War and Civilian Mental Health with Dr. Ken Miller

In this conversation, Dan chats with Dr. Ken miller about his work in the area civilian mental health in war zones.

In this conversation, Dr. Miller discusses his journey from studying adolescent suicide to working with refugees affected by armed conflict. Dr. Miller explains the importance of addressing both war-related trauma and day-to-day stressors in the lives of civilians affected by war. He highlights the need to prioritize parents' well-being in interventions and shares an example of a stress management technique called counting the breath. Miller emphasizes the impact of these interventions on improving parents' mental health and parenting practices. In this conversation, Dr. Miller discusses stress management techniques, mindfulness, and deescalation techniques that can be used to manage triggers and maintain emotional well-being. He emphasizes the importance of addressing the social determinants of distress and creating supportive environments for children. Dr. Miller also shares his experiences working with fathers and the impact they have on their children's development. He highlights the need for practitioners to go beyond individual therapy and consider the larger social and cultural contexts when working with refugees and immigrants. Lastly, Dr. Miller reflects on the ongoing conflicts in Ukraine and Gaza and the importance of creating safety and ending the Israel-Palestine war for healing to occur.

Links to Dr. Miller's work:
Book: War Torn
Book: The Mental Health of Refugees
Film: Unholy Ground
Blog: The Refuge Experience
Blog: Dispatches from the Field: War, Culture, and Mental Health
Connect with Ken on LinkedIn
See Dr. Miller's Academic Work

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📬TheAppliedPsychologyPodcast@gmail.com

Transcript

Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a Professor of Counseling Psychology at the University of British Columbia. Welcome to episode number eight of Psychotherapy and Applied Psychology. Here we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and have some fun along the way in an attempt to bring insights to practitioners, those training to be practitioners, and the applied psychology curious.
I want to hear from you. You'll notice in the show notes a link that says, click here to text the show. If you click that, you can send me a text.
On my end, I get the last four digits of your number, so you don't have to worry about me calling. Let me know what you think of the show, who I should have on as a guest, or just say hi. On today's show, I am so excited to have this conversation with my excellent guest, who's a leader in the area of civilian mental health in war zones.
In our conversation, we discuss day-to-day stressors versus traumatic events, parenting interventions, stress management techniques, mindfulness, involving fathers in mental health interventions, working with refugees and immigrants, and we conclude by talking about the current situations in Israel and Palestine, as well as Ukraine. We also discuss his book, War Torn, and several other projects he's been a part of. In the show notes, I provide links to several of these projects, so please check them out.
We begin this conversation with my guest answering my question about a time early in his career when he wasn't sure if he was cut out to be a psychologist. Without further ado, I'm thrilled to have one of the world's foremost experts in Civilian Mental Health and War Zones. He is the Edith Landau Professor in Counseling for Refugee and Immigrant Youth and Families at the University of British Columbia.
Please welcome Dr. Ken Miller.
I was a second-year grad student at the University of Michigan. And at the time, I was studying adolescent suicide. And I had a wonderful mentor, someone I'm still in touch with, Cheryl King.
She's a psychologist at the University of Michigan in the Child and Adolescent Psychiatric Hospital there. And I was studying teen suicide, the family dynamics of it. And she's really just a wonderful expert on suicide, but also kind of an expert on mentoring graduate students.
So I was learning a lot about research methodology. But I remember it was New Year's Eve. I think it was my first or second year now.
I can't remember. And I didn't have plans. I think I'd gone through some sort of breakup.
And I was sitting at home alone with a stack of books on suicide and thinking, this is not where I want it to be. This is not a good spot. And by just sheer coincidence, I met a Mexican psychologist in the Faculty of Ed.
I was in the psych department, which is a different part of the university. And she was extraordinary, Christina Jose. And she agreed to set up a special independent study on teaching with me, a really kind of progressive approach to pedagogy.
And she reconnected me with a lot of the activism that I had been involved with as an undergrad and that I'd moved away from as I moved into graduate school. And I started reconnecting with a lot of the issues that had, I was a political science major at Cornell. And I've been very involved in Latin American politics, Latin American politics and social justice issues.
And with Christina coming from Mexico and having worked with just incredible folks there, she was working on issues of battered women who killed their husbands in moments of self-defense and were serving life sentences in prison. And she gave me her dissertation to read one night, and I stayed up all night reading it. And the next morning, I knew I needed to drop out of Michigan's psychology program and go to law school and study either domestic violence law or human rights law.
I had been reconnecting with a lot of what was going on in Latin America at the time. Very excited about the Nicaraguan Revolution, the possibilities that was opening up. And really fascinated by this question of what is it that motivates people in situations of profound depression to risk their lives in the name of social change, knowing that they may be killed in the process.
I looked at some of the earlier video types from Selma, Alabama, where you had these protesters walking across the bridge, knowing that the first 20 rows were gonna be beaten, possibly to death, before the world demanded that it stop. Same with India under Gandhi. What is it that empowers people, that gives them the courage to engage in these kinds of social change efforts?
Anyway, I started thinking more and more progressively about the linkages between psychology and social change and social justice. And not only was my research on teen suicide getting me down and uninspiring me and feeling kind of depressing, but the program I was in at the time, and Michigan has changed dramatically, but was extremely psychoanalytic. And psychoanalysis at the time in Michigan, it was one of the kind of bastions internationally, but it was also wed to all kinds of very conservative politics.
It was also wed to a particular way of thinking about mental health, where you didn't look at things like poverty and racism and discrimination and social injustice as factors. Everything could be explained by early childhood experience that could be corrected later in life. And you didn't look at the social determinants of distress.
And I began to feel more and more alienated in my program. And I remember hitting this one point where I thought, I can't continue. I can't make it in this field.
This is too alienating for me. This doesn't fit. And Cheryl was wonderful.
Cheryl King was super supportive of whatever I wanted to do. She just wanted me to see through my master's thesis on teen suicide, which I did, but she was supportive. Anyway, I'm on the fence and thinking about dropping out and applying to law school.
And I had joined a Latin American students group and we had brought a couple in from Guatemala that was doing this extraordinary creative arts, expressive arts intervention in the highlands of Guatemala with villages that had survived the genocide that was sort of winding down there, Mayan Indian villages. And I helped organize it, but I came home from the hospital from my work with Cheryl that day. I just found out that I had not gotten a big fellowship grant I'd applied for to do my dissertation on teen suicide.
It was a mixed blessing. I wasn't so excited about it anyway, but it's never nice to get rejected on a grant. And I came home and I didn't feel at all motivated.
It was a Friday night. I didn't feel like going to hear another academic talk. So I lay down on the couch, kicked my feet up and thought, that's it.
I'm just gonna apply to law school. I'm done with this. And then something moved me, and I can't explain what it was, but the next thing I knew, I kicked my shoes back on, walked over to the student union, where the talk had just begun, and I listened to these two people describing this marriage of innovative approaches to mental health work with social justice.
They were clearly on the side of the oppressed in Guatemala, and they were doing really interesting work to help people heal, to help communities heal. And it was love at first sight. That's the best way I can describe it.
I fell in love with it. I spent the whole weekend talking to them. By the end of the weekend, I'd agreed to go down and see their work, and if it was a good fit, I would study Spanish down there.
I would join their project. I would carve a dissertation out of it. And ever since that night at the Student Union, I've never once looked back at whether I could make it in the field or whether this was the field for me.
And everything has evolved out of that seemingly innocuous decision. Do I go hear a talk at the Student Union?
Can you describe what that innovative work that they were doing was?
So one of the two was an American psychologist, Brinton Likes, and one was an Argentine actor who had worked, they had worked together in Argentina with folks impacted by the, what they call the Dirty War, the Seven Year War, really dictatorship in Argentina. My dates are always bad, but I think that was 1976 to 83. And it was a very dangerous time to do mental health work.
And then what they did is they wove together acting exercises and expressive arts act, and group arts and express, kind of expressive arts therapy activities, you could really say. Meant to restore the capacity for creativity, meant to restore social bonds, connections in the community, meant to restore a kind of inhabiting the self again after really community level trauma. I mean, individual trauma, of course, but these were whole communities devastated by the genocide.
And the government of Guatemala had really just waged war on half the population, the indigenous Mayan population, who lived in the highlands, the mountainous area, and that's where the guerrillas were hiding. And I think they did get a lot of support from the Indians because they represented the absolute devastation of indigenous lives under the government. So it was an American military tactic called drain the sea to catch the fish.
If you can kill all the support that the guerrillas might be getting by killing as many villagers as possible, you can catch the guerrillas. So in a fairly short time, they raised over 600 Mayan villages. In the village of San Francisco, where I met the only two survivors, actually I met the one survivor, the other was killed.
The army came in and they killed all 350-something people in a single day. And that was a routine kind of practice. So that's what happened throughout the highlands.
And that was the idea, to build up this project. Just before I went down to Guatemala to join their project, because I saw what they were doing and I fell in love with it, I met a woman, Debbie Billings, who was studying sociology. And just coincidentally, I had also planned to go to Guatemala to study indigenous women as carriers of the culture during the genocide.
And so we ended up, we got involved, and we moved down to Guatemala together and spent six months on that project. I realized at some point, actually, we both volunteered on, she on another project, I on this one, we began to realize that doing our research in Guatemala was going to really endanger people's lives. This is something that's come up for me throughout my career, is having to ask what is the impact of me, of somebody witnessing me talking to someone in this community.
And every village in Guatemala had what they call an oreja, a spy, an ear, literally, and who would report to the army. And we eventually realized we could not risk people's lives. It might be an apocryphal story, it might be true, but what I heard from a colleague was a story, this is what really made up our minds.
This was a young woman doing her dissertation in Brazil under the dictatorship there, interviewed all these survivors of the violence. After she left Brazil to come home and analyze her data, the army came in and killed every participant in her study. In Guatemala, that would not have been at all surprising.
People disappeared with extraordinary frequency. And so then we moved across the border to where about 150,000 Guatemalan refugees were living, just a four-hour walk across the border in refugee camps, and we had a lot more freedom there. And so we kind of got adopted by one family and one camp, and we spent the better part of a year working in that and another refugee camp.
And for me, that's where I began. I really had the freedom to adapt the work that was being done, what they call creative techniques. We called it Playing to Grow.
And we adapted it for use in the refugee camps. We trained the schoolteachers in it, which was my introduction to a way of working that has guided all of my work since then, which is you train local people to implement interventions rather than having scarce or non-existent professionals do that. At the time we were doing that, I remember writing a grant proposal to the National Institute of Mental Health, talking about having local community members implement a mental health program, and getting very angry, indignant reviews.
One psychiatrist in particular made clear that he found this ethically problematic. Well, here we are a lot of years later, and what we know is that paraprofessionals or this model, which has come to be called task shifting or task sharing, has actually really good evidence. A lot of what mental health professionals can do, well-trained local folks can actually do, if not as well, then almost as well, but actually the effect sizes are pretty similar.
But at the time we were doing it, a lot of folks weren't doing it, and so there was some resistance to the idea. But we were, yeah, so we implemented this model there. We adapted it, implemented it, and then that's where I did my dissertation research on the mental health effects of the genocide in Guatemala, but also the conditions of here and now in the refugee camp, on kids in the refugee communities.
And that is really what set my whole career off on the path that it's been on ever since, which is all the literature, everything I was reading was about the impact of war on civilians. That became my focus, that was my area. And everything people were writing, whether they were talking about refugees or people still in war zones, they would measure two things.
They would measure exposure to different war events, violence, all the things we think of, bombing, shooting, physical violence, torture, all these things. And then they'd measure mental health. But in many cases, like in a lot of refugee communities, people got out before they witnessed all the horrific violence.
But their mental health was still heavily impacted. And what we heard in the refugee camps is it was impacted by poverty. It was impacted by shame at not being able to, and powerlessness, not being able to afford medication for children, watching every family had lost a child to a preventable disease, malnutrition.
There was a graveyard in the refugee camps with little gravestones, gravestones for the little ones lost to malnutrition. And nobody was talking about that. They weren't talking about domestic violence.
But men who are humiliated and shamed are much more likely to engage in violence. They weren't talking about the agony that the men went through at being unable to work their lands because they weren't allowed to. All of the things, what it felt like to be a Mayan Indian living far from your ancestral lands to Mayans, that's enormously important and meaningful.
So they weren't talking about these things. And yet when Debbie and I listened to what people were in pain about, if you asked them about the war, there was a substantial minority who really were still impacted by the violence. But what mostly they were talking about was the here and now.
And that was missing. And that became, in some ways, that's been my sort of life's professional mission, is to document the ways in which the here and now impacts refugees and those affected by armed conflict, and to develop interventions that can address those things.
This is going to be an unfairly broad question.
Sure.
But how have you come to understand or frame the mental health impacts of war on civilians? Or think about? It's a vague question, but...
Yeah. My really dear friend and one of my two closest collaborators, Andy Rasmussen at Fordham University, he was in town when I was living in Boston at the time, visiting, and we got to talking about some research that we've both been doing over the years, looking at sort of the relative contribution of direct war exposure, these awful events, and then what we call daily stressors, the here and now stress, that is often caused or made worse by armed conflict, forced migration. And we kind of tried to put that into a model.
So you've got experiences of war-related violence, and those have a direct impact on well-being, of course. But they also give rise to a host of day-to-day stressors. They exacerbate poverty.
People lose their social networks, which leads to loneliness and isolation. We know about the impact of that on mental health. They lead to unemployment, and they worsen health in every possible way.
They lead to an increase in domestic violence and in harsh parenting and a drop in warm parenting, because parents are stressed out of their minds. So the way I, and I want to say Andy and I, because he's really been my partner in thinking all this through, the way we think about it, and we've written about this in several papers over the years, is war-related trauma is a real thing and it is an essential thing to try and address, whether it's through group interventions or any of the evidence-based treatments that we have available, which again, I want to reiterate, can be effectively implemented by local folks who are well-trained and supported. But it's only part of the picture.
And we can't undo the impact of war. We can't undo what people have been through. Let's put it that way.
Can't undo sexual assault or the destruction of one's home or the death of a sibling. We can heal the effects of it that people carry around. But these day-to-day stressors that war gives rise to, we can do something about that.
We can address poverty. We can address unsafety in a refugee camp. We can foster greater social support and increase new social networks.
We can have programs to address parent stress, parental stress so that parents feel more able to use the knowledge and skills they have and in that way protect kids and support their kids, which they want to do. Of course they want to do it. So that's really how I think about it more broadly, that we have to think not only about the effects of prior exposure to armed conflict, but to here and now.
So it's a both and. And the model that's caught on, I think it's sort of the guiding model that I think, and it's not just Andy's and my model, I think we sort of put it forth based on our and a bunch of other folks' research, and said maybe we need to rethink this war exposure model, this model that only looks at what happened in the past. Let me give you a really concrete example of how absurd it can become.
When I was in Guatemala, I remember a research team came down and they wanted to study mental health in the camp. And these are, at that point, people had been in the refugee camps and out of Guatemala for ten years. And their lives in the camps were hard.
They were hard. These were, the average income was $200 a year. Which meant that if you needed to go to the hospital and pay $25 for transportation, that was a month and a half of income.
So people didn't, and they died. The researchers came down and they had two sets of questionnaires. One assessed what people had been exposed to in Guatemala ten years ago, and one assessed their current mental health.
And they assumed that all the distress they were measuring was a result of what people had been to ten or twelve years ago in Guatemala, because that's all that they measured. They didn't ask a single question about the impact of the here and now. And if they had, what they would have discovered is, yeah, that stuff in the past matters, but the power of it would have gone way, way down.
And what they would have found, and what we found, and what a lot of other folks have found since, is that when you factor in, when you include the impact of the here and now stressors, they actually account for more, or they explain, or they cause, if you will, more distress than even the violence people have been through at home. This is, crazily enough, this can even be true with something like sexual assault. You'd think, boy, rape as a weapon of war, there's something that if anything is going to have a direct effect on trauma, that's going to give rise to trauma, that's it.
And it does, it does. But what's interesting and people forget about it is what happens to women who have been sexually assaulted in their communities and in their families, right? They can become considered unmarriageable.
In some parts of the world, they're expected to commit suicide to restore the honor of their family or family members can without sanction kill them to restore the family's honor. They may be forced to live away from their family because of the shame that their rape brings on the family. So if you are just looking at healing rape-related trauma and you're not looking at the day-to-day experience of rejection and shame and marginalization, you're never going to really help these women build their lives back again.
And the interventions clearly need to go beyond just healing symptoms within women, the kind of cognitive and affective symptoms we think about in wonderful treatment manuals like Edna Foa and Barbara Rathbom's Treating the Trauma of Rape. I think it's the Bible of rape treatment. I think it's brilliant.
But it's too narrow. It doesn't look at how do you help families and communities restore a place, a non-shaming place for these women in their worlds. A brilliant story from Bosnia.
There was one village where the Bosnian Serbs came in and they raped as many women as they could. It was a weapon of war. The village decided that one of the best mental health interventions they could do was to very publicly declare the women heroines of the war, that they were heroes of this war.
They were survivors and that they would be viewed as heroes because they survived. Somehow this group of non-psychologist villagers got it that what happens after the assault can have as big or bigger effect than the assault itself. I thought it was a brilliant example of doing something at a community level.
How has your understanding of the importance of day to day stressors impacted your thinking and what you've done in terms of interventions in these contexts?
Well, yeah, I love that question because it... So I moved to British Columbia. I moved to the University of British Columbia a couple of years ago.
But before that, I was a researcher at a Dutch non-profit called War Child Holland in the Research and Development Department. And I remember my colleague Mark Jordans and I, we, you know, early on in my... We had both arrived there about the same time, and we were looking at War Child's toolkit of interventions.
And we thought, you know, we're... We know a lot about what impacts children. At this time, the Syrian war had been going on for about five years.
It was... There were 25% of the Lebanese population were Syrian refugees living in abject poverty. And we knew from all the research on refugee kids' mental health that they are impacted as much by what goes on in their homes as by whatever war they escape from.
And this is true in every refugee community. And what happens? The pathway is pretty clear.
Parents, in this case Syrian parents, are dealing not only with their own war trauma and grief, but also with the... just the terrible stress of six people, seven people living in a basement apartment with no windows, of living in extreme poverty, of discrimination, of malnutrition. All of the things that make living in a refugee community so difficult, or maybe they were in a tented community.
And that was having a real impact on their capacity for warmth and patience and increasing the kind of harsh parenting. So Mark and I thought, well, you know, we really want to focus on Syrian refugees. That was an interest that we both had, and a war child was doing some work.
And we said, let's go find a parenting program that can really help these parents, really support them. And we looked around. What was being done in the humanitarian world?
And every parenting intervention had the exact same model that we found, which was, I call it a deficit model. They would, you know, the most well-known one would go in, and the primary focus during the ten weeks was teaching parents how to parent, teaching them knowledge and skills. Half of one session of the ten sessions was on caregiver stress, parent stress, half of a session.
And that's a powerful statement about how little parental well-being was even considered as the real explanation. You can always infer how people understand a problem by how they go about treating it. My favorite quote comes from Kaplan and Nelson, and it's a book on, it's a very sexy title, Psychology and Public Policy.
But the title of the book is, well, that's the title, but the quote is that how we explain a problem determines how we try and solve it. Well, you can sometimes figure out how people are explaining a problem by looking at what they're trying to do to solve it. And when I looked at all these parenting programs that were simply teaching people knowledge and skills of parenting, it became really clear that they were explaining the harsh parenting and the lack of warm parenting as simply due to a lack of knowledge and skills.
But the research wasn't consistent with that. Everything we've read showed that these daily stressors and the war exposure, the impact of the trauma and the grief, were really impacting parents' ability to parent and to use the knowledge and skills that they had. So that's when Mark and I sat down and we thought, you know what, we don't want to do more of the same.
Let's create, let's develop an intervention, group intervention that can be, that actually prioritizes parents' own well-being. And yeah, we'll layer on some of the evidence-based parenting techniques called positive parenting, because all parents can benefit from that. Not just Syrian refugee parents, but Canadian parents, American parents, German parents, anyone can benefit from that.
But let's prioritize that. And we drew heavily, I have a background in mindfulness work, and there's a lot of good literature on mindfulness as a very accessible set, a lot of techniques you can use that are very simple and easy to use. So we created this nine-session program called the Caregiver Support Intervention that brings together groups of about ten women, ten men separately, and 25% of every session is focused on learning a new stress management technique.
We never use the term mindfulness, because these are traditional Muslim communities, and that would be a potential trigger. We talked about them as relaxation exercises, and we used a variety of sort of just anger management techniques to help parents slow things down, to de-escalate when they felt really angry. And we first tried this out in Gaza, and that was 2016, and we had a team there that was eager to try it out, and so we first tried it out in Gaza, and we were able to get men involved, which we were very excited about, and they loved it, and they loved the mindfulness stuff.
They really reported a dramatic reduction in anger and increase in patience and warmth, and improved health, right? And so then we got some funding, some more substantial funding to bring it over to Lebanon and expand it and really test it out rigorously. We adapted it, we did a lot of basic research, and we ended up with this...
We tested it out in a randomized control trial with 240 couples, 480 parents, over nine weeks. First we did a pilot study, a smaller version of that, and on that we found that on every outcome, parents' distress, their depression went down there, their general mental health improved, they became warmer with their children, they started using less harsh parenting, their stress management improved, and they felt less stressed, and their kids' mental health improved. And I think we had 150 parents in that study, from 75 families.
Then we did this big, big trial of it, and the only problem with the trial was that well, just as we were starting it, Lebanon, the pandemic hit, and halfway through the study, we had to stop. Half the parents only got part of the program, and we had to switch to collecting all the data by cell phone. It got impacted, but we still found that even with partial implementation, parents' mental health improved substantially in that intervention, and their harsh parenting reduced, and their kids' mental health improved.
And what we found, even in that impacted study, was that when you improved parents' own well-being, their parenting improved substantially. And that improvements in caregiver well-being or parent well-being really explained a lot of the changes in their parenting. If I translate it into non-research speak, what I would say is, teaching parents how to parent better, knowledge and skills, there's a place for that.
Everyone can benefit from that. But if that's all you do, you're starting from an assumption that parents simply don't know, and that harsh parenting and a lack of warmth reflect simply a deficit in knowledge and skill. And you're failing to consider that in fact, maybe chronic stress and distress limit parents' ability to use all the knowledge and skill they already have.
And so that program, we even did another study. Mark just finished a study in Jordan where he found even more clearly that the more parents practice these stress management, mindfulness-based exercises, the bigger the impact on their own well-being and their children's well-being. We're replicating that now in South Sudan.
So this is an example of addressing what I would call daily stressors in the lives of children. Because the biggest daily stressors for kids in their mental health in refugee camps is their parents' stress, as expressed through their parenting, just through their general moods. If you change that, you improve kids' mental health.
The old school model was you got kids together for an hour and a half, and this is still a dominant model, and you give them some expressive arts activity, like we were doing in Guatemala, but you don't touch the family environment. Effective of what we're doing in that model, and what I have to say, what we did in Guatemala in the refugee camps, you're kind of assuming that kids' distress is related to what happened only in the past, and that if you can give them a healing space for an hour and a half or two each week, they'll get better. But actually, the research on those interventions for kids is pretty disappointing, really mixed.
And I think we understand that better now. It's because we're then sending kids home to really high-stress environments that are actually stressing them out and causing a lot of the pain that we're seeing. And that if we can address those ongoing environments, stressful environments, we can have a lasting effect on kids.
Regarding these stress management techniques, I think I have a sense of what they are, but I'm wondering if you could just give one example of a technique that you guys use to facilitate stress management in parents.
So women and men had two... One of them, we did an exercise in the ninth session where we asked people to... It was just kind of a creative technique.
We put all the techniques on pieces of paper on the wall and gave people ten stars and said, put the stars next to your favorite techniques. You can put them all on one or you can spread them out. And what emerged really quickly was women had one technique that they loved, men had another.
And for women, we called it counting the breath. Counting the breath is really simple. I use it with clients a lot.
It comes from research showing that when we exhale, we activate our parasympathetic or relaxation nervous system. We have these two key nervous systems we talk about. We have a kind of a sympathetic system that is activated with every inhale.
And that's our fight or flight response system. When we perceive threat, then the sympathetic nervous system gets activated. And when we feel relaxed and safe, the parasympathetic system gets activated.
And they can never both be activated at the same time. Well, there's this really interesting finding that when we exhale, that's a parasympathetic activator. When we inhale, that's a sympathetic.
Relaxation on the exhale, and then activation, or if you will, stress response on the inhale. So what you can do to use that as a really accessible, simple technique is teach people, I call it ratio breathing, to breathe in to a count of three, and then to breathe out to a count of four, or a count of five, and you let people experiment with that and find the one that's comfortable. What you're effectively doing is you're spending a little bit more time in the exhale than the inhale.
And what you're really doing is you're... It's a sort of bottom-up way of, rather than sort of cognitively trying to calm yourself down, you're actually sort of putting your body into a parasympathetic or relaxation state a little bit more, a little bit more, a little bit more. And Bo Forbes, who's a yoga teacher that I first learned this from in Boston, she has you do this really simple technique, which is you use a heart rate monitor or just check your pulse at the start, then do this for about one or two minutes.
And you'll find you can actually watch your heart rate come down. So this is one of the techniques we teach to people. And the homework is a really big part of this intervention.
People are asked to practice each technique at least three times during the week and then to talk about it. We spend a quarter of every session talking about the practice, barriers to practice, what went well, trying things out together. So the women love that.
The men, they love a version of that. But for them, sitting still in the home was just too hard. So they did a version that we call peaceful walking.
In peaceful walking, you can walk anywhere. Now you can do the ratio breathing as you're walking, but you can also just focus on your feel of your feet on the ground. You can focus on the sounds and the smells, the sights, whatever you see around you.
The key thing in both of these, and this is where I think the power really comes from, even more than shifting into a parasympathetic state, relaxation state, the key is you bring your attention out of the anxiety-producing thoughts.
The thinking about your wars over and over again. There's a concept in psychology, psychiatry called thinking too much. It's an idiom of distress.
You could call it perseveration, rumination. It's the most common symptom of distress in almost every society where it's been studied. In our study of Afghanistan, it was the most common symptom of distress in Kabul, certainly true in the Middle East.
And it's a really pernicious symptom because not only does stress lead us to think too much about our problems, but thinking too much about our problems worsens our stress. So what both of these techniques do and all the other ones that we teach is they help people step out of that thinking. And the relief you can feel can happen within about two minutes.
It can happen with remarkable speed. So those are examples of the kind of mindfulness-based techniques. And then, of course, you know, like if your kid comes in or spills milk or comes in late to dinner, your baseline stress may be lower and you may be more likely to react in a good way, but you may still get really triggered.
So we also needed techniques to help people manage those intense triggering moments when you need to de-escalate quickly. And there, it's not rocket science. The most helpful technique people found was stepping away for a minute or two, maybe then doing a few breaths or counting to ten, the counting to ten people loved, and then coming back.
And the number of stories we heard about parents who were about to really hurt their children physically and came back after stepping away for a minute and instead asked the child why they'd come home late or what had happened or they'd suddenly seen that the kid had fallen by accident and it wasn't intentional. And they would pick up a child and hug a child. I remember a father saying, you know, I was about to really hit my kid hard because he came home late without permission.
And then I went away, counted to ten, came back, and I said, why did you come home late? And he said, I got beaten up by other kids on the way home. And so then I hugged my son and I took him to work with me the next day.
Those are the stories.
So literally just walking into another room or taking a walk around the house or whatever it happens to be for 60 seconds and then coming back.
Think of it in our world, right? Think of it like you get an email that triggers you, right? You get an email from whoever and you're pissed off.
You're angry about it. It triggers you and you see red. And you want to write a response.
And there's these email programs. There used to be one called Hot Chili's. I don't know what they have now.
And if you started to write a response, it would flash the number of chilies in your response to say, do you really want to send this now? And the secret is to walk for a minute or two and come back to your desk. And invariably you go, wow, okay, you know what, I'm going to save this as a draft.
And you don't get yourself in trouble. Because when the heat is high, right, when our tempers flare, and we can all get triggered by kids' behavior, the trick is to be able to de-escalate. So it's a combination of stress management techniques, mindfulness techniques and de-escalation techniques that you can use in the moment.
And I mean, if I zoom back in, so the bigger picture, like this is just one intervention, but the bigger picture is that we can help people by addressing what psychologists call the social determinants of distress.
And in this case, the kind of day-to-day stressors that impact their well-being, changing things that go on in their environment, in this case, the environment of kids, and then we have a big impact on kids' well-being beyond the kind of hour-and-a-half fun play activities that they get. Now, there's a role for that. Kids need to recover the ability to play and to form connections and to learn all the skills that they're missing out on when they can't go to school because of war or forced migration.
But that's not enough.
At the risk of going too far down this rabbit hole, I think that the example that you gave of walking away from the situation for a minute and then coming back, I think that that's for the practitioners listening, and frankly just for anybody who's listening, thinking about their own experience, that that is a tremendously useful practice for anybody. And it seems to me just in listening to you, I think, oh, that makes a lot of sense. And I think the challenge is when I do go to Red, to in that moment of Red, have that automatic response of Dan, take a walk, Dan, take a walk.
Like that second, two second, half a second, 10 seconds, it's like, man, I don't know if I'd be able to make myself or remember to do that. It's really remember. So do you have any thoughts about how to facilitate that either in yourself or more when you're working with somebody else?
How do you facilitate them making that leap?
Right. It's a great question. So this is also why I think there's a really interesting finding in the behavior change research, which is that information rarely leads to lasting behavior change.
So you can tell parents or caregivers, grandparents, whoever's taking care of kids, you can tell them these things, right? Or you can just tell your colleagues, hey, step away from the computer for a minute. It doesn't have a big effect.
I think the way you get an effect is, in our intervention, the way we made those things work is that we gave home practice every week, and then people were accountable to talk about how the home practice went. Not accountable to have succeeded. That was okay.
You could have failed to do it. You could have done it unsuccessfully. And then the group supported you in exploring how to make it work better.
And so week after week after week, all nine weeks, parents had a place where they were accountable to people that they had come to care about. The social support was quite powerful within that group. And that is, you know, so when you get the heat going and you're about to enact, if you're about to act, if you remember, I have this group that's behind me and that I'm going to be seeing, I need, it's a really helpful motivator to do this thing and to try and to do differently.
I think it's much harder, which is why I think in psychotherapy, this can really work because you see people on a regular basis. I think this is much harder. What I suggest is that if parents are going to try this, you know, on their own, that they hold each other accountable.
If colleagues are going to do this, grab a buddy. And, you know, I remember recently something happened at work and I got triggered by something. And I just went next door to a colleague and friend's office and I said, hey, I need to talk this through before I respond.
And ten minutes later, I was in a completely different place with it. I think we're asking a lot of ourselves to just do this on our own. You know, we think, particularly in the West, that we are these very powerful individuals with will that is more powerful than the environment that we're in.
And we can just choose to do things differently. But I think that's a very narrow and problematic view of ourselves. We're impacted by our context, for better and worse.
So can we use our context in ways that support the kinds of changes we want to make? And that's the idea behind the intervention.
So you'd mentioned the difference between moms and dads. I know that you've done, sort of over the years, you've had some experiences that has influenced your thinking about fathers and sort of fathers' involvement. Can you talk about that a little bit?
Yeah, well, when I was first looking into, you know, developing this program with Mark and our extraordinary team in Lebanon and the other team in Gaza, I had read all the studies I could find on parenting interventions. And they all seemed to end with the same paragraph. This study only included mothers.
Future research should include fathers because they're important to children's mental health and ongoing development. And it began to feel like such a cop-out. Like either say, you know what, we just couldn't include dads because it was too hard, or do it.
Get them involved. Or try and fail, but document all the ways that you tried. And I wasn't seeing that.
So I said to the two teams, look, we are going to get fathers involved. There is a powerful literature showing cross-culturally how important dads are for their children's development, especially during the first five years. Now in a lot of cultures, dads don't know that they are that important.
Dads may think that their real role is just providing money for food and shelter. They have such a bigger effect on their children's social, psychological development, their cognitive development, their success at school. They impact boys and girls throughout their lifespan.
They are the role model for kids for what it means to be male or to have a male in your life. And I thought we have to get them involved. And everyone that I talked to said, that's not going to happen.
This is traditional Muslim culture here in Gaza or Syrian refugees in Lebanon. And I said, well, how do we know that? What are the barriers to involvement?
And we did a really in-depth analysis of talking to people, talking to experts, reading. What are the barriers? Well, the first barrier turns out that programs are offered when men have a chance to work.
If you have a choice between a parenting intervention or a chance to earn money to feed your family, that's an easy one. Secondly, if you're offering interventions called parenting interventions in cultures where men think parenting is primarily for women and that they're providers, they're not going to come. So, you know, and there's a variety of other things like that.
So the first thing we did is, well, let's try offering the men's groups in the evening and the weekends. Let's make sure we never compete with income generation opportunities. Then let's not call it a parenting program.
Let's call it a support program for parents and for caregivers. And when we were trying to recruit people and tell people about it, let's talk about stress management and a program really aimed at helping parents deal with stress. Well, we had no problem recruiting men.
In Gaza, we immediately got them in the multiple ways in Lebanon. We had very few. I think we had...
We wanted to get 480 parents or caregivers in Lebanon for the big study. Maybe... We didn't have, unfortunately, careful enough records on refusals.
Somewhere between 10% and 15% of people we approached said no. So 85% to 90% said yes. And the men did not...
They stayed in. They didn't just join the study. The retention rates were, I think, overall 91% in the study.
And they liked it. And they talked about their wariness on the first day. What was this going to be?
What's this psychosocial support stuff? And by the end, the number of men who talked about feelings was so much more patient and less angry. Stories.
One man talked about how when he would come home, his children used to just run and hide. They were so frightened of him. But now after the program, when he comes home, they come running out and they want to give him hugs and kisses, and they want him to tell stories about when he was a kid.
Things like that. Now look, not every guy had that success story. But they were often enough, they were frequent enough.
I was very moved on the last day of implementation before the pandemic hit. It was the first wave, so we were able to do the first half of the sample. We got to the last ninth session, and one man couldn't make that session.
He was at a funeral two hours away. He left the funeral early to catch buses to get to the ninth session because he wanted to be able to say goodbye to the other men in the group. Men, there's a really important corrective, there's a really important focus on women and children because they have specific vulnerabilities in refugee communities and conflict-affected areas.
But men have specific vulnerabilities, and that gets lost. And I think men were so appreciative of a place where they could feel valued and heard and supported beyond any specific technique that we taught. They came to care about each other and to feel cared about.
That's what I've learned. Self-fulfilling prophecies work for better and worse. If you assume men aren't going to get involved, they won't.
If you assume that they will, if you take the right steps to address the barriers, there's no reason they won't. And a lot of women, what they said that was so interesting, I said, you know, if you had not gotten my husband to be part of this intervention, there is no way he would have let me change the way I raised the kids. He would have absolutely said no.
But now he knows, and so we do it together.
So listening to you for the last few minutes, or when you're talking about the intervention stuff, I sort of think, my experience of listening to you is, oh, okay, I could do that. But listening to you in the first part of our conversation when you were talking about, you know, your experiences in Guatemala and other places and sort of the terrible experience of these folks, I just have this emotional reaction of, it's sort of like reading parts of your book where you talk about, you know, your experiences. Like, I just want to sort of curl up into a ball.
You know, I don't, I think this is not in my DNA to be able to do this. I'm curious, what do you think in terms of yourself, in terms of your colleagues, what is it that facilitates your ability to go into some of these really terrible contexts and to be able to work and to be able to have it not just weigh you down so much? I'm just curious about your sort of introspection on that.
Well, it's really funny because I was just thinking, I'm laughing because I was thinking about how early on I was talking about as a grad student, I was studying suicide and it really impacted me and I couldn't do it, it was getting me down. It just hit me, I'm talking to an expert on suicide, this is what you study. And you really, I mean you've really established, I think, an outstanding reputation for your research on suicide.
And so I would almost invert the question, how do you do that without getting you down? I think we're all just wired differently. Look, I'm not saying it doesn't get to me.
The poster behind me, it's for this film, Unholy Ground, it's about survivors of a massacre in a front line village in Sri Lanka. It's a village literally on the front line of the Civil War, it ended in 2009, and one night, one horrible, horrible night, the Tamil Tigers, this armed opposition group, walked across the rice fields and slaughtered 52 or 54 people, including 12 children, in their homes. I came across the village seven years later.
Every night, they were emptying out at sunset to stay either in the jungle or in other people's homes farther away from the front line. They were so terrified, so traumatized. And then they'd come back early in the morning to get the kids into their white school uniforms and off to school.
Talk about resilience. Talk about a remarkable capacity to insist on giving your children a childhood.
We made a documentary film with a bunch of the survivors about how they'd put their lives together, how they'd survived, how they had failed to over some of them, how they had been unable to overcome the trauma that many of them had.
There were times when we were shooting the film and I was watching the interviews, I was directing the film, so I wasn't doing the interviews, I was just standing present, having everything translated into my ear. I would go off camera occasionally and I would just go into the woods and cry. I remember being in Afghanistan and hearing stories of such tragic heartbreak and unbelievable brutality.
I would occasionally go into the restroom and I would have a cry, and then I would come back. That happens, but I'm sure if you do suicide research or if you do other kinds of research about people suffering, there are times when it gets to you, there are times when it gets under your skin. I think we are all just wired differently.
People sometimes ask, how can you be a therapist, how can you sit with people's pain? And I don't know the answer to that, other than I care deeply about the people I work with clinically, but I don't, when I go home at night, I'm not usually thinking about it. I'm not impacted after the session.
I'm somehow able to set those boundaries, and I don't know how we do that. I do think one thing that makes, I talk about this in this book, War Torn, that you mentioned, about my experiences in different countries doing this work, that the thing that makes the work most sustainable for me is that I have a sense of doing something that counters the helplessness I feel when I look at sort of the evil in the world, the harms being done to people in the world. In some tiny droplet of a droplet way, I have the sense of doing something, and that counters that helplessness.
The other thing is whether it's in Bosnia or Afghanistan or Iraq or Sri Lanka, what I found is that I meet the most courageous, inspiring people. I remember talking with a lawyer from Baghdad when I was up in northern Iraq. I was working with a group of lawyers, training them to work with torture survivors.
And this lawyer was representing detained, innocent detained civilians who had been tortured in prison. He was a lovely, lovely man. Every morning, he said to me, he said, I kissed my wife goodbye, and we never know if we'll see each other again, because we might get shot or a roadside bomb or a bomb in a bakery or the gas station.
And I said, you have the resources to get out. Why don't you get out? You could do it.
And he said, if I don't do it, who's going to represent these people? He said, we have the possibility of democracy here. I have to stay.
This is my home, and this is the fight I have to fight. And he did it without... there was no ego in it.
There was just a sense of, this is what I need to be doing. And I knew I was going to get on a plane a few days later and fly back to Amsterdam, where I was living. And I thought, I can only aspire ever, ever, ever to live a life of the sort of values that this man guides his life by.
It was so inspiring to me. And I have met those people everywhere I've worked. And so my life has been richer for this work, certainly not poorer.
We've mostly been talking about working with folks in their homeland. What about for the practitioners who are listening, who are working with refugees or immigrants who are coming from war zones? You just have, and obviously a lot of what you've already said could apply here, could apply in that context.
But a few sort of drops of advice or wisdom or thoughts for folks who are working with immigrants or refugees coming from war zones.
I'll tell you a story. This comes from Chicago. I directed a clinic there for Bosnian refugees for a couple of years before I went into university life.
And this is a story of one of my great clinical failures. I like to tell them because Edward Pavlovsky, who was a wonderful Argentine psychologist, once said, you know, we could learn a lot more from each other if we would talk about our, he called them stumbles rather than all our successes. So there was a woman at the clinic, and she was one of the most Bosnian Muslim, maybe, I don't know, mid-forties, young boy, five-year-old boy, absolutely traumatized, like I'd never seen someone traumatized.
I wasn't actually her therapist. We had one of our interns working with her. Actually, one of the Bosnian counselors was working with her, and she was on all kinds of medication.
We had a wonderful psychiatrist to help control her trauma, to lower the depression, and nothing worked. Her son would stay with the father in the waiting room, and the father would pace back and forth, back and forth. And she just wasn't getting better.
Nothing helped her. And nine months went by. And her story, living through the war, when the Bosnian Serbs entered her village, the relatives killed the violence she saw, the sexual violence that the Serbs perpetrated, all the horrors, the move into the refugee camp in Croatia, the journey to Chicago, living in a tough, gritty Northside Chicago neighborhood.
We just assumed that this was war trauma embodied. Anyway, I get a call as the director of the clinic, not as her counselor, but I get a call from one of the local hospitals, and I say, can you get over here right away? We've got somebody who I think is a patient in your clinic.
She's acutely suicidal, and we've got her in the emergency room. Can you come over? So I raced over with her counselor, this wonderful Bosnian physician who was working as a counselor at the time, and she caught me up on the case.
And something about the story she was telling me about this woman, I had done a lot of work on domestic violence issues over the years. Something like a flashing light was going off for me, and the anxious husband in the waiting room, the one time she'd come to a session with a scar that no one could explain, she said she fell. So we get to the ER, and she's in there, and she's hysterical, and she sees us, and she becomes utterly silent, and she won't talk, she won't talk, so then finally I say to her, through the interpreter, are you being hurt at home?
And her eyes get wide, and I said again, are you being hurt at home? And then she just bursts forth in sobs, telling us how for the last two years, every day in their one room studio apartment, her husband has been raping her in front of their child, and has told her that if she tells anyone, he'll kill them both.
For nine months, we were treating her for war trauma. That had little to do with the war in Bosnia. And I said to her, I think the war you're living through is still going on, isn't it?
It's the one in your living room. And then, of course, what we did... Go back to that quote I told you earlier, right?
How we explain a problem determines how we try and treat it. If this is war trauma, you use EMDR, you use Prozac, you use whatever will control the symptoms of war trauma. If this is the trauma of sexual assault, that's not what you do.
You get her and the child out. Our whole intervention... You know, we got the police involved, we waited till he was out of the house.
Actually, when we went over there, he was in the middle of raping her. When he opened the door with his pants around his knees, we got her and the child out, and we were able to get them to safety. That's a long story to give a kind of simple answer.
If you're working with refugees in Canada, in the United States, in Germany, wherever, don't assume that all the suffering, the distress that you see is the result of what happened before. Make sure when you do an assessment, you're exploring all the aspects of people's lives in the here and now. What is it like if somebody is unemployed?
What impact does that have? What does that feel like? If you've got a family of five living in a one-room apartment, what stressors does that create?
And when you see half-parenting, when you see parents reacting harshly to their kids, is it that they don't know better? Or are they living in such chronic stress that their patience is just at an edge? They're out.
What resources exist in communities that you can connect people to? So when I trained, it was very psychoanalytic back in Michigan, right? You didn't connect people to resources.
They called that a savior complex. Now we call it good practice. If you're working with refugees, you should know about what community centers exist where they can find new sources of social support.
What language programs exist? Are there English language programs they can attend that are designed for people who might be struggling with trauma or depression? It's a newer model, but it's really exciting because it reduces the dropout rate of refugees who have trouble focusing their attention in an English class.
My colleague Steve Wine in Chicago had this marvelous story. He created what was meant to be a trauma treatment program for Bosnian refugee families in Chicago. And in the very first meeting, it turns out nine of the ten guys, there were couples there, nine of the ten men were unemployed.
It was a major source of distress. And one had a good job. By the end of the group, he'd gotten work at his company for every other man in the group.
I'm willing to wager that that was a better mental health intervention than anything else that happened in those guys' lives. Suddenly their dignity was restored, they could provide for their families, they could buy food, maybe they could move to a somewhat nicer home. So that's it.
It's not that you should stop treating trauma. But even that's the other thing I would say. When you see trauma, don't assume it's war trauma.
When we have traumatized kids, sometimes kids are getting traumatized at home. That happens in every society. Refugees aren't any different.
Just being a refugee kid doesn't mean that all your trauma is necessarily from the war that you lived through. And when you see trauma among women, women are battered in every society that we know of. So let's not assume that if you're a refugee woman, it must be the war.
We have to ask about these things, and they're personal. But if we don't, we risk making the mistake that my team and I made in the clinic. The other last bit of advice I would have, I'm sorry if this is a bit long-winded, but it comes from just another really quick story from Greg Worthington, who is a wonderful psychologist in Michigan.
He was an intern that I supervised at the clinic with Bosnians. We had a woman who had been grieving the death of her son. He was killed in Bosnia, and she was in a severe depression.
This wasn't just grief. This was complex grief. I think now we call it Prolonged Grief Disorder.
She would not get better, and Greg was a lovely, wonderful therapist, and she was on every antidepressant. Nothing helped her.
And we finally got her to articulate why she thought she was stuck in the depression. She said she would dishonor her son if she stopped grieving. So we found an Orthodox Christian priest in the area, with her permission.
She was a Serb Orthodox woman, and she gave us permission to talk to him, and we explained the situation, and he met with her. He said, You know what? You've honored your son.
If you continue to grieve, you're going to begin to dishonor his memory. Her depression lifted by like 90% in about a week. He did something that we could never do.
It was about using resources in the community that went beyond what we could provide as a clinic, but that were powerful. Psychology has a long history of ignoring religion, and I think we do that to our own peril. Many of the people we work with have a powerful spiritual or belief system, and if we fail to help them make use of that, we lose a tool from our toolbox.
I think listening to you talk about that last example, that I think sometimes we also, when a client comes from a different culture than our own, might say, oh, this is just part of their culture. And perhaps it is, and perhaps there's nothing necessarily to do there, but your group took it a step farther to investigate, to say, hey, tell me if I'm wrong here if I'm misrepresenting. But you took the step of saying to the client, would it be okay if we talked to a religious leader in your community to get their experience or their thoughts about your, to an extent, your interpretation of?
And you did. And that's quite a, frankly, that's a leap to do that, right? That's a lot of extra work for you and your team or whoever was doing that.
And then you were able to then bring those two people together and do something, facilitate an interaction and a new understanding from your client that changed everything. And in a way, you did both nothing and everything.
I mean, I err more on the nothing side. I think we facilitated a process. But, you know, Maurice Eisenbrook, this psychiatrist who was working with Cambodian refugees, I can't remember if this was in Australia maybe, there had been a death in the community.
Cambodians represent a highly, highly impacted community because of the genocide there, the mental health issues have been enormous. And in this community, after the death of this one community leader, there was just tremendous conflict and violence and despair. And the traditional psychotherapy, Western individual psychotherapy model just seemed to him utterly inadequate to the task.
So they were working with some traditional healers, Cambodian healers or Khmer healers. And my healers, they organized a community bereavement event to allow the community to grieve the death of this individual. And after that ritual, everything calmed down.
Maybe that, you know, I have this, early in my career, Lisa Rascal, a colleague of mine, and I edited a book called The Mental Health of Refugees. And the subtitle is Ecological Approaches to Healing and Adaptation. Ecological, all we mean by that is sort of going beyond changing the individual to look at the other, the larger settings that individuals live in, the family, the community, the society.
I think in psychology, psychiatry, social work, social work less so, but psychiatry and psychology, certainly, we're very focused on working with individuals and changing things inside of them. What I'm suggesting, and the whole thesis of this book and all the people who contributed to it is that sometimes we need to go beyond the individual. We need to find ways of changing the settings that people live in to better support the well-being of those who live in them.
Whether it's strengthening social support within those settings, maximizing the healing potential of resources in the community. There were Ethiopian Jews flown over to Israel many, many years ago who were highly distressed from all of the experience. They're black Jews, actually, from Ethiopia.
And they had a hard time in Israel, but partly because of the conditions in Israel and some of the racism they encountered, but partly because of what they lived through. And there was a social worker who wanted to provide support, and none of them would come into a clinic. It wasn't part of their worldview.
So she went to where they all communally washed their clothes, and she brought her clothes to the washing well. And she began washing clothes with them and befriended them and then began to shift the conversation towards some of the things that were challenging in their lives. She moved from the clinic to the community and used this community ritual of communal clothes washing as a healing setting.
That's what I'm saying. Is it more work? Damn right it is.
And it's not for everyone. It's not a model if your goal, which is I think wonderful, is to do office-based individual psychotherapy. I'm grateful for my own life, for the psychotherapist that I've had the opportunity to work with over my lifetime.
And I love doing that work. So this is not a critique of that. It's more to say if you're going to work with people impacted by armed conflict and forced migration, that model is not sufficient.
You have to be willing to do more than that. And I do think more and more and more community organizations are recognizing that.
So before I let you go, I wanted to just take a moment. We happened to be, we're in May of 2024 right now having this conversation. And we happened to have a war going on in Ukraine and as well sort of Israel and Palestine.
So considering your background, just sort of wanted to get your thoughts, your insights. It's funny actually, yesterday, I met a Ukrainian refugee, just happened to meet him and, you know, chat with him for a little while. And so, you know, domestically, there are going to be refugees that's going to increase in our, in our treatment context or in our social services and this sort of thing.
But just sort of feel like it's appropriate to get any of your thoughts.
Well, let me, let me, let me just clarify. So thoughts specifically regarding...
It could be, so it could be regarding sort of what sort of thoughts for people in sort of social services context. Could be, it could be thoughts about the experiences, what might be the experiences that are going on right now. It could be thoughts about, you know, political thoughts or thoughts about what we can be doing to be supportive of civilians, just sort of broadly speaking.
It's a hard time. It's the first time, I have to say, first time in my life. I've always somehow been maybe a naive optimist.
I always thought the world was moving in a better direction. I don't feel that as strongly anymore. The war in Ukraine, there are...
So these are very different settings. Ukrainians are fleeing. They're fleeing to Poland.
They're fleeing to Europe. Some are making it all the way to North America. And everything that I said about how to understand and work with refugees until now, it applies to Ukrainian refugees.
In that sense, it's no different. Understand the culture, the context, understand the impact of the here and now, as well as whatever people have lived through in the war. Gaza is different.
Gaza is different. Gazans are not showing up all over the world. Gazans can't get out of Gaza.
In that sense, it's very different. I don't think Western practitioners or treatment organizations are going to be dealing with lots of Gazan refugees.
I struggle to understand the role of mental health work in a setting where people are getting bombed on a daily basis, and where people are starving to death, and don't have access to safe shelter or food or medicine. To me, thinking about mental health care in that setting, I don't know what you do. I know there are some wonderful NGOs in Gaza trying to do things.
I know that Israel has bombed and killed so many of the mental health professionals. The Gaza Community Mental Health Center is one of the great community mental health programs serving more affected people, and specifically Palestinians. So many of their staff have been killed.
So many.
I think it's important for the listener to know that you've spent time in Gaza.
I have spent time in Gaza. I have a very dear friend, a Gazan psychologist, who is now... She was able to get out.
Some of her family has gotten out to Egypt. She got out. It was enormously difficult for them to get out.
I got to know Gaza a bit. It was one of the most heartbreaking places I'd seen. Also inspiring.
And I loved so many of the people I met, young professionals who were implementing this parent support program. It is very much what people describe it as an open-air prison. Gazans could not go out to the north or east.
That was Israel. They couldn't get out. They couldn't get out south to Egypt.
And if they went west, more into the sea, on boats, more than five or seven kilometers, the Israelis would turn them back or shoot them down. So it was a place ready to explode. If you imagine a country where 50% of young people were unemployed and had no futures, it was waiting to explode.
My heart... I also have spent a lot of time in Israel. And I had roots in Israel.
So I had... When the war first broke out, of course, my heart was devastated for what the Hamas did.
But, I can no longer try and have a balanced view. When I look at the 1200 Israelis who were slaughtered, and my heart breaks for those who were kidnapped and taken back. But then I look at the over 34, 35,000 Gazans who have been killed, thousands of children who have been killed.
And I look at the sheer brutality of just raising a society, raising a society that Israel is engaged in. And I've written about this in my blog on Psychology Today called The Refugee Experience. The healing for Gazan children and Israeli children will be very different.
Israeli children went through a nightmarish day. And they have got the enormous task of rebuilding their lives and sense of safety and normality in the wake of that horrible massacre. But the massacre happened.
And by and large, they have access to all kinds of healing resources. They have food and school and shelter and the support of their society. And they are not being shot at and exploded.
Bombs are not exploding in their neighborhoods. And they are not being dislocated every few days to a new place that then gets bombed. Gazan children are living with traumatic stress.
That activation, that sympathetic nervous system, the fight or flight response, that's really meant to turn on for a few minutes at a time until the danger passes, has been on in Gazan children's brains and bodies for months and months now. And I think we can't even begin to predict what the long-term effects of that is going to be. But this is not a time when we can think about them healing.
This is a time we have to think about stopping the war. Then we can think about how you heal trauma. You don't, I mean, it's a cardinal rule.
Judith Herman, who wrote the Bible on treating trauma, treating PTSD. What is her very first rule of treating trauma principle? Create safety.
Then begin dealing with trauma. How do you create safety? You have to stop the war.
And that just hasn't happened. Now that, of course, is also true in Ukraine. The difference is, there are a lot of Ukrainians who have gotten out, and so a lot of good work can happen with them.
Within Ukraine, of course, that war needs to come to an end. But I think Gaza's a very different situation. Gaza's a, it's just a, it's a nightmare.
It's an unending nightmare.
Well, Ken, I can't tell you how much I appreciate this conversation. I'm really glad that you and your colleagues are doing the work that you're doing. It's really important work, as I said, work.
Just, I think it takes, I think there's few that are able to do the work. So I'm really appreciative that those who can do, and I appreciate this conversation.
That's a wrap on today's conversation with Dr. Ken Miller, to whom I want to send my sincere appreciation. It was a fascinating conversation, and I hope you enjoyed it as much as I did. And please don't forget to get in touch by sending me a message.
Until next time.