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Presentation of HHRI GBV Manual

GBV manual presentasjon for website 15.11.16

Elisabeth Langdal

on 14 November 2017

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Transcript of Presentation of HHRI GBV Manual

Please contact us if:
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The Butterfly Woman - Her good life


When the worst has happened

Experiences triggers and flashbacks some time after the trauma
Gradually healing
I will now tell you a story about the Butterfly Woman.
Listen – and notice what happens to the Butterfly Woman’s
Once upon a time, a Butterfly Woman lived in a small village surrounded by green hills. The Woman had a good heart and a strong body. The days went on. In her
righ wing
were all the good memories of her life – like the green hillside, the sound of the river she loved, and the fragrance of her favorite flowers. Thinking of the trees and animals made her feel calm. Looking at the house made her feel safe.

In the
left wing
, she kept her dreams about the future and some worries too, though they weren’t too big to handle. Sometimes she dreamed of a new dress, and some good shoes to keep the rain out. But her strongest dream was for her children’s education..............
The Butterfly Woman Metaphor
Health and Human Rights Info
presents the training manual

Mental health and gender-based violence Helping survivors of sexual violence in conflict

Butterfly woman -
When the worst has happened

Butterfly Woman experiencing
trigger and flash backs

Stories or images.

Tools for teaching and learning.

Can describe our experience.

Shift between insights and experience.

Is a charged meaning.
What and how can it be helpful?

Why we use metaphors during our work with survivors?
Butterfly Woman before trauma


Making visible and understandable

One morning she went down to the river. Some soldiers found her there. She was filling containers with water. After that day, everything changed.

At first she
tried to flee
, but she could not escape. The soldiers laughed when they caught her and threw her down in the dust of the riverbank.

Then she tried to
fight them
. Her
heart pumped
in her chest, the
face became warm
, her arms were
than ever before. But they were four big men and they were even more brutal when she
tried to fight back
hitting, biting, kicking, scratching and screaming for help. Their laughter rang in her ears. The
of their bodies
scared her heart to silence.

Her legs became
as if dead
her hands and arms too
. Her face became
and it was as though she had lost all her spirit. She heard the sound of the river and the breath of the soldiers. She
lost her sight for a moment.
It was
as if she had left her body
or was
hiding in her heart
, looking at the soldiers from a distance, watching them do bad things to her. She saw it like a scene in a film, she
did not feel anything
. It was as if the men were hurting a stranger, though she knew she was the person being hurt.

Soon after she arrived at the health center, the Butterfly Woman had to go to the hospital because she had suffered injuries during the rape. She knew that the nurses and doctors wanted to heal her but, as soon as she had to lie on the bed and spread her legs to be examined,
horrible memories from the rape returned.
Suddenly she thought the doctor was the soldier who had raped her. She tried to flee.
The memories flooded her thoughts and body and she could not separate them from what was happening to her now at the hospital.
A wise nurse repeated the Butterfly Woman’s name over and over again in a calm and strong voice. She said: “You are in the hospital now”, “You are safe now”, “It is [Wednesday, September 21 2016]”, “We are here to help you”. The tone of her voice and what she said helped the Butterfly Woman to return to the present. She realized that she was at the hospital receiving help, and she managed to calm down.
Butterfly Woman - Gradually healing
The helper explained to the Butterfly Woman that she needed to find ways to reconnect herself, and relocate herself in the here and now. The helper said: "
If you focus on the present moment, memories of the past will remain in the past"
. The Butterfly Woman found it hard to understand what this meant. The helper said: Memory of the rape can invade the present, taking away your sense of time and place. She explained that trauma memories belong to time past.
The secret is to experience the present through our senses: this anchors us to the here and now.

The helper put hot tea and two cups on the table in front of them. She said:
, what do you hear? Then she poured tea into the cups. The Butterfly Woman listened, paused, and said that she heard the sound of the water pouring, a bird singing, and the voices of some of the women outside. The helper replied: You have now
focused your hearing.
These sounds tell you what is happening right now. This is how you connect yourself to the present moment by using your ears.

(page 43)
So what is a Therapeutic Metaphor
Life is turned upside down (page 49)
Triggers and flashbacks
(page 61)
Using the recovery skills
(page 85)
The manual contains practical perspectives, tools and exercises.

The main tool of the manual, the Butterfly Woman metaphor is used to:
better understand trauma
to explain what trauma means in the life of the survivor
to describe trauma reactions and how to deal with these

We explain the course that trauma takes in generic terms through the story of the Butterfly Woman.

The story is based on clinical as well as scientific experience and knowledge, in other words it is clinically accurate.

Health and Human Rights Info

Makes information about mental health more accessible to personnel working with people exposed to human rights violations. We bring this material together through evaluation, analysis and editing.

HHRI provides relevant and comprehensive information that can be of practical use and support in situations where more specialized services within mental health care are not available and the need to provide care is of essence.

We have a special interest in material that focuses on the
mental health
of survivors of trauma, especially trauma associated with Gender Base Violence.

The story of the Butterfly Woman story is divided in 4 main parts.

Butterfly woman - the good life
Butterfly woman when the worst happens
Butterfly woman experiencing triggers and flash backs
Butterfly Woman gradually healing

In each of these parts we can identify the generic course of the trauma.

She is satisfied and content with her life.
She stores all her good memories.
She dreams about the future.
She has control of her life.
She has good memories in her right wing.
She has plans for the future in her left wing.
She is grounded.
What does this part of story tell?
What does this part of the story tell?

Making a good ending

It is important to make a realistic good ending for the Butterfly Woman history
with the participation of the survivor.

For the story to be healing, it needs to end with some kind of hope. Try to identify all the possible resources that are available within the Butterfly Women herself and her community.
Then make the good ending.
This section describes the bad turning point in the Butterfly Woman's life.
Identifies reactions in the five focus areas.
Identifies the main survival strategies.
She tried to flee.
She tried to fight.
Her heart pumped.
Her face become warm.
Her legs, hands and arms became dead.
As if she had left her body.
What does this part of the story tell?
How we use one metaphor as a tool in our work with survivors
The Butterfly Women Metaphor
To set the note for the training we would like you to spend a 5 minutes to watch this little film. It is about the Good helpers in Congo who first inspired us to write this manual.
Mama Congo
by Arild Kumar - Join Good Forces
Added value
For the trainer -
Learning new skills for helping survivors

For the survivor -
Empowerment by knowing and understanding and finding ways to deal with traumatic memories when they appear (grounding exercise).

For the community -
Strong survivors participating actively in local community, taking part in decision making processes with their knowledge and experience.

Human Rights perspective -
Awareness of human rights, may assist both in understanding the suffering and in finding ways to respond to it in a respectful and helpful way.

Discussing Humanitarian Charter and Protection Principles

GBV does not occur in isolation. Interventions to protect the mental health of survivors must take account of broader humanitarian guidance. One example is the Sphere Project. This handbook introduces quality and accountability to humanitarian response by using the
Humanitarian Charter:

the right to life with dignity
the right to receive humanitarian assistance
the right to protection and security

and the
Protection principles:

Avoid exposing people to further harm as a result of your actions
Ensure people’s access to impartial assistance – in proportion to need and without discrimination
Protect people from physical and psychological harm arising from violence and coercion
Assist people to claim their rights, access available remedies and recover from the effects of abuse.

A human rights based approach is about empowering people to know and claim their rights and increasing the ability and accountability of individuals and institutions who are responsible for respecting, protecting and fulfilling rights.

This means giving people greater opportunities to participate in shaping the decisions that impact on their human rights. It also means increasing the ability of those with responsibility for fulfilling rights to recognize and know how to respect those rights, and make sure they can be held to account.

There are some underlying principles which are of fundamental importance in applying a human rights based approach in practice.

These are:
non-discrimination and equality
empowerment and

Give some examples in your work with survivors that does not have a HR approach?
How could it be done differently to give the situation a HR approach?
What does it mean to have a human rights perspective?
How to read the manual
There is a left side and a right side
What the trainer needs to know
What is said aloud
Taking care of yourself as a helper
The techniques used to help victims (such as stabilisation exercises, sleeping advice, etc.) can often be helpful to the helpers themselves.

Helpers need to understand that it is important to recognise their own needs and reactions, and understand what triggers and modifies them.

Acknowledge that your reactions are normal and unavoidable

Consciously try to relax

Talk to someone with whom you feel at ease

Express your feelings in ways other than talking: draw, paint, play music

Listen to what people close to you say and think about the event

Take care of yourself

Do grounding exercises
Discuss between the two of you what makes you relax or you can write down a list of things you should do when you detect any of these signals.

When you are in need use your list.
Warning signals that can occur after prolonged period of time on a job
Can you think more signals?

• Wounded ideals
• Cynicism
• Feeling unappreciated or betrayed by the organization
• Loss of spirit
• Grandiose beliefs about own importance
• Heroic but reckless behaviors
• Neglecting one’s own safety and physical needs (not needing breaks, sleep, etc.)
• Mistrusting colleagues and supervisors
• Antisocial behavior
• Excessive tiredness
• Inability to concentrate
• Symptoms of illness or disease
• Sleep difficulties
• Inefficiency
• Excessive use of alcohol, tobacco or drugs.
So what do you do?
The good helper

The good helper
The qualities of a
good helper.

This image was shared
in the
Republic of the Congo
The aim of this manual is to let the helpers discover their own tools and maybe give them some new ones.
What are the qualities
for a good helper in
your community?
Tools in work with survivors

Listening, respecting and acknowledging painful reactions
Communicate that you «see» her
Create safe place
Stabilizing by being here and now oriented
Grounding exercises
Relaxation and energising exercises
Psycho-educational approaches

Strong international efforts to combat gender based violence in conflict and war.

A large number of valuable initiatives including guidelines and reports exist

But how do we support the survivors?

How can we ensure that the survivor and her family are helped?

And how to support the helper?

Why this manual?
To ensure that the manual would be cultural applicable, we piloted the manual in 5 different countries
Jordan, Cambodia, Turkey, Colombia, Norway.
The manual was publish
The manual:

Focus on mental health, and psychological reactions to traumatic events.
Practical interventions, exercises and skills training.
Resource oriented – survivor as well as helpers.
Builds on experience and local knowledge.
Tool for training, supervision, group-work and self-study.
Lots of room for adaptation and adjustment for each context.
Developed by clinicians but can be used without formal training.
Aims at being self-explanatory.

Here we will give you an example of the first meeting between a helper and a survivor.

Notice what the helper say and the posture and body language. Also notice how the human rights principles are included in this first meeting.

Afterward we would like for you to do a role-play of that same situation.

Role Play: First meeting
A brief introduction to ‘trauma’
A trauma is “a personal encounter
with death and violence”.
A ‘traumatizing event’ is one that has the capacity to cause mental or physical damage.

Faced with such an event, the immediate response of the body and the mind is to struggle for survival (‘fight, flight or freeze’ responses, submission or ‘playing dead’)

To understand better how the brain works, we have added a short film
about Trauma and the brain
Judith Herman
is a distinctive form of trauma
because the violation involved is
extremely invasive and gives
rise to feelings of shame, self-blame
and guilt. When combined with fear
of being injured or killed, it is traumatizing in almost all cases.
What characterizes a traumatic event?

A brief introduction to ‘trauma’
The situation is overwhelming, inescapable and very frightening

Loss of control and beyond what we are prepared to deal with

Threaten life and integrity

Most people will struggle with serious reactions such as intrusive memories, re-experiences, flashbacks and sleeping problems after wards

Sexual-Gender-Based Violence and trauma.
What are trauma reactions?
How the brain works?

• Survivors of traumatic event that experience a similar situation, can behave differently after the event.

• Events associated with trauma reactions are often intense, grave and disruptive.

• The reactions that survivors show initially are survival responses.

• Traumatic events affect people in different ways also in the longer term.
Important aspects of trauma
What are trauma reactions?

Human beings (and animals) developed very early on an alarm system that assisted them to survive. These basic physical responses to danger occur below consciousness and are controlled by a part of the brain called the

They enable the body to react to danger before you have even started to think about what is happening. They can respond in as little as 1/100 of a second.

These physical responses,
also called survival strategies, are:

- You experience a strong physiological reaction without mental planning.

- You feel less contact with the ground; your body mobilizes to run as fast as it can, without thinking or planning.

- Flight and fight are impossible, energy levels are intense but the body is immobilized (tonic/muscular immobility).

‘Playing dead’
- When no other options are available, submission or ‘playing dead’ may be the final survival strategy.

Do you recognize these responses
or do you know other possible trauma reactions that could be of interest to discuss with the group?
Triggers and trauma reminders
Trauma-reminders are events or situations that remind survivors of their painful experiences, and awaken memories

Such reminders may elicit trauma reactions over and over again

Triggers, trauma reminders and flashbacks
They can be extremely stressing and create such anxiety that the survivor can be afraid
to go out,
of meeting people,
of hear certain sounds or
of doing ordinary things
Triggers, trauma reminders
and flashbacks
Triggers or trauma reminders
are events, objects or situations that revive memories of trauma.

, which are sudden, strong re-experiences of a past traumatic event. They are triggered by sensations – smells, images, sounds, touch. Senses are gateways that trigger memories.

The triggers, trauma reminders and flashbacks can be recognized in
thoughts, feelings, breathing, heart

The responses are natural ones to an extremely serious and painful experience.

Human Rights Perspective

To empower survivors is a skill. To let the survivor learn about her reactions and how to handle them is one way of empowerment.

We will explore other skills that can help to stabilize survivors and assist them to feel more in control and less frightened.

To stabilize a survivor we need to help her to connect with her senses, this will help the survivor to manage danger and fear.

We can use our senses to regulate responses, such as trigger reactions, in the 5 focus areas:


Scan the five focus areas before and after using a stabilizing tool to notice the difference.

As in all cultures, we must adapt what we do in our culture. And, since every person is unique, we need to make the tools and exercises as helpful as possible by adapting them to the needs of each survivor.
Use your senses
We will now to talk about stabilization and stabilization techniques. This is an approach that helps to handle trauma-related reactions, to improve the ability to be present in the here and now. Techniques or therapeutic actions to make a survivor react in a normal manner to stress factors.

Education about the effects of trauma helps survivors better understand their own stress responses, and knowledge of coping strategies provides a sense of control over these responses.

To be able to concentrate, to learn and to understand it is important that the survivor is present in the here and now – that means that the survivor has to be stable.

Some traumatized survivors can go from being stable to unstable during your meeting, and need to be stabilized before we can start or continue talking. This will be one of the tools you have working with survivors.
Grounding exercises
Grounding exercises
To monitor the effects of these techniques, we can ask these guiding questions before and after doing the exercise:

• What happens in your body?
• What happens to your feelings?
• What happens to your breathing?
• What happens to your thoughts?
• What happens in your heart?
Grounding is a stabilization method for handling strong emotions of fear or flashbacks, when a memory ‘takes over’ and is experienced as if it happens in the present.
Grounding exercises can help a survivor to reconnect:
• With the present moment in time
• With the here and now
• With her body, and reassert personal control
• To the safe context of the room in which she is

Grounding is one way to reduce reactions or symptoms of anxiety or panic that threaten to overwhelm a survivor.
One way the survivor can stabilize herself is by doing grounding exercises

Always remember to invite the survivor to participate in a grounding exercise. Let it be an open invitation. If she does not feel ready to participate in an exercise, respect her wish.

Window of tolerance
This is a model used to understand reactions to stress and trauma.

Each individual has a window of tolerance in which events are successfully experienced, processed, given meaning, and integrated.

Traumatized survivors have narrow windows of tolerance, are quick to leave their window, and may swing between hyper- and hypo arousal.

The aim is to keep the survivor within the window which indicates that she is in the ideal state of emotional response. In this state she can absorb and respond to information effectively.

the window she experience hyper arousal (often associated with the body’s ‘
fight and flight
’ response).

the window, she experience hypo arousal (associated with
freeze, ‘playing dead’,
submission and dissociation responses).
Window of tolerance is a tool
The window of tolerance is a therapeutic metaphor that we can use to explain trauma reactions.

Think of situations where you have been out of the window...


We all use a
when we work.
With your knowledge and experience you already have many tools that you use through your work.
as a helper, are the most important tool. In these sessions, we will practice different tools and skills so that they can be available to you when you need them.
The toolbox
What is stabilization?
Here we give you an example of the first meeting between a helper and a survivor.

Notice what the helper say and the posture and body language. Also notice how the human rights principles are included in this first meeting.

Afterward we would like for you to do a role-play of that same situation.

Role play: How to approach a survivor who is overwhelmed by what has happened to her.
You can work in pairs to practice.

One of you is the Helper, the other the Survivor.

Use a scarf to indicate the one who is the survivor.

Think about the different good qualities of a helper when you approach a survivor who is overwhelmed by her emotions and by what has happened to her.

At the end, take off the scarf if you are the Survivor, brush off your role as Helper or Survivor. Brush yourself down physically and say aloud “Now I am [me]”
Discuss between the two of you how it felt to be a survivor and how it was to be a helper.

Was there anything you would have liked to be different?

Would it be different without the human rights principle?
Role Play: First meeting
Role Play: First meeting
Explore the notion of ‘success’ and construct a suitably realistic ending.

To clarify the many challenges that may arise for a survivor when she returns to her community, and what kinds of assistance can make her return easier or more successful.

Be aware that some women may be marginalized and rejected by their families or community. And that some women will not wish to return to their old life.
Making a good ending
When ending the story:
(Please write your suggestions in the chat column)

Together we make a good ending of the Butterfly woman story.

Dag Nordstøms explains the window of tolerance in an excellent way (only in Norwegian)

This exercise can help a survivor to come down from hyper arousal and find a more balanced emotional state. It can also be used to focus survivors who are in ‘freeze-mode’.

Sit on your chair. Feel your feet touching the ground. Stamp your left foot into the ground, then your right. Do it slowly: left, right, left. Do this several times. Feel your thighs and buttocks in contact with the seat of your chair (5 seconds). Notice if your legs and buttocks now feel more present or less present than when you started focusing on your legs.

Now move your focus to your spine. Feel your spine as your mid line. Slowly lengthen your spine and notice if it affects your breath (10 seconds). Move your focus toward your hands and arms. Put your hands together. Do it in a way that feels comfortable for you. Push your hands together and feel your strength and temperature. Release and pause, then push your hands together again. Release and rest your arms.

Now move your focus to your eyes. Look around the room. Find something that tells you that you are here. Remind yourself that you are here, now, and that you are safe. Notice how this exercise affects your breathing, your presence, your mood, and your strength.

Source: Jacobson, Edmund. 1974. Progressive Relaxation. Chicago: The University of Chicago Press, Midway Reprint.
1. Grounding the body. (10-15 minutes.)
Creating a safe place
. (10-12 minutes.)

This exercise helps survivors who are in “freeze-mode”, feeling numbed and frozen.

Make yourself comfortable, with your feet on the ground. Feel and relax your body, your head,
your face, your arms, spine, stomach, buttocks, thighs, legs. Choose whether you want to close
your eyes or keep them open during this exercise. Listen carefully to the Trainer’s voice.
• Think of a place in which in the past you were calm and confident and safe. It may be outdoors,
at home, or somewhere else. It can be a place to which you have been once or many times,
which you saw in a film or heard about, or imagine. You can be there by yourself or with
someone you know. It can be private, unknown to others, somewhere that no one can find
without your permission. Or you can decide to share it with others.
This place must suit you and meet your needs. You can constantly recreate or adapt it. It is
comfortable and richly equipped for all your wants. Everything you need to be comfortable is
present. It is somewhere that fits you.
It shuts out every stimulus that might be overwhelming.
• Imagine this place. Imagine you are there. Take time to absorb it in detail: its colours, shapes,
smells and sound. Imagine sunshine, feel the wind and the temperature. Notice how it feels to
stand, sit or lie there, how your skin and your body feel in contact with it.
• How does your body feel when everyone is safe, and everything is fine? In your safe place you
can see, hear, smell and feel exactly what you need to feel safe. Perhaps you take off your
shoes and feel what it is like to walk barefoot in the grass or in the sand.
• You can go to this place whenever you want and as often as you want. Just thinking about it
will cause you to feel calmer and more confident.
• Remain there for five more seconds. Then prepare to return to this room, open your eyes,
stretch yourself, do what you need to return to the present.

Sometimes it will be important to report violent incidents to relevant bodies. Always do so with the consent of the survivor, and in collaboration with her.

What are best practice rules when a survivor decides to describe her experience formally?

How to consider the possible risks involved in reporting?


Pros and cons of reporting.

Using the best practice rules, what are advantages and risks of reporting?

Consider what helpers can do.

During this process troubled sleep and nightmares often occur, this is how we can prepare for that?
Before reporting
What reporting means and implies, including risks.
Explore the outcome, hopes and her fears.
Never put pressure to report if she is not ready or willing.
When ready ensure all implications,
Make sure she realises that the outcome may not bring a result that benefits her.
Prepare her for the possibility that retelling her story may re-traumatize her

During reporting
Ensure that a confidence is with the survivor.
Encourage her to use grounding techniques for staying in the present moment.
Make sure the environment is as safe as possible, and that support are available.
If a helper can be present to support the survivor when she makes her report, she should:
Agree a stop signal with the survivor, because this will help the survivor to hold her boundaries
Let her tell her story in general terms (headlines) to avoid triggers.

After reporting
Find a good process of closure for the survivor.
If possible ensure that people are available to talk through the event.
Help her to ask for information about the continuation of the case.
Plan and make arrangements for the following days, shelter and safety etc.

The survivor consider reporting
During this process remember to use your tools to stabilize the survivor
Basic principles

• Say that you want to give support.
• Show respect.
• Ask for permission to sit down together.
• Balance distance and closeness.
• Give the survivor time to take you in.
• Do not ask a lot of questions.
• Let the survivor understand that she can talk or she can be silent.
• Remind her that she is in command of her own story.

Every case and every survivor is unique
A helper must think for herself and always use her own imagination and judgement
when she decides what stories to tell, what advice to give, and what grounding exercises to use.

Important to ask certain questions:
• What resources can the survivor draw on, in herself and in others?
• Will I (or other helpers) see her regularly or just a few times, or only very occasionally?
• As a helper, how much do I know about her situation? Do I know enough?
• If I ask her to trust me, am I in a position to sustain that trust?
• Am I in a sound position to advise her?
• As a helper, am I promising too much? Can I sustain the help that I am offering?
• Can I sustain the help that I am offering?

The most common trauma reactions
This part of the story describes that through managing traumatic memories by using learned tools (grounding exercises, window of tolerance, psycho-education etc.), a survivor can be helped to identify, manage and eventually weaken traumatic memories - thus expanding her window of tolerance and being more stable (refer to pages 84-95 recovery skills).

In this way she will be able to focus on other things and thoughts, and to recreate the good memories from the past in order to create new memories that stretch into the future. This allows her to build new hope, to recall her old plans and longings, and to find new dreams. In the metaphor we use the antennas to give a symbolic reference to this process.

The Butterfly Woman wakes up good memories and old resources. Good new experiences waken her dreams and longings for the future.

Through learning and practicing tools and exercises the survivors will feel stronger and help her to control her thoughts, body, breathing, feelings and heart.
She listens
She feels
She tastes
She smells
Through her senses the survivor will be able to connect to the present time.

That unexpected situations can suddenly trigger trauma reactions.
What happens in the 5 focus areas when trauma memories are triggered.
That it is possible to prepare against these reactions, by using the senses to feel more present.
Good ways to bring a person back to the present moment.
That being prepared helps survivors to manage situations that might trigger their trauma memories.

Why do we tell this part of the story?
Full transcript