Health Promotions Survivors of Torture & War Trauma

REFUGEE HEALTH PROMOTIONS

Refugee Health Promotions (RHP) is a state-funded, collaborative pilot program between the International Rescue Committee, Catholic Charities Community Services and the Refugee Women‟s Health Clinic (RWHC).

RHP‟s goal is to increase the capacity for regional behavioral health providers to access and treat Arizona‟s . Survivors of Torture and War Trauma

Through this training, providers will…

• Understand the definition of torture, its prevalence, reasons for use and international laws regarding the use of torture.

• Demonstrate the ability to screen and identify survivors of torture and war trauma

• Increased knowledge of the conditions survivors of torture are most at risk for and how to integrate this knowledge into treatment plans

• Ability to access resources and additional trainings to strengthen capacity to access & treat survivors of torture and war THE REFUGEE EXPERIENCE

A refugee is primarily defined as a person who has fled their home country and is unable or unwilling to return, owing to persecution or a well-founded fear of persecution based on… o Race

o Religion

o Nationality

o Membership in a social group

o Political opinion

• The United States does not THE REFUGEE require a person to demonstrate EXPERIENCE their ability to achieve economic self-sufficiency or integration potential as a condition for admission as a refugee.

• This includes the admission of refugees with physical or behavioral health needs, who are often some of the most fragile individuals admitted for resettlement.

THE REFUGEE EXPERIENCE

A refugee may have a chronic health condition due to the following reasons:

o Torture or trauma incurred during conflict

o Lack of and/or limited health care services available; either in country of origin or /urban refugee setting

o A pre-existing condition separate from the individual‟s refugee experience

PHOENIX RESETTLEMENT AGENCIES

Catholic Charities Community Services

International Rescue Committee

Refugee Focus

Arizona Immigrant and Refugee Services

TUCSON RESETTLEMENT AGENCIES

Catholic Charities Community Services

International Rescue Committee

Refugee Focus WHO ARE TORTURE SURVIVORS?

https://www.youtube.com/watch?v=78hW3-bmGJY

THE REFUGEE EXPERIENCE

IMMIGRANTS

REFUGEES

ASYLUM SEEKERS

TORTURE SURVIVORS WHAT IS TRAUMA?

• Direct exposure to actual or threatened death, serious injury, or sexual violation as a victim, witness, or perpetrator.

TRIPLE TRAUMA PARADIGM

Pre-Flight Flight Post-Flight -Torture -Living in hiding -Loss of status

-Harassment/Threats -Loss of home/ -Legal and medical possessions worries -Exposure to War -Exploitation -Language barriers -Human Trafficking -Long waits in refugee -Social isolation -Violence camps - Familial conflict/ -Imprisonment -Uncertain future cultural adjustment

-Death/ Disappearance -Separation from family - Worsened PTSD or depressive symptoms WHAT IS TORTURE? WHAT IS TORTURE?

The Definition of Torture as given by the Torture Victims Relief Act of 1998:

“Torture” means an act committed by a person acting under the color of law specifically intended to inflict severe physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions) upon another person within his custody or physical control (US Code: 2340{1} Title 18). WHY IS TORTURE USED?

Torture is the most effective weapon against democracy

Countries use torture to instill fear in communities

Torture destroys trust and tears apart the fabric of societies. „UNDER THE COLOR OF LAW‟ EXAMPLES

The survivor must • Members of government bodies have experienced • Members of military groups torture at the hands • Police officers of someone in an • official, Militia and insurgent groups authoritative • Guerilla and rebel groups capacity. • Warlords and their agents THE PREVALENCE OF TORTURE

• 141 countries practiced torture from 2009-2013, and in at least 61 countries, torture was widespread

• 5-35% of all refugees are torture survivors.

• Between 150,000 and 1,050,000 torture survivors were resettled in the United States since 1975. COMMON TYPES OF TORTURE

Beating Deprivation Wounding Physical Sensory Stress Psychological Burning Mock Execution Electrocution Threats to Self/ Loved One Forced Stress Positions Hanging/Stretching Use of Drugs to Alter Mental State Asphyxiation Witness Torture of Amputation/Mutation Others Dental Torture Severe Humiliation /Sexual Violence Rape/Sexual Violence WOMEN AND TORTURE

• Femicide: Killing of women and girls with impunity. • Rape/Sexual Torture: DRC = rape capital of world • Forced Prostitution/Trafficking • Forced Abortions/Steralization/FGM • Sexual assault during flight/in camps • Sexual assault in US (asylum-seekers in detention)

Most vulnerable: Women, children, LGBTQI UN DECLARATION ON VIOLENCE AGAINST WOMEN

• Declaration on the Elimination of Violence against Women (1993) • The first collaborative international human rights declaration exclusively addressing the issue. • The UN declaration emphasizes that the global problem of violence against women crosses national boundaries into the realm of basic human rights. • Declaration states that violence against women violates a woman's fundamental human rights and freedoms and that the international community has an obligation to protect and promote those rights. • Definition of violence against women: • Physical, sexual, & psychological violence perpetrated by family members, community, or the state. • Battery, dowry related violence, of children, marital rape, rape, female genital mutilation, sexual harassment, trafficking, forced prostitution, and others. • Isn‟t all-inclusive, and recognizes that various other forms of violence exist around the globe. • Does not provide sufficient guidance regarding controversial issues such as, for example, whether control over a woman's reproductive rights constitutes violence against women. EFFECTS OF TORTURE

PHYSICAL Scarring Chronic Pain Migraines/ Chest Pain Unexplained Ailments

PSYCHOLOGICAL FAMILY/COMMUNITY Memory Loss Loss of Trust Extreme / Social Chaos Communication Avoidance/Survivor Breakdown Guilt Intergenerational Sleep Troubles Conflict Hopelessness Shame

POST-TRAUMATIC STRESS DISORDER (PTSD)

DSM5: A disorder lasting more than 1 month following a trauma, characterized by 4 types of symptoms: • Re-experience of the event • Negative changes in mood or thought • Avoidance of reminders of the event • Hyper arousal of the nervous system TORTURE SURVIVORS WITH PTSD

• Have strong feelings of humiliation • Have difficulty trusting family or friends • Have damaged self-esteem. • Have high amounts of somatic complaints. TORTURE SURVIVORS W/ PTSD MAY EXPERIENCE:

• Insomnia / Nightmares • Excessive Watchfulness • Poor Concentration • Jumpiness • Intrusive Thoughts/Images of Events • Flashbacks • Self-Blame • Physical Panic • Memory loss SOME SURVIVORS WITH PTSD MAY EXHIBIT:

• Dissociative Symptoms that continue after trauma result in: • De-personalization: Feeling detached from oneself • De-realization: Feeling like everything is unreal

• Delayed Expression • Most symptoms don‟t arise until 6+ months after event • Frequently occurs when: • There are prolonged periods before the person is completely safe (Like living in a refugee camp, or living “on the run.”) • There is a new significant life stressor or trauma. TREATMENT CONSIDERATIONS

• Culturally and linguistically appropriate interpretation. • Face-to-face is preferred for sensitive questioning. • Telephone may be preferred by some survivors (anonymity). • Strength Based involving survivor’s family & key individuals. • Focus on family‟s survival and coping strategies that were effective. • Recognize achievements & collaborate with family to solve problems • Normalize current stressors & explore effective coping strategies • Network & Coordinate with community & medical providers. • Involve community and religious leaders when possible. • Use a holistic approach. SPECIAL Shame or Fear May Prevent CONSIDERATIONS Disclosure FOR TORTURE • May think that they are in SURVIVORS danger if they talk

Interviewing May Feel Like Interrogation • Be sensitive during questioning: Go slowly • Explain what you are doing and why

Extreme Distrust of Authority Figures • May be triggered by government offices or people in uniform SPECIAL • Location is Important CONSIDERATIONS FOR TORTURE • Small, enclosed rooms may SURVIVORS feel like cells • Use professional interpretation • Do not use family members • If possible, ensure confidentiality • Due to shame, anonymity may be important to some survivors • (i.e. phone interpretation rather than in-person)

DR. RICHARD MOLLICA’S 11 POINT TOOLKIT

1. ASK About the patient’s “trauma story” 2. Identify Concrete physical and mental effects 3. Diagnose & Treat Grief reactions, generalized anxiety, depression, PTSD, and insomnia 4. Refer Screened cases of serious mental illness 5. Reinforce & Teach Positive coping behaviors 6. Recommend Altruism, work, spiritual activities 7. Reduce High Risk Behaviors 8. Be Culturally Attuned In communicating and prescribing 9. Prescribe Psychotropic drugs if necessary 10. Close & Schedule Follow-up Visits 11. Prevent Burnout By discussing with colleagues. TRAUMA STORY

Four Elements of the Trauma Story 1. Factual Accounting of Events 2. Cultural Meaning of Trauma 3. Enlightened View of the World 4. Listener-Storyteller Relationship

©Richard F. Mollica, MD, MAR Harvard Refugee Trauma Program

• Intro Video • Hopkins Symptom Checklist (HSCL- 25): Harvard Refugee Trauma Program has translated the HSCL-25 and a manual for its use into Bosnian, Cambodian, Croatian, Japanese, Laotian, and Vietnamese. All of these include an English translation. • Harvard Trauma Questionnaire Revised (HTQ-R): inquires about a variety of trauma events, as well as the emotional VALIDATED & symptoms considered to be uniquely associated with trauma. Translated into TRANSLATED Bosnian, Cambodian, Croatian, Japanese, SCREENING Laotian, and Vietnamese • Refugee Health Screener (RHS-15): TOOLS* Pathways to Wellness includes translations of the RHS-15 into Amharic, Arabic, Cuban Spanish, Burmese, Farsi, French, Karen, Kinyarwanda, Mexican Spanish, Nepali, Russian, Somali, Sorani Kurdish, Swahili, & Tigrinya.

*Screening instruments should be administered by health care workers under the supervision and support of a psychiatrist, medical doctor, and/or psychiatric nurse. They were not designed to be used as a self-report; no checklist can replace the role of a mental health professional.

ASSESSING TORTURE AND WAR TRAUMA

• Can you tell me what made you leave your home country? • Have you ever had problems because of your culture/tribe? Your political beliefs? Your gender? • Did you or your family ever receive threats of harm? • Have you ever been arrested or put in jail? • Have you ever been beaten or attacked by soldiers, police, or rebel groups? • Were you or anyone in your family kidnapped? CULTURAL CONSIDERATIONS

Ask about an individual‟s literacy level. Some may not be able to read after-care directions or prescription/dosage requirements, even in their native language.

Some refugees, particularly those who have been in protracted refugee camp situation, may “save” medication or ration dosages, appearing to be non-compliant with treatment.

Many refugees aren‟t familiar with a “medical home,” and accumulate multiple prescriptions from ER, urgent care, family doctor, etc.

The following may be new concepts to refugees and you may need to take NEW CONCEPTS additional time to explain:

o Patient/Client confidentiality o Informed consent o Release of information o Instances where confidentiality is broken o Involuntary vs. voluntary treatment o Ability to ask questions about care/treatment WHAT CAN YOU DO? ADVICE FROM EXPERTS

1. Realize you may be working with people who are survivors of extreme trauma and even torture. 2. Set up realistic expectations and work to build trust. 3. Focus on empathy, safety and empowerment. 4. Meet clients where they are at. 5. Give the Survivor control over the process. 6. Know when to take an appropriate trauma story. 7. Help clients prioritize their needs. 8. “Give the best to the least.” 9. Practice self-care. https://www.youtube.com/watch?v=pTkaFDH79Co

ARIZONA STATE REFUGEE RESETTLEMENT PROGRAM

The Arizona State Refugee Resettlement Program (RRP) is under the responsibility of the State Refugee Coordinator, and provides a variety of longer-term services to refugees in Arizona. https://des.az.gov/services/aging-and-adult/arizona-refugee-resettlement-prog

ADDITIONAL RESOURCES

•Bellevue/NYU Program for Survivors of Torture: http://www.survivorsoftorture.org/

•Gulf Coast Jewish Community & Family Services – Information Guides: https://gulfcoastjewishfamilyandcommunityservices.org/refugee/resources/information-guide/

•Harvard Program in Refugee Trauma: http://hprt-cambridge.org/

•Heal Torture: http://healtorture.org/

•Measuring Trauma, Measuring Torture (w/ HTQ-R & HSCL-25): http://hprt-cambridge.org/screening/measuring-trauma- measuring-torture/

•Pathways to Wellness (w/ RHS-15): http://www.lcsnw.org/pathways/

•Refugee Health Technical Assistance Center: http://refugeehealthta.org/physical-mental-health/mental-health/

•Refugee Women‟s Health Clinic (Phoenix, AZ): http://www.refugeewomensclinic.org/

• The New H5 Model, Trauma and Recovery (Summary): http://www.nasmhpd.org/sites/default/files/THE_NEW_H5_MODEL_TRAUMA_AND_RECOVERY.pdf