TIRA

Traumatic Incident Reduction Association

Case Studies using TIR and Related Technique

The views and opinions expressed in these articles and interviews are those of the individuals speaking, and do not necessarily represent those of Applied Metapsychology International or the TIR Association.

Culture, Trauma, and Other Reflections

By: Dr. Rusanna Ohanjanian
Excerpted from the Fall 1993 issue of the Institute for Research in Metapsychology Newsletter
Foreword by Gerald French

Dr. Ohanjanian is a native of Armenia, a teacher, clinician, and researcher who received her Ph.D. at the National Academy of Science in Moscow. When we first met in the fall of 1991, Dr. Ohanjanian spoke virtually no English, and I was able to train her in the use of Traumatic Incident Reduction (TIR) only because her associate Feodor Konkov trained with her and was able to act as a translator. Knowing by then something of the situation in Armenia, I never truly expected to see her again when she left California to return to Yerevan. I only hoped that despite the thousands of miles separating her from the nearest source of support she might have found in working there with TIR, she would find it possible amidst the relative chaos to make some good use of the material and techniques she had studied during her brief stay at the Institute.

To my great delight, I found that not only had she been able to do that, she also managed subsequently, with the help of Dr. Konkov and others, to return to California. We reestablished contact, and following a conversation we had concerning her life and experience as a therapist both pre- and post-TIR training, I asked if she would be willing to write an article about it for the Newsletter.

I use the term "conversation" advisedly, for her English has improved dramatically and I had no difficulty at all in either understanding the story she had to tell or in imagining that it might prove to be of more than passing interest to others besides myself. Dr. Ohanjaian, however, had serious misgivings about attempting to write an article in English for publication, observing correctly that there's a significant gap between communicating effectively in speech and putting words together as eloquently as she would wish to in print. Eventually, however, she allowed me to persuade her, but only on the condition that I would take responsibility for "putting flesh on the bones" of her draft. This I in turn agreed to only on the condition that she would work with me patiently to re-translate and approve every word I might add to what she gave me to work with. The writing of her story thus became not only a collaboration, but something of a labor of love as well, one which required numerous meetings, discussions, and emendations. In the end, Rusanna did me the honor of telling me that the "flesh" I had added came "as if from a mirror", and that I had "read her heart", words that meant a lot to me.


Culture, Trauma, and Other Reflections

In the spring of 1990, I was teaching psychology and clinical psychology at Yeravan State University in Armenia and received a phone call in my apartment one morning from Dr. Feodor Konkov, a friend and professional colleague then working in Moscow. As might have been expected, given the chaotic upheavals then and still being experienced throughout the splintered elements of what had been the USSR, much of Feodor's work and mine at the time was focused on trauma-related issues, and we shared an intense and vital interest in the subject. Dr. Konkov's purpose in calling me was to tell me that through a correspondence recently begun with a group in California called the Institute for Research in Metapsychology, he had discovered the existence of what appeared to him to be a "really amazing technique for dealing with trauma." "Believe me," he said, "this is something really different."

That was my first exposure to Traumatic Incident Reduction (TIR), and although Feodor went on to tell me a bit more about TIR, Applied Metapsychology, and the Institute, and although I found it interesting, I came away from the conversation with a lot of questions. Sometimes, you have to touch something to understand what it really is, and the opportunity for me to do that did not come until the next year.

In the fall of 1991, Feodor and I met Dr. Gerbode and Gerald French in Washington, D.C., during the annual conference of the International Society for Traumatic Stress Studies [ISTSS] which I was attending to deliver a paper concerning the traumatization of Armenian children by the horrific earthquake that had happened there in 1988.

While at the conference, I went to a presentation on TIR by Gerbode, French, and others, and was particularly impressed by the videos they showed of live TIR sessions. The results ("end points", as I later learned to call them) were astonishing to me. We were able to watch - not just to be told about, but actually to see - the entire process of pain being transformed into relief in a single session, and I became really interested in finding out more about "viewing", and this technique called "TIR".

Let me I'll try to explain the intensity of that interest with a bit of history:

I would not wish on anyone the experience of having seen as much trauma or as many severely traumatized people as I have in my life. Armenia, December, 1988...the heart of a bitterly cold and terrible winter. One grey morning, without warning, the earth rolled over in its sleep and in the space of less than two minutes, a convulsive earthquake devastated a heavily populated area roughly the size of the San Francisco Bay area. In those few appalling seconds, Leninakan, Spitak, and many other villages and small towns were badly damaged or simply erased: reduced to frozen and indifferent rubble, forming prisons for the living and tombs for the thousands, perhaps more fortunate, who died without the chance to realize what had happened to them.

The weakening cries of conscious survivors, trapped in the ruins, went on for hours...days. Thousands of others, unconscious or too severely injured to make themselves heard, simply awaited death. Many were rescued, but for thousands of others, the help which eventually came from all around the world, arrived too late. Among those who perished were my own dear father and mother and my lovely, angel-faced nephew, only four years old. My beloved childhood home, whose every inch was sweet to me, I'll never see again.

There were hundreds of thousands who, like me, were given burdens difficult to accept and impossible to forget.

For the uninjured survivors on the site of the disaster, though, there was no time for the luxury of entering or remaining in the apathy of depression. Without food or roofs to shelter them, they were nevertheless the first of the rescuers to reach, where possible, their own families and children... and then others, strangers to whom they were linked only by their common humanity.

Among the survivors and the others earliest to begin the work of rescue - doctors, disaster aid workers, and relief teams - there were none who were not in shock. Three or four days after the quake, "psychological first aid" for their condition began to arrive in the form of psychologists, therapists, and mental health and social workers, initially our colleagues from Moscow and Georgia. Eventually they were joined by a host of unpaid volunteers - psychologists from all over the world, especially France and the USA - and they began to work in several Centers established for the purpose by the Ministry of Health. These were located in the cities most affected by the quake, and in Yerevan, the capital, where many of the evacuees were brought.

What were these centers? In many cases, they were nothing more than a couple of cold, uncomfortable rooms, each with two hard chairs and perhaps a desk. And outside, a long, barren hall where crowds of people, ever growing, sat and waited their turn to enter one of the "magic rooms". And after their first visit they would return, bringing families...kids... friends...neighbors.... Because within its limitations, the "first aid" worked for them, and nothing else could even palliate the pain and grief they suffered. We used many tools, the most effective of which in the first weeks were deep relaxation, NLP (Neuro-Linguistic Programming), and hypnotic suggestion.

Armenia is a small country. There are few psychologists there, and among those, only a handful are psychotherapists. That's why, little more than a week after the disaster, a group of my colleagues came to my home and asked me to join them in helping at the Center in Yerevan. "Your place is there," they said. "We need you to come and work with us."

I didn't understand. I couldn't. How could I, myself so hurt and needing help, be any help to others? My days and nights were indistinguishable and without end. I was incapable of meeting the eyes of my only sister, grief-torn mother of my nephew. I wanted only to be left alone with the hopeless hope that all of this might be just a nightmare from which I would soon awake to see my loved ones laughing once again in the doorway of our home. "No, no," they said, "none of us can understand these people as you do. Please, just come there once, and you'll understand everything." And the next day they came again and took me with them, numb and docile, to the Center.

The first time I entered that place, I felt as if I were seeing scenes and events through some sort of screen, a gauzy curtain that kept everything at arm's length, a part of some other reality. I saw many people waiting, keeping silence, hopeless and helpless. Some of them had been evacuated from little mountain villages and knew nothing of "psychotherapy". They only knew they had been told, "It's help," and "It works."

The following day I returned to the Center and little by little, as the days passed, I began to work. Often I'd be told, "Oh, doctor, you can't understand... you can't imagine the pain... how it is to lose the dearest people, to lose your home and everything you've worked for all your life, to feel so alone and hopeless." I did understand, and came to understand as well that it was right and good that I should be there, using such skills and knowledge as I possessed to help them to experience relief, however slight.

During the first month after the quake, there were so many patients that we needed to stay at the Center from 8:30 in the morning until 11:00 at night every day. As therapists, even those among us who had not suffered personal bereavement were traumatized simply by the constant exposure to the trauma of others, and so the last two hours of each day consisted of workshops and group therapy for the therapists.

In the ensuing months, the patient load diminished only slightly if at all, but our time got much more organized. It began to be possible to actually establish schedules and to see people by appointment. Nonetheless, we frequently found ourselves with "late" clients because the Center was affiliated with and situated quite close to one of the hotels in which many of the evacuees had been housed. And all of them soon knew that we existed, and were there nearby, and that that they could come to the Center for help "any time until midnight." And they did.

The Clash of Care and Culture

We really worked hard, and in that short and taxing time, we gained experience as therapists that would have taken years and years to acquire in a conventional psychotherapeutic practice. And we learned, not only from the experience but also from our fellow psychotherapists and colleagues in the Center. Each of us practiced different techniques and represented different schools and philosophies of psychology. Some of our tools were very effective; some were not. But all of us came to agree that any approach, tool, or technique that ignored or failed to take into account the national background, traditions, and cultural bias of the client would fail miserably. The best and most proven of techniques, employed by the most competent and caring of therapists, proved no exception to this rule, whose workings may be clarified by my describing a curious incident that happened at the Center while I was working there.

About six weeks after the Center opened, someone brought in a lovely young woman, 29 years old. She had lost her husband in the earthquake, and had gone to live with their two children in the home of his parents' family. Devastated by the loss, she was in deep depression and complained of terrible flashbacks, sleeplessness, and anxiety, stating that she felt as if she had died with her husband.

During that period, one of the psychotherapists volunteering at the Center, a very competent professional, trained in France, was a woman born in France to an Armenian family and fluent in the language, but one whose life had been spent entirely in Europe. She began brief therapy with the young widow. Over the course of two or three sessions, wanting to shed at least some small ray of light into the depths of her client's depression, she attempted to suggest to her some positive ways of thinking.

"You are young and very pretty," she told her. "You will be happy again one day. You'll have love and a new family in your life...."

The next morning, when we arrived to open the doors of the Center, we found a very large and very outraged delegation of the widow's husband's relatives waiting for us. The head of the delegation was her mother-in-law, determined, irate, and intent on meeting "that 'Doctor' who is teaching my daughter-in-law to hurt the children, destroy the family, and break my broken heart a second time!"

The psychotherapist from France was stunned.

This is far from being the only example I could cite of the sorts of difficulties that arose whenever one of us attempted to employ what were recognized in other contexts as valuable and productive techniques without first recognizing the backgrounds of the people we were attempting to help, and making adjustments for them. As the Center grew and we began to deal not just with Post Traumatic Stress Disorder (PTSD) but with a much broader range of psychological problems as well, that point was driven home to us over and over again, especially when it came to dealing with rural folk and members of the older generation. Some of the techniques we used proved more generally useful and less culturally dependent than others. None had universal applicability, and as our client base expanded to include refugees from Azerbaijan, survivors of army violence in Georgia, and victims of the Chernobyl disaster, we wished earnestly for one that did. Despite the satisfaction we got from the knowledge that we were making an important contribution, the work raised many, many questions.

In the autumn of 1991, I began to believe that I had found some answers - especially to this question of how to deal effectively with representatives of such widely disparate ethnic groups and cultural backgrounds. That fall, I spent two weeks at the Institute in Menlo Park learning some of the theory of Applied Metapsychology and the practice of TIR. The more I came to understand it, the more TIR seemed to me be a really powerful verbal technique whose efficacy might prove to be in no way dependent on its having to "match" the ethnic backgrounds and cultural traditions of the client population. And on my return to the former Soviet Union, I found to my great delight that indeed it was not culturally bound. It worked "across the board".

Resistance

TIR also helped me to overcome another obstacle that we met often in our work. One of the most common ethno-culturally determined phenomena we encountered in our clients was a very strong resistance not only to psychotherapists but to the entire concept of psychotherapy. This resistance is firmly rooted in cultures that frown heavily upon "washing your dirty laundry in public" (a phrase whose Armenian equivalent is "showing your garbage to your neighbors"). On the one hand, they knew they needed help; it was why they had come to us. On the other, the idea of revealing even the fact - let alone the nature and details - of their personal problems and suffering was shameful and abhorrent to them. One ought to have no personal problems, and one's family relations ought to be exemplary. In short, one must present a strong face to the world. And that world includes even the therapist to whom one has come for help. Thus it was common for clients to come to us "because my kids could use some help...", or because "I have a friend who is suffering a lot...", and only after such subterfuge, if at all, might the real story begin to come out.

There were other reasons as well for such resistance. For one thing, the mere fact of seeing a psychologist might cause one to be labeled "mentally ill". (In the former Soviet Union [FSU], as elsewhere, few people recognize the difference between psychology and psychiatry.) For another, all forms of psychotherapy in the FSU were, and for the most part still are, free to the client, and thus he has no "stake" in "getting to the point"; many clients would come to us day after day, reciting as if it were a mantra, "Nothing and no one can help me...nothing works", simply for the attention we gave them.

Such clients constitute a heartbreaking and exhausting drain upon the time and energy of even the best and most dedicated of therapists. And I came to value TIR for the ease with which it often enabled me to address and resolve my clients' suffering without having to fight this resistance.

A case in point:

One of my patients, another young woman, had been married for less than a year to "a very good man" with whom she had been very happy. She came to me, however, complaining of a number of symptoms: disappointment, burnout, and extreme anxiety. She had recently acquired them, and told me that she had no explanation for them and that her despair was becoming unbearable. They seemed to center on her husband, and though she said she still loved him, she had become very cold ("frozen") towards him and was even considering a divorce. Her husband, who loved her very much, was unable to do or say anything that helped, and was thoroughly distraught by the thought of losing her for "reasons" that weren't clear to either of them.

I asked her what had precipitated her feelings and - typically - at first she said, "just nothing ... nothing special...." Then she recalled an incident a couple of months earlier in which she and her husband had gone to a party. In the course of the evening her husband had consumed a lot of alcohol and his drunken behavior had embarrassed her a great deal. She had left the party with him, feeling "terribly frustrated" and "ashamed". The next day, her properly and truly contrite husband had apologized profusely and begged her to forgive him and forget about it, promising that it would never happen again.

In fact, the husband normally drank very little and had certainly had no trouble in keeping his promise. But though his wife had indeed forgotten the incident within a few days (until remembering it again in my office), the feeling of angst that had begun the night before had remained and grown worse, and she had continued to be very upset with him and the marriage, feeling, as she said, that "something terrible has happened, or is going to soon." Normally a very social person, she had become withdrawn, no longer visiting her friends or inviting them to her home.

In using TIR with her, I was able to avoid what would otherwise almost certainly have been the impossible task of bringing her by analytical means to a resolution of her situation. Instead, I simply asked her to review and recount the incident at the party that she had identified as containing all of her unwanted symptoms. Step by step, the procedure led her further and further back in time until she found herself looking with growing clarity and amazement at a period in her life and incidents it contained that she had completely suppressed and forgotten, and in that single session, with no suggestion or interpretation from me, she realized the source of her malaise and the fact that it had nothing whatsoever to do with her good husband or her present life. Her symptoms vanished, she reported feeling "easier and all better", and she returned home, happy, to an overjoyed husband and a marriage that had been restored.

What she had discovered was this:

She had grown up with her mother a single parent, her father having died when she was only five or six years old, and having been divorced and separated from her mother some time earlier. All her life she had remembered only this, but during the session, as later emotional charge was "removed", she became able to recall details of her earliest years that had previously been quite unavailable to her - which details, for reasons that will appear obvious in a moment, had been "triggered" by the events that had taken place at the party with her husband and which had become unconsciously confused in her mind with her present circumstances.

Specifically, her father had been an alcoholic and had abused her mother terribly. She recalled her mother crying, and saying that she hated him, but after the father's death, her mother never spoke to her again about these episodes, and they had been totally forgotten. These memories brought her to the end point of the session. Feeling as if she had "taken off something very heavy" (a statement I've heard echoed in many TIR sessions I have given), she realized that her recent despair had stemmed from the fact that she had identified with her mother to such an extent that a single instance of her (affectionate and utterly non-abusive) husband's drunkenness had been sufficient to drive her into fear and to convince her that she would suffer terribly if she permitted her marriage to continue. "Now I know where those feeling came from," she said, "and they're not going to rule my life any more!"

Though I found its ability to resolve such early traumatic experiences to be one of the most important therapeutic aspects of TIR, it was not the only one. TIR creates a very comfortable atmosphere for the client; its use precludes - practically as well as philosophically - any consideration that the client is "ill". On the contrary, by enabling the client to reach her own insights without any interpretation or evaluation on the part of the therapist, TIR makes her the more active and responsible of the two session participants in the process of "viewing" her own life and experience. She, and not the therapist, resolves her difficulties.

Tea and TIR

Another related aspect of TIR that I found to be enormously rewarding is the ease with which it can be used informally. Not infrequently, people around one need help, but close friendship, reluctance, or a familial relationship rules out the possibility of their coming to one as a therapist in a formal setting. But they will talk over a cup of tea ... and tea and TIR can go very well together. Though it is an elegant formal procedure, it doesn't have to be presented as one in order to work small miracles.

Another case in point:

One of my closest friends in Armenia was a funny girl with a pretty face who had been seriously overweight throughout her life. She had never gone and would never go to a therapist to talk about her weight problem, and chose instead to cope by playing the role of a totally happy person who attached no significance to her personal appearance. In reality, it caused her a lot of suffering, and maintaining the false facade made her tired and drained her energy. She finally encountered a situation that forced her to confront the fact the she really wasn't fine.

One morning shortly after that event occurred, we were having coffee together and I observed that despite her attempts to be her "normal, happy self", she really was unhappy and needed to talk about it. I told her nothing at all about the TIR procedure, moving into it by simply asking her to tell me what had happened. The regular acknowledgements inherent in TIR helped make its intrinsic repetitions acceptable to her, and the "session" went beautifully. Over its course, she realized - again, with no prompting whatsoever from me - that she really wasn't confident in her appearance, and came to accept the fact that she really did have a problem. She dropped the facade and became truly happy, not with her weight, but with the fact of discovering that the answer to her problem lay not in the attitudes and behavior of others but in herself ... and that she could do something about it. She didn't have to be perfect in order to change. "I know I can deal with this," she told me. She felt very much better, and ended our "session" by saying "I'm so glad I don't have to be 'Superwoman' any more!"

Children and TIR

One of my primary interests has long been in working with children affected by trauma, and I found that this kind of informal use of the TIR procedure lends itself extremely well to working with young people as well as adults. In fact, the ease and rapidity with which TIR enables one to reach an end point with a traumatized child is sometimes astonishing.

Unlike adults, children lack the experience to even begin to analyze what may have happened to them. Typically, the only things accessible to them are feelings and emotions. Thus, classically, most effective attempts to work with traumatized children have tended exclusively to require the use of either non-verbal or purely cathartic tools. TIR, however, seems to invite a second and critical look at this requirement, a consideration I found myself beginning to entertain one afternoon following my use of it with a young friend of my then 10-year-old daughter, Irene. The two came home after school together that day, and the friend was very visibly distressed.

"What happened?", I asked.
"I don't know ... nothing ... I just feel so unhappy today ....", she said.
"Did something happen in school?"
"No...."
"Try to recall the whole day", I told her, "and find some part of it that wasn't OK."

After a moment, she came up with an incident: there had been a school rally that morning at which she'd thought at one point that "all of us kids were supposed to jump up out of our seats and give a loud cheer." She had done so ... but no one else had. Her schoolmates had laughed at her solo performance, and she had been utterly mortified. Following that incident of awful exposure, she had spent the rest of the day immersed in feelings of abject shame that most of us as adults can recall having experienced, if at all, only in our own fragile childhoods.

Using a simplified version of TIR, I had the girl run through the incident a few times, and in a matter of only ten or fifteen minutes, she reached a "classic" end point, certainly the equal of any that one might have wished to have been able to "get across" to her using the more usual tools of psychological intervention. She realized, all on her own, that the horror wasn't really horrible! "What's the big deal?", she said to me after what was perhaps only our third pass through the incident. "It could have happened to anyone! It's not as if I got run over by a train or something!!" We ended off ... and that was that. She was happy, and I was again impressed with the power of the tool I had employed.

This short essay is not an exhaustive description of the valuable uses to which I have come to believe that TIR can be put. I am convinced that the procedure has very rich possibilities, many of which will be discovered only through its regular and systematic use by many people. And this can be done, I think, because TIR has the advantage of being a very "plastic", flexible technique; in consequence, it can easily be added to the lay or professional armamentaria of therapists and helpers of many and disparate backgrounds and philosophical persuasions.

There is a sense in which TIR cannot be considered to be "plastic". During the course I took I was told that it cannot be mingled successfully in a single session with other verbal techniques. I believe that is true; the nature of the procedure itself, the particular handling of the viewer's communication that is required to ensure its successful use, and the Rules of Facilitation that govern the use of TIR preclude such fusion. But I found the technique to work very well in alliance with non- verbal relaxation techniques, particularly when people are very anxious and tense and can't talk about their problems. One can begin a session by relaxing the client, relieving her tenseness, and thus increasing her trust in the therapist. Then one can go deeper with the procedure of viewing. The client is made more comfortable and open with the therapist, and then her problems addressed with TIR. The two procedures work very harmoniously together.

My current understanding of the capabilities of TIR came to me only gradually as I acquired more and more experience in its application, and I feel that it represents a resource that as yet contains many undiscovered practical uses. For having taught me the basics of the philosophy underlying TIR and its technical possibilities, I am grateful to Gerald. Very carefully, step by step, he helped me to overcome a daunting linguistic barrier, to understand and eventually to accept as demonstrably valid the ideas of metapsychology, to really "touch" the material I learned, and to make a new and welcome approach to helping traumatized people an integral part of my own difficult duties.

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