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International Collaborative Training Project Update
March, 2008
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Objective: This innovative clinical project proposes a strategy to diminish the self-perpetuating cycle of violent death bereavement in the Middle East conflict through a collaborative training of community based support for complicated grief after violent death. By teaching Middle East clinicians - local caregivers with knowledge of local customs, language and conditions already committed to providing support after violent death - the collaborative training builds a knowledge base and skill set to manage long-term grief complicated by rage and retaliation associated with violent death in both populations.
Background: Planning for this collaborative training project was inaugurated by Dr. Rynearson in 2004 and has been sponsored by the University of Washington, Jackson Middle East Center with additional funding from a United States Institute of Peace grant, the Dart Foundation and private donations.
Dr. Rynearson traveled to the Middle East for a series of training visits in 2004, 2005, 2006 and 2007 and through these repeated visits formed a collegial connection with Middle Eastern regional trauma centers at the following sites:
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Palestinian Training Sites:
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Treatment & Rehabilitation Center for Victims of Torture |
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Ramallah, West Bank |
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Hosted by Suad Mitwalli MPsych, Khader M. Rasras MPsych |
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Mahmud Sehwail MD |
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| Gaza Community Mental Health Program |
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Gaza City, Gaza |
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Hosted by Eyad Sarraj MD, Abdel Aziz Thabet MD |
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Israel Training Sites:
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| Tel Aviv University School of Social Work |
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Hosted by Ruth Malkinson PhD. |
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| Tel Aviv Israel Trauma Center for Victims of Terror and War |
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Hosted by Rony Berger PhD |
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| Haifa University Department of Clinical Psychology |
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Hosted by Simon Rubin PhD |
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| Ben Gurion University, Spitzer School of Social Work |
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Hosted by Alean Al-Krenawi PhD |
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| Israel Center for the Treatment of Psychotrauma |
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Hertzog Hospital, Jerusalem |
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Hosted by Danny Brom M.D. |
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| Tel Aviv Sourasky Medical Center |
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Jerusalem |
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Hosted by Prina Elad PhD |
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| Parents' Circle - Families Forum |
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Tel Aviv, Israel |
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Hosted by Aaron Barnea |
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| Tel-Hai College, Department of Social Work |
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Upper Galilee, Israel |
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Hosted by Shira Hantman PhD |
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| The Community Stress Prevention Center |
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Kiryat Shmona, Israel |
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Hosted by Mooli Lahad PhD |
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Regional Training Sites:
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| Medical School of Kocaeli University, Dept. of Psychiatry, |
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Kocaeli, Turkey |
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Hosted by A. Tamer Aker MD, Elif Krimizialsan MD |
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Pinar Onen PhD |
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| University of Cairo, Department of Psychiatry |
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Cairo, Egypt |
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Hosted by Ahmed Okasha MD, Magdy Arafa MD, Azza Bakray MD |
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Initial Collaborative Interactions and Results:
In November of 2006 Dr. Rynearson organized a three day collaborative training session in a neutral setting (Istanbul Turkey) with a working group of Israeli and Palestinian clinicians. This meeting was supported through combined funding from the USIP grant and the Dart Foundation.
Despite continued warfare, the participants felt reassured that their purpose was to focus on the clinical needs of their community members - and not on resolving the political differences that divided them.
Each day of the training began with a didactic session highlighting the clinical needs of children and adult family members after violent dying from the faculty (Dr. Rynearson and Dr. Alison Salloum, an expert on clinical support for children) - followed by discussion. The didactic sessions focused on community outreach, case identification, clinical measures and protocols of intervention. The remainder of the training encouraged presentations from each of the participants (including several Turkish associates) describing their centers efforts in meeting community needs for support and intervention after violent death.
The participants, associates and faculty continued conversation over breakfast, lunch and dinner - further enhancing the opportunity for discussion and engagement.
It is noteworthy that of the eight sites included in the collaborative training, only Ramallah had a support program specific for violent death.
Over the course of three days the working group made progress in completing the meeting objectives --
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- Protocols for outreach and case identification - distributed
- Treatment manual planning - in Arabic and Hebrew - completed and posted on an internet site: www.vdbs.org
- Multi-site clinical measures registry
- Network for consultation - established
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The participants requested continued collaboration at a second meeting to include clinicians from contiguous regions to expand the collaborative network.
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Expansion of Collaboration:
Dr. Rynearson maintained contact with participants through a quarterly newsletter in 2007 and actively planned an extension of the collaboration through exploratory contacts with clinicians working with traumatic bereavement in Cyprus, Jordan and Lebanon. Despite the relatively low frequency of violent death in their country, the Cypriot clinicians, offered to host the second collaborative meeting in Cyprus, but later could not commit to making the local arrangements, so it was decided to return to the same venue in Istanbul which had been so successful with the first meeting.
Arrangements for the second collaborative meeting in March of 2008 in Istanbul, Turkey followed and the Jordanian clinicians asked Dr. Rynearson to visit Jordan en route to Istanbul to give a series of lectures at the following centers:
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| March 10, 2008 |
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| Jordan University, Division of Psychiatry |
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Amman Jordan |
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Hosted by Tawfik Daradkeh MD |
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| March 11, 2008 |
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| Jordan University, Department of Psychology |
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Amman Jordan |
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Hosted by Arwa Aamiry PhD |
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| March 12, 2008 |
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| Amman Ahlia University, Department of Psychology |
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Amman Jordan |
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Hosted by Wisum Breik PhD |
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This was a very productive visit because the number of psychiatrists and psychologists in this country of five million people is limited to 84 psychiatrists and just over 100 psychologists allowing Dr. Rynearson to identify and meet with those clinicians working directly with the traumatized populations of Palestinian and Iraqi refugees.
There is a virtual absence of structured or systematic mental health services for individuals or families traumatized by violent death in Jordan for these vulnerable groups. However, after attending Dr. Rynearson?s lectures, the Jordanian clinicians proposed he return for a two day clinical workshop on the psychological effects of violent death in the next year to better prepare their local clinicians in providing support.
Several of the Jordanian clinician working directly with refugee populations asked to be included as collaborative participants in future international meetings - and proposed hosting the next international collaborative gathering in Jordan in 2009, before or after the training workshop.
Jordan would be an excellent venue for a third collaborative gathering because of its proximity to and political "neutrality" with the surrounding countries of Israel, Palestine, Lebanon and Turkey.
Following this brief visit, Dr. Rynearson traveled onto Istanbul for the second international gathering with the collaborative participants
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LIST OF INVITED PARTICIPANTS:
2008 INTERNATIONAL COLLABORATIVE TRAINING PROJECT
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Time: March 14 & 15, 2008
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| Place:Istanbul, Turkey |
* attended 2006 meeting |
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| FACULTY: |
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EK Rynearson MD* |
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Clinical Professor of Psychiatry |
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Univ. of Washington, Seattle, Wa. |
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Alison Salloum PhD * |
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Assistant Professor |
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School of Social Work |
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Gaza City |
Dr. Abdel Aziz Thabet M.B. ChB.* |
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Assistant Professor Child & Adol. Psychiatry |
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Al Quds University |
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Gaza Community Mental Health |
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Dr. Ahmad Khader Abu Twahina |
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Director General of Gaza Community Mental Health Program |
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Ramallah |
Khader Rasras M.A. |
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Director of Clinical Services |
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Treatment & Rehabilitation Center for Victims of Torture |
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Mahmud Sehwail |
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Psychiatrist and Director General |
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Treatment & Rehabilitation Center for Victims of Torture |
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Bethlehem |
Salam Khatib* |
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Alquds University, Abu-Dies |
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Director Psychiatric Nursing Department |
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Tel Aviv |
Ruth Malkinson PhD* |
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Professor of Social Work |
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Tel Aviv University, School of Social Work |
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Beer-Sheva |
Alean Al-Krenawi PhD* |
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Professor & Head of Department |
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Spitzer School of Social Work, Ben Gurion University |
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Haifa |
Simon Shimshon Rubin PhD* |
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Professor of Psychology |
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Haifa University Dept. of Psychology |
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Beirut |
Brigitte Khoury, Ph.D. |
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Assistant Professor |
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American University of Beirut Medical Center |
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Psychiatry Department |
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Beirut, Lebanon |
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Marwan Gharzedinne Ph.D. |
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Assistant Professor |
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American University of Beirut Medical Center |
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| Associates: |
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Turkey |
Ahmet Tamer Aker MD* |
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Medical School of Kocaeli University. Istanbul Turkey |
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Vadat Sar MD |
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Professor of Psychiatry |
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Istanbul University |
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Unfortunately four of the invited participants were unable to attend - Drs. Salloum and Sehwail because of illness, and Drs. Thabet and Twahina because of the border closure in Gaza.
Despite their absence, the working group of 10 participants made progress in completing the objectives of the two day meeting:
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- Review violent death demographics & available/needed services:
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Palestine - Salam Khatib reviewed the demographics of violent death in the West Bank and Khader Rasras described the Ramalla community outreach program which continues to run time limited group therapies for traumatic bereavement and offers training and support for local clinicians.
Dr. Thabet had planned on presenting a school based intervention program of support he has established in the last year for children with traumatic bereavement through the Gaza Community Mental Health Program. This intervention program includes a data set of clinical measures which he and Dr. Salloum are organizing for journal submission.
Israel - Alean Al-Krenawi described his work with traumatized Arab children in Israel and his efforts to organize multi-site studies with traumatic bereavement in Palestine and Israel. Ruth Malkinson and Simon Rubin reviewed the state subsidized mental health intervention available for all family members of Israeli soldiers killed in combat and presented their two track model of bereavement and measure. The measure has been translated from Hebrew into English and Arabic - though the Palestinian and Lebanese had recommendations for a more accurate Arabic revision - and the participants agreed to consider using the measure in a multi-site trial after further revision.
Lebanon -- Brigitte Khoury described the traumatizing events of the recent Israeli incursion into South Lebanon eight months before, accompanied by 1200 civilian deaths, and the virtual collapse of the mental health care system during the month of active combat. She emphasized the vulnerable structure of public institutions and agencies in Lebanon because of the persistent civil war. Apparently the most stable public agency was the school system itself. Homeless and displaced families gathered in schools for food, shelter and safety and that is where mental health services were based.
Marwan Gharzedinne initiated a school based intervention offering psychological first aid and support to children. He designed and collected data on over 3000 subjects and presented the results for the first time. Not surprisingly, his data suggested that the death of a mother during the war was associated with the most intense distress. He and Alison Salloum will begin working together in developing a school based intervention for children and assistance in organizing a formal submission of his data set for publication.
In a remarkable meeting, the group spent an entire morning helping the Lebanese participants in planning a systematic community based outreach - in cooperation with Lebanese political and religious officials - to contact the 1200 families who lost family members to violent death and protocols for offering support, case identification and intervention. The Lebanese clinicians requested that Drs. Rynearson and Salloum visit Lebanon in the next year to train a group of selected clinicians in organizing time limited group interventions for those with prolonged grief.
Turkey - Drs. Aker and Sar referenced the traumatic bereavement suffered by hundreds of families in the major earth quake of twelve years ago - and their continuing efforts to support some of those families. They were also concerned about the possibility of increased casualties with the recent acceleration of terrorist attacks and are interested in organizing community based support and intervention.
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- Seminar/Training Outline:
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The group began preliminary consideration of a collaborative training agenda and syllabus on community-based support for traumatic bereavement. The training material would conform to various formats - one or two day workshop for local or regional clinical meetings, written teaching manuals for clinicians in training, perhaps a multi-authored book - and would include the following topics
Restorative and Clinical Essentials after Violent Death
- the synergism of righteousness, force, and loss of compassion
- death concepts and rituals (socio-cultural similarities & differences)
- bereavement, trauma and resources of resilience
- complicated grief after violent death (adults and children)
Restorative and Clinical Interventions
- community outreach (home visits, schools, mosques, temples, media)
- case identification, measurements
- intervention models for children (individual, group)
- intervention models for adults (individual, group)
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The group decided that a training agenda and materials would be more relevant and practical as we organized, completed and evaluated a collaborative training event together -- the two day training scheduled in Jordan in the next 6 to 12 months. Each of the participants agreed to contribute to its planning and volunteered to serve as adjunct faculty members with Drs. Rynearson and Salloum. After serving as adjunct faculty, they could begin to assume the role of primary faculty at local and regional trainings.
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Immediate Goals: (3 - 6 months)
One Day Training Seminar: Plan and complete a collaborative written proposal for one day seminar to be presented in Amman Jordan entitled:
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Under the Shadow of Complicated Grief:
The Clinical Impact of Violent Death
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The agenda and materials from this training will serve as a template for submission to the International Society for Post Traumatic Stress Disorder in Atlanta, Georgia, November, 2009.
Intermediate Goals: (6-24 months)
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Training Syllabus: Collaborative development of teaching syllabus (community based support after violent death) is a natural extension of the organized training - for students and mental health professionals in the Middle East.
Multi-authored book: The additional benefit of collaborative planning and presentation will be an opportunity for participants to share in authoring written handouts. These could later be elaborated into chapters for a book with collaborative authorship.
Long Term Goals: (12-24 months):
Formation of an organization: Planning and funding for a regional Middle East Study Group on the psychological effects of violent death - form an affiliation of clinicians and academicians from countries of the Middle East -- to promote research and training for clinicians supporting those suffering from complicated grief after violent death.
Regional funding: Such an organization (an established association of cooperative clinicians and academicians) would be in a unique position of political transcendence in seeking funds to counter the specter of grief after violent death that hovers over the entire region.
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