamic process. Initially, we had also planned to conclude the session with five-to-ten minutes dedicated again to body activity, with the purpose of stimulating the integration of body and mind dimensions. Anyway, it showed quite early that it was not that easy (and maybe meaningful) to shift mode intervention, bridging language and verbal interaction to physical action and more physical emotional experiences.  So, this physiotherapy intervention was left more flexible, and not as structured as the opening one. The exercises and body activities proposed throughout the whole duration of the project took form springing both from the previous experience of the physiotherapist and from joint reflections during the briefing and debriefing at each session. Reflecting together between us co-therapists over the group’s dynamics, and the stance and progression of the single participants, this informed and inspired on what body interventions could best fit to sustain, nurture or challenge the group during various phases of the therapeutical process, and to address specific aspects that the group was working through. For example, exercises at the beginning were more oriented to stabilization, enhancing body self-awareness in sitting or standing positions, without amplitude movement nor with direct physical interaction among participants but still sharing an experience. In an intermediate phase, when the group was in a phase of exposure, we introduced exercises in a supine position challenging the ability to let go and allowing for contact with sorrow and mourning for the traumatic experience and its consequences in the participants’ life. Also, we used the titration technique, alternating tension and relaxation of musculature to explore and expand the window of tolerance for each individual and the group-as-a-whole. In a later phase approaching the conclusion of the process, we introduced amplitude movements and exercises, like standing, going, and interacting with each other at different levels, to challenge rigid nonverbal unconscious communication patterns.

A central theme that we, as group leaders rooted in different professions, have struggled with during the whole process is the “administration” of verbal and nonverbal therapeutic interventions and modalities, and the switch between a more directive and a listening approach. This patient group has experienced traumatic events, some of which were extremely life-threatening and dehumanizing. These experiences have placed the group in a realm of the unthinkable and unnamable. The effects of trauma, such as a failure in symbolization and breakdown of body perception, tend to place the group – including the therapists – in a field ruled by a fragmented, uncontained, and unthinking system (Stubley, J. personal communication). In this field, projections and unconscious communication mediated by the body are prevalent. The ability to put mental representations and emotions into words is undermined and group cohesion is challenged, particularly when exposed to primal annihilation anxiety associated with traumatic material. (Hopper E., 2003).

We would now like to invite you to enter with us into the therapy room. We will present clinical material and share a couple of moments to try to illustrate significant methodological challenges and therapeutical breakthroughs during the process.

Clinical piece 1

We will start with a passage from session 3, when the group was still in the very early phase, focusing on safety and initial interpersonal relating. Both the patients and we as therapists are exploring the group’s mode of communication, and in this session, we had the intention to introduce a new way to view and delve into the experiences the patients bring with them to the group.

The session starts with a directive body-oriented intervention, a simple 1-2-3 rhythmic tapping that encourages play, coordination, focus and intonement to a shared rhythm. When ended there is a moment of silence and the psychologistlooks a little inquiring at the physiotherapist who says: “If the body could speak, what would it tell right now?” 

Silence persists, but then the group member start sharing:

We can note that some say: “I” and some say “IT” (the body).

The body as a metaphor and a bearer of meaning, filled with life experiences, is enquired and given a voice. What emerges is suffering in various forms: a desire to resign, to give up, to surrender, to cry out, to complain, to be acknowledged and recognized. An experience that is shared by the group-as-a-whole. We would like to mention that in a later phase of the process, the group was invited to lie on mats on the floor, which reactivated this material, than could then be explored and worked with.

Clinical piece 2

Well in the process in the session number 17 the group has established a safe holding environment. The members are dynamically responding to each other and can shift emotionally. The session starts with a standing exercise and Giuseppe gives a short psycho-pedagogical explanation. This is intended to stimulate anchoring, balance, grounding, and contact with the musculature in the legs, for participants to feel it. Everyone actively engages without much resistance.

The verbal interaction among the group members in the beginning of the session touches on material related to bodily limitations and pain primarily focusing on one patient who complains and is trapped in a depressive helplessness. Some patients take on a “positive stance” encouraging acceptance and trying to introduce hope, still failing to connect.

Another patient talks about her cancer and her pain, and at the same time addresses the issue of silence surrounding trauma and questions the primary purpose of group therapy.

In this passage, it’s evident how the group struggles with a profound conflict and ambivalence regarding shame and the fear of both physical and mental breakdown.  It is starting to become clearer for the group how discussions about somatic conditions might hinder other forms of communication.  Simultaneously, it is sometimes the only language they speak, which seemingly enables them to express their suffering. Group members are starting to reflect on each other and confront one another’s resistances more.

The last passage that we will share with you aims to highlight the challenges and possibilities of co- therapy as we intend it.

This dynamic between us co-therapists repeat in various critical moments during the therapeutic process. One of the group therapists ends up talking more than she consciously intends to, while the other gets more silent and inhibited than he intends to be. This pattern reflects the therapists’ characters and personality traits that, when exposed to dreadful material exacerbates, creating a rigid dynamic between us, leading to splitting and frustration, and reducing our capacity to lead the group in a favorable direction.

In this session, the patient’s overwhelming behavior dominates and our interplay as co-therapist is at stake. The group climate is dense but still maintains its nourishing environment. The time for body-oriented intervention at the end of the session is reduced to a minimum. At this critical point in the session, as the ending approaches, the physiotherapist intervenes spontaneously, intuitively, with a closing act where the whole group is invited to stand together in silence just one minute in a circle. The group becomes aware of the time limit and the session concludes.

During the post-session discussion, we co-therapists found ourselves unable to communicate openly and comprehend the dynamics of the session. A feeling of frustration, confusion, and misunderstanding emerged, and initially, we avoided addressing it. It took some time for us to fully regain our “capacity to think”, (Garland C., 1998) mentalize and develop an intersubjective understanding of the phenomenon that occurred during the session. As a co-therapy couple, navigating these ruptures and exploring in supervision the underlying unconscious dynamics, helped us understand that our initial struggles concerning verbal and nonverbal interventions, our level of activity, and specific methodological issues were less important. This made it possible to develop a more dynamic stance contributing to a safer and more cohesive group-matrix. (Hopper, 2003)

Reflections about learned lessons

Integrating two therapeutical approaches for group-treatment in a way that is cohesive and effective, demanded structure, systematic discussion between co-therapists, and collaboration. Pre- and post-sessions discussions transformed into a crucial working model that allowed us to reflect, rewind and tune before each session. This allowed us to create a working couple, seemingly very different but internally attached to a common understanding and task. Negotiating interventions and orchestrating the process together from each one’s own perspective has required self-reflection and dialogue. We could argue that the desire for sameness in a co-therapy couple may lead to the exclusion of what is different. Differences can sometimes become associated with delusional projections, fears and have a negative impact on the therapeutic process, activating splitting as a defense. It is helpful to understand co-therapy as a creative and dynamic intersubjective phenomenon, a dance between different positions and identifications that come into play. Having this clear stance is extremely important when working with groups in general, and even more with trauma groups where the psychic material presented is potentially highly disruptive.  During the process, we have been able to accept and develop our personal therapeutic styles and tasks in the group. Moving from a directive/orchestrating and an observant/ listening leadership has allows for a polyphony of voices and silences in the group-as-a-whole. The goal has been to counteract the inherent dilemma that traumatization entails between compulsively speaking and repeating trauma or remaining silent and avoiding dread.

Overall, the co-therapy process was a challenging but rewarding experience. The process required a dedicated commitment, willingness to embrace differences, curiosity, recognition and respect. It ultimately resulted in a more holistic and hopefully effective approach to trauma treatment.

References:

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Authors:

Marian Cabrejas, Reg. Psychologist, Reg. Psychotherapist, Specialist in clinical psychology, Group psychotherapist IGA. Gothenburg. Sweden.

maria.bergill_cabrejas@vgregion.se

Giuseppe Daverio, PT, MSc. Physiotherapist specialized in psychiatric and psychosomatic physiotherapy. Master’s degree in mental healthcare. International work experience. Extensive training in body-oriented psychotherapy, and in group psychoanalysis. Interest in applied phenomenology, trauma treatment, and cultural sensitivity.

giuseppe.daverio@vgregion.se