ORGANISATION DE VICTIMOLOGIE ET DE PSYCHOTRAUMATOLOGIE EUROPÉENNE (OVEPE), FINAL REPORT: EUROPEAN COMMISSION, DAPHNE 1997, PROJECT NUMBER 97/248/WC

Institut de Victimologie

• Project Chief: Dr. Philippe Werson
• Project Co-ordinator: K. Sadlier

TABLE OF CONTENTS

Project resume                                                                                         

General information                     

Project Report  

    Introduction                                                                        

           Part I: Treatment and training standards proposals

                       Proposed training standards

                       Training standards workgroup

                       Proposed treatment standards

                       Treatment standards workgroup

Part II: National reports from the OVEPE network  

           France

           Germany

           United Kingdom

           Italy

           Sweden

           Belgium

Part III: Motion for a Resolution to the European Parliament   

Project Procedure   

           Initial goals

           Project difficulties

Database Information       

Accounting Report    

National network reports for France and Belgium are presented in French, as is the Accounting Report. All other information is presented in English.

PROJECT RESUME

OVEPE, the European Organisation of Victimology and Psychotraumatology, was founded by Gérard Lopez (France), Gisela Perren Klinger (Switzerland), and Marc Van Knippenberg (Belgium) in November of 1997. Each of these psychiatrists and clinical psychologists works with distinct trauma populations, i.e., victims of war, crime, natural disasters and intra-familial violence. OVEPE is currently being co-ordinated by the Institut de Victimologie (France).

In January of 1998, OVEPE was awarded a start-up grant from the European Commission’s Daphne Project. In conjunction with Daphne’s aims, OVEPE seeks to improve mental health services to women and children who have been victimised by diverse aggressions. To date, national OVEPE representatives have been identified in France, Belgium, the United Kingdom, Sweden, Germany and Italy. The role of these representatives is to co-ordinate the creation of a specialised psychotrauma centre network in their respective countries. Expert consultants from Norway (Lars Weisaeth), and Switzerland (Gisela Perren Klinger), have graciously accepted to participate in the project. In addition, a liaison with the European Society for Traumatic Stress Studies has been created in order to pool common efforts towards the enhancement of mental health services to victim/trauma populations.

Two workgroups have been constituted in the areas of training and centre specialisation. These workgroups have proposed guidelines in each of the aforementioned domains. In addition, a motion for a resolution to improve mental health treatment for victim/trauma populations was drafted in conjunction with the European Society for Traumatic Stress Studies and European Victim Support. All of these documents are available to the public.

In terms of the project’s future, the European Society for Traumatic Stress Studies will take over the workgroups on training and treatment guidelines. The continued creation and monitoring of a European psychotrauma treatment centre network will be spearheaded by Gisela Perren Klinger of Switzerland for the 1999-2000 work year.

GENERAL INFORMATION

1. Organisation: Institut de Victimologie
2. Project: Organisation de Victimologie et Psychotraumatologie Européenne
3. Address: 16 rue Jean Leclaire, 75017 Paris, France
4. Telephone: (331) 40.25.04.04
5. Fax: (331) 40.25.04.04
6. Email: cpv@worldnet.com
7. Contact person: Dr. Phillipe Werson
8. Materials available for distribution:

• Resolution draft to the European Parliament on improved mental health services to victims of diverse aggressions
• Proposed European standards for training in psychotraumatology and victimology
• Proposed European standards for functioning of psychotraumatology centres

PROJECT REPORT

Introduction

OVEPE, the European Organisation of Victimology and Psychotraumatology, was founded by Gérard Lopez (France), Gisela Perren Klinger (Switzerland), and Marc Van Knippenberg (Belgium) in November of 1997. Each of these psychiatrists and clinical psychologists works with distinct trauma populations, i.e., victims of war, crime, natural disasters and intra-familial violence. OVEPE is currently being co-ordinated by the Institut de Victimologie (France).

In January of 1998, OVEPE was awarded a start-up grant from the European Commission’s Daphne Project. In conjunction with Daphne’s aims, OVEPE seeks to improve mental health services to women and children who have been victimised by diverse aggressions. To date, national OVEPE representatives have been identified in France, Belgium, the United Kingdom, Sweden, Germany and Italy. The role of these representatives is to co-ordinate the creation of a specialised psychotrauma centre network in their respective countries. Expert consultants from Norway (Lars Weisaeth), and Switzerland (Gisela Perren Klinger), have graciously accepted to participate in the project. In addition, a liaison with the European Society for Traumatic Stress Studies has been created in order to pool common efforts towards the enhancement of mental health services to victim/trauma populations.

Two workgroups have been constituted in the areas of training and centre specialisation. These workgroups have proposed guidelines in each of the aforementioned domains. These guidelines are presented in Part I. Descriptions of national centre networks are described in Part II. Part III presents a motion for a resolution to improve mental health treatment for victim/trauma populations which was drafted in conjunction with the European Society for Traumatic Stress Studies and European Victim Support. All of these documents are available to the public.

Project Report, Part I: Treatment and training standards proposals

Everyday throughout Europe, a significant number of children and adults face terrifying events: rape, assault, homicide, natural catastrophes, major transportation accidents, terrorist attacks, physical and sexual maltreatment. Encountering such situations can leave lasting psychological scars on any of us, scars that place a crushing burden on both personal and social resources.

As society becomes more and more aware of the effects of traumatic events on individuals, an increasing demand has been made on the mental health community to effectively prevent and treat trauma-related psychological suffering. In the last twenty years, trauma-specialised mental health professionals have made important contributions in the field and have disseminated their knowledge through both scholarly papers and training programs. Interest in issues related to victims of traumatic events has led to a recent increase of training courses, some of which risk being spearheaded by unqualified professionals.

In Europe, no co-ordinated accreditation exists for trauma-related training programs or treatment centres. The lack of accreditation means that it is currently impossible to monitor standards. This situation has important implications for the quality of services which mental health professionals ultimately provide victims of traumatic events. In areas as sensitive as the treatment of those who have directly experienced abuse, crime, warfare, natural catastrophes and terrifying accidents, a lack of training and treatment standards risks re-victimising traumatised clients via poor or unsatisfactory knowledge concerning both related psychological disorders and the particularities of the social and legal networks in which victims may find themselves inscribed.

The goal of the OVEPE work groups is to propose the basic architecture for European training and treatment standards in psychotraumatology, i.e., the understanding, prevention, and treatment of those psychological disorders commonly experienced by trauma victims. Training and treatment should be done so with victimology in mind, i.e., the study of the social and legal networks in which trauma victims find themselves inscribed. This report presents the workgroups’ proposals with the hope that it will stimulate efforts to improve mental health services for traumatised persons. The work group underscores that although both treatment centres and training programs do exist throughout Europe, the field appears to be riddled by fragmentation, caused in part by a lack of co-ordination of standards.

Proposed Training Standards

Throughout Europe the paucity of training in psychotraumatology and victimology is becoming an urgent issue: as social stigmas surrounding victimisation are lifted, increasing numbers of mental health professionals will come into contact with victims, yet they are poorly trained to evaluate and treat this population. As such, it is important that they optimise their prevention and intervention approaches via specialised coursework.

Some European Union countries (for example, the United Kingdom) include lectures on trauma and victims during basic medical training. However, the amount and type of training is disappointing and their content often fails to make specific reference to issues related to women and child victims. In addition, this training does not include specialised practical skills that would assist psychiatrists in later treating trauma/victim populations. Sweden is an exception in this respect: it is insisted that psychiatric students treat at least one victim presenting a trauma-related disorder during their medical residency under supervision. However, and as for other European countries, no standardised training exists for either psychiatry or clinical psychology students. Various universities throughout Europe do include courses on victims of trauma during clinical psychology studies, but again, these tend to be the exception to the rule.

For those European psychiatrists and clinical psychologists who wish to enhance both their theoretical and clinical knowledge about trauma victims, the current option is post-graduate training primarily offered by private institutions and organisations. Unfortunately, since no accredited standards exist in the fields of psychotraumatology and victimology, it is not possible to monitor the quality of training dispensed nor its upkeep with research and theoretical developments in the effective treatment of victims.

The OVEPE workgroup on training issues has attempted to address this situation by proposing a basic architecture for education in psychotraumatology and victimology. The workgroup is composed of the following professionals :

Monica Becker Fischer Institut fur Psychotraumtologie Springer 26 53804 Much GERMANY tel. (02245) 91940/919420	Deborah Lee Traumatic Stress Clinic 73 Charlotte St., London W1P 1LB UK Tel/fax 44 171-530-3666/3677
Tom Lundin Dept. of Psychiatry Uppsala Univ. Hospital Sparrisgaten 2 S-754 46 Uppsala SWEDEN tel. (46)18-178822 fax (46)18-178890	Gisela Perren Klinger Institut Psychotrauma Schweiz PO Box 189 CH 3930 Visp SWITZERLAND tel (41) 279 46 3422 fax (41) 279 46 3423
Marc Van Knippenberg Centrum voor Psychotrauma Gitschotellei 230 2140 Antwerp BELGIUM tel (323)272.2525 fax(323)216.1200	Lars Weisaeth Division of Disaster Psychiatry University of Oslo Buiding 20, Sognsvannsveien 21 0320 Oslo NORWAY tel. (47) 22-14-24-90 fax (47) 22-92-36-65
Karen Sadlier Institut de Victimologie 16 rue Jean Leclaire 75017 Paris FRANCE tel/fax (33) 1 40 25 04 04	Roderick Orner Dept of Clinical Psychology Baverstock House St. Anne’s Road Lincoln 1N2 5RA UK fax (44) 1522-546-337

 In the workgroup’s report on training, recommendations for standard topics are presented. The content of topic modules should reflect up-to-date practical and research findings. Training is targeted towards four groups of professionals liable to work with trauma/victim populations: emergency workers, primary health care professionals, general psychiatrists and clinical psychologists, and trauma-specialised psychiatrists and clinical psychologists.

a) Emergency Workers

Training for emergency workers is focused on basic psychological first aid/crisis knowledge and skills. Emergency workers include policemen, firemen, rescue workers, paramedics and emergency room personnel. These professionals are often the first to encounter the trauma victim and his or her family, sometimes in catastrophic situations.

Emergency workers’ direct exposure to traumatic events places them at high risk for burnout. Furthermore, their position on the “frontline” implies that some of these professionals can highlight the eventual support needs of trauma victims.

Excellent training for emergency workers already exists in several European countries. Based on these programs and on the needs of trauma victims, the OVEPE workgroup proposes that accredited training programs for emergency workers should include:

• Knowledge of traumatic stress risk factors
• Knowledge of critical incident stress reactions
• Knowledge of the preliminary signs of traumatic stress reactions in adults and children
• Knowledge of information-giving techniques to concerned relatives
• Knowledge of secondary trauma reactions and available support services
• Knowledge of media-management techniques
• Demonstrated proficiency in psychological first aid techniques for both adults and children
• Demonstrated proficiency in connecting victims to psychotraumatology and victimology networks

It is proposed that accredited training programs for emergency professionals be comprised of 10 hours of knowledge modules and 5 hours of practical skill modules.

b) Primary Health Care Professionals: General Practitioners and Pediatricians

Primary health care providers are often gatekeepers to specialised psychiatric and psychological services. They are likely to see early trauma and stress reactions, which have not yet become rooted. They are also likely to encounter victims of domestic violence and child abuse in the course of general practice. As such, accredited training for this group should be focused on both detection, prevention and referral skills. The group is constituted of both highly qualified health professionals who serve the public, such as general practitioners and pediatricians. In some European countries, nurse practitioners, non-clinical social workers and even clergy members may be appropriate candidates for this training level.

The OVEPE workgroup proposes that accredited training programs for primary health care professionals should include:

• Knowledge of behavioural and clinical signs of victimisation (i.e., child abuse, domestic violence, sexual assault, torture)
• Knowledge of national laws and ethical guidelines concerning victim issues, (i.e., child abuse reporting)
• Knowledge of trauma disorder risk factors
• Knowledge of clinical signs of acute stress disorders, traumatic stress disorders, and trauma-related dissociative disorders in children and adults
• Demonstrated proficiency in psychological first aid techniques for both adults and children
• Demonstrated proficiency in connecting victims to psychotraumatology and victimology networks

It is proposed that accredited training programs for primary health care professionals be comprised of 8 hours of knowledge modules and 2 hours of practical skill modules.

c) Secondary Health Care Professionals: General Clinical Psychologists and Psychiatrists

Ideally, training in victimology and psychotraumatology should form part of the general curriculum in psychiatry and clinical psychology studies. Given that most mental health professionals will encounter trauma-victims at some point in their careers (research indicates that 2 to 15 percent of the general population suffers from trauma-related disorders), the OVEPE workgroup believes that all mental health professionals should have a working knowledge of psychotraumatology and victimology. Furthermore, they should be able to evaluate as well as treat a range of simple trauma disorders and provide appropriate referrals to both victim assistance networks and specialised psychotraumatology centres.

The standardised program outlined by the OVEPE workgroup was done so with the goal that it form part of the general university curriculum in psychiatry and clinical psychology. The proposed program, however, may be taught as a continuing education requirement for psychiatrists and psychologists. In those European countries that do not have continuing requirements for these professionals, the program can be strongly recommended by professional boards.

The OVEPE workgroup proposes that accredited training for general psychiatrists and clinical psychologists include the following theory, assessment and treatment modules:

Theory

• Knowledge of the biological, psychological, social and cultural implications of trauma
• Knowledge of cultural, anthropological and gender issues related to trauma
• Knowledge of child development issues related to trauma
• Knowledge of the effects of exposure to traumatic events throughout the life span
• Knowledge concerning trauma’s relationship with memory
• Knowledge of transgenerational issues related to traumatic events

Assessment

• Knowledge of diagnostic criterion (ICD-10 and DSM IV) for the full range of trauma disorders (i.e., acute and chronic traumatic stress disorders, dissociative disorders, personality disorders, disorder not otherwise specified)
• Knowledge of diagnostic criterion (ICD-10 and DSM IV) for co-morbid trauma disorders (i.e., substance abuse, depression, panic disorders, eating disorders, brief reactive psychosis)
• Knowledge of somatic symptoms (e.g., hyperventilation) and psychosomatic disorders related to trauma exposure (e.g., high blood pressure, stomach ulcers).
• Distinction of pathogenic factors (e.g., bio-psychological vulnerability) and salutogenic factors (e.g., social support) in trauma-exposed individuals
• Demonstrated proficiency and knowledge of national laws and ethical guidelines concerning victim issues (i.e., child abuse reporting, political asylum demand process)
• Knowledge of legal and clinical issues particular to victimised women and children (e.g., child placement, battered women socio-legal programs)

Simple Treatment Skills

• Treatment skills for early stress reactions including psychological and pharmacological methods
• Treatment skills for simple trauma disorders among children and adults including psychological and pharmacological methods
• Demonstrated proficiency in linking patient to socio-legal victim assistance networks including general crime, war, and disaster victim agencies, domestic violence and rape assistance programs, as well as child protection programs

In order to enhance learning related to trauma and victim issues, the clinical practicum generally required during clinical psychology and psychiatry training, should include:

• In vivo or video observation at least 2 trauma victims in a natural setting (i.e., at the emergency room, when filing charges, during a judicial proceeding)
• Assessment and diagnoses of at least 2 trauma victims, child or adult, under supervision.
• – Treatment, or observation of treatment, of at least 1 adult trauma victim 1 child trauma victim under supervision

The proposed training program comprises 40 hours. However, most of the information can be woven into existing university lectures and practicum, and can be evaluated through the course of general curriculum evaluation.

d) Tertiary Mental Health Care: Trauma-Specialised Clinical Psychologists and Psychiatrists

Training here is focused on those mental health professionals who choose to specialise in the treatment of victims presenting trauma-related disorders. Performed at the post-graduate level, participants should demonstrate competence in those issues covered in the general psychotraumatology/victimology university level training for clinical psychologists and psychiatrists.

Training standards at this level follow the format of assessment, theory, treatment issues and practicum. Participants who successfully complete this training program would have the necessary requisites to be practice in accredited Psychotrauma Mental Health Centres, were such centres officially recognised in Europe. The advanced training program is comprised of the following theory, assessment and treatment modules:

Theory

• Advanced knowledge of the biological, psychological, social and cultural implications of trauma
• Advanced knowledge of cultural and gender issues related to trauma (i.e., genocide, genital mutilation)
• Advanced knowledge of trauma and victimisation from a minimum of two diverse theoretical models (i.e., psychodynamic, psychoanalytic, cognitive-behavioural, systemic)
• Advanced knowledge of child development issues related to trauma
• Advanced knowledge of collective traumatisation on family functioning (i.e., multiple incest) and societal functioning (i.e., warfare)
• Detailed knowledge of national laws and ethical guidelines concerning 2 victim issues (e.g., child abuse, domestic violence, political asylum)
• Detailed knowledge of secondary traumatisation processes among specialised mental health professionals which may interfere with treatment

Assessment

• Advanced knowledge of diagnostic criterion (ICD-10 and DSM-IV) for the full range of trauma-related disorders (i.e., acute and chronic traumatic stress disorders, dissociative disorders, personality disorders, disorder not otherwise specified, maladaptive adjustment disorder) with emphasis on age and gender related characteristics
• Advanced knowledge of diagnostic criterion (ICD-10 and DSM-IV) for co-morbid trauma disorders (i.e., substance abuse, depression, panic disorders, eating disorders, brief reactive psychosis)
• Advanced knowledge to differentiate trauma-related somatisation and somatisation of other origin
• Advanced knowledge of memory processes related to trauma, including recovered memory, false memory, flashbacks and psychogenic amnesia
• Advanced proficiency in using structured and semi-structured trauma related disorder interviews and instruments
• Advanced knowledge of socio-legal issues related to trauma with demonstrated proficiency in co-ordinating the socio-legal network
• Advanced proficiency in the assessment of children (i.e., non-suggestive interviewing techniques in cases of suspected child sexual abuse) OR Advanced proficiency in gender sensitive evaluation methods (i.e., interviewing techniques with female rape victims) OR Advanced proficiency in assessment techniques with the use of translators (i.e., refugee populations)

Complex Treatment Skills

• Advanced skills for the prevention of trauma/stress reactions including psychological and pharmacological methods
• Advanced treatment skills for early trauma/stress reactions including psychological and pharmacological methods
• Advanced treatment skills for complex trauma disorders among adults and children including psychological and pharmacological methods
• Practical OR conceptual proficiency in the utilisation of at least two evidence-based trauma symptom reduction techniques (e.g., exposure techniques, cognitive restructuring, relaxation, eye movement desensitisation and reprocessing)
• Demonstrated proficiency in generating appropriate reports and certificates concerning victim’s psychological status for the legal and social
• systems
• Demonstrated proficiency in treating at least 2 trauma areas (e.g., war, refugees, sexual abuse, physical abuse, terrorism, transportation accidents, natural disasters)
• Demonstrated ability to co-ordinate the patient network linked to 2 socio-legal victim assistance programs: general crime, war, and disaster victim agencies, domestic violence and rape assistance programs, as well as child protection programs
• Recognition and management of secondary traumatisation processes among psychiatrists and clinical psychologists which may counteract treatment

In order to enhance learning, the proposed program should include a practicum, in which the participant:

• Assesses and diagnoses at least 6 victims, constituted of either 4 children and 2 adults, or of 4 adults and 2 children. Assessment and diagnoses should be performed in conjunction with 6 hours of supervision.
• Performs at least 100 hours of therapy in conjunction with 40 hours of individual supervision. Therapy should be performed with at least 8 cases presenting two different types of traumatic situations (e.g., rape, natural disaster, maltreatment, etc). Therapy should be performed according to the treatment modality chosen by the participant (i.e., psychodynamic, psychoanalytic, cognitive-behavioural, systemic) in conjunction with 46 hours of supervision

The specialised training module is comprised of 240 hours of coursework plus 160 hours of practicum. Learning will be evaluated via a standardised written examination, oral examination, and supervisor assessment. Specialised training could be co-ordinated by existing Psychotrauma Clinics in conjunction with national universities and teaching hospitals.

Proposed Treatment Standards for Psychotrauma Centres

Psychotrauma centres are tertiary treatment centres: it is here that the most complex cases of traumatisation should be treated. Psychotrauma centres should also have an educational function, working with national universities and teaching hospitals in order to improve mental health training in trauma for professionals. Finally, psychotrauma centres should have a research function, thus contributing to the pool of knowledge which permits constant scrutiny of appropriate trauma evaluation and treatment approaches.

As stated earlier, no co-ordinated accreditation exists for specialised psychotraumatology centres in Europe, despite a rising demand and interest for the treatment of victims. The lack of accreditation means that it is currently impossible to monitor standards, thus implying that we run the risk of re-victimising traumatised individuals through inappropriate treatment and lack of specialised knowledge.

Furthermore, professionals who work with this population are often called upon to enter in complex relationships with the judicial, social service, press and insurance sectors. These demands can highlight issues related to confidentiality and the protection of clients’ best interests. Specialised psychotrauma centres may well be better geared to deal with such issues given their unique experience. As such, psychotrauma centres can protect clients not only from inappropriate treatment but also from complications arising from an inappropriate articulation between clinicians and other concerned professionals.

It should be underscored: research findings related to trauma and victimisation has indicated rapid and often dramatic shifts in our understanding of trauma processes and implications. As such, it is extremely important, that basic treatment standards which reflect these issues be established for those clinics which position themselves as specialised centres for the treatment of trauma victims.

The OVEPE workgroup on treatment standards has attempted to address this situation by proposing a basic architecture for psychotrauma centres. The workgroup is composed of the following professionals:

Deitrich F Koch XENION-Psychotherapeutische Beratungsstelle Roscherstra.2a D-10629 Berlin GERMANY tel. (49) 30-32-32-933 fax (49) 30-32-48-575	Gisela Perren Klinger Institut Psychotrauma Schweiz PO Box 189 CH 3930 Visp SWITZERLAND tel (41) 279 46 3422fax (41) 279 46 3423
Tom Lundin Dept. of Psychiatry Uppsala University Hospital Sparrisgaten 2 S-754 46 Uppsala SWEDEN tel. (46)18-178822 fax (46)18-178890	Karen Sadlier Institut de Victimologie 16 rue Jean Leclaire 75017 Paris FRANCE tel/fax (33) 1 40 25 04 04
Ranieri Benedetto Degli Oddi Corso Vannucci N63 06100 Parugia ITALY tel/fax (39)-75-57-23-384	Stuart Turner Traumatic Stress Clinic 73 Charlotte St., London W1P 1LB UK tel. 44 171-530-3666 fax 441 171 530 3677

In this report on treatment centres, recommendations for standard guidelines are presented. Guidelines are proposed in four areas: staff qualifications, treatment quality, secondary traumatisation, and ethical issues.

It is further proposed that guidelines be reviewed annually on the national level and biannually on the European level. Such a review could be performed at European Society for Traumatic Stress Studies Congress in order to ensure active development of the proposed guidelines.

1) Staff qualifications

Psychotrauma centre staff should be composed of competent professionals in child, individual, family and group treatment and evaluation. These competencies should be proportional to the needs of the trauma population targeted by the centre (i.e., abused children, refugees, etc.). Psychotrauma centre services offer access to a sufficient range of clinically and empirically evidenced based treatment approaches, mindful of the needs of the client and the resource constraints of the health system. It is recommended that staff be selected from a range of clinical backgrounds and that they have completed specialised training in psychotraumatology. It is recommended that staff include:

• A psychiatrist with expert knowledge of psychopharmacology, dangeriosity evaluation, and complex diagnoses. The psychiatrist should be fully integrated into the treatment team. It is suggested that the psychiatrist have additional expertise in either forensic psychiatry, liaison psychiatry or psychotherapy.
• Psychotherapists, i.e., clinical psychologists, or where appropriate clinical social workers, family therapists, and psychiatric nurses with expert or specialised knowledge of psychotraumatology and victimology.
• A social issue liaison in order to co-ordinate links with existing social, judicial and victim assistance services.
• Trained special needs personnel in accordance with the unique issues of the trauma population targeted by the Psychotrauma Centre, e.g., interpreters, academic assistants, and compensation specialists.
• Administrative support staff carefully trained in confidentiality issues, media management and crisis referral techniques.

2) Treatment quality

In order to ensure the quality of treatment provided, it is proposed that Psychotrauma Centres be primarily funded through national health systems, thus providing the checks and balances of National Health Service review boards and mainstream quality assurance.

Active peer group supervision between Psychotrauma Centres is strongly encouraged. In addition, it is suggested that consensus meetings be held annually at the national level and biannually on the European level in order to review treatment approaches and methods utilised at Psychotrauma Centres. The European meeting could form part of the European Society for Traumatic Stress studies biyearly Congress and thus benefit from the input of European expert clinicians and researchers in the field.

Continuing education of Psychotrauma Centre is viewed as requisite. Ongoing training allows staff to maintain their knowledge base up to date. Given the dramatic advances in the field of psychotraumatology, this issue is particularly important. Furthermore, continuing education allows staff to continually evaluate the strengths and limitations of treatment approaches in the light of current research. Finally, continuing education contributes to prevention of secondary traumatisation processes among staff that can counteract effective treatment.

In those countries where national standards for continuing education do not exist for certain professions, it is suggested that approximately 10 percent of work time be allotted to continuing education via specialised reading, conference attendance and training programs.

3) Secondary Traumatisation

The staff of Psychotrauma Centres is indirectly exposed to the traumatic experiences of their clients throughout the treatment process. Such multiple exposure creates the risk of secondary, or indirect, trauma reactions among Centre staff. These reactions can curtail the professional’s ability to effectively provide specialised services to traumatised individuals. Although clinicians may be most affected by secondary traumatisation given their intimate access to client histories, support staff are also at risk.

It is recommended that several measures be taken in Psychotrauma Centres in order to prevent and manage secondary traumatisation:

• Provide available materials for self-evaluation of secondary traumatisation warning signs
• Provide internal or external support and treatment for secondary traumatisation
• Provide regular internal or external case supervision
• Permit a balance of either clinical and other trauma related professional responsibilities (e.g., research and teaching) OR permit a balance of trauma focused clinical work and general clinical work (e.g., availability of half or quarter time clinical positions)

4) Ethical issues

Ethical issues are commonplace in the field of mental health, yet in work with trauma victims they are particularly important. Working with this population often implies making complex decisions concerning confidentiality, the content of judicial reports, media demands for information, memory issues and the appropriateness of early intervention techniques.

As the field of psychotraumatology matures, guidelines for these questions need to be developed in accordance with both national and European ethical standards. It is recommended that a task force be composed in order to refine this area and to review ethical questions and practices during yearly Psychotrauma Centre national meetings and biyearly European Congresses.

Project report, Part II: National reports from the OVEPE network

Introduction

The OVEPE network seeks to create links between European professionals who treat victims of diverse aggressions. To date, national network representatives have been identified in France, Germany, United Kingdom, Italy, Sweden, and Belgium. In these countries, over 50 centres form part of the OVEPE network. Following is a listing of national representatives as well as their annual reports.

OVEPE NATIONAL REPRESENTATIVES

Belgium Marc Van Knippenberg MA Centrum voor Psychotrauma Gitschotllei 230 2140 Antwerp BELGIUM tel (323)272.2525 fax (323)216.1200	Italy Ranieri Benedetto Degli Oddi MA Corso Vannucci N63 06100 Parugia ITALY tel/fax (39)-75-57-23-384
France Mirelle Lasbats MA CAPS, Hasbruck, France tel/fax (33) 1 40 25 04 04	Sweden Tom Lundin MD Dept. of Psychiatry Uppsala University Hospital Sparrisgaten 2 S-754 46 Uppsala SWEDEN tel. (46)18-178822 fax (46)18-178890
Germany Deitrich F Koch PhD XENION-Psychotherapeutische Beratungsstelle Roscherstra.2a D-10629 Berlin GERMANY tel. (49) 30-32-32-933 fax (49) 30-32-48-575	United Kingdom Stuart Turner MD Traumatic Stress Clinic 73 Charlotte St., London W1P 1LB UK tel. 44 171-530-3666 fax 441 171 530 3677

a) France

Le réseau français a été constitué sous la direction du CAP Hazebrouck (Mireille LASBATS- psychologue clinicienne). Il s’est rapidement développé et compte désormais 16 membres :

Consultation d’Aide Psychologique Mme M LASBATS 5, ave Boufflers 59130 Lambersart	Institut de Victimologie 16, rue Jean Leclaire 75015 Paris
Centre des Buttes Chaumont 31, rue Mouzaïa 75019 Paris	C.R.I.S.C 29, rue Boulard 75014 Paris
Institut du Couple et de la Famille (Dr Benghozi) 3, villa Croix-Nivert 75015 Paris	Service de Médecine Légale (Pr L Barret) CHU La Tronche 38700 Grenoble
Dr Sehri SMUR Hôpital Val de Seine 76170 Lillebonne	Centre de psychologie clinique (B. Daunizeau) 22, Les Nouveaux Horizons BP 42 – 78997 Elancourt Cedex
CMPP (Dr J M Grellet) Allée Newton 93500 Pantin	Jacques Roques 66, rue Azalais d’Altier 34080 Montpellier
Dr P Louville Cellule Médico-Psychologique 149, rue de Sèvres 75015 Paris	C.M.P (Drs Grappe, Vaysse, Prado) 16, ave Mal Juin 93260 Les Lilas
COMEDE Hôpital Bicêtre 94272 Le Kremlin Bicêtre Cedex	Urgences Médico-Judiciaires Hôpital Jean-Verdier 93143 Bondy Cedex
Dr B Birnes Service de psychiatrie Hôpital Purpan 31059 Toulouse Cedex	Dr G Vila Service pédopsychiatrie Hôpital Necker 149, rue de Sèvres 75015 Paris

Les activités du réseau français ont été importantes :

Une Conférence de presse a présenté le projet OVEPE à l’Assemblée nationale, en présence de M Anthony Simpson, le 31 mars 1998. Divers journaux et magazines s’en sont fait l’écho, dont le journal “ Le Généraliste ” du 16 juin 1998 et la chaîne de radio “ Europe n° 1 ”.

Le réseau français a organisé les réunions de travail avec les représentants de L’ESTSS dans les locaux de la “ Fédération française de Psychiatrie ”, à Paris.

Le Dr G Lopez a présenté OVEPE au “ Forum Européen des Services d’aide aux Victimes ”, au parlement de Strasbourg, du 27 au 31 mai 1998 pour lui proposer de s’associer OVEPE et à l’ESTSS pour élaborer une Résolution concernant l’importance de la prise en charge psychothérapeutique des victimes.

Le 4 juillet 1998, il s’est réuni au SAMU de Paris, sous la direction de Mireille LASBATS, pour préparer l’enquête sur les pratiques thérapeutiques et les liens avec le réseau d’accompagnement socio-judiciaire des victimes. Ceci a permis d’élargir le réseau et de créer des groupes de travail :

1. un groupe de travail sur le debriefing (G Lopez, P Louville, M Grappe)
2. un groupe sur les problèmes des migrants (T N’Guyen, M Grappe)
3. un groupe “ Enfants ” (M Lasbats)
4. un groupe “ Formation ” (P Benghozi, G Lopez)

Les 28 et 29 septembre 1998, le Dr G Lopez a présidé le Simposio Internazionale SOS Catastrofe organisé par OVEPE Italie.

Un livre intitulé “ Psychothérapie des Victimes[1] ”, a été publié pour promouvoir les pratiques du réseau OVEPE, comme cela avait été prévu dans le cahier des charges OVEPE déposé par l’Institut de Victimologie auprès de la Commission Européenne.

Le 26 octobre 1998, le directeur du projet OVEPE a donné sa démission pour protéger OVEPE, en raison de rumeurs calomnieuses faisant état de son appartenance à la secte de scientologie. Il a déposé une plainte au Tribunal de Grande Instance de Paris contre un propagandiste. Philippe Werson, président de l’Institut de Victimologie, devient le nouveau chef de projet avec l’agrément de la Commission Européenne. Karen Sadlier demeure la coordinatrice du projet.

Le jeudi 5 novembre à 20 heures, au SAMU de Paris, sur l’initiative du Groupe de travail “ enfants ”, Maître Isabelle STEYER a échangé avec les membres du réseau français sur les modalités pratiques du signalement des enfants et adolescents en danger (rédaction des certificats, suites judiciaires, responsabilité médicale).

Le Réseau français entend poursuivre son travail au-delà de l’Initiative Daphné. Il entend poursuivre son action et continuer à promouvoir des centres de soins en France et en Europe :

1. un diplôme de “ Gestion des Crises Humaines ” organisé par l’Université Paris XIII, associe les membres d’OVEPE et ceux réseau d’aides aux victimes pour promouvoir les objectifs d’OVEPE.
2. des psychiatres russes ont fait appel à OVEPE France pour participer à ses activités universitaires concernant la victimologie et la “ gestion des crises humaines ”.

b) Germany

The German network was constituted by clinical psychologist Deitrich Koch, PhD. Following is a description of participating German centers and their services to women and child victims:

1-Refugio München

Beratungs- und Behandlungszentrum für Flüchtlinge und Folteropfer

(Counselling and Treatment Centre for Refugees and Torture Survivors)

Rauchstrasse 7

D – 81679 München

Germany

Phone: + 49 89 98 29 570

Fax: + 49 89 98 29 57 57

Statistic on patients/clients 1997:

Main Activities

Treatment

The Centre for Counselling and Treatment of Refugees and Victims of Torture offers social counselling, psychological diagnosis, psychotherapeutic counselling and treatment, medical diagnosis and treatment, art and music therapy, as well as physical therapy. Interpreters are provided when necessary. Other activities include art workshops for children.

Training

Supervision and training are carried out for other social workers and institutions working with refugees, and training is conducted for interviewers and staff of the federal refugee authority. Workshops dealing with refugees, trauma, and therapy have also been held.

Resources

Financial support is provided by the city of Munich, the EU, the UN, welfare organisations and donations.

Staff

The multi-disciplinary and inter-cultural staff comprises 11 employees from different professional fields. These are assisted by 20 freelance therapists and 20 freelance interpreters.

Future Plans

Future plans are to continue the services currently offered.

2- Psychosoziales Zentrum für Flüchtlinge

(Psychosocial Centre for Refugees)

Graf-Adolf-Strasse 102

D – 40210 Düsseldorf

Germany

Phone: +49 211 35 33 15 or +49 211 35 33 16

Fax: +49 211 35 33 14

Established: 1987

Primary Objectives

The Psychosocial Centre for Refugees in Düsseldorf works to provide psychosocial counselling and psychotherapy mainly for traumatised refugees. Courses and group activities are carried out for refugees. Information events and supervision as well as public relations networking and information efforts are conducted also on behalf of refugees.

Statistics on clients/patients 1997:

In 1996, psychotherapy (Gestalt, GT) including family therapy, art therapy, dance and movement therapy was provided for 151 refugees (both individuals and families) while psychosocial counselling was provided for 214 refugees (both individuals and families). German lessons are also among the services offered to refugees.

Main Activities

Treatment

The target groups for the services of the Centre are refugees (irrespective of their residence status and country of origin), who are in need of psychosocial counselling and therapy due to traumatisation and uprooting. The specific therapeutic needs of children and women are also addressed.

Training

Seminars have been held concerning Bosnia, Kurds form Iraq and Turkey, trauma and therapy, as well as the situation of child and adolescent refugees. Training sessions have also been conducted for interpreters, and centre staff have participated in relevant seminars and conferences. Supervision is conducted in two continuous groups, and sensitivity training has been offered by centre staff to those working for the federal authorities regarding he acceptance of refugees.

Research

An ongoing project addresses the situation of interpreters in therapy, their training and evaluation.

Publications

The centre has published extensively on the work of traumatised refugees.

Networking

PSC Düsseldorf is a member of BAFF (German Association of Psychosocial Centres for Refugees and Victims of Torture) and co-operates at the local, regional and federal level with social, therapeutic, medical, and other institutions and professionals.

Resources

Funding

The PSC is supported by the Federal Government, UNHCR, the European Commission, the German Foundation for UN-Refugee Aid, Diakonisches Werk, the Protestant Church, the Government of North Rhine-Westphalia, the city of Düsseldorf, church parishes, and members of the centre’s association.

Staff

The staff team comprises one psychologist with therapeutic qualifications (of Kurdish-Syrian origin), one social scientist, one educationalist/social worker with therapeutic qualifications, one secretary, and one office assistant. In addition to this, honorary staff includes one educationalist/therapist from Afghanistan, one medical doctor from Bosnia, two ethnologists/family therapists from Germany, one art therapist from Iran, one social worker of Kurdish origin from Turkey, one dance and movement therapist from Germany, seven interpreters from Kosovo, Germany, Erithrea, Iran, Croatia, and Sri Lanka, three course leaders, and two students completing an internship.

Future Plans

The main activities and issues addressed to be in the future are the following:

• Development of structures for therapeutic and medical treatment of refugees in the region
• Training and research regarding interpreters in therapy
• Psychological and somatic consequences of torture
• Social integration of traumatised refugees
• Psychosocial situation of traumatised women
• Counselling and therapy for child and adolescent refugees
• Integration of professionals from the countries of origin of the refugees
• Workshops on trauma and culture with key persons from refugee communities

3- Psychosocial Centre For Refugees and Victims of Organised Violence

Fichardstraße 46

60322 Frankfurt a.M.

Germany

Phone: +49 69/553110 or /553116

Fax:     +49 69 553140

Established: 1979

Primary Objectives

• psychological and medical rehabilitation of torture victims and their families
• assisting victims in the organisation, adjustment and integration process
• organising and monitoring empowerment and selfhelp working-groups
• organising seminars and workshops to professionals on torture violence and trauma related topics
• educating and increasing awareness amongst the public about the effects of torture and uprooting
• documenting torture-related cases

Statistics on clients/patients 1997:

Psychotherapeutic treatment:                       211

Psychotherapeutic Counselling:                   309

Total:                                                            521

Countries of origin:                                      34

Main Activities

Treatment

• psychotherapy (behaviour, gestalt, family, client centred), counselling, medical assistance and adjustment related social support for rehabilitation of traumatised refugees and victims of organised violence
• self-help and preventive groups for youth, men and women
• 521 clients were treated at our centre in 1997

Training

• seminars on torture, trauma and PTSD were held for government agencies and the judiciary
• organising and executing workshops, seminars, lectures and events on refugee relevant issues (racism, violence, problems of acculturation, rehabilitation and health matters
• the centre has developed two projects located in the city of Frankfurt:

– “Martinushaus”, a home where refugees who come from psychiatric hospitals could further be stationary treated

– “Regenbogen”, a community based counselling and activity centre in a district of Frankfurt (Bonames) where many refugees live

– supervision and practice orientated help to single persons and institutions in the refugee-work

Research

• conducting research and developing new concepts and intervention techniques on the issues of torture, trauma, violence and intercultural counselling and therapy
• project psychotherapy for children in crisis: traumatised children as victims of political organised violence in Natal/South Africa (Durban)

Documentation

The centre has a library at ist disposal comprising a variety of specialist literature about torture, trauma, diagnostic manuals, social work, education and law. These books are used mainly by staff members but also by people who are interested such as students, psychotherapists or other center’s staff.

Publications

Since 1990 several studies written by staff members of the centre have been published. Some of them are:

–          Mehari, Fetsum: “Migration und Krankheit” /IKO-Verlag Frankfurt, 1995

–          Mehari, Fetsum: “Exilleben und Rassismus” / in: Psychologie Heute, Heft 12, 1993

–          Mehari, Fetsum: “Der integrative Ansatz in der Beratung und Therapie von Flüchtlingen” in: “Die Betreuung und Behandlung von Opfern organisierter Gewalt” IKO-Verlag Frankfurt 1993

–          Mehari, Fetsum: “Interkulturelle Beratung” / in: Info EKFUL, Evangelische Konferenz für Familien- und Lebensberatung, 1995/2

–          Peltzer, K., Aycha A., Bittenbinder E.: “Gewalt und Trauma”/ IKO-Verlag, 1995

–          Peltzer, K., Diallo, J.-C.: “Die Betreuung und Behandlung von Opfern organisierter Gewalt im deutsch-europäischen Kontext”/ IKO-Verlag Frankfurt, 1993

Prevention

The Psychosocial Centre has organised many meetings, discussion-forums, workshops and seminars for the purpose of creating awareness in the public on the issue of torture, trauma and violence. Besides there are preventions selfhelp-groups (women and youth) for refugees organised and executed at our centre.

Networking

The centre staff are members of and participates regularly in meetings of the German Amnesty International Medical Health professional group, the working group of the German Association of Psychosocial Cetres for Refugees and Victims of Torture (BAFF) and other international human rights organisations.

Ressources

Funding

The most significant sources of funding are the Federal Government of Germany (Bundesministerium für Familien, Jugend und Senioren), the Provincial Government of Hessen (Hessisches Ministerium für Umwelt, Energie, Jugend, Familie und Gesundheit), the Evangelical Church (Evangelischer Regionalverband in Frankfurt a.M.) and Diakonisches Werk Hessen/Nassau. These fundings are subject to annual cuts.

Staff

The staff comprises two Psychologists with therapeutic qualifications, a medical doctor, a pedagogue, two social workers and a secretary.

Future Plans

– working on the ethnocultural aspects of PTSD

– research on postwar-trauma in the country of origin

– research on empowerment and selfhelp-groups and their relevance in the rehabilitation process

the treatment of traumatised women, children and adolescent refugees

4- Psychosoziales Zentrum für ausländische Flüchtlinge

CARITAS-Asylberatung Köln e.V.

Psychosocial Centre for Refugees

Spiessergasse 12

D – 50670 Köln

Germany

Phone: +49.221.16074-0

Fax:     +49.221.1390272

Established: 1985

Primary Objectives

The Psychosocial Centre for Refugees seeks to offer relevant therapy and case work for refugees and victims of torture.

Statistics on clients/patients 1997:

Psychotherapeutic treatment:

Total: 234

35 different countries of origin

Social work:

Total: 623

53 different countries of origin

Main Activities

Treatment

Treatment includes medical and psychiatric assistance, diagnostic and therapy. Therapy is offered to couples, families and individuals, and dance, movement and art therapy is also used. Crisis management is applied in emergency situations. Priority is given to torture victims. Case work is carried out for asylum seekers and recognised refugees. Priorities are to offer legal assistance in the asylum procedure to assist refugees in obtaining residence and work permits as well as family reunification. German language courses are also offered.

Training

Training and supervision is carried out for the voluntary helpers at the centre, and centre staff assists in the training of students of social work, education and psychology.

Research

A project is being prepared addressing the importance of transforming inner images in a context of treating victims of torture. The working title is “Transforming inner images, life in exile as a challenge?”

Resources

Funding

Funding is provided by a number of sources including UNHCR, the Federal Miistry for Womes, Senior Citizens, Family and Young People, the CARITAS Association, the Arch Bishopery of Cologne, the UN Voluntary Fund for Victims of Torture, the EU, the German Foundation for UNO Refugee Aid, the City of Cologne, the Federal Employment Office, and the state of North Rhine-Westphalia. Specific projects have been funded by the Catholic Training Organisation and other foundations and individuals.

Staff

A total of 17 staff members include psychologists, social workers, family therapists, medical doctors, dance therapists, and secretaries.

Future Plans

Priority issues include the following:

• meeting in Cologne “Torture, Trauma, After-effects”. This conference, arranged in co-operation with the General Medical Council of North Rhine-Westphalia, will focus on methods of treatment and counselling for victims of torture and human rights violations and will address possibilities in a public health context and legal aspects in Germany.
• a research project intensifying the ethnological point of view in a psychotherapeutic context will be carried out when the team is expanded with an ethnologist
• documentation and publication of the latest findings concerning methods of treatment for victims of torture.

5- XENION

Psychotherapeutische Beratungsstelle für politisch Verfolgte

Psychotherapeutic Counselling Centre for Politically Persecuted Refugees

Roscherstraße 2a

D – 10629 Berlin

Germany

Tel.: +49 30 323 29 33

Fax.: +49 30 324 85 75

Established: 1986

Primary Objectives

XENION has set itself the objective of promoting the welfare of politically persecuted refugees and their families who have been traumatized
•          by state violence, especially imprisonment, incarceration in concentration camps and torture
•          as a result of acts of war and civil war
•          as a result of expulsion and exile
•          by racist violence in Germany.
The centre’s main aim is to contribute to a qualitative improvement in the psycho-social and health care of this target group. Our work is focused especially on helping refugees who have suffered torture and other human rights violations. Further explicit aims of the association are to disseminate information on the destructive effects of torture and human rights vio­lations among the public and to improve refugees’ access to the health and social services.

Statistics on clients/patients 1997:

A total of 152 refugees from 31 countries consulted the XENION Counselling Centre in 1997.

Main Activities

Treatment

XENION provides individual psychotherapy, couples and family therapy based on systemic and integrative family therapy and individual and group psychotherapy based on Psychodrama. Treatment includes psychological diagnosis and crisis intervention in emergency situations. A consultative medical service is provided by a specialist in neurology, psychiatry and psychoanalysis. Medical examinations and reports and initial treatment of physical sequelae of torture can be given. With the aid of trained interpreters working in 18 different languages the treatment can be offered in the clients’ own languages.

Psychosocial Assistance

In combination with the treatment XENION offers social-work-based and psycho-social counselling to promote the development of the personal prerequisites for an improvement in the social and economic integration of refugees. A series of interventions are also employed to stabilise the social context and to create living conditions that foster rehabilitation by helping to bring families together. These include supporting a client’s wish to be allocated a residence close to his or her relatives or to move to a more suitable form of accommodation. The Centre compiles psychological assessment reports in order to lend credibility to the clients’ cases at court proceedings. Where necessary XENION also provides external support to doctors, lawyers, external legal aid providers, other human rights organizations and authorities and co-ordinates referrals and co-operation between client and sources of external support. In individual cases psychosocial assistance also includes outreach care and guidance.

Training

Xenion’s main training activities are assisting individuals and institutions working with refugees, giving lectures, seminars and workshops to students, professional colleagues and other workers in the field about the special requirements of therapeutic treatment and psychosocial work with traumatized refugees and victims of torture. Another subject covered by our training is the work of interpreters in therapy and the co-operation between interpreters and therapists.

Documentation

Thorough medical and psychological diagnosis of the sequelae of torture is an integral part of the treatment and the systematic documentation of human rights violations. Clinical aspects of the sequelae of torture and other traumatic life events experienced by the person in the context of their political persecution must be ident­ified and recorded as biographical case histories. Survivors of torture can use their case reports to gain recognition, both in the sense of drawing attention to the deeds and responsibility of the persecuting states and in the sense of supporting their claims to political asylum or at least obtaining protection from deportation.

Co-operation

XENION co-operates closely with other NGOs working with refugees and in the field of health and human rights. These are, in particular, counselling centres run by charity organisations, the two churches, Amnesty International and many other small non-governmental organisations, also lawyers and social workers in refugee hostels. Clients who are not receiving adequate guidance on social and legal issues that Xenion is not equipped to deal with are put in touch with the appropriate person or institution. The same applies in the case of medical problems. Here we work in close co-operation with medical specialists working in independent practice, most of whom are themselves foreigners. Finally, associations and self-help groups organised by the refugees themselves are also impor­tant collaborators. In individual cases so-called helpers’ conferences and intervision with others providing support and treatment are called upon.

Networking

XENION is one of the founding members of the German Association of Psychosocial Centres for Refugees and Victims of Torture (BAFF) and member of its executive committee. This organization was founded in January 1997 as a joint initiative of institutions and health-care professionals operating in the field of refugees’ health and human rights. XENION is also a member of the OVEPE (Organisation de Victimologie et Psycho­traumatologie Européenne, a European organisation for practice and research on the effects and treatment of severe traumatization and has applied for membership of the International Society of Health and Human Rights ISHHR. General aims are participation in political working groups, media work, lobbying, public relations and information.

Research

Our current research focuses on quality assurance in psychotherapy and psychosocial work with victims of violence (evaluation) and the special difficulties involved in cross-cultural diagnosis and therapy. We are in the process of trying out and developing qualitative and quantitative tools with which to monitor the quality and success of our work and conduct a process evaluation of our approach.

Resources

Funding

The XENION Centre is funded by the Senate Department of Health and Social Affairs, Berlin,
The Commission of the European Union, Directorate General I,
External Political Relations, Human Rights and Democratisation, Brussels,
The United Nations Voluntary Fund for Victims of Torture, Geneva, and
other welfare organizations and private donors

Staff

Permanent staff

The XENION Centre currently employs a team consisting of four members:
• the project manager: clinical psychologist and integrative family therapist
• a second psychologist and psychotherapist (Director of Psychodrama)
• a specialist in pedagogics and systemic family therapist
• an administrative worker and secretary.

Staff who work for Xenion on a freelance basis

• a medical consultant (specialist in psychiatry and neurology)
  • interpreters specially trained for work in psychotherapy and counselling (18 languages)
  • a psychologist and graduate in interpreting and translating (Great Britain) responsible for
  translations and quantitative and qualitative evaluation
  • a psychotherapy supervisor

Future Plans

expansion of our therapeutic work to include children and adolescents

building up of a network of voluntary guardians for unaccompanied young refugees below the age of majority

development of proposals for evaluation guidelines for psychosocial work with traumatized refugees for the German Association of Psychosocial Centres for Refugees and Victims of Torture

provision of information and training for government bodies and authorities that have to do with refugees

c) United Kingdom

The United Kingdom network was constituted by psychiatrist Stuart Turner, MD.

Introduction.

In the UK, the concept of having a meeting for heads of trauma centres is not new. We have been meeting since 1996 in what is now called the UK Trauma Group. This report provides some of the background and describes the most recent event.

Background.

In the UK, psycho-social trauma services developed in a patchy way and with a short life-span (2 to 3 years) following some of the well-publicised incidents such as the Bradford City Stadium fire, the Herald of Free Enterprise sinking and the Kings Cross Railway fire.

In the late 1980s, there were regular disaster researchers meetings in London but these came to an end, as did the routine funding of these services.

Following the Gulf War, two national centres were established – the Traumatic Stress Clinic (my own service, then in the Middlesex Hospital and now in 73 Charlotte Street, London W1P 1LB in purpose built space) and the Traumatic Stress Project at the Institute of Psychiatry.

Shortly afterwards, Dora Black established a child trauma service at the Royal Free Hospital and in 1995 this joined the Traumatic Stress Clinic in Charlotte Street. This is an integrated trauma service separate from a department of psychiatry providing treatment for individuals and families after a wide range of traumatic events.

This was a time of development for small-scale specialist services – but on routine funding. The incorporation of services onto mainstream health funding was a major step forwards and one which we encouraged.

In early 1996, I decided that it would be a good idea for all the emerging centre heads (and those likely to develop centres) to meet together. This generated a lot of enthusiasm and we have met as a group twice a year since then.

Membership of the group is open to existing members and to those potential members who meet both the following criteria:

• Head (or joint head) of a specialist trauma service.
• Committed to the application of evidence-based care.

The group includes regular participants from Northern Ireland and Scotland as well as England and Wales. Until the establishment of OVEPE, people were self funding – an indication of utility.

Aims.

The UK Trauma Group may be characterised as having the aims of

• Peer group discussion
• Sharing research in hand, near publication or at the stage of developing protocol
• Discussing new techniques (eg recently we had a session on EMDR)
• Reviewing evidence (eg Critical Incident Debriefing)
• Providing a focus for service and policy development in the UK.

In addition, we follow the meetings by a meal for those who wish to stay and so encourage social as well as strictly professional contact between centre heads.

Membership.

At the last count, we invite 38 people to UK meetings and usually about half are able to come. Members come from all across the UK. They all work in health rather than social services and are drawn from two main professional groups – psychiatrists and psychologists. A full list is available if required.

1998

In 1998, we only had one meeting (unusually) and this took place on 13^th October. Seventeen people attended and the OVEPE funding was used to support travel costs in some cases. In 1999, we have booked the 21^st April and 21^st October for the next two meetings.

The UK group concentrated on “power therapies” and especially on EMDR. Cautious acceptance of the evidence for EMDR emerged although without any clear explanation as to mechanism of effect.

We also discussed some of the feedback on the work of OVEPE on training. There was some concern about the imposition of a bureaucratic process of accreditation and also concern that training standards needed to include nurses, social workers and others as well as psychiatrists and psychologists. The group is keen to hear more of the work of OVEPE.

Centres

In preparing this report, I have struggled with the definition of a centre. There are a number of physically discrete centres – with their own buildings or dedicated space. There are other services where the centre is formed by people coming together to offer a particular service.

This information should not be published on the internet or elsewhere without further guidance, validation and consent by participants.

Scotland:

We have two participating centres – one in Aberdeen (leader Professor David Alexander) and one in Edinburgh (named after WH Rivers, led by Chris Freeman and Claire Fyvie). Both are outpatient services. The Aberdeen service has strong links into the emergency services. The Edinburgh service has strong links into psychological treatment services.

England:

There are several services or centres participating in the UK group. In Leeds, Professor Andrew Sims (former President of the Royal College) heads a relatively new outpatient service. In York, Mark McFetridge heads a service which offers inpatient care as well as outpatient treatment. It is based in the Retreat, a famous innovative hospital set up originally by the Quakers.

In Lincoln, Roderick Orner (current President, ESTSS) has established a strong service with the emergency services and also offers outpatient treatment.

In London, there are specialist centres in North West London (West Middlesex Hospital, led by Professor Chris Brewin and Sue Rose); in South West London (St George’s Hospital (inpatient as well as outpatient) led by Gillian Mezey and Ian Robbins; in South East London (the Maudsley Hospital – several services loosely united led by Professor William Yule for children and by Felicity De Zulueta, Professor John Gunn and Professor Isaac Marks for adults); in Central/North West London (my service in Charlotte Street, led by Stuart Turner, Gwen Adshead, Debee Lee, James Thompson for adults, and Lionel Bailly, Dora Black and Annette Mendelsohn for children). The Charlotte Street service works with refugees as well as other trauma survivors.

Just outside London John Spector runs a service which focuses on EMDR treatment and is a UK co-ordinator for EMDR training and treatment services.

In Kent, there is an inpatient service led by Gordon Turnbull at a private hospital (Ticehurst House Hospital). Gordon has experience of a similar service in the RAF and has worked with hostage survivors.

In Oxford, there is no centre but there are two services with significant PTSD services. These are led by Mike Hobbs (psychotherapy) and by Professor David Clark (cognitive-behaviour therapy).

In Manchester, Professor Nick Tarrier has led a major research programme evaluating different treatment approaches.

Wales:

In Cardiff, there is a loose service led by Jonathon Bisson.

Northern Ireland:

Many services have been developed there – insofar as many people have gained experience of PTSD. The contributor to the UK group is Oscar Daly who heads a specific service.

There are other services around the country, including some being established at present but these are some of the main centres.

Finally, we have members of the group responsible for treatment services in the armed forces. It is likely that this relationship will expand further.

Conclusion

There is a well established network of trauma centres in the UK although there are still some parts of the country with limited coverage. We meet twice a year and have successfully developed a co-operative style of practice with a commitment to the evidence-base. This work will continue regardless of OVEPE funding but this certainly assists.

d) Italy

The Italian network is co-ordinated by clinical psychologist Ranieri Benedetto deggli Oddi.

Dozens of professional and grassroots centres, which dispense varied levels of counselling services to victims of violence, were identified. However, it was felt by the national co-ordinator that the focus of OVEPE’s Italian efforts should be focused on increasing political and professional sensitivity to victim issues. As, such, a Symposium was organised in Rome at the Palazzo Barbarini in October of 1998. Over 40 professionals from around Europe presented papers on mental health issues, clinical prevention and intervention strategies, as well as supportive services to women and child victims of diverse aggressions to an audience of 350. A full listing of both symposium participants and presenters, as well as potential victim treatment centres in Italy is available from the Italian co-ordinator.

e) Sweden

The Swedish network was co-ordinated by psychiatrist Tom Lundin, M.D. Following is his annual report.

Over a dozen psychotrauma centres exist in Sweden. These centres provide services for victims of violence as well as other traumatised individuals (for example, major burn victims). Psychotrauma centres dispense specialised, high level mental health services. Patients are not divided based on the type of trauma experienced, except for refugee populations. In terms of age differences, different structures exist for child and adult populations.

Low level counselling (please note, this is not psychotherapy) exists at the emergency level by trained volunteers or entry level professionals. On call psychiatric liaison services often refer patients to Psychotrauma Centres.

Psychotrauma centres are primarily funded by public monies and constitute a specialist health service. They are typically located outside of either general of psychiatric hospitals in order to reduce stigmatisation of traumatised individuals as “ill” and in order to increase accessibility. As such, they tend to be structured as specialised outpatient community mental health programmes.

In Scandinavia, patients are addressed to Psychotrauma Centres by the primary care system (general practitioners and pediatricians) or by the secondary care system (general psychiatrists and clinical psychologists). This referral process is a result of both existing national health service referral guidelines and the sensitivity of primary and secondary health care professionals of the specialised mental health treatment needs of victims of violence.

The judicial system tends address patients solely for the purpose of specialised forensic evaluations. It is assumed that primary or secondary health practitioners will refer patients if needed for treatment.

EC funding for the 1997-1998 fiscal year was used to further consolidate the relationship between existing centres and to cover travel costs to OVEPE pan-European workgroup meetings on training and treatment standards. In terms of future OVEPE efforts, the relationship between Psychotrauma Centres and victim assistance efforts needs to be improved. Currently, there is little articulation in Scandinavia between Psychotrauma Centres and victim assistant networks. Reasons for this are partially due to the different levels of services provided: victim assistance networks tend to provide initial counselling limited to one or two contacts while Psychotrauma Centres offer a full range of brief and long term psycho-pharmacological therapies.

f) Belgium

The Belgium effort was spearheaded by psychotherapist Marc Van Knippenberg. The report on Belgium is presented below.

 La Belgique représentée par le Centrum voor Psychotrauma d’Anvers a été un des principaux membres du projet.

Mac van Knippenberg a participé à la réunion initiale où les bases du projet ont été jetées à Bruxelles.

Il a participé à l’élaboration du projet.

Il a noué des contacts avec le Pr Fischer de Cologne et a organisé une réunion dans les Ardennes belges pour promouvoir un réseau avec l’Université de Cologne. Ce travail est en cours.

Il a été présent aux réunions de travail avec l’ESTSS, organisées à Paris.

Il est venu à Rome pour participer au Simposio Internazionale SOS catatrofe organisé par OVEPE Italia.

Il a noué des liens et jeté les bases d’un réseau belge de Centre de soins ayant des liens très privilégiés avec la Suisse, l’Italie, l’Allemagne et la France.

Le Dr Goffioul de Liège a également activement participé à l’élaboration du projet et a préparé le Colloque qui était prévue à Bruxelles pour clore le projet Daphné. Il est déterminé à organiser une réunion pour présenter la Résolution qui a été élaboré et voté par les membres d’OVEPE et d’ESTSS.

Le réseau Belge a été désorganisé par la démission du premier directeur de projet, mais espère qu’OVEPE poursuivra ses travaux.

Une réunion est prévue en mai pour discuter de la suite à donner au projet.

PROJECT REPORT, Part III: Motion for a ResolutionTo the European Parliament

DRAFT

Resolution on the report from the European Organisation of Victimology and Psychotraumatology (OVEPE – European Commission, Daphne project no. 97/2/248), in collaboration with the European Society for Traumatic Stress Studies and the European Victim Assistance Forum,

The European Parliament,

• having regard to Recommendation no. R (83)7 on public participation in crime policies,
• having regard to Recommendation no. R (85)4 on family violence,
• having regard to the European Convention on compensation to victims of violence,
• having regard to Recommendation no. R (85) 11 on the role of the victim in judicial proceedings,
• having regard to Recommendation no. R (87)2 on victim assistance and prevention,

A Whereas despite preventive efforts in European Union member states, children and adults who are victims of diverse aggressions, accidents and catastrophes constitute a public health issue due to resulting mental and physical health disorders which lead to increasing demands on the public health, social service, judicial, compensation and employment sectors;

B Whereas a lack of co-ordination exists between victim assistance programmes and the psychological treatment of victims,

C Whereas clinical experience indicates that early interventions may attenuate the mental health and physical health disorders resulting from victimisation;

D Whereas some victims of diverse aggressions, accidents and catastrophes develop persistent mental health problems requiring access to specialised treatment;

E Whereas psychotraumatology centres exist in insufficient number in the majority of European union member-states and are non-existent in others, thereby implying the need to create specialised centres in both the public and private health sectors, at no charge to victims;

F Whereas the absence of relevant knowledge among health, social service and emergency professionals prevents referral of victims to specialised service providers;

G Whereas the lack of accredited training in the mental health needs and the social needs particular to victims among concerned professional disciplines hinders the assurance of the quality of services currently provided to victims;

1. It is the opinion that the Commission should put forward concrete proposals, within its competencies, to deal with the following issues:

a) The promotion of research on the individual and social consequences of trauma and victimisation, as well as on appropriate mental health prevention and interventions modalities;

b) The promotion of co-ordination of relations between specialised psychotraumatology centres and victim assistance organisations;

c) The adoption of European public policy on the creation of psychotraumatology centres, principally financed by public funds as part of national public health policies in each member state and by both organisations sensitive to the importance of diminishing the individual, social and financial consequences related to diverse aggressions, accidents, and catastrophes;

d) The promotion of European public policy on accredited training at the university level and at the continuing education level for mental health professionals on the requisite knowledge concerning the treatment of victims and their orientation to existing public and private victim assistance networks;

e) The promotion of European public policy on accredited specialised training for non mental health professional in contact with victims, e.g., paramedics, health professionals, victim assistance personnel, social workers, clergy, law enforcement, justice professionals and volunteers;

f) The promotion of the creation of a specialised task-force for the dissemination of scientific research on appropriate mental health interventions targeted at victims; the accreditation and monitoring of specialised psychotraumatology centres, the services provided there-in, the qualifications of centre personnel and their adherence to ethical standards in vigour in European Union member-states; as well as the quality of university, continuing education and specialised training programs in psychotraumatology and victimology.

PROPOSITION DE RESOLUTION

Selon le rapport de l’Organisation de Victimologie Et de Psychotraumatologie Européenne (OVEPE – Commission Européenne, Initiative Daphné/97/2/248 et le Forum Européen des Services d’Aide aux Victimes.

Le Parlement Européen :

• Vu la Recommandation n°R(83)7 sur la participation du public à la politique criminelle,
• Vu la Recommandation n°R(85)4 sur la violence au sein de la famille,
• Vu la Convention européenne relative au dédommagement des victimes d’infractions violentes,
• Vu la Recommandation n°R(85)11 sur la position de la victime dans le cadre du droit pénal et de la procédure pénale,
• Vu la Recommandation n°R(87)21 sur l’assistance aux victimes et la prévention de la victimisation ;

A         Considérant que malgré les efforts de prévention entrepris dans les états membres, les enfants, les adolescents, les femmes et les hommes victimes de violences, d’accidents divers et de catastrophes, en nombre croissant, constituent une population susceptible de présenter des troubles psychologiques :

• créant un problème de santé publique,
• augmentant les demandes d’aide sociale et judiciaire,
• entraînant des dépenses indemnitaires et de nombreux problèmes sociaux comme la perte d’emploi ;

B         Considérant qu’il existe un manque de coordination entre le secteur de l’aide aux victimes et celui du traitement psychothérapeutique des victimes ;

C         Considérant que l’expérience clinique indique qu’un traitement psychologique précoce pourrait atténuer les conséquences des traumatismes psychiques ;

D         Considérant qu’un nombre significatif de victimes d’accidents collectifs et de catastrophes nécessitent une intervention psychologique immédiate et certaines des soins différés à moyen ou long terme ;

E         Considérant que les structures de psychotraumatologie sont soit en nombre insuffisant soit même inexistantes dans certains pays membres et que les soins psychologiques aux victimes nécessitent la création de centres de psychotraumatologie hospitaliers ou extrahospitaliers, publics ou privés, dispensant des soins si possible gratuits aux victimes ;

F         Considérant l’absence de formation spécifique des professionnels de santé, travailleurs sociaux et personnels d’urgence médicale, leur permettant d’orienter les victimes vers des Centres de psychotraumatologie pour leur assurer des soins ;

G         Considérant le manque de formation spécifique des professionnels de la santé mentale en matière de psychotraumatologie, de connaissance et de pratique du réseau de l’aide aux victimes

1. Proposent aux états membres de l’Union européenne d’adopter une résolution sur les propositions suivantes :

a) promouvoir la recherche empirique sur les conséquences personnelles et sociales des traumatismes psychiques et sur les interventions et les traitements psychologiques capables de les prévenir ;

b) améliorer la coordination entre les centres de soins et les services d’aide aux victimes ;

c) promouvoir une politique de création de Centres de psychotraumatologie financés par les pouvoirs publics selon les dispositions nationales de santé publique en vigueur dans chacun des états membres et par les organismes publics et privés intéressés à voir diminuer les conséquences individuelles, sociales et financières des agressions, accidents et catastrophes (compagnies d’assurance, Fonds de garantie, secteur économique exposé, compagnies de transport, etc.) ;

d) promouvoir une politique de formation universitaire et post-universitaire accréditée pour les personnels de santé mentale, dispensant les connaissances indispensables pour traiter efficacement les victimes d’agressions et d’accidents divers présentant un traumatisme psychique et les orienter vers le réseau d’aide aux victimes ;

e) promouvoir une politique de formation accréditée pour les autres personnels travaillant au contact des victimes (médecins, professions paramédicales, personnels des services d’aide aux victimes, travailleurs sociaux, action humanitaire, clergé, policiers, juristes, etc.)

f) promouvoir la création d’un Organisme de coordination européen de psychotraumatologie et victimologie pour :

• favoriser la recherche scientifique, faire circuler l’information, développer les meilleurs types d’interventions thérapeutiques et orienter la formation universitaire des professionnels de santé en psychotraumatologie et victimologie ;
• accréditer et assurer le suivi (monitoring) des Centres de psychotraumatologie en matière de qualification professionnelle des thérapeutes, de nature des soins dispensés, de respect des dispositions déontologiques en vigueur dans les différents pays membres et de formation professionnelle continue en psychotraumatologie et victimologie.

Bruxelles, le 5 décembre 1998

PROJECT PROCEDURE

Initial goals

OVEPE’s goals for 1997-1998 were to :

• Identify mental health centres throughout Europe which work with diverse victim/trauma populations
• Co-ordinate the creation of a European network of such centres
• Propose European guidelines for training programs in trauma/victimology
• Propose European guidelines on standards for specialised centres in trauma/victimology

In conjunction with these goals, OVEPE identified over 50 centres working victim populations throughout six European Community nations, i.e., France, Germany, the United Kingdom, Sweden, Italy and Belgium. National representatives in each country worked towards creating a centre network via regional meetings and active dialogue with European colleagues. Workgroups on training and treatment standards were composed which proposed recommendations on standardised guidelines at the European level.

In addition to meeting these goals, OVEPE created liaisons with both the European Society for Traumatic Stress Studies and the European Victims’Assistance Forum. These liaisons allowed us to pool common efforts by drafting a motion for a resolution to the European Parliament aimed at improving mental health services for victims of diverse aggressions.

Difficulties in meeting goals

As is the case for all ambitious projects, OVEPE suffered from several difficulties in meeting its goals.

First, time and material resources did not allow us to identify related professionals in the totality of European Union member countries. Furthermore, we were disappointed at not having been able to garner active interest in the project from potential colleagues in southern European countries, particularly Spain, Portugal and Greece. Given the difficulties we experienced with these nations, and given our experience with the Italian network, we have come to believe that an increased awareness of victim issues at the national level is prerequisite to the creation of a viable service infrastructure. As such, we suggest that future funding be targeted at enhancing public and political sensitivity to victim issues in southern European countries.

Another difficulty, which we experienced seriously, endangered the future of the OVEPE project. OVEPE had originally planned to hold a symposium at the European Parliament in December of 1998, during which time the motion for a resolution draft would be presented. Difficulties surrounding the then project chair, Dr. Gerard Lopez, led us to cancel the symposium despite the fact that Dr. Lopez had graciously stepped down from his position. Given the situation, it was felt that judicious decisions had to be made concerning the project’s future. As such, the European Society for Traumatic Stress Studies will take over the workgroups on training and treatment guidelines. In terms of continued creation and monitoring of a European treatment centre network, Dr. Gisela Perren Klinger of Switzerland has agreed to continue this aspect of the OVEPE project.

DATABASE INFORMATION

Both the project resume and general information sheet are included on the enclosed disk, as is the totality of this report.

Dr Philippe WERSON

NOTES

[1] G Lopez, A Sabouraud Seguin et coll. (1998). Psychothérapie de Victimes. Paris, Dunod.