Treatment of Torture Survivors - Influences of the Exile Situation on the Course of the Traumatic Process and Therapeutic Possibilities*

SCIENTIFIC ARTICLE

Treatment of torture survivors - influences of the exile situation on the course of the traumatic process and therapeutic possibilities*

Mechthild Wenk-Ansohn, M.D.**

Abstract 1. The traumatic process Traumatized refugees often suffer from complex under stress factors in exile posttraumatic disorders with a high tendency of Refugees living in Germany have often suf- chronicity. This is due to severe and often repeated fered from severe and repeated man-made traumatization in the course of political persecu- traumatic situations in the course of political tion on one hand and uprooting and ongoing persecution, detention and torture. Some- stress caused by leaving their home country and times the trauma also included the circum- society and living under an adverse situation in exile on the other hand. This article shows how stances of their flight. Depending on the positive and negative factors going along with mi- country of origin, about 40% of refugees are gration interfere with the course of the traumatic suffering from PTSD by the time of their ar- process and the therapeutic possibilities and how rival in the country of exile.1 An even higher the therapeutic process can be adjusted to the percentage has gone through potentially situation. traumatizing situations. These individuals are at risk of developing trauma sequelae later Key words: torture survivors, traumatized refugees, on, if preventive measures are not granted in treatment the country of exile. Having been uprooted and having lost their material and social basis of living, close and beloved persons, social support, their home country and their cultural and political context, refugees are weakened in their capacity to cope with the traumatic impact to which they have been submitted. In addi- tion to severe trauma, refugees pass through a situation of loss and ongoing stress. Getting to Germany or other European countries means to the survivors that they can finally feel safe from persecution. The anxiety due to external factors (“Realangst”) *) Revised version from paper presentation is reduced and the hope for a better future Volume 17, Number 2, 2007

u r e may alleviate depressive moods and pain. t **) Behandlungszentrum für Folteropfer Berlin, Turmstr o r

T 21, 10559 Berlin, Germany, [email protected] But on the other hand – especially if the 89

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refugees are not granted asylum right after means that treatment will be under a situ- their first interview with the German immi- ation of ongoing stress and uncertainty. gration authorities (BAMF) – they will soon Being forced into a passive role is one of the suffer from an exile situation with a variety important factors that hinder refugees in of adverse factors such as: developing coping strategies after a trauma; it weighs heavily on their self esteem and re- • ongoing uncertainty (insecure residence inforces states of depression. status: asylum seekers, temporary permis- Migration always means a process of sion to stay) changes and adaption. Sludzki3 described • lack of prospects for the future the process of relocation as one in which • inactivity, interdiction to work/study, de- the emotional needs of individuals increase pendency on social aid markedly, while their support social network • subjection to degrading and incompre- is severely disrupted. As a result, relocations hensible bureaucratic acts are strongly associated with increased psy- • housing in mass accommodations often chosomatic and interpersonal distress. far away from cities and exile commu- nities As Hans Keilson4 found out in his study of • restriction to leave their residence areas holocaust child survivors, the period after • isolation within the German society and the traumatic incidents is crucial for the de- difficulties with communication velopment of the traumatic process. His con- • sometimes violence with xenophobic con- cept of sequential traumatization, which dis- text tinguishes three consecutive phases of stress, • lack of access to adequate medical/psy- is still fundamental to understanding the chological care2 traumatic process that is induced by traumatic experiences but influenced by many About 90% of the patients treated annually external and internal factors (Figure 1). at the Berlin Centre for the Treatment of Torture Victims (bzfo) do not have a secure Refugees are very likely to experience an residence status at the time of intake and extremely stressful and depressing situation sometimes for many years to follow. This (“ongoing stress”) in the important third

1st phase 2nd phase 3rd phase Repression Persecution/flight Exile

Discrimination Torture, prison Uprooting (new culture asylum T War Lifethreat/agony, loss situation) r o t Anxiety Traumatic events Uncertainty e r u Isolation Anxiety Anxiety 2007 2, Number 17, Volume Dissociation Chronicity of posttraumatic syndromes

Other influences: personal and social meaning of the trauma, consequences/losses age, sex, pre-traumatic resources of the personality, active modus, social support

Figure 1. Sequential traumatization.4 90

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phase of their traumatic process. The ongo- is a risk for a so called retraumatization ing exposure to situations that are adverse with acute crisis and eventually persistent to a process of trauma compensation goes exacerbation of the trauma related psycho- along with a high tendency of chronicity of pathology. Unfortunately the life of a refugee posttraumatic stress disorders. The more bears a relatively high level of risk for retrau- severe the traumatization is and the longer matization. We especially see such heavy the traumatic process under conditions of decompensations when traumatized refugees ongoing stress continues, the higher the are threatened with deportation to their tendency to develop complex posttraumatic countries of origin. disorders with persistent or periodic PTSD symptomatology accompanied by increasing 2. Adapted forms of treatment comorbidity such as: 2.1 Basic measures and necessary elements of health care • alterations in the regulation of affect and If we want to support torture survivors to impulses overcome the traumatic impact that has • disorders of attention and consciousness shattered their lives, we have to try to mini- • depression mize the risk factors for the worsening of the • somatization traumatic process on one hand and to in- • anxiety crease protective factors on the other hand. • alterations in systems of meaning, endur- The initial treatment of torture survivors ing personality changes in exile is focused on secondary prevention • changes concerning the interpersonal in order to increase health promoting fac- area tors. What helps to overcome the traumatic • worsening of pre-existing mental and so- impact and find a way into a worthwhile life matic disorders5,6 after trauma and uprooting are basic measures in areas such as: Laban, Gernaat, Komproe, Schreuders and De Jong7 recently published a study of • security the impact of long asylum procedures on • housing the prevalence of psychiatric disorders of • access to legal advice asylum seekers. The overall prevalence of • access to health care (with interpreters!) psychiatric disorders increased from 42% to • access to social support 66.2% when the (Iraqi) refugees had lived • supporting autonomy wherever possible more than two years as asylum seekers in the • adequate physical conditions Netherlands. • language skills, access to education A posttraumatic stress disorder, even if • occupation, access to work if there is the symptoms are already in remission, can ability be reactualized (updated) by renewed stress • respect, acknowledgement and stimuli which are connected with the • social contact, integrative activities trauma. If the victim is confronted with a • developing future prospects (the survi- severe or long lasting stressful situation or vors and their families) a new loss of safety and coping possibilities Volume 17, Number 2, 2007

u r e or with reactualizing stimuli in a situation Health care and the access to psychologi- t o r

T that is experienced as uncontrollable, there cal care are important, but they are not the 91

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only concern in the process of rehabilitation so-called low threshold offers. Some of the of torture survivors. There are many other refugees need psychotherapy over a long pe- factors playing an important role in the riod of time or at various times of the proc- outcome of treatment for the traumatized ess after the traumatizing experiences. refugees – some of them we can influence, others not. 2.2 What is offered by the Berlin Center for the Following the EU Council Directive lay- Treatment of Torture Survivors ing down minimum standards for the recep- At the Berlin Centre for the Treatment of tion of asylum seekers,8 adequate material Torture Victims (bzfo) and the connected conditions and the “necessary treatment of Center for Migrants and Refugees we offer: damages” should be granted to persons who Diagnostics and medical reports, psycho- have been subjected to torture, rape or other logical and social counseling, language and serious acts of violence. Taking into account professional training courses to support the the experience of the treatment centers for process of integration in the country of exile, torture survivors and refugees, the access to, medical and psychiatric treatment, physi- and the realization of, a “necessary treat- otherapy and psychotherapy. At the bzfo ap- ment of damages” consists of various steps proximately 400 to 500 patients are treated (figure 2). annually. Like other trauma centers, the bzfo Upon arrival in the exile country all refu- works in an interdisciplinary, multi-pro- gees need basic medical care and access to fessional and integrative manner, using psychological diagnostics if it is wanted and elements of different forms of trauma ori- necessary. Traumatized refugees need ap- ented therapy. We have colleagues working propriate living conditions and psychosocial psychodynamically and others who have a support and the possibility to take part in cognitive behavioral background and offer

Somatical basic care + structured interview about psychosocial health status and information about health care possibilities

>if experience of violence or psychological stress: psychiatric/psychological diagnostics (qualified specialists/interpreters!)

Psychosocial counselling and support T r o

appropriate material and social conditions, low t threshold offers, occupation, access to e r u primary psychiatric/ 2007 2, Number 17, Volume psychosomatic care (interpreters!) case management

Psychotherapy

Figure 2. Elements of necessary health care.2 92

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modules like psychoeducative groups with support should strengthen the autonomy of information and control focused elements or the clients, thus avoiding the trap of creating biofeedback programmes. There is a service new dependencies. But, as always in trauma for children and youth with specialized col- therapy, it has to be “safety first”. Due to the leagues who work with a systemic approach restrictive asylum politics of Germany (and with unaccompanied minors and families. other European countries) about 90% of Physiotherapy, body oriented psychotherapy, the patients do not have a secure residence art therapy and music therapy and resource status at the time of intake. That is why we work in our “Intercultural Healing Gar- have to provide medical/psychological re- den” are offered as additional therapeutic ports for the asylum process of the torture approaches. We have an outpatient setting survivors and traumatized war victims that and also offer a day clinic program for sur- we take in for treatment. We are also asked vivors who are psychologically very unstable by courts to give expert opinions for refu- and who had frequently been admitted to gees that are not in treatment at our center. psychiatric wards. Medical and psychiatric For the medical report it is necessary to go treatment is embedded in social therapeutic through an initial narrative of the incidences and psychotherapeutic processes. Interac- of persecution and trauma. This means a tions between psychic suffering and physical difficult task for the refugees and a high complaints and impairments require an in- responsibility for the therapists. It requires tegrative method, both in the diagnostic area profound clinical experience with trauma in and in the therapeutic area. The integration order to avoid destabilization or even retrau- of the different views and approaches is matization. On the other hand patients often possible through regular staff meetings and feel relieved after overcoming their avoid- supervision where we evaluate cases, indica- ance behaviour. They note that they start tions, the therapeutic relation, the long term to control their PTSD symptoms and get course of treatment and necessary steps in encouraged to continue the treatment. the social area. A scientific service offers The form of treatment varies depending standardized diagnostics and evaluation. on the individual indication and the wishes We work in close exchange with centers of the patients. It can be merely supportive abroad (in Iraq, Ukraine, Uganda, Ethiopia with medical psychosomatic or psychiatric and Kenya) especially on the topic of cross treatment and stabilizing and social-thera- cultural diagnostics and treatment. Since in peutic elements. In those cases, after an Germany there are not enough treatment initial intensive phase of building trust opportunities specialized in diagnostics and and getting to know the patient and his/her treatment for traumatized refugees with a former and current worlds, the frequency of cross cultural approach, the bzfo also offers sessions may be low, e.g. every two weeks or courses, counseling and supervision for col- once a month, often accompanied by other leagues that work in the public health sector. measures such as physiotherapy or group activities. In most cases though, treatment con- 2.3 Special aspects in the course of treatment sists of an intensive process of psychotherapy Due to the persistently stressful psychosocial with individual sessions and sometimes situation of traumatized refugees, clinical group therapy. As we see a lot of traumatized Volume 17, Number 2, 2007

u r e social work often represents a main focus families we offer family interventions, if nec- t o r

T in the first phase of therapy. Giving social essary. The average time of the phase of in- 93

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tensive therapy with at least weekly sessions work can be fruitful because it facilitates is about two years. vivid input of good memories and cultural Of central importance for the course of richness. The resource orientated treatment, treatment are: including the reconstruction of the biog- raphy and the strengthening of good inner • a trusting and stable relationship between objects,15 often leads to a stabilization and therapist and patient9 reduces the posttraumatic symptomatology • sensitivity and openness for cross cultural so that life can be confronted in a more pos- encounters itive and active way. Ongoing avoidance be- • working with specially trained interpret- haviour and dissociations often go together ers with persisting nightmares and pain. Furthermore, to reduce the trauma The psychotherapeutic work may remain related symptomatology it is important to stabilizing and resource oriented or offer the look for symptom stabilizing psychodynamic opportunity to work more deeply in trauma aspects and cognitions like guilt or shame focusing after a “good enough” stabilization and to work on them. In order to reduce dis- of the patient. The course of psychotherapy sociations and the impact of the traumatic has to be adjusted to the individual psy- experience, trauma focusing and trauma re- chosocial and psychodynamic process. A lated work is offered. Trauma focusing ther- schematic approach has turned out to be of apy, especially after such shameful events as limited practicability.10 However, a “phase sexual torture, normally has to take place in model”, that shows the elements of treat- an individual setting. Due to the necessity ment, is helpful (figure 3). for elaborate expert opinions for the asylum process (see above) in our institution, the Following man made trauma and disrup- first disclosure of the traumatic experiences tion of social connections patients prefer usually takes place in an early stage of treat- individual therapeutic settings because of ment. In most cases this will be during the the mistrust and shame induced by the first translation of the traumatic memories traumatic experiences. However, additional into a narrative. After this important and psychoeducational13 and resource work14 can very relieving step of verbal, or at least sym- be done in a group setting, e.g. with art or bolic communication, of traumatic experi- music therapy or Concentrative Movement ences the further processing of the trauma, in Therapy. Patients will meet others and learn most cases, ensues in a gradual process. For that they are not the only ones who react example, on the basis of the patient’s stress- T this way after abnormal situations. Resource ful dreams or thoughts, a repeated focusing r o t e r u Volume 17, Number 2, 2007 2, Number 17, Volume 1. Orientation 2. Stabilization 3. Focus on past 4. Focus on future 5. Farewell Security Information Reconstruction Perspectives Integration Trust building Control Trauma focused Relationships Employment Diagnostics Resources Transformation Social contact Aftercare – social Support Medication Crisis intervention Goal setting Mourning (possibly group (Individual therapy) therapy)

Figure 3. Elements of a trauma oriented treatment.11,12 94

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on traumatic experiences and the associ- stress, a schematic approach has turned out ated complexes from different perspectives to be of limited practicability in the treat- takes place. If the patient feels up to the ment of traumatized refugees even though task at that particular point in time in her/ trauma oriented modules are useful parts in his particular life situation to confront the the therapeutic work. The therapeutic pro- traumatic experiences, then it can be pos- cess has to be individually adjusted to the sible to dissolve dissociations gradually and living conditions of the victims as well as to assemble scattered fragments to integrate to their personal way of dealing and coping them into the patient’s biographical context. with the trauma. Sometimes, though, it is not possible to Of central importance is a trusting and work more intensively on trauma focusing stable relationship between the therapist and because the patients are too unstable or de- patient and flexibility, sensitivity and open- cide that they want to stay in their avoidance ness to the cross cultural encounter as well behavior – which we have to respect. Trauma as working with specially trained interpret- focusing work can only take place when ers. there is sufficient outer and inner stability. The patient should have made a conscious decision after having being informed of the therapeutic steps. In the later phase of therapy central References points are questions of self-confidence, inter- 1. Gäbel U, Ruf M, Schauer M, Odenwald M, Neu- ner F. Prävalenz der Posttraumatischen Belas- personal relationships and prospects for the tungsstörung (PTSD) und Möglichkeiten der Er- future and integration in the country of ex- mittlung in der Asylverfahrenspraxis. Zeitschrift ile. A group setting can be very enriching in für klinische Psychologie und Psychotherapie this later phase of therapy. The farewell has 2006;35:12-20. 2. Wenk-Ansohn M, Gutteta T. Therapeutische Ar- to be prepared as a gradual process. beit mit Folterüberlebenden: Möglichkeiten und Psychotherapy does not undo the Hindernisse: Soziale Psychiatrie 2005;110:35-40. trauma. Especially in those cases where 3. Sludzki CE. Migration and family conflict. Fam- people are already suffering from chronic ily Process 1979;18:379-90. 4. Keilson H. Sequentielle Traumatisierung bei trauma sequelae, one should not expect a Kindern. Stuttgart: Enke, 1979:58-60. full recovery. However, an important im- 5. Hermann J. Complex PTSD: a syndrome in provement in symptomatology, stabilization, survivors of prolonged and repeated trauma. J development of coping strategies and the Trauma Stress 1992;5:377-91. 6. Maercker A. Besonderheiten bei der Behandlung opening of new scopes of action (e.g. the der posttraumatischen Belastungsstörungen. In: ability to work and to have social contacts) Maercker A, ed. Therapie der posttraumatischen usually is possible. Belastungsstörungen. Berlin: Springer, 2003:37- We offer aftercare for the patients. They 51. 7. Laban C, Gernaat H, Komproe I, Schreuders B, can participate in self help groups that meet De Jong J. Impact of long asylum procedures of regularly or other activities offered by the the prevalence of psychiatric disorders in Iraqi bzfo. In crisis situations patients might come asylum seekers in the Netherlands. Journal of Mental Disease 2004;192:843-51. back for individual sessions. 8. Council Directive 2003/9/EC of 27 January 2003

Volume 17, Number 2, 2007 laying down minimum standards for the recep-

u r e 3. Conclusion tion of asylum seekers. Official Journal of the t

o r European Union, 6.2.2003.

T Due to contextual factors and ongoing 95

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9. Wenk-Ansohn M. Folgen sexualisierter Folter – therapeutische Arbeit mit Kurdischen Patien- tinnen. In: Birck A, Pross C, Lansen J, eds. Das Unsagbare. Berlin: Springer, 2002:57-70. 10. Gurris NF, Wenk-Ansohn M. Folteropfer und Opfer politischer Gewalt. In: Maercker A, ed. Therapie der posttraumatischen Belas- tungsstörungen. Berlin: Springer, 2003:221-46. 11. Meichenbaum D, A clinical handbook – practical therapist manual for assessing and treating adults with post-traumatic stress disorder (PTSD). Wa- terloo, Ont.: Institute Pr., 1994:331-6. 12. Biemans H. The process of employment rehabilitation of torture survivors. Curare 2001;16:245- 51. 13. Knaevelsrud C, Liedl A. Psychoedukative Grup- pen als psychosoziale Intervention für traumatisi- erte Flüchtlingen – ein Überblick. Verhaltensther- apie und psychosoziale Praxis 2007;39:75-85. 14. Reddemann L, Sachsse U. Stabilisierung. PTT – Persönlichkeitsstörungen 1997;3:113-47. 15. Haenel F. Zur Bedeutung der Psychiatrie in der Therapie von Folterüberlebenden oder: braucht eine Behandlungseinrichtung für Folteropfer einen Psychiater? In: Birck A, Pross C, Lansen J, eds. Das Unsagbare. Berlin: Springer, 2002:173- 86. T r o t e r u Volume 17, Number 2, 2007 2, Number 17, Volume