‘Circles of light’: A therapeutic, non-verbal group for survivors of torture

by Lorena Sánchez Blanco

Every man is two men; one is awake in the darkness,
the other asleep in the light.          Kahlil Gibran

Introduction
According to the United Nations High Commissioner for Refugees (2016) there are approximately 22.5 million refugees worldwide. More specifically, in Ireland in 2016, 2,244 asylum applications were received (Immigration Annual Review, INIS, 2016). Many of these asylum seekers receive therapeutic, medical and psychosocial support at Spirasi, the Irish Rehabilitation Centre for survivors of torture who are refugees, asylum seekers or other vulnerable migrant groups.

Torture leaves a very deep wound on survivors, their families, and their communities. Compared to the general population, studies of asylum seekers have showed consistently higher rates of mental distress or mental disorders. Some of these long-lasting effects include depression, anxiety, demoralisation, stress, fear, physical pain, and Post Traumatic Stress Disorder (PTSD; Monaldi & Strummielo, 2001). Group treatments are very valuable for torture survivors since they allow individuals to come together, to develop new relationships, reduce social isolation and reclaim a sense of trust and social connection lost through the torture experience (Bunn, Goesel, Kinet & Ray, 2016). Nonetheless, the efficacy of treatments for PTSD in asylum seekers and refugees has been hardly studied (Crumlish & O’Rourke, 2010). Therefore there is a need to research and develop new treatments for torture survivors (Drožđek, 2013).

In this article I present a synthesis of ‘Circles of light’, a therapeutic group that I, as a psychotherapist, carried out in Spirasi with women and men who are asylum seekers and survivors of torture. This intervention is comprised of 13 experiential workshops led in a circle. The primary goal of the group is to help clients to regulate their stress response while developing nurturing connections with others.

The reality of torture survivors and asylum seekers
The concept of asylum seekers refers to individuals who have to flee their country because of persecution, violence, repression or wars. These children, women and men arrive to the country of exile in pursuit of safety. However, upon their arrival, in addition to mental health symptoms related to PTSD such as re-experiencing, avoidance or hyperarousal, asylum seekers and torture survivors experience multiple psychosocial problems, such as unemployment or inability to work, uncertainty regarding their legal status, language difficulties, unstable housing, isolation, acculturation, racism, loss of trust, and grief (Bunn et al., 2016). Due to the imprints of the trauma on the mind, body and soul of the torture survivor, treatment poses important challenges for rehabilitation services, calling for the development of holistic and culturally informed interventions (Berliner, Nikkelsen, Bovbjerg & Wiking, 2004).

Treatments such as sensorimotor psychotherapy, or arts therapy, appear to be an appropriate intervention for torture survivors due to the implicit and wordless nature of traumatic memories (van der Kolk, 2014). Trauma survivors are left at the mercy of overwhelming physical reactions such as muscle tension, constricted breathing, trembling, headaches and limited body awareness, along with dissociation of self from the body (Gray, 2001). They experience dysregulated emotions, intrusive memories, smells or sounds, and numbing. Considering those multifaceted trauma symptoms, a therapeutic treatment based on ‘talking therapy’ can be limited, since clients find it very problematic to form a coherent verbal narrative of past trauma (Ogden, Minton, Pain, 2006).

Ubuntu -Umuntu Ngumuntu Ngabantu
I am what I am because of who we all are      African Proverb

Circles of light
‘Circles of light’ is a non-verbal therapeutic group which is specifically based on sensorimotor psychotherapy and integrates elements of expressive arts and cognitive behavioral therapy (CBT). Sensorimotor psychotherapy proposes that the body, mind, emotions, sensations, impulses, movement and thoughts are interconnected parts of the bodily experience that influences a person’s internal life as well as their behaviours and way of relating with others (Ogden et al., 2006). The aim of this therapeutic approach is to raise bodily awareness to processing unassimilated reactions to trauma from the physical level (ibid).

Anxiety and stress management techniques alongside emotional regulation skills are incorporated throughout the treatment by means of experimental activities, games and crafts. This approach has a cultural perspective, hence Eastern traditions and rituals as well as Western techniques are employed (Bunn et al., 2016). Bearing in mind Herman’s (1992) theory of the therapeutic treatment, this group is based on the initial stage of the rehabilitation which is focused on client safety and symptom stabilisation.

This open therapeutic group was held in fortnightly sessions of 60 minutes over seven months. In order to guarantee confidentiality, pseudonyms are used for the clients. The group was comprised of nine members, aged 20 to 55 years, five females and four males from seven different countries: Sudan, Bangladesh, Pakistan, Nigeria, Georgia, Iran and DR Congo. Six different languages were spoken by the participants of the group: Bengali, Georgian, Dorod, Mbote, Edo language and Arabic. Participants of the group spoke limited English.

Despite the group diversity, all the women and men who attended the therapeutic group ‘Circles of light’ have in common their experiences of complex trauma: a terrifying past, related to the horror of war, torture or violence encountered in their countries of origin. A suspended present in a new country marked by multiple losses: the loss of a home, their family life, their cultural values, their jobs, their status; in essence the loss of their own identity. Ultimately, as asylum seekers, they share an uncertain future regarding their legal status.

Furthermore, from a holistic perspective, all have the imprints of trauma on body or mind in some shape or form. As in the case of Victoria, a 25 year old woman from Congo, who was tortured, raped and persecuted due to her sexual orientation. From a physiological perspective, Victoria reported having the feeling of inhabiting an alien body; she complained about general pain, experiencing tension in the back and shoulders, nerves in the chest and abdomen, shallow breathing, hyperarousal and the lack of any body sensation. From a psychological perspective she had difficulties concentrating, memorising and sleeping. She experienced nightmares and flashback as reminders of what happened in the past, a lack of control over the present and fear for the future.

The therapeutic journey
Every group session has a similar structure, where visual or graphic materials are employed to create a safe and predictable space. Sessions initiate with a physical exercise that is co-created by the members of the group and the facilitator over a number of sessions. Subsequently, sessions shift into an experiential activity in which a topic is introduced and explored by the use of arts and the body. To finish every session, a relaxation or breathing technique is carried out. The structure of the sessions are reviewed below in more detail.

The first group session can evoke feelings or reactions of confusion, mistrust or avoidance in the participants; thus it is important to inform group members about the nature of the group (it is a voluntary group), group content, objectives and rules. After this intervention, one participant decided to leave the group because he was exclusively seeking legal support.

The sessions continued with an activity named ‘Welcoming’, which consisted of tapping different parts of one’s body (arms, hands, shoulders, back, abdomen, legs) while greeting every part of the body using the different languages spoken in the group. With this activity participants learn about physical boundaries, they connect with their body through the movement and relate to each other in a respectful space. Usually, participants laugh when other group members and the facilitator say some words in their own language. After this initial practice, participants appeared physically more relaxed and energised. As the group progressed, participants manifested an interest to interact verbally with one another and the therapist, thus gradually elements of ‘talking’ therapy were introduced within the group.

Thereafter, experiential activities using psychoeducation, arts and somatic exercises are used. The combination of these exercises is fundamental to help survivors of torture to feel their body, to tolerate emotions and to connect them to psychological events (van der Kolk, 2014). On the one hand, mindful art activities help participants to focus on the present moment. Examples of activities related to arts are the following ones:

• The tree of my life: This activity consists of making a group poster with pictures of trees. Each tree represents a participant of the group. The image of all the trees together creates a sense of cohesion, diversity and integration which helps to form the group identity. This activity is carried out in the first session.
• Friendly hands: With the goal of developing external resources, in this technique each client traces his or her hand and, on each finger, draws or writes an external resource: a supportive person, food they like, favourite animal, preferred place and colour. Afterwards clients do a breathing exercise. With each inhalation and exhalation participants hold one finger while recalling their external resources.

• Group Mandala: Each participant colors a mandala, then a collective group mandala is designed. Mandalas are defined as any artistic design created within a circular context. Mandalas were found to be calming and soothing, as well as enhancing individuation and concentration (Pisarik & Larson, 2011).
• Origami: In this session we make an origami paper bucket representing a flowerpot. Using the metaphor of a plant, we explore what materials help flowers to flourish and what resources help individuals to grow. The purpose of this session is to recognise the participant’s internal resources.
• Collage: Using the technique of a collage, clients are invited to create a card for themselves as an expression of gratitude and appreciation to the self. Participants engaged very well in this activity but instead of making a gift to themselves all decided to share their cards with another group participant whose birthday it was.
• River of life: This is a technique that focuses on drawing a river which represents the individual’s life. It is a visual narrative method that helps participants tell stories of the past, present and future. This activity deepens the sense of clarity and the integration of the fragmented parts of the self, at the same time as it reconstructs their life story and allows them to look into the future.

On the other hand, sessions are focused on particular trauma treatment-related issues such as: the interconnection between thoughts, emotions and behaviours; stress response to trauma; basic techniques for regulating arousal; sleeping disturbances; implicit memory; flashbacks and grief. These topics are introduced via a psycho-educational presentation by the facilitator, followed by exercises designed to support acquisition of related skills practiced within the group. Some of the non-verbal techniques employed are: abdominal breathing techniques; imagery breathing practices; progressive muscular relaxation; self-massage; mindful practices such as mindful eating; safe space meditation; and yoga exercises.

An important theme shared by all the group members was grief, the grief provoked by the multiple losses that asylum seekers must face in their lives. All cultures mark life transitions with different rites of passage, however most asylum seekers were deprived of these experiences when they fled their countries of origin. In response to to the sudden loss of their homeland, the therapeutic group allows the group members to have a ritual around ending.

In the last group session, participants engaged in the creation of a mandala with stones, flowers and candles. Through this practice, which symbolises the beginning and ending of the group, the expression of feelings was encouraged. The ‘group journey’ was reviewed and participants had an opportunity to say goodbye to each other and the facilitator. This was a very emotional moment for some participants of the group. It was especially hard for Hassan, a 45-year-old man from Sudan, who due to political reasons had to leave his country, leaving behind his pregnant wife and three children. Hassan burst into tears while acknowledging how helpful the group had been for him. This complicated moment was met with compassion and acceptance by the facilitator and other group members. The group itself acted as a container for the expression of feelings of anger, sadness and gratitude. It can be considered that the group allowed Hassan to live the ‘missing experience’ of grief and to say goodbye while recognising his own pain.

The group ended with a common potluck which consisted in sharing traditional homemade world cuisine. Thanks to these experiences participants could celebrate the end of the group. All the group materials were

given to group members and a bracelet was offered to each member as a grounding resource. Equally important was to evaluate clients’ opinions and progression within the group. Following from here, an evaluation of the group will be reviewed.

Evaluation
Due to the changes in the group and its variability, just three group members could participate in a quantitative pre-and post-treatment assessment. The Hopkins Checklist Scale was administrated to those participants. The symptoms of those clients for anxiety and depression decreased slightly after the group intervention. Furthermore, a qualitative approach was utilised. A semi-structured interview was carried out with six participants, and interpreters facilitated for this purpose. All group participants in the interview valued very positively the opportunity of learning new ways to deal with their symptoms but, overall, they highlighted the fact of belonging to a supportive group, which was considered by many of them as a ‘family’. Nonetheless, due to practical complications, the results of the evaluation are irresolute.

Conclusion
As a response to the increasing numbers of torture survivors presenting to Spirasi, this article presents a model of a non-verbal therapeutic group for the rehabilitation of survivors of torture. The group, called ‘Circles of light’, provides a safe space in which body and artistic therapeutic approaches are employed in the treatment of torture survivors.

The group allows participants to transcend verbal barriers and to bridge their internal and external world in attunement with themselves and others (Callaghan, 1998). Body psychotherapy enables participants to be present, to release tension stored in the body and to develop a sense of playfulness.

Despite the methodological limitations of this study due to the group variability and lack of resources, participants’ testimonies contributed to shedding light on the relevance of non- verbal group interventions with survivors of torture.

Recommendations
A number of recommendations and considerations for future interventions emerged from both the evaluation of this study and from the research reviewed:

Individual therapy is recommended for survivors of torture with complex trauma or with no English at all.

In order to manage group dynamics and to be able to focus on clients’ needs, the presence of two group facilitators is highly recommended.

It is suggested that working with a consistent and stable number of clients could facilitate the group progress.

Despite current research preference for homogeneous therapy groups, it seems that at an initial stage of the treatment heterogeneous group can be beneficial.

Prior to initiating the therapeutic group, clients’ practical needs, such as legal or psycho-social issues, should be addressed and the client should be referred to the appropriate services.