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Healing Invisible Wounds: Helping our Patients Find Hope &
Recovery in a Violent World
Richard F. Mollica, MD, MAR
Professor of Psychiatry, Harvard Medical School Director, Harvard Program in Refugee Trauma
Director, Cambodian and Refugee Clinic, Lynn Community Health Center
Funded by the Office of Refugee Resettlement (ORR/ACF/DHHS)
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Self-Healing
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The Concept of Self-Healing
The healing of the emotional wounds inflicted on mind
and spirit by severe violence is also a natural process.
Mind and body are powerfully linked, from the molecular
level up to the thoughts and social behaviors of a person.
Mind and body are similarly interrelated in their potent
curative influence. After violence occurs, a self-healing
process is immediately activated, transforming, through
physical and mental responses, the damage that has
occurred to the psychological and social self. Mollica, Richard F. (2006). Healing invisible wounds: Paths to hope and recovery in a violent world. Nashville, TN: Vanderbilt University Press.
Self Healing Elements
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• Facts
• Cultural meaning of trauma
• Revelations (looking behind the curtain)
• Listener (story–teller relationship)
Trauma Story
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The Universal Nature of Traumatic Life Experiences
• Every human being experiences tragedies in their lifetime.
• This is inescapable.
• A profound pain and fear enters us when we realize that one human being has intentionally hurt another.
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Major Instruments of Violence
• Humiliation
• Empathic Failure
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“ It is an intense pleasure, physical,
inexpressible to be at home, among friendly
people and to have so many things to
recount: but I cannot help noticing that my
listeners do not follow me. In fact, they are
completely indifferent: they speak
confusedly of other things among
themselves as if I was not there. My sister
looks at me, gets up and goes away without a
word… A desolating grief is now born in
me.” - Primo Levi
Primo Levi, Survival in Auschwitz and The Reawakening: Two Memoirs, trans. Stuart Woolf (New York:
Summit, 1958), 60.
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Major Responses to Trauma
• The “Will to Deny”
– Friends, family members, and society actively
reject acknowledging the trauma story and the
impact of trauma on the survivor.
• “Losing the World”
– When visiting Philoctetes the
Greek chorus immediately sings,
“I am a stranger in a strange land.”
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Body, Mind, and Spirit are Imprinted by the Trauma Story
TRAUMA
STORY
SYMPTOMS
DISABILITY
EVENTS LIMITATIONS
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Elements of the Trauma Story (TSAT*)
• Factual accounting of events
• Cultural meaning of trauma
• Looking behind the curtain (revelations from the trauma experience)
• Listener – storyteller relationship
*Trauma Story Assessment and Therapy (TSAT) Notebook: Therapist Journal for Field and Clinic
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A Cambodian
Oral History
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Therapeutic Power of the Trauma Story
• Dialog and empathic listening between
survivor and clinician maximizes the
benefits of emotional disclosure.
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Self Healing Elements
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Working with the Self-Healing Response (SHR)
• All trauma survivors have an active SHR.
• The client/patient is the teacher.
• The clinician needs to build on SHR.
• Major social instruments of SHR are altruism, work, and spirituality.
• Altruism
• Work/school
• Spirituality
Social Instruments of Healing
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Social Resiliency and Risk Factors
Altruism
Work Spirituality
• Healing begins when the patient feels they can become a whole person again
Self-Efficacy
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“People guide their lives by their beliefs of personal efficacy.”
- Albert Bandura
• The process of enabling people to increase control over, and improve their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions.
WHO 2005
Health Promotion
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The ACE Study: Childhood Abuse Categories
• Direct exposure to childhood abuse –Psychological –Physical –Sexual
• Household dysfunction during childhood –Substance abuse –Mental illness –Mother treated violently –Criminal behavior in household
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of Childhood Abuse and Household
Dysfunction in Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive
Medicine.1998; 14(4):245-258.
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The Ace Study: The Relationship Between Childhood Abuse and Household Dysfunction (n=9,508)
Risk Factors % AOR 95% CI
Current Smoker 0 2 4+
6.8
10.3 13.9
1.0 1.5 2.0
(1.1-1.8) (1.7-2.9)
Severe Obesity (BMI>35) 0 2 4+
5.4 9.5
12.0
1.0 1.4 1.6
(1.1-1.9) (1.2-2.1)
2 or more weeks of depressed mood in past year 0 2 4+
14.2 31.5 50.7
1.0 2.4 4.6
(2.1-3.2) (3.8-5.6)
Ever attempted suicide 0 2 4+
1.2 4.3
18.3
1.0 3.0
12.2
(2.0 - 4.6) (8.5-17.5)
Relationship Between Childhood Trauma and Medical Risk Factors
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Risk Factors % AOR 95% CI
Considers self alcoholic 0 2 4+
2.9
10.3 16.1
1.0 4.0 7.4
(3.0-5.3) (5.4-10.2)
Ever use illicit drugs 0 2 4+
6.4
19.2 28.4
1.0 2.9 4.7
(2.4-3.6) (3.7-6.0)
Ever injected drugs 0 2 4+
1.3 1.4 3.4
1.0 3.8
10.3
(1.8-8.2) (4.9-21.4)
Ever had sexually transmitted disease 0 2 4+
5.6
10.4 16.7
1.0 1.5 2.5
(1.2-1.9) (1.9-3.2)
Relationship Between Childhood Trauma and Medical Risk Factors
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Risk Factors % AOR 95% CI
Ischemic Heart Disease 0 2 4+
3.7 3.4 5.6
3.7 0.9 2.2
(0.6-1.4) (1.3-3.7)
Any cancer 0 2 4+
1.9 1.9 1.9
1.0 1.2 1.9
(1.0-1.5) (1.3-2.7)
Stroke 0 2 4+
2.6 2.0 4.1
1.0 6.7 2.4
(0.4-1.3) (1.3-4.3)
Chronic Lung Disease 0 2 4+
2.8 4.4 8.7
1.0 1.6 3.9
(1.1-2.3) (2.6-5.8)
Diabetes 0 2 4+
4.3 3.9 5.8
1.0 0.9 1.6
(0.6-1.3) (1.0-2.5)
Fair/poor health self-rating 0 2 4+
16.3 19.9 28.7
1.0 1.4 2.2
(1.2-1.7) (1.8-2.7)
Relationship Between Childhood Trauma and Chronic Medical Conditions
• Acknowledgement
• Apology
• Compensation
• Punishment
• Forgiveness
Justice
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1. What traumatic events have happened?
2. How are your body and mind repairing
the injuries sustained from those events?
The Basic and Essential Self-Healing Questions Clinicians and Trauma Survivors Need to Ask
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3. What have you done in your daily life to help yourself recover?
4. What justice do you require from society to support your personal healing?
The Basic and Essential Self-Healing Questions Clinicians and Trauma Survivors Need to Ask
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Resources: Trauma Story Assessment
and Therapy (TSAT)
www.lulu.com
36 www.lulu.com
Resources: Textbook of Global
Mental Health: Trauma and Recovery
37 www.amazon.com
Resources: Healing Invisible
Wounds: Paths to Hope and Recovery in a Violent World
38 38
www.hprt-cambridge.org
