Healing the Hurt: a Guide for Developing Services for Torture Survivors

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© SEBASTIÂO SALGADO, MASTERS-OF-PHOTOGRAPHY.COM e HEAe LING h h t ACKNOWLEDGEMENTS t THIS GUIDE WAS PRODUCED by the staff of the National HURT Capacity Building (NCB) Project at the Center for Victims of Torture (CVT). Funding for the manual was provided by the Office of Refugee Resettlement (ORR) under the C H A P T E R Torture Victims Relief Act. NCB staff include Alison Beckman, Jean Choe, Evelyn Lennon, Ann Lundberg,

Andrea Northwood, and Carol White. In addition, M TORTURE REHABILITATION ...... PAGE 5 O C discipline-specific chapters and sections were contributed .

N A worldwide movement A

by David R. Johnson and Kathleen McCullough-Zander, L P clinical staff members at the CVT, and Michele Garnett A K N

McKenzie and Mary C. Ellison, attorneys at Minnesota H O J Advocates for Human Rights. . 1 W

MANY OTHER PEOPLE PROVIDED valuable assistance W W

in reviewing, editing and formatting this publication. © We would like to thank the following people who reviewed chapters of the guide: Maria Blacque-Belair, therapist, Safe Horizon/Solace, New York; Melinda Czaia, administrator, CVT, Minnesota; Dina Dajani, international health officer, Office of Global Health Affairs, Washington, D.C.; Pete Dross, administrator, TORTURE SURVIVOR S ...... PAGE 9 CVT, Minnesota; Iman Elkadi, social worker, Center for

/ Family and community issues

Multicultural Human Services (CMHS), Virginia; G R O

Carlos Gonsalves, psychologist, Institute for the Study . R of Psychosocial Trauma, California; Karen Ferguson, C H N

psychologist, Alaska; Lisa Ide, physician, CVT, Minnesota; U . 2 Douglas Johnson, administrator, CVT, Minnesota; Erin W W

Johnson, nurse, CVT, Minnesota; Shahid Kamal, physician, W

F.I.R.S.T. Project, Nebraska; Sarah Kelley-Pegg, nurse, © Abbott Northwestern and Children’s Hospitals, Minnesota; Sharyn Larson, nurse, CVT, Minnesota; Rebecca Lien, tech staff, CVT, Minnesota; Tabetha Mack, student intern, F.I.R.S.T. Project, Nebraska; Toby Mailman, social worker and psychotherapist, Safe Horizon/Solace, New York; Joanne Meehan, social worker and volunteer, CVT, M WORKING WITH TORTURE Minnesota; Kim McDonald Roth, nurse, Florida; O C .

Annemarie Monkemeier, social worker, CVT, Minnesota; N SURVIVORS ...... PAGE 19 A L

Linda Nielsen, clinical social worker, CVT, Minnesota; P A

Lyn Clark Pegg, psychologist, University of Minnesota K Core competencies N (Duluth), Minnesota; Francisca Peterson, therapist, H O J . 3 F.I.R.S.T. Project, Nebraska; Emir Plicanic, case manager, W

F.I.R.S.T. Project, Nebraska; Rachel Porter, administrator, W W

Doctors of the World, New York; Maria Prendes-Lintel, © psychologist, F.I.R.S.T. Project, Nebraska; Jane Reilly, clinician, Safe Horizon/Solace, New York; Mary Jane Sommerville, program officer, ORR, Washington; Eva Spranger, social worker, CVT, Minnesota; Heather Tracey, social worker, CVT, Minnesota; and Chuck Tracy, clinical social worker, CVT, Minnesota. SOCIAL SERVICES ...... PAGE 39 Rosa Garcia-Peltoneimi, administrator and psychologist, CVT, Minnesota, and Rachel Tschida and Holly Ziemer, communications directors, CVT, Minnesota, reviewed E

the document as a whole. T I H W

THE READERS are not responsible, however, for any L 4 O

errors that may have unintentionally found their way R A into this document. C © THE GUIDE received editing by Laura Littleford, Philip Deering, and Tricia Cornell. It was designed by Ruth Weleczki and was printed and bound by Insty Prints, 8840 Seventh Ave. N., Golden Valley, MN 55427. ON THE COVER: Photo of Aiah Tomboy, 29, in Soewa, Kono, district, Sierra Leone, by John Kaplan, courtesy MEDICAL SERVICE S...... PAG E 49 of www.johnkaplan.com /

OTHER PHOTOS were provided by Melinda Czaia; G R O the International Institute of Minnesota; Revolutionary . R C

Association of the Women of Afghanistan Web site H N

Sebastiâo Salgado, courtesy of U www.rawa.org; . 5 www.masters-of-photography.com; U.N. High W W

Commissioner for Refugees Web site www.unhcr.org/; W and U.N. Relief and Works Agency Web site © www.un.org/unrwa/.Use of the Guingamp labyrinth icon courtesy of www.labyrinthos.net.

M PSYCHOLOGICAL O C

. SERVICES ...... PAGE 61 N A L P A K N H O J . 6 W W W ©

LEGAL SERVICES ...... PAGE 75 / G R O . R C H N U . 7 W W W

PLANNING PROGRAMS FOR TORTURE SURVIVORS ...... PAGE 87 / G R O . C S F A . 8 W W W

/ APPENDIX...... PAGE 103 A W R N U / G R O . N U . W W W ©

HEALING THE HURT: A GUIDE FOR DEVELOPING SERVICES FOR TORTURE SURVIVORS. Copyright © 2005 by the Center for Victims of Torture. With this copyright, reproduction of this book for resale is strictly prohibited. However, we encourage groups to copy and distribute this document or portions of it free of charge, crediting the National Capacity Building Project and the Center for Victims of Torture. This book is also available for download free of charge at www.cvt.org.

ISBN 0-9759789-1-8 F O R E W O R D

y name is Richard Oketch. I am a Eventually, I did not take the medications pre- M teacher by profession and was born scribed. in Uganda. I am a survivor of torture. When I finally ended up at the I was a young man in Uganda Center for Victims of Torture when the brutal regime of Idi Amin cut (CVT), there was a sense of calmness short my youth and disabled my entire family struc- about the environment. The psychiatrist, physician, ture. Tribal and political affiliation landed us on the clinical psychologist, and the rest of the staff all have wrong side of the government. My two brothers, my reverence in approaching the clients. I felt complete- younger sister and her boyfriend, the husbands of my ly safe going there. two sisters, and other relatives disappeared. My uncle After a series of multi-disciplinary treatments, was shot and thrown in a river. My father was badly including physiotherapy and psychotherapy, a heavy beaten and left for dead. He survived but died from load was lifted from my psyche. My nightmares were those injuries several years later. significantly reduced within six weeks and my abili- From the coup of 1971 through 1979, military ty to sleep returned within the first few weeks of harassment of the population in Uganda was constant medication. My healing process proceeded at first and brutal. By the end of the regime in 1979, half a weekly, then bi-weekly, followed by monthly and then million people were dead or missing. occasional visits. Between 1973 and 1977, I was arrested three times I am a father of six children, four boys and two and mostly held at military detention centers. At this girls. Two of them were born in the United States. I time, military detentions were known as death traps met my present wife during the course of my treat- because no one really came back. Soldiers tortured us ments and while on my first adventure out to a social prisoners with whips, canes, sticks, gun butts, fists, gathering in many years. Currently, I am on special assignment from bayonets and large knives. We were forced to ingest Special Education teaching working for the large amounts of vodka. I had to wash away others’ Multicultural Excellence Program, an inner city cur- blood and load wasted bodies on trucks. I endured riculum to prepare and encourage minority students broken ribs, a dislocated shoulder, serious lacera- to attend college in Minnesota. I also serve on the tions, wounds on my back and thigh and, most lasting, board of the Center for Victims of Torture. My chil- mental numbness. dren and I have started a development association to When I escaped from the prison in Uganda, I care for the many widows and orphans in my former received treatment and healed well physically. village in Uganda. I was in Uganda this past summer Psychologically, I felt that there was a scar some- to attend the launching of this project. These events where in my head and the memory could not and would never have been part of my life without the would not leave me alone. treatment and services I received at CVT. When I came to the United States in the early I feel like I came back to life to embrace my fam- 1980s, my nightmares got worse. Regular health care ily and friends and to provide a new world for my was not meeting my needs. The hospital setting older children with whom I was reconnected in 1999. brought back bad memories, and it was difficult to The bonds of suffering have been broken, and trust tell people what had really gone wrong with me. The and love have been restored. doctors never asked questions about the source of my nightmares but gave me medication anyway. My symptoms were not clear cut and the medical staff suspected me of having a drug-related mental illness. P R E F A C E

“I didn’t know what to do. My pain was almost unbearable. I was afraid to ask for help because I thought M no one knew what I had O C . Y H P

suffered. Then I heard A R G O about The Center and T O H P - found hope.” F O - S R E LIENT AT THE ENTER FOR T

— C C S

VICTIMS OF TORTURE, MINNESOTA A M

, O D A G L A S

O A I T S A B E S

growing number of treatment centers provide rehabili- THE PURPOSE OF THE GUIDE A tative and supportive services for many of the This multidisciplinary guide was designed to encourage more than 500,000 survivors of political torture in the individuals and organizations who want to help torture United States. By offering specialized assessment and care, survivors. It was produced by staff at the Center for Victims these programs help survivors to heal and to rebuild of Torture who provide training and consultation to pro- lives of self-reliance and hope for themselves and their grams for torture victims in the United States under a spe- families. cial grant from the Office of Refugee Resettlement — the The existing torture rehabilitation programs and adjunct National Capacity Building Project. services cannot meet the needs of all torture survivors living It does not specifically reflect the clinical program at in the United States. Services may not be geographically the Center for Victims of Torture. Instead, the expertise accessible to all survivors. gained from direct work with clients at the Center has Not all torture survivors require a full-service been generalized through many years of providing train- torture treatment program. Sometimes survivors are looking ing to a wide variety of audiences. for specific services, e.g., counseling, medical services, legal The information offered is not exhaustive, nor is it a sub- assistance, help with family reunification, or in finding stitute for training. This is a “getting started” and “where to housing and/or employment. go for more information” type of guide. We present options Sometimes they may simply want help and are unsure for providers along a continuum of services, from imple- what they need or the services possible to enable their recov- menting a helpful service component to developing a full- ery process to begin. In either case, torture survivors can service torture rehabilitation program. benefit from referrals to the appropriate agency or The guide is also useful to mainstream health and social individuals that can help. service providers who want to serve the special needs of

2 this population among their current clientele. would provide services to survivors. You may read the entire guide, or you may choose to read CONTENTS OF THE GUIDE only the chapter that relates to your discipline or the disci- To best prepare personnel to work with survivors, pline that is most pertinent to the work that you do (Chapters this guide presents both general and discipline-specific 4-7). If you plan to read one of these chapters, begin with information in the following chapters: Chapter 3. Note that there are cross-references in each chap- CHAPTER 1: The torture rehabilitation movement ter to other places in the text that offer information that may CHAPTER 2: The effects of torture on families also be of interest to you. and communities As you read, you will want to learn more about serving Core competencies in working CHAPTER 3: torture survivors. Access the in-depth literature of your with survivors profession and connect with others doing this work. A list CHAPTERS 4-7: Interventions and treatments of U.S. torture treatment programs is included in this hand- in social work, medical, psychological, and legal services book. Reach out to members of these organizations for CHAPTER 8: Existing models of treatment and resources and as teachers and mentors. suggestions on how to build communities Building a network of services, either community-wide of support for torture survivors or within an agency or several agencies, will be the next step SUPPLEMENTAL RESOURCES: Listing of Web in your journey. Volunteer or partner with appropriate indi- resources and referral agencies to connect viduals or agencies; this can strengthen your response to readers with a national network of experts your clients and connect you with other services. Pull HOW TO USE THIS GUIDE together those interested with a consortium-building or an This guide was written and reviewed by professionals educational event. who work with torture treatment centers in the United Join activists for human rights on the local, national, States: therapists, social workers, attorneys, nurses, physi- and international policy level. Strong efforts are needed to cians, and administrators. The information given is relevant sustain and to improve the provision of resources to aid in for practitioners in these fields and also for human services the rehabilitation of survivors. Of equal importance are the workers, leaders of communities affected by torture, volun- steps taken at all levels to uphold human rights and to teers, interpreters, and others. It is meant for use by anyone prevent torture worldwide. who works with clients who have experienced political tor- We hope this guide is helpful to you as you join the reha- ture. This book is a primer, a starting point for those who bilitation movement on behalf of survivors of torture. I

he symbol of the labyrinth T cycles, that of life and of death E N .

has been used throughout S and of rebirth.

T O D H R T A

history in many diverse cultures N In this guide, the labyrinth I W R A Y S

B and has had many meanings. symbol marks personal stories F A F L E . J

W Most often, it consists of a of clients as they struggle to © W W

THE LABYRINTH SYMBOL path leading in a patterned © rebuild their lives as survivors at left and its inspiration way from the entrance to the of torture. Their names and cer- above, the pavement center and back out again. It symbolizes the tain identifying characteristics have labyrinth in the porch of Guingamp’s church journey through the daily and seasonal been changed for this publication. in Brittany, France.

Permission for use of the graphic labyrinth by www.labyrinthos.net. Photo by Jeff Saward.

H H H H E E E E REHABILITATION REHABILITATION A A A A WORLDWIDE A A H H H H C C C C WORLDWIDE L L L the L MOVEMENT MOVEMENT H H H H U U U U A A A A I I I I TORTURE TORTURE P P P P N N N N T T R R T T R R E E E E R R R R G G G G T T T T : : 1 1 1 1

©WWW.JOHNKAPLAN.COM 1 R E T

P CHAPTER 1 A H

C HEALING THE HURT TORTURE REHABILITATION: A WORLDWIDE MOVEMENT M

They told me, ‘You’ll be alone O

IN THIS CHAPTER C . N A

with this for the rest of your life. You’ll L P A

I THE NATURE K

die with this alone.’But when N of Torture H O J I heard about... the Center, I knew . I THE TORTURE W W

Rehabilitation Movement the torturers had lied. W © I A TOOL FOR — CLIENT AT CENTER FOR VICTIMS OF TORTURE, MINNESOTA "I WAS FORCED TO watch as three men lifted Human Rights a heavy rock and crushed my mother's head,” Aiah Tomboy, 29, of Soewa, Kono district, he practice of torture is so extensive that Sierra Leone. “I could not bear to watch and burst into tears. Because I cried, a guy came it could be called an epidemic (Gangsei, and cut me in six places with a machete." T2003). Government agents or others with official sanction practice torture in more than . . . any act by which severe pain or 104 countries (Amnesty International, 2005). suffering, whether physical or mental, In response to the needs of torture sur- is intentionally inflicted on a person vivors, a growing number of treatment centers for such purposes as obtaining from offer resources and restorative services to sur- him or a third person information vivors of torture. These facilities gain number or a confession, punishing him for an and strength annually. From the first program act he or a third person has committed or is suspected of having committed, established in Denmark in 1982, nearly 250 or intimidating or coercing him or programs and centers serve survivors and their a third person for any reason based families in 75 countries today. on discrimination of any kind, when 1 Medical, psychological, social, legal, and such pain or suffering is inflicted other services assist survivors in overcoming by or at the instigation of or with the the long-term consequences of torture as they consent or acquiescence of a public regain and rebuild their lives. Specialized treat- official or other person acting in an official capacity. ment centers, with other non-center-based services, constitute a worldwide rehabilitation Although the Convention is widely accept- movement on behalf of torture survivors. ed as the foremost legal and political definition of torture, interpretations vary. Psychological, THE NATURE OF TORTURE medical, and sociological representations TORTURE DEFINED reflect professional cultures, as well as other The United Nations Convention Against root factors and belief systems. For example, Torture is a carefully negotiated definition the World Medical Association in 1975 distin- approved by the United Nations system and guished torture more broadly: ratified by 100 nations in 1989. According to …torture is defined as the deliberate, the Convention, torture is: systematic or wanton infliction of

6 1 R E

A TOOL FOR T P physical or mental suffering by one HUMAN RIGHTS

THE PREVALENCE OF TORTURE A “Our role is an or more persons acting alone or on the It is difficult to establish a precise number H

orders of any authority, to force another extremely strategic C of torture victims worldwide. Experts project that person to yield information, to make a one for the human between 5% and 35% (Baker, 1992) of the confession, or for any other reason. This rights community, world’s refugees (11.5 million in 2004, according characterization may include 1) torture because our purpose to U.S. Committee on Refugees and Immigrants) perpetrated by rebels and terrorists acting is to regain the outside of an official capacity; are torture survivors. In Minnesota, a recent com- human leadership 2) violence during war that is random; munity-based study of Oromo and Somali refugees that was stolen, to and 3) punishment allowed by govern- found an overall prevalence rate of 44% exposed to put it back to work. ments that uses techniques that are similar torture. Torture exposure varied by ethnicity and But secondly, through to the techniques of torturers. gender among these East African populations, rang- the treatment centers, Rehabilitation specialists commonly define ing from 24% of Somali men to 69% for Oromo the human rights torture as the calculated, systematic infliction of men studied (Jaranson, et. al, 2004). The number of community regains suffering by at least one person upon another. A torture survivors in the United States is estimated at hope." key component is the complete physical control 400,000 to 500,000. — DOUGLAS JOHNSON, DIRECTOR, THE CENTER of the victim by the perpetrator (Nightingale, FOR VICTIMS OF TORTURE, MINNESOTA 1990). Once seen as a product of foreign totali- THE TORTURE tarianism and repressive regimes, torture is a REHABILITATION MOVEMENT weapon of terror used also in war, prison, and In the 1970s and 1980s, a number of individu- chaotic political situations. als and facilities treated survivors of torture in Physical and psychological means of torture repressive regimes in the southern hemisphere and may include: in other conflict-torn regions of the world

• Beatings and mutilations (Jaranson and Popkin, 1998). Cambodia, Laos and Vietnam in Southeast Asia; post-colonial Africa; • Asphyxiation and submersion countries with military regimes in Central and • Mock executions and threats South America; and Greece, Turkey, and Northern • Electric shock Ireland in Europe represent some of the troubled • Over- or under-sensory stimulation regions of that era. Treatment services operated • Rape under difficult conditions, with arrest and harm Humiliation and threats • possible for both practitioners and clients. • Witnessing the torture or In the 1970s, torture treatment work received a murder of others boost from Amnesty International (AI), which • Denial of food, medical care formally established a network of over 4,000 and sanitary surroundings physicians in 34 countries (Amnesty Inter- Torture constitutes a major life event, a trau- national, 2000). The purpose of this work was to matic experience not expected to occur to any- examine and treat survivors of torture. Services one in a lifetime (Nightingale, 1990). Torture eventually expanded to address the medical needs destroys individuals and sends them back to their of survivors as well as the other complex needs of communities as examples to others. As a tool of clients: social, psychological and legal. repression, torture is the most effective weapon In 1979, the Danish AI medical group examined against democracy. torture victims at Copenhagen University Hospital in

7 1 R E T P Denmark. Three years later, they founded the potentially powerful tool for human rights in REFERENCES A

H Rehabilitation and Research Centre for Victims countries with active or recent repression. In Amnesty International. (2005,

C of Torture (RCT) in Copenhagen as an inde- countries of refuge, rehabilitation centers May 25) Amnesty International statistics covering January to pendent institution. The Canadian Centre for develop new constituencies against torture December 2004. Retrieved and in support of human rights. July 1, 2005, from http://www. Victims of Torture opened in Toronto in 1983, amnestyusa.org The U.S. Congress’ 1998 passage of the followed by the Center for Victims of Torture in Baker R. (1992). Psychosocial Minneapolis, Minnesota, in 1985. Torture Victims Relief Act (TVRA) was sig- consequences for tortured nificant progress in the torture rehabilitation refugees seeking asylum and The establishment of these centers and refugee others represents a global movement. The movement. It authorized funding for domestic status in Europe. In Basoglu M. (Ed.), Torture and its conse- number of treatment centers and resources and international programs that provide med- quences: Current treatment ical, psychological, legal, and social services approaches (Chapter 5). has expanded dramatically in the past two New York: Cambridge University decades, and networks have formed for the to victims of torture. In addition, the TVRA Press. purposes of support, knowledge-sharing, designated funds to promote research and to Gangsei, D. (2003). Torture provide training for health care providers out- treatment programs provide research-gathering, and political impact. holistic care, seek pain profes- In 2003, the International Rehabilitation side of treatment centers. In 2003, Congress sionals’ participation. American Pain Society Bulletin. 13(2). Council for Torture Victims (IRCT), an inde- reauthorized the TVRA through 2006. International Rehabilitation pendent network of programs and centers, Council for Torture Victims CONCLUSION (IRCT). (2003). Directory published a directory of 177 rehabilitation The movement to provide specialized retrieved Jan. 29, 2005, from centers and programs in 75 countries. http://www.irct.org/sr/irct/ treatment to survivors of torture is relatively home.nsf/unid/. The National Consortium of Torture new. It is growing in strength as profession- Jaranson, J., Butcher, J., Halcon, Treatment Programs (NCTTP) is the network L., Johnson, D.R., Robertson, C., als become aware of the nature of torture and of torture treatment providers located in the Savik, K., et al. (2004). Somali respond with appropriate services. and Oromo refugees: Correlates United States. The member programs gath- of torture and trauma history, There remain places in the world, includ- American Journal of Public ered for the first time as a group in 1998 and Health, 94 (4). ing parts of the United States, where substan- the NCTTP incorporated in 2001. Of the 35 Jaranson, J. M. & Popkin, M.K., programs represented by NCTTP, 24 were 5 tial numbers of torture survivors live, but Eds. (1998). Caring for victims where no rehabilitative programs exist. of torture. Washington, D.C.: years old or less in 2004. American Psychiatric Press. The established network of providers Nightingale, E.O. (1990). A TOOL FOR HUMAN RIGHTS offers a rich vein of experience and expertise The problem of torture and the response of the health Many survivors of torture were national and for sharing with individuals and organiza- professional. In J. Gurshow & K. Hannibal (Eds.), Health community leaders in their own countries, tar- tions wishing to offer professional services to services for the treatment of geted for their leadership. Others were tortured survivors in these areas. torture and trauma survivor (pp. 8-9). Washington, D.C.: as part of political strategies of social control. Education, resources, and consultations American Association or the Advancement of Science. Torture rehabilitation helps restore offered by the established treatment centers to survivors to their full capacities and roles. At U.S. Committee for Refugees mainstream medicine, mental health, social, and and Immigrants (2005). World the same time, the rehabilitation movement refugee survey 2005 — legal services providers will help to build new Inventory of refugee rights. helps communities understand and cope with networks of support for torture survivors. I Retrieved July 1, 2005, from the intentional legacy of fear. Healing commu- http://www.refugees.org nities is a prerequisite to developing open, FOR MORE INFORMATION World Medical Association, Declaration of Tokyo. Adopted For more information on democratic cultures. in Tokyo, Japan, October 1975. TVRA, see CHAPTER 8. The rehabilitation movement represents a

S S S S U U U U T T T T R R R R O O O O V V V V R R R R I I I I C C C C V V V V T T T T H H H H COMMUNITY FAMILY COMMUNITY AIYAND FAMILY A A A A O O O O U U U U P P P P T T T T R R R R R R R R ISSUES E E ISSUES E E R R R R AND E E E E S S S S 2 2 2 2

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H TORTURE SURVIVORS

C FAMILY AND COMMUNITY ISSUES

orture affects not only individuals but also IN THIS CHAPTER the families and communities in which / G

I IMMIGRATION R O

they live. Indeed, a primary goal of torture is . Statuses for Survivors T R C H N

I CONTRIBUTIONS to terrorize entire communities into silence U .

of Survivors W W

and submission by making examples of W

I MANY PATHS © to Healing individuals and their families. The message sent I EFFECTS OF TORTURE to communities is: “If you dare to challenge us on Communities religion, nationality, membership in and Families in any way, this could happen to you, too.” a particular group, or political opinion, Survivors, who are valued members of is outside the country of his nationality, communities and extensive family systems in and is unable to or, owing to such fear, their home countries, face many obstacles as is unwilling to avail himself of the they work to rebuild these structures and protection of that country (1951, p.16). substitutes in the United States. The difference between refugees and asy-

IMMIGRATION lum seekers relates to when and where their STATUSES FOR SURVIVORS applications to resettle in the United States take place. Refugees apply for processing in Many people have little understanding other countries before reaching the United of why torture survivors around the world States; asylum seekers apply for processing in come to the United States. Most survivors left the United States after they have entered the home in order to save their lives or those of country or are at the border. loved ones. They left their countries due to 2 If asylum seekers are granted political asy- unsafe conditions and are unwilling or unable lum, they become asylees. to return. Torture survivors might arrive under forms Torture survivors arrive in the United States of immigration status that were necessary to with various immigration statuses. Some are get out of the country (e.g., visitor’s visa) and political asylees or asylum seekers; others then apply for political asylum once they are come to the United States as refugees, visitors, safely on U.S. soil. students, or employees. According to the Statistics on the actual numbers of torture United Nations High Commissioner for survivors are difficult to obtain, while figures Refugees, an asylum seeker or refugee is are readily available on refugees and immi- someone who: grants. In the next two sections, the text uses ... owing to a well-founded fear of statistics from studies or reports on immi- being persecuted for reasons of race, grants and refugees. 10 2

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economy and take away jobs desired by T T P CONTRIBUTIONS OF SURVIVORS E N . S O American workers. Yet evidence overwhelm- A H T N

CONTRIBUTIONS TO I H R

ingly indicates the opposite. Y THE COMMUNITY B A L C .

In the most comprehensive study ever con- W Torture survivors strongly value the W ducted on immigration, the National Research W concepts of community and mutual assistance, Council of the National Academy of Sciences CONTRIBUTIONS as many come from cultures that value service to TO THE COMMUNITY found that immigration has a positive one’s people over individual or material gain. Berhonu, a torture economic impact at the national level, with That degree of commitment to community serv- survivor from Ethiopia, immigrants adding $1 billion to $10 billion was shocked to see ice explains why they are targets for torture and directly to the national economy each year hundreds of cars persecution by repressive governments. (Commission on Behavioral and Social passing someone whose Before the political upheavals that forced Sciences and Education, 1997). car had broken down them into exile, many survivors’ families lived on a U.S. highway. The typical refugee or immigrant and his or in the same village or city for generations, It was unthinkable to her descendants pay an estimated $80,000 even centuries. In these environments, people him that he could drive more in taxes than they will receive in local, depended on each other for support, fostering by without stopping to state and federal benefits over their lifetimes strong social bonds and collective identity. help, even though he (Moore, 1998). had just arrived in In their new country, torture survivors Most, including torture survivors, arrive in the country and had strive to rebuild relationships and a sense of the United States in the prime of their working fears of encountering community. Many are eager to know their strangers because he years, making them a fiscal bargain neighbors and contribute to neighborhood had heard that many for our country, saving $1.43 trillion in celebrations, events, and activities. Americans have guns. educational costs (National Immigration In addition to cultural enrichment, newcom- He stopped and drove Forum, 2000). ers to the United States bring fresh ideas, the man to a nearby Torture survivors are, by definition, gas station. energy, excitement about the American dream, resilient people who possess great strength of and motivation — often to blighted and character. Many are highly educated and were depressed metropolitan areas. Immigrants and professionals in their home countries. Others refugees revitalize neighborhoods, providing were small business owners, farmers, and demands for goods and services as well traders. As a group, they bring strengths to the as contributing to the economic base by build- workforce in the United States, which include ing businesses and purchasing homes. They the following: “largely employ neighborhood residents, serve as leaders in their communities, and offer loca- • Work training and experience tions where groups and associations can meet,” • Adaptability and resourcefulness (Greater Twin Cities United Way, 2002). • Strong survival skills • Strong desire to work CONTRIBUTIONS TO THE ECONOMY AND WORKFORCE • Problem-solving expertise There is a widespread perception that • Community-building skills refugees and immigrants are a drain on the • International perspective

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T Regardless of their level of education and Torture survivors are among the most highly P E N . S O A previous job or leadership status back home, determined, skilled, and resourceful newcom- H T N I H R

Y language barriers and other obstacles often ers received. B A L C .

W restrict newcomers. As a result, they enter the W W workforce in the United States by taking low- MANY PATHS TO HEALING CONTRIBUTIONS TO THE paying, low-skill jobs not wanted by others. As ECONOMY, WORKPLACE For many torture survivors, obtaining offi- such, they fill a critical niche in the labor mar- William, a journalist and cial permission to work and to resettle them- student from a West ket, particularly in service-industry jobs not selves and their families safely in a new coun- African country, spent sought by other workers. According to Andrew try aids them in recovery from the effects of three years working Sum, the director of the Center for Labor torture. Not all torture survivors need rehabili- two full-time jobs as a Market Studies at Northeastern University: tative services that specifically address the parking lot attendant The American economy absolutely effects of the torture. and security guard. needs immigrants. Our economy However, most will need some form of ini- While seeking political has become more dependent on tial assistance in one or more service domains: asylum, he supported immigrant labor than at any time legal, social, medical, nursing, and mental his wife and two chil- in the last 100 years. (Cohn, 2002) dren, who remained health. Others will need longer-term services. in hiding back home As those in the current workforce begin Beyond the issue of demonstrable needs is due to the risk of to retire at a rate higher than the rate of citizens the issue of human rights in the aftermath of persecution. Once he joining the workforce, this dependency is “hell on earth,” as many survivors describe obtained asylum, he likely to increase. their experiences. The position of the torture- was able to bring Refugees and immigrants, and the torture rehabilitation movement is that society has a his family to safety. survivors among them, are thus essential to the He then returned to moral obligation to work toward the prevention school to finish his economy and society of the United States. The of torture and to provide as complete university education. civic and economic benefits of community rehabilitation as possible for its survivors. He went on to obtain revitalization, increased revenue and job cre- To understand what this means, it is neces- a master’s degree in ation from refugee/immigrant businesses, sary to understand the effects of torture. The public administration increased demand for goods and services, and remainder of this chapter introduces the effects and became the a resilient and newly energized workforce are of torture on targeted communities and families. executive director of profound. a nonprofit organization that helps African Throughout the history of the United States, EFFECTS ON COMMUNITIES immigrants start and still today, American society has profited AND FAMILIES small businesses. greatly from the ideas, inventions, labor, indus- EFFECTS ON COMMUNITIES try, and social and cultural enrichment brought Torture is one of many weapons of repres- by those in search of safety and freedom. sion in political arsenals designed to monopo- FOR MORE INFORMATION lize power and to reign through terror. The

For information on the effects media often portrays the use of torture to of trauma on individuals, extract information or the “truth” from individ- see CHAPTER 3. uals. Yet the primary purpose of most torture

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practiced systematically against a citizenry is institutions. Chronic fear becomes a way of T P E N . S O to gain or maintain power and control by life and paralyzes the community as a whole. A H T N I H R

silencing any opposition. Torture gives rise to discord and conflict Y B A L C .

Furthermore, information obtained under within families, ethnic groups, and community W W torture is notoriously unreliable. The United support structures. Lifelong neighbors, friends, W States Army Field Manual on Intelligence and sometimes relatives, lose their trust in one EFFECTS ON THE COMMUNITY Interrogation states: another as group is set against group. Former “All their lives my friends and confidants become bitter rivals and Use of torture and other illegal parents, along with a methods is a poor technique that enemies. In a very short amount of time, entire nation of Dominicans, yields unreliable results, may damage communities become polarized and fragmented. had learned the habits of subsequent collection efforts, and Fear, distrust, loss, and traumatic experi- repression, censorship, can induce the source to say what he ences force a constriction of families’ social terror. ... And so, long thinks the interrogator wants to hear. after we had left, my (1992, pp. 1-8) networks, resulting in social isolation and parents were still living community-wide censorship. Ricardo, a Many survivors report that they made up in the dictatorship inside Uruguayan citizen living in a community information under torture — anything to make their heads. Even on where government-sponsored torture was ram- the pain stop. American soil, they pant, poignantly describes these effects in the were afraid of the awful Others report that when they did talk, they following quote: consequences if they were told the authorities already knew every- spoke out or disagreed “…our own lives became thing they had to say but wanted them to suffer with authorities. The First increasingly constricted. The process the defeat of betraying their friends and fami- Amendment right to free of self-censorship was incredibly lies. The terror, shame, and sense of betrayal speech meant nothing insidious: It wasn’t just that you generated by torture create a culture, climate, stopped talking about certain things to them. Silence about or community ethos of pervasive fear, distrust, with other people; you stopped anything “political” was the rule in our house... . and silence. thinking them yourself. Your internal dialogue just dried up. To our many questions Basic trust in others is essential to hold And meanwhile your circle of about what was going together the social fabric of any human relationships narrowed.... One on, my mother always society. Torture is in continual use worldwide was simply too scared. You kept had the ready answer, because it is so destructive in this regard. to yourself, you stayed home, “En boca cerrada no Members of targeted communities know entran moscas.” No flies someone or have heard of someone who was fly into a closed mouth. punished, tortured, or disappeared for speaking Later, I found out that this very saying had out against those in power. been scratched on the Reports among torture survivors include lintel of the entrance of experiences of betrayal (being turned in to the SIM’s torture center authorities) by friends, colleagues, or even rel-

G at La Cuarenta.” R O . atives. Feelings of distrust permeate various A — JULIA ALVAREZ W A R

. SOMETHING TO DECLARE, levels of a repressed society, which pave the W

W 1998, PP. 107-109 W

way for widespread distrust of all people and ©

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T you kept your work contacts to a ence, and the widespread lack of hope ture survivors must consider that in most P minimum. The suspicion of A that things can ever change for the better. affected communities, tensions and con- everyone else, the sense that they H When communities affected by flicts among groups will arise. These

C were monitoring everything — or else just that reflex of torture resettle to a new country, they conflicts relate to the historical, social, self-protection, how it was usually have not had an opportunity to and political conditions in their coun- better not to extend one’s repair or even address the effects of frac- tries of origin. affections to people who tured social networks and ties. Social Some people may be from the perse- might at any moment be isolation and a collective desire to forget cuted group in their home country, while picked up and taken away: all of that served further to the past often become the norm in reset- others may be from the group that per- famish the social fabric.” tled communities. petrated the torture. Torture survivors (Wechsler, 1990, pp. 88-89) The practical need to focus consider- often live with the fear of encountering their torturers or unknowingly befriend- For communities under prolonged able effort and attention on learning a ing current informants in their new political repression and torture, feelings new way of life reinforces these norms. communities. This fear may be realistic; of community hopelessness and resigna- That new life includes the American cul- it is common for the “eyes and ears” of tion can develop as an adaptive response tural norm of working longer hours and a terror-based regime to extend into to the daily reality of having little or no spending less time in social or family communities of exile. control over one’s life. It is adaptive to relationships, in contrast to the more To summarize, some of the common “look the other way” when faced with communal orientation of many sur- effects of torture trauma on resettled overwhelming despair and unspeakable, vivors’ original cultures. communities include the following: incomprehensible atrocities day after The larger society in the United States day, year after year. is often unaware of meaningful intra- • Collective silence and/or Elizabeth Lira is a pioneer in the group differences among newcomers denial about what really happened torture-rehabilitation movement who from the same country, such as educa- • Chronic fear and distrust worked as a psychologist under condition, social class, tribe, clan, religion, • Constriction of social networks tions of state-sponsored terror in ethnicity, political affiliation, gender, and and social isolation Argentina. She has written extensively age, as well as rural vs. urban dwellers. • Apathy and hopelessness Longtime residents tend to expect group about the community effects of a chron- following prolonged political ic situation in which “people had to get unity or identity based on a single factor, oppression accustomed to torture, exile, disappear- such as national origin or language. • Conflict, politicization of ance, rape, execution, the naked corpses They often make mistaken assump- community issues, and polarization among various of one’s neighbors lying in the street, tions about intra-group cohesion, elements or subgroups i.e., to atrocities that nobody would have including, for example, that within a within communities imagined” (Lira, 1997). given national group, there will be little People need to find ways to continue conflict and much commonality. Issues EFFECTS ON FAMILIES functioning in environments of extreme of conflict and strife, continued discrim- Torture survivors rarely flee as intact and chronic fear. They can resist com- ination, and marginalization can occur families. Many survivors are forced to munity effects of torture such as collec- within these communities. leave family members behind due to the tive denial, apparent apathy or indiffer- In fact, providers working with tor- dangerous and often unplanned circum-

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COMMON EFFECTS T stances surrounding their departure. and obtain means of travel. Cultural

OF TORTURE ON FAMILIES P

Due to ongoing danger to family differences in definitions of family A LOSS OF CULTURAL and social members in the country of origin, asy- and documentation practices create supports due to fear, distrust, H lum seekers go through a grueling peri- additional barriers. For example, cer- sense of betrayal, etc. C od of lengthy separation from their tificates of adoption are unheard of in SOCIAL WITHDRAWAL or isolation families in which communication and many countries. Often reunification is MARITAL AND/OR intergenerational conflict support are hampered. Survivors fear a piecemeal process that causes PARENTAL FUNCTIONING IS their mail is opened or phone calls are considerable emotional distress and affected by parents’ symptoms (e.g., parents are often less traced, leading to increased danger of bureaucratic headaches for survivors. emotionally attuned and attentive family members being harassed or Once a family is reunited, there is a to children than they otherwise would be, due to being even tortured into revealing their loved honeymoon period. Family members exhausted and distracted by symptoms of depression and one’s whereabouts. are overjoyed with the sheer miracle of post-traumatic stress disorder)

Sometimes authorities come to reunification and their survival as LOW TOLERANCE for negative family members’ homes or workplaces a family against incredible odds. emotions (e.g., a parent can’t stand to hear a baby cry and threaten them with death or impris- Families that shared traumatic expe- because it reminds the survivor of memories of other prisoners’ onment if they do not produce the per- riences and relied on one another for screams) son who has fled. survival show particularly close bonds SILENCE WITHIN the family Asylum seekers generally must wait and continue to do everything together. regarding the torture and other trauma (i.e., what happened a minimum of one year, and often As the family’s resettlement to whom and why), sometimes leading to confusion, much longer, before their family mem- proceeds, the effects of torture trauma misunderstanding, multiple versions of what happened, bers are legally able to join them. begins to surface in a complex manner. and unaddressed blame, Family members living in danger or Such effects interact with the shame, anger, disappointment, and sadness hardship abroad have limited under- stresses of cultural adjustment, loss PARENT-CHILD ROLE REVERSAL standing of the legal system in the of economic and/or social status, (parents experience disempowerment due United States and the barriers torture events back home (e.g., war, destruc- to both trauma-related survivors face in bringing family tion of property, deaths and torture of symptoms and loss of their traditional role in the new to safety. friends or extended family), and other culture; children prematurely assume adult roles due Since the United States is seen as a ongoing trauma the family may be to more rapid language acquisition and acculturation) world leader in democracy, human experiencing in their new community PRESSURE ON CHILDREN to rights, and economic opportunity, (such as racism, neighborhood be immune to effects of many family members find it difficult violence, etc.). the family’s ordeals and to succeed (often to make to believe or understand the delays in Cultural differences may create up for what the family lost) joining their loved one, which is a conflict and upheaval for families source of anger, resentment, and blame coming from different cultural con- within families. texts. For example, compared to more Reunification takes many forms, traditional societies, culture in the depending on factors such as the United States places relatively greater family’s ability to locate one another emphasis on individualism, competi-

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T tion, mobility and fast pace, materialism, on television. P

A youth culture, technological innovation and This response can take many forms in a par-

H change, and the nuclear family as the basic ent, ranging from withdrawal to one’s bedroom C family unit. Resolving conflicts between tradi- for prolonged periods to acute trauma reac- tional and newer values is difficult without tions, such as flashbacks. These reactions can trauma. When one or more family members is be confusing and frightening to children. coping with effects of torture, these issues Torture survivors are afraid of family mem- become even more daunting. bers dismissing them as “crazy.” Family members are alarmed and saddened to discover that IMPACT ON CHILDREN AND YOUTH the survivor is no longer who she or he was The issues faced by families of torture sur- before the torture. vivors, especially the youth, are often over- Living in families and communities affected looked. Along with their parents, young people by torture conveys profound messages to youth. endure many of the stresses inherent in the The lessons of torture, as identified by youth, pre-flight, flight, and post-flight stages are embedded in the following messages: (see Chapter 3 for more on the Triple Trauma Paradigm) for refugees and asylees. “The world is not a safe place.” Children and adolescents may be torture “You should not trust anyone.” survivors themselves. In other cases, they are “Death can happen at any time.” affected indirectly by the torture of another “Nobody will believe you.” family member or members, such as parents, “Stay away from all politics.” siblings, grandparents, and cousins. “Parents and adults can’t protect you.” As parents, many torture survivors fear that “Your problems are not as serious the intensity of their own feelings could over- or difficult as mine were.” whelm them. Coping with the expressed or unexpressed feelings of their children is even These messages affect how young people more frightening. Parents feel guilty about the behave in school and in the broader circumstances their children endured and community. Without corrective experiences or continue to endure. appropriate intervention, they experience For parents of children who were tortured or social isolation, adjustment difficulties, and traumatized, guilt over their inability to keep marginalization. their children safe and feelings of helplessness For various reasons, children of torture affect their parenting. Parents may under- survivors may not have access to religious, report or overlook both past trauma and current community, or school supports. This is unfor- problems suffered by their children. tunate, given that social support and under- As another example, children are affected standing from others is very helpful. when they witness how a parent or caregiver Sometimes, young people in highly trauma- acts when confronted with memories of the tized and isolated families view attempts past or traumatic reminders, such as violence to reach out to others as a betrayal of their

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ing in ways that seem strange or inappro- REFERENCES T P

priate, it is crucial for professionals to A Alvarez, J. (1998). Something

investigate the history and meaning of that to declare. Chapel Hill: H behavior in previous environments he or Algonquin Books of Chapel Hill. C Cohn, D. (2002, Dec. 2). M she managed to survive. O

C Immigrants account for half of . N A

L Again, it is important to know that not new workers. Washington Post, P A

K p. A01. H

O all torture survivors, primary or secondary, J .

W Commission on Behavioral and W will need specialized services to address W

Social Sciences and Education. © the effects of their torture. As with any (1997). The new Americans: SAHR, 18, LEFT: “If I refused, they would Economic, demographic, and kill me . . . I was instructed how to cock trauma, how a person deals with torture is fiscal effects of immigration. the gun and fire. It was an AK47. I cannot contingent upon individual, family, Washington, D.C.: The National remember exactly how many times I fired. Academies Press. ... It was the young boys who destroyed cultural, and environmental factors. Sierra Leone.” Lira, E. (1997, February). Human rights violations: Torture and SAHR, 19: “I was encouraged to join the CONCLUSION rebels. I saw a rebel kill a man, a young terror. Paper presented at the man, and drink his blood.” Attending to the needs of communities Center for International Studies at Duke University, Durham, N.C. Last names and hometowns withheld. and families affected by torture is instru- Moore S. (1998). A fiscal mental in fostering a healing environment. portrait of the newest Americans. parents, or they have internalized the The thoughtful provider considers the indi- Washington, D.C.: National Immigration Forum and fears of their parents. They fear getting vidual torture survivor not in isolation but Cato Institute. their parents into trouble with author- as a part of a larger support system of fam- National Immigration Forum (2000). Economy: Immigrants ities by bringing attention to the family. ily and community. and the economy. They fear a reoccurrence of what hap- As a group, torture survivors are Retrieved Jan. 19, 2005, from http://www.immigrationforum.org. pened back home. hardworking, principled individuals who The Greater Twin Cities United Young people may also experience have sacrificed themselves to address the Way Research and Planning symptoms related to their trauma or the political and social problems in their Department. (2002). Immigration and the economy. Minneapolis: torture trauma of their family, as well as home countries. Twin Cities United Way. symptoms related to the catastrophic loss- They are leaders with abilities, talents, The Torture Victims Relief Act, es they have endured. intelligence, and survival skills that made (1998) PL105-320. Children of torture survivors endure them a threat to those who rule through United States Army. (1992). Field manual on intelligence many unsafe transitional living arrange- fear. As newcomers to this country, they interrogation. Washington, D.C. ments while their families attempt to find make invaluable contributions to our econ- FM 34-52. safe neighborhoods in the United States. omy, neighborhoods, and social, religious, United Nations High Commissioner for Refugees. This disrupts their educations as well as and civic institutions. (1951). Convention and protocol the development of stable attachments and They deserve welcoming and healing relating to the status of refugees. Res. 2198 (XII). normative peer relationships. communities. The rest of this manual Wechsler, L. (1990). A miracle Affected youth, like their parents, are addresses the role of health care, social a universe: Settling accounts highly resilient and develop strong sur- services, and legal services in creating with torturers. Chicago: University of Chicago Press. vival skills to adapt to these abnormal such communities. I environments. If a young person is behav-

17 CASE STORY

EDITOR’S NOTE: The following States, relatives phoned the family is a story of a family affected by and informed them that Sarah’s torture. Unfortunately, this family’s father was executed because of experiences are common among their escape.

torture survivors. T E

N The children worry constantly . S O H ohamed, the father of the T about their mother’s physical and N I R Y

B psychological condition, sometimes

family, spoke out against a A L .

repressive leader. Soon the family W leading one or more of them to stay W

M W began to receive threatening phone home from school to do the cooking calls and notes left on their door. One was tortured, Sarah and her family or cleaning so that Sarah will not day, Mohamed disappeared on his owned several homes and enjoyed have to after she gets home from way to work. No one has heard from relative safety and a comfortable work. Other students ridicule them at him since and the family presumes lifestyle. Here, the family lives in a school because of their accents and he is dead. rodent-infested apartment that Sarah limited financial resources for cloth- The mother of the family, Sarah, will not leave or complain about ing, field trips, etc. and her four children were subse- because she fears the landlord and For both Sarah’s medical appoint- quently imprisoned together for 12 police. ments and interactions with the months. During that time, the chil- Sarah works full-time in house- school system, the children are in the dren witnessed Sarah taken away for keeping for a hotel chain. The fami- roles of interpreter and cultural bro- daily interrogation and torture ses- ly is completely isolated from other ker. They have learned to take care of sions. Following each session, she families from their country. Sarah the bills and the outside appoint- returned to them bloody and injured. does not permit relationships with ments for the household. She was severely beaten and burned those in her cultural/ethnic commu- Both Sarah and teachers describe as part of her torture. The children nity due to distrust and shame. two of the girls, Eleni and Martha, as and Sarah also witnessed many Following her release from prison, depressed. The son, Ahmed, strug- atrocities in the prison and lived others shunned, shamed, and gles to assume his culture’s tradition- under deplorable conditions. betrayed her, mostly out of their own al role of head of the household at After their release, they escaped fear that they would also be targeted age 11. He suffers from insomnia, on foot through the mountainous if they extended themselves to help traumatic nightmares, flashbacks of region of their country and came to her. She says she cannot forgive this. the prison experiences, and other the United States as refugees several She allows the family to have rela- symptoms of post traumatic stress. years ago. tionships with people from other The children do not know or Sarah suffers from chronic pain countries who share the family’s reli- understand what happened to their in areas of her body that were tor- gion, as well as health-care and father, Mohamed, but they know that tured, as well as severe post traumat- social service providers. their mother cannot tolerate discus- ic stress disorder and major depres- The family continues to live sion of this topic and they have sion. Despite this, she attempts to with worry and anxiety that relatives stopped raising it. make a life for herself and her chil- back home will be persecuted His fate hangs over the families’ dren. This is difficult. because they escaped. Shortly interactions with one another like a In her home country, before she after they arrived in the United heavy, ever-present cloud. I

C H A P T E R 3 M O C . N A L P A K N H O J . W W W © WORKING WITH TORTURE

SURCOREVICOMPETENCIES VORS 3

CHAPTER 3 R E T WORKING WITH P

A TORTURE SURVIVORS H

C CORE COMPETENCIES M O C . N A L

hen providers are familiar with and P IN THIS CHAPTER A K N H

respect the culture, language, and trauma O J I LIFE EXPERIENCES . W

and Resettlement experience of their clients, they create bridges of W W W Issues © understanding. In order to provide appropriate I COMPREHENDING “THEY RAPED ME three times a day for eight Torture and effective services, professionals need to months,” said Addnar Mondeh, 45, of Koidu, Kono district, Sierra Leone. “It made me I CULTURAL develop a degree of expertise in the following four Competence afraid of men. I do not feel like having sex any longer." I WORKING WITH core fields of competency: Interpreters KNOWLEDGE OF the life experiences tion to bringing the new and pressing chal- and resettlement issues of refugees, lenges of starting over in a foreign land. asylum seekers and asylees before, To appreciate what was lost or changed, during, and after the violence service providers need an understanding of the COMPREHENSION OF torture and its long-term effects on survivors, survivor’s life before the trauma and uproot- their families, their community, and ing, including knowledge of the survivor’s past professionals who work with them resources, strengths, roles, status, and other CULTURAL COMPETENCE with core aspects of identity and meaning. traumatized people Thus, learning how to learn about survivors’ WORKING EFFECTIVELY with life experiences and resettlement issues is cru- interpreters cial in understanding the impact of torture and 3 This chapter provides information on the rehabilitative priorities for a given individual, four competency areas that apply to providers family, or community. Acquiring this type of in all disciplines and service domains. The learning skill requires hands-on training and following chapters address each competency supervision, which no manual alone can pro- area in further detail for social services vide. However, the following section provides providers, medical professionals, psychologi- an introduction to common life experiences cal services professionals, and legal services and resettlement issues that can serve as a first providers. step in developing greater awareness.

LIFE EXPERIENCES AND LIFE BEFORE TORTURE RESETTLEMENT ISSUES Torture survivors coming from situations of Torture is rarely the only trauma a torture longstanding political conflict or repression survivor has experienced. Exile involves the may not have known a pre-trauma period of loss of an entire world and way of life, in addi- their lives. For these survivors, family histories

20 3

DEFINITION or collective histories contain information and • Family, social, and community roles

OF TORTURE R beliefs about earlier periods of stability or (e.g., how was this family regarded E

‘‘... the term torture T within its native intact community? prosperity that carry important meaning in P What were the responsibilities means any act by which A their current lives. severe pain or suffering,

associated with various family roles, H

For other survivors, events such as the start such as oldest son or daughter?) whether physical or C of a war in a previously intact society or an • Pre-trauma functioning, or highest level mental, is intentionally inflicted on a person overthrow of the government in a formerly sta- of functioning in the home country (e.g., who was this person or family for such purposes as ble system, clearly demarcate normal life and before the torture?) obtaining from him times of hardship or suffering. For others, • Homes and/or ties to the land or a third person pockets of normalcy may be interspersed with- (e.g., responsibilities for ancestral information or a in their countries’ periods of upheaval and lands, farms) confession, punishing destruction. • Other aspects of status or resources him for an act he or a third person has At the collective level, sources for learning the person or family possessed committed or is about the living history of a people include the • A basic understanding of how daily life was lived (e.g., was life mostly lived suspected of having following: outdoors? Were activities and physical committed, or intimidat- • Guest speakers and other resources from space mostly communal or shared ing or coercing him local refugee and asylee communities versus individual or private? To what or a third person for and organizations (e.g., printed extent did the genders interact in any reason based on materials and events) daily life? What were the normative discrimination of any • Written histories sleeping and eating customs?) kind, when such pain • Oral history projects • Beliefs and practices relevant to health, or suffering is inflicted • Country reports from governmental, healing, wholeness, suffering, by or at the instigation nongovernmental or human rights sickness, loss, grief, and mourning of or with the consent organizations (with the understanding that these or acquiescence of beliefs and practices often undergo • The media a public official or transformation during subsequent other person acting • Accounts from cultural anthropology periods of repression, flight, and exile) and sociology in an official capacity." THE REFUGEE/ASYLEE EXPERIENCE — ARTICLE I, UNITED NATIONS • The arts (drama, poetry, memoirs, CONVENTION AGAINST TORTURE, visual arts) 1984 Refugees and asylum seekers typically • Web sites maintained by political or encounter traumatic experiences and human social justice organizations within rights abuses in the phases of their lives called the the country as well as outside refugee experience. Knowing about traumatic When assessing at the individual or family events associated with the various periods of the level, the following information from the refugee experience is necessary for providing home country is pertinent: assessments and services to torture survivors. • Social, economic, educational, and This requires a paradigm shift for service political status providers trained to think of trauma in terms • Beliefs, values, practices, rituals, ceremonies, significant achievements of single events, such as a car accident or hurri- or milestones that gave life meaning cane. In addition, as implied in the term post-

21 3

PRE-FLIGHT: This period covers R

E the series of events, sometimes T

P occurring over years, that leads to the A decision to flee. It includes events in the sur- H

C vivor’s life as well as the broader sociopolitical a

v context that created a climate of constant fear. e e k a M

. Often there is a pattern of escalation of trau- T / R C

H matic events over time. Less severe forms of N U

© harassment or repression (e.g., restrictions on SPUTNIK Tented Camp. movement, brief arrests, monitoring) escalate traumatic stress, providers may see trauma as to the infliction of suffering and threats on having a discrete beginning and end. one’s life (e.g., disappearance of friends or rel- For refugees, asylees, and asylum seekers in atives, public display of atrocities, loss of exile, there is no end to the ongoing destruction job or property, detention, torture). of their family, property, and community back The decision to leave one’s homeland is home. Nor is there an end to events they experi- often one of the most difficult decisions a per- ence as life threatening, such as the ongoing son or family makes. It is common for some- threat of deportation for someone who is seek- one to undergo multiple periods of detention ing asylum. and torture before deciding to flee. The sur- To help the provider understand common vivor may attempt to escape several times phases of the refugee/asylee experience, the before succeeding. Triple Trauma Paradigm was developed. (See Providers need information about the barriers Figure 3A, next page.) This model was adapted to medical care faced by torture survivors in this from other stage models (e.g., Gonsalves, 1992; stage. Both modern and traditional healers can be van der Veer, 1998) listed as references at the end expensive and difficult to access under conditions of this chapter. of repression. Phases of the refugee/asylee experience Beyond social and cultural influences on include not only traumatic events, but also the type and availability of care, many torture other significant and meaningful life experi- survivors are afraid or ashamed to seek treat- ences. The Triple Trauma Paradigm describes ment for a variety of reasons. For example, three phases of traumatic stress that apply to some physicians are involved in torture or torture survivors in exile who may or may not connected to repressive governments, and sur- enter the United States with refugee status. vivors fear arrest in the hospital.

FOR MORE INFORMATION In addition, clinics refuse to treat members of For more information certain groups or political parties. on implications for social and psychological FLIGHT: The flight period covers the service providers, see escape and flight to the country of CHAPTERS 4 and 6. eventual refuge. It lasts from one day

22 3 to years, the latter being more common. care or social services. Service providers to torture survivors R

At the psychological level, characteriza- People in this stage are caught in a no- need to receive training about these dif- E T tions of this period include profound man’s land between the past life they ferences and their implications for serv- P uncertainty and fear due to lack of secu- knew and an unknown future in an unde- ice delivery. A H

rity, the unpredictable future, and vulner- termined location they hope offers them C POST-FLIGHT: Post-flight is ability to additional trauma. basic security. It is important for service the period of resettlement and Torture survivors may spend consid- providers to understand the psychological exile. The challenges of post-flight include erable time living in hiding within the implications of this limbo for political the shock and stress of adapting to a new home country, or cross borders of several asylum seekers currently in the United culture and society while ongoing events countries under perilous conditions. They States. in the home country bring additional trau- also live in refugee camps in conditions The survivors feel they are still ma and loss to the survivor. of squalor, crime, unemployment, malnu- in flight until they gain asylum and During the post-flight period, sur- trition, and threat of attack from rebel or reunite with family members who vivors experience ongoing traumas and military forces. remain in danger in the home country. stresses due to their marginalized or for- Barriers to obtaining treatment for tor- The process of asylum and reunification eign status in the new country, along ture-related injuries and psychosocial can take years. with poverty, racism, or anti-immigrant needs are extreme in this stage. The tem- The uncertainty and length of the asy- prejudice. They are vulnerable to crime porary and impoverished nature of living lum process makes resettlement different because of their lack of knowledge of conditions rarely permits access to health for asylum seekers than for refugees. cultural norms, less protected legal

FIGURE 3A

THE TRIPLE-TRAUMA PARADIGM

PRE-FLIGHT FLIGHT POST-FLIGHT

I Harassment/intimidation/threats I Fear of being caught or returned I Low social and economic status I Fear of unexpected arrest I Living in hiding/underground I Lack of legal status I Loss of job/livelihood I Detention at checkpoints, I Language barriers I Loss of home and possessions borders I Transportation, service barriers I Disruption of studies, life dreams I Loss of home, possessions I Loss of identity, roles I Repeated relocation I Loss of job/schooling I Bad news from home I Living in hiding/underground I Illness I Unmet expectations I Societal chaos/breakdown I Robbery I Unemployment/underemployment I Prohibition of traditional practices I Exploitation: bribes, falsification I Racial/ethnic discrimination I Lack of medical care I Physical assault, rape, or injury I Inadequate, dangerous housing I Separation, isolation of family I Witnessing violence I Repeated relocation/migration I Malnutrition I Lack of medical care I Social and cultural isolation I Need for secrecy, silence, distrust I Separation, isolation of family I Family separation/reunification I Brief arrests I Malnutrition I Unresolved losses/disappearances I Being followed or monitored I Crowded, unsanitary conditions I Conflict: internal, marital, I Imprisonment I Long waits in refugee camps generational, community I Torture I Great uncertainty about future I Unrealistic expectations from home I Other forms of violence I Shock of new climate, geography I Witnessing violence I Symptoms often worsen I Disappearances/deaths

23 3 status, and limited eligibility for services as Due to these barriers and unmet basic T R E N . E S noncitizens.

O needs, service providers need to expand their H T T N I P R At the psychological level, survivors ini-

Y traditional professional roles. Survivors B A A L .

W tially feel relief at having left the daily fright require advocacy, case management, and phys- H W W

C and uncertainty of the flight stage. This is fol- ical accompaniment to situations where they Tamba was at home lowed by a deepening awareness of loss and may require the presence of a supportive, trust- when he received a overwhelming feelings. ed ally. Dealing with authorities and institu- phone call soliciting Psychological symptoms or distress become tions is particularly difficult and potentially re- contributions for an manifest for survivors when they are not as pre- organization that helps traumatizing for torture survivors who have children with cancer. occupied with daily struggles for physical sur- suffered from abuse of power by these entities The caller identified vival. Some survivors experience significant in their homeland. depression as they feel overwhelmed by the himself as a volunteer Service providers need to address ongoing with the police union, tasks required for adjustment and with the grief trauma and to accommodate interruptions or and pleasantly explained they feel at leaving their country behind. delays in treatment — sometimes lasting years — this was their annual Torture survivors encounter barriers to due to life circumstances and different develop- fund-raising drive. accessing health services in this period, includ- His voice and hands mental pathways in trauma recovery. ing the following: shaking with fear, The post-flight stage, characterized as accul- Tamba offered to • Transportation and child-care turation, bicultural integration, resettlement, or contribute, though he needs exile, is complex. Personalities, behaviors, and was already out of • Language and cultural barriers functioning look very different in the same sur- money for the month. • Negotiating complex vivor or family, depending on the stage of reset- From his perspective, U.S. health care and social service tlement, the situation in the home country, and he could not say no. institutions current level of acculturation stress. Service That night he had • Ineligibility for services due to providers need to assess these factors in relation nightmares of being lack of insurance or immigration back in his home country status to current problems or symptoms and design where the police would • The stigma of mental health interventions accordingly. come to his house and and illness (of being considered For those who have never imagined what it he would pay them “crazy” and in need of treatment) would be like to lose one’s entire world, it is money to avoid • Unmet basic social, legal, and helpful to supplement academic learning with abduction. physical needs training tools that connect the learner to a • Misdiagnosis and/or lack of range of personal stories. facilitated referral from other service sectors COMPREHENDING TORTURE • Racism and classism The effects of torture exist in human

FOR MORE INFORMATION responses to other extreme trauma. However,

A handout on the effects of the nature and meaning of torture distinguish it torture can be found on from the individual traumatic events that many PAGE 25, FIGURE 3B. practitioners trained in the West treat.

24 FIGURE 3B A HANDOUT FOR SURVIVORS AND THEIR FAMILIES 3

COMMON EFFECTS OF TORTURE E T P

POSTTRAUMATIC STRESS DISORDER DEPRESSION PHYSICAL SYMPTOMS A H C Nightmares Feeling sad or angry a lot Headaches Bad thoughts or memories of the Difficulty thinking or Feeling dizzy, faint or weak torture come into your mind making decisions when you don’t want them to Chest pain Difficulty concentrating or Acting or feeling like the torture remembering Heart beats very fast is happening all over again (e.g., flashbacks) Feeling worthless or Stomach hurts or feeling hopeless sick in the stomach Feeling very upset when something reminds you of the torture Feeling excessive guilt Shaking or trembling Trying to forget the torture, Feeling that you do not care Hands or feet feel cold trying not to think about it about life, that you are not interested in things Hot or burning feelings Staying away from anything that reminds you of the torture Feeling too hungry or not Numb or tingling sensations hungry at all, gaining Cannot remember important or losing a lot of weight Sweating things that happened during without trying to the torture Diffuse or generalized Sleeping too much or sense of pain, Feeling like you do not care about too little weakness, misery life or what happens to you Feeling tired a lot, Other pains in the body Feeling like no one understands not having energy or cares about you, like you are alone and cut off from Thinking about death a lot, others thinking about killing yourself Feeling numb, like there are no feelings inside you Feeling like you have no future or that you may die sooner than most people Difficulty falling asleep or staying asleep at night Feeling angry a lot, easily upset Difficulty concentrating Can’t relax or feel comfortable, often afraid something bad will happen

25 3 Because torture is a political weapon used to T R E N . M S E O

O terrorize entire communities by targeting indi- C H . T T Y N H I P R P A

Y viduals, a care provider needs to understand the R B G A L A . O T W

political and historical context in order to pro- O W H H P - W F C O

vide appropriate treatment. Psychologist Yael - S R E

Sara avoided the T S

Fischman, from the Institute for the Study of A M

local grocery store. , O

Psychosocial Trauma in Palo Alto, California, D A

She had been in the G L A

offered the following admonition: S

store once when some O A I T S

local youths entered who A . . . clinicians working with survivors of B E S

were dressed in baggy human rights violations need to © fatigues with bandanas consider a conceptual framework that Association, it has been established that post- on their heads. Sara goes beyond the posttraumatic stress traumatic stress disorder “may be especially shouted something — disorder model — one that incorpo- severe or long lasting when the stressor is of she could not remember rates the historical and political context what — and cowered in which the trauma originated…. If human design (e.g., torture, rape)” (1994, in a corner. The patients perceive that the therapist p. 424). That is, higher levels of symptoms and views their symptoms, reactions, and youth were dressed longer-lasting symptoms are associated with difficulties solely as products of somewhat like the human-perpetrated traumas such as torture. adverse personal traits and events, they child rebels who are likely to feel confused, misunder- The effects of torture vary widely at the indi- had detained and stood, or even angry. For the survivor vidual level, ranging from temporary distress or raped her at a of political repression, the elaboration a few symptoms to full-blown psychiatric disor- checkpoint in her and integration of a traumatic history ders. Nevertheless, the effects of torture are country. She could requires an understanding of the ways not return to the in which the political/historical context severe and disabling for many survivors. store out of fear of this type of trauma differs from that Many factors affect how individuals react and embarrassment. of traumas stemming from private to severe stress. The intensity and duration of encounters and events. (1998, p.28) the trauma experience (sometimes referred to

This broader concept of trauma goes as exposure variables) are two important fac- beyond individual symptoms and disorders to tors. In general, torture survivors who endured address issues of meaning, power, and identity. long periods of detention and multiple forms Torture destroys these core elements of the of interpersonal trauma are likely to be symp- individual and social structure. tomatic and/or functionally impaired. Many torture survivors struggle with the However, torture is torture. Distinctions effects of society’s collective silence and among degrees of atrocity can become mean- denial that such atrocities happened. This may ingless when dealing, by definition, with the lead them to question the reality of their own extremes of human trauma. experiences and reinforce the shame and pow- EFFECTS OF TORTURE erlessness imposed on them during the torture. The following effects of torture may affect sur- While research on torture is in its infancy, vivors, with the understanding that culture and according to the American Psychiatric individual differences influence the range and

26 3 manifestation of these effects. In general, these SILENCE AND SELF-EXPRESSION: Torture T R E N . S E effects logically follow the reality that torture is is used around the world because it is highly O H T T N I P R designed to break down the spirit, mind, and will. effective at silencing individuals and commu- Y B A L A .

nities. Torture affects people’s thinking and W W DISTRUST:Torture influences many relation- H W

willingness to express themselves. Their fun- C ships: one’s relationship with oneself (body and During Jamal’s damental views of the world, other people, and mind), with family and friends, with groups and imprisonment, the themselves are altered to accommodate what institutions, and with humanity in general. jailers placed a they experienced under torture, which is often Survivors commonly say that torture changes severely mentally dis- bizarre, sadistic, and incomprehensible. them forever and that they feel like strangers to turbed man in Jamal’s State censorship becomes self-censorship prison cell. The man themselves. under repressive regimes. People are afraid to appeared to be psychotic They feel betrayed by their bodies and the speak or even to think certain things that may and was not in control degree of pain they allowed them to experience. be dangerous to utter. of his behavior. He Survivors distrust their own perceptions or inten- In addition, the horrific nature of these incessantly attacked tions, as well as those of others. They feel as if Jamal and screamed to atrocities reinforces the silence surrounding they are no longer fully human, or that they are himself and at Jamal. the trauma, as words often seem inadequate somehow different from other people. At one point, he started for explaining what one experienced. injuring himself by Survivors have experienced deliberate cru- Survivors find it difficult enough to under- banging his head elty and betrayal under highly intimate condi- stand and believe their own experiences, so against the cell wall tions. Many torturers knew their victims per- the task of explaining them to someone who and lurched toward sonally, and torture often involves intimate was not there can seem overwhelming or Jamal to try to “eat contact. Those in positions of authority who pointless (Dalenberg, 2000). his arm.” The torturers were supposed to protect people perpetrated told Jamal that this DISEMPOWERMENT AND HELPLESSNESS: torture. Understandably, many survivors man was a ghost that Empowerment is a fundamental principle of trau- resolve never to trust another human being. had risen from the ma recovery. Survivors of torture experience dead to haunt Jamal One challenge for service providers is to unpredictability, helplessness, and lack of control because he was bad. understand the depth of the survivor’s distrust under torture. Torturers control their victims’ Because Jamal believes and its many manifestations over time. most intimate and basic bodily functions, such as in spirits, he continues Showing understanding and acceptance of dis- eating and elimination. Victims under detention to believe that this trust in torture survivors, even when much of live for long periods with the feeling of not man is a ghost that still haunts him. the internal experience of the torture survivor knowing what is going to happen next, of not may go unspoken, is a powerful intervention. knowing when death might come. Distrust affects the length of time it takes for The complete control that torturers have someone to acknowledge what happened, and over victims is not just physical but also it will affect the survivor’s ability to build rela- mental. Mental forms of torture include sleep tionships with the service provider and with deprivation, mind games, direct threats, others. For torture survivors, rebuilding trust is psychological abuse, brainwashing, pharma- a long-term recovery goal. cological torture, and many other psychological methods.

27 3 Frequently, victims are told, Your mind is away personal identity and shames victims R

E no longer your own. You belong to us now. The through indecent exposure to others. T

P torturers force them to participate in their own Nakedness is one of many techniques that A torture or the torture of others. serve as a continual reminder of the differences H

C Often torture victims receive a false sense in power between torturers and victims. of choice. They believe they are responsible Other forms of sexual torture result in shame for what happens, when in reality the torturer and humiliation. Even survivors who appear has complete control over the situation. (e.g., quite willing to talk about their experiences will Tell us what we want to know, or we will kill not reveal their most shaming experiences. your wife.) Although it is not a choice, sur- Providers can never assume they know the vivors still feel responsible for the actions of worst of what a survivor experienced. the torturer, which in some cases is the killing, In some cultures, it is unacceptable to dis- torture, or disappearance of other people. This close sexual torture. Female survivors are con- kind of scenario inevitably leaves survivors cerned they will lose their husbands or their with tremendous guilt that leads to self-pun- communities of support. Because of the poten- ishing behaviors and questions of self-worth tial social and economic consequences, rape and self-blame. survivors may not be able to disclose this to This type of powerlessness undermines anyone. Similarly, men who are victims of sex- people’s ability to act or to assert themselves. ual torture struggle with extreme feelings of Even questions such as “Do you understand shame, humiliation, and emasculation. what I said to you?” or “Are you feeling all Torturers call women whores or prostitutes right?” are difficult for torture survivors to and name men as women or wives during tor- answer. They try to assess what is the right ture. They tell survivors they enjoyed the rape, answer or what the authority figure wants to or deserved sexual assault. hear. They answer yes because they do not Many survivors say they will have to live want anyone mad or upset with them. with sexual torture their entire lives. The effects This presentation places providers in a of this type of torture can be long-lasting and very difficult position. It is important not to severe, including suicide when the shame confuse these responses with passivity and becomes intolerable.

indifference. What the provider might be DENIAL AND DISBELIEF: Simply put, tor- seeing is the chronic fear and helplessness ture is difficult to believe. Torturers tell their created by torture and repression. victims no one will believe them even if they SHAME AND HUMILIATION: Torturers intention- live to tell the story. Sometimes the torture is so ally produce feelings of shame and humiliation sadistic and bizarre that survivors find it easy to that undermine identity and prevent survivors accept that, indeed, no one else will believe from talking about what happened to them. For what happened. example, forced nakedness is one technique Torturers use torture to distort victims’ commonly used under captivity. This act strips sense of reality. The world turns upside down.

28 3

The incomprehensible and unbelievable FIGURE 3C R become true, and social norms and the SHORT-TERM ONGOING ASSESSMENT E LEVELS OF INVOLVEMENT TASK INVOLVEMENT INTERVENTION T rules of logic or common sense in the cul- ADDRESSING UNRELATED TO UNRELATED RELATED TO TRAUMA P

TRAUMA TRAUMA (E.G., INCOME TO TRAUMA (E.G., MENTAL HEALTH A ture no longer apply. For these psycholog- MAINTENANCE WORKER) (E.G., ESL TEACHER) PROFESSIONAL) H

ical reasons, survivors deny, distort, or C Ask only questions X X repress memories of the torture. relevant to your task Torture survivors may fear laughter or Do not identify trauma X X in order to help disbelief if they talk about the torture. Know about appropriate X X X They are sensitive to the slightest gesture referral resources Consider culture and X X X (often unintentional) from a provider that traumatic experiences may imply doubt, disbelief, or denial. Avoid/reduce potential X X X for reactivation of trauma DISORIENTATION AND CONFUSION: Respond to spontaneous X X X Under torture, the assault on the senses disclosures of trauma Respond to expressions X X X and the strangeness of everything that is of distress (crying) happening confuses victims. Torturers Acknowledge prevalence X X of trauma for refugees manipulate the environment to create Normalize trauma X X illusions and fears of losing one’s mind. reactions Under captivity, even if it is only a Explore relevant refugee X X and trauma experience matter of hours, people lose their sense of time. This is especially true when there is common among torture survivors. Trauma-related rage interferes with also sensory deprivation (e.g., blindfold- the ability to remember, to think clearly, RAGE: Rage is a natural response to the ing, imprisonment in complete darkness), and to express oneself, especially in violations of torture. Many survivors sup- multiple episodes of similar interrogation threatening situations where survivors pressed rage for a long time. and torture, or solitary confinement. either feel out of control or fear losing The force of their own rage often Survivors report not knowing what week control. Providers may witness behaviors frightens survivors. Survivors may feel or even month or season it is. that the torture survivors used during Survivors may lack memories of what more rage or anger toward a current situ- their torture to survive. happened under captivity. They do not ation than would normally be expected, remember start and end dates of impris- given the situation. Conversely, they may PSYCHIATRIC SEQUELAE: Many tor- onment. Confusion and disorientation shut down when upset, in order to protect ture survivors meet criteria for one or influence the ability to recall events, cre- themselves from their feelings. more psychiatric disorders. However, use ating inconsistencies and gaps in their They may be able to discuss their fear of the term disorder or any concept that stories. Some torture survivors have of their anger but are often at a loss as to so labels the survivor is a very sensitive experienced pharmacological torture or what to do with it. They are embarrassed matter. loss of consciousness. or ashamed, recognizing what they are Some survivors are relieved to know Providers should use caution when feeling is out of proportion to the present that what they suffer has a name, a his- interpreting memory issues, and be aware situation and feel helpless against their tory of professional study, and treatment that memory gaps and inconsistencies are own fury. options. Other survivors feel misunder-

29 3

T stood or misrepresented by individual diag- E R N . S E M O O

H noses. They are acutely aware that torture is T C T . N Y I R H P P Y

B fundamentally a political and social problem, A A R L . G A O W which receives little attention or acknowledge- T W O H H W P - F C

ment worldwide. O - S

An interpreter for R E T

Survivors suffer from normal, expected S A

Bosnian refugees M

human reactions to extremely abnormal and O D

related that many A G L

disturbed sets of events and environments. A S

Bosnians went to O Â I T

the American doctor Providers need to communicate this under- S A B E S complaining of headaches standing to survivors and to normalize the © or stomachaches. effects of the torture in ways that have meaning Torture survivors commonly report that during They were alarmed for survivors. their torture, they experienced loss of con- when the doctor did Diagnoses, while useful, focus on not ask them any sciousness following beatings to the head. particular symptoms and on individuals. They questions about their Professionals overlook or underdiagnose organ- experiences before do not cover the full range of effects on sur- ic impairment, as some of the symptoms of arriving here, but vivors, their families, and communities. organic impairment mimic PTSD and other ordered a battery of Common psychiatric disorders associated psychological disorders. diagnostic and routine with torture and severe trauma in adults Trauma-related symptoms are not readily tests. In their home coun- include the following: apparent to survivors. Changes in feelings and try a doctor would only behavior often occur subtly over time. Family order expensive tests • Posttraumatic stress disorder if the patient was (PTSD) and other anxiety members may observe these changes and it is disorders thought to have a critical to include them in assessment and treat- • Major depressive disorder very serious illness. ment. Trauma symptoms affect survivors’ rela- • Somatoform disorders tionships, including those with family members. • Substance abuse (usually to self-medicate TALKING ABOUT TRAUMA anxiety and depressive symptoms When working with survivors, it is not in the absence of other therapeutic always necessary or even appropriate to address alternatives) the trauma directly. Training in addressing tor- • Sexual dysfunctions ture trauma must be tailored to the setting and For torture survivors, the most common psy- service provided. However, some consideration chiatric diagnoses are PTSD and major depres- of trauma issues (e.g., minimizing the potential sion. More rarely, there may be a delusional dis- for re-traumatization) is relevant for all services. order (usually persecutory in nature) or psy- Figure 3C, on Page 29, gives examples of appro- chosis. Organic impairment (actual brain priate levels of engagement for the following injury) has a higher base rate among refugees categories of service: than other populations due to conditions and • Short-term involvement events they experience (e.g., starvation, sensory • Ongoing involvement unrelated deprivation, head injuries from beatings). to trauma symptoms, and

30 C ULTURAL 3 C • Involvement that • Methods for addressing COMPETENCE R

specifically addresses secondary trauma DOES NOT MEAN E some aspect of trauma, T Organizations or clinics providing services to P whether expressed or not knowing everything A torture survivors can implement policies and about every culture. H

SECONDARY TRAUMA procedures that prevent or ameliorate secondary It is a mindset that C FOR THE PROVIDER trauma at the organizational level. Many con- leads to lifelong learning with: Service providers often experience unex- tributing factors to secondary trauma are con- • Respect for pectedly strong feelings — or numbness or nected to the workplace and may be outside the differences shock — when talking about torture or hearing control of the individual worker. Organizational • Eagerness to learn survivors’ stories. The effects of being exposed strategies that deal openly with secondary trau- • Willingness to to trauma indirectly through others are referred ma help reduce the sense of isolation, stigma, accept that there to as secondary, or vicarious, trauma. Among and shame that workers may experience. are many ways of providers working routinely with extreme trau- viewing the world ma such as torture, secondary trauma is con- CULTURAL COMPETENCE sidered to be an occupational hazard — some- In the policy paper, “A Manager’s Guide for thing that can be reduced and managed, but not Cultural Competence Education for Health avoided completely. Professionals,” the California Endowment Secondary trauma affects the relationship adapts the widely accepted definition of between the provider and torture survivor, the cultural competence from Cross, Bazron, treatment process, other work relationships, Dennis and Issacs: and the provider’s life outside of work. Cultural and linguistic competence Providers who come from communities affect- is a set of congruent behaviors, ed by torture must contend with both second- knowledge, attitudes and policies that ary and primary trauma. The work can trigger come together in a system, organization or reactions related to their own history of perse- among professionals that enables effective work in cross-cultural situations. ‘Culture’ cution and flight. refers to integrated patterns of human It is essential that providers who work with behavior that include the language, torture survivors receive training on secondary thoughts, actions, customs, beliefs, and trauma and have access to professional consul- institutions of racial, ethnic, social or reli- tation regularly. Training should cover the fol- gious groups. ‘Competence’ implies having the capacity to function effectively as lowing subjects: an individual or an organization within the • Signs and symptoms of context of the cultural beliefs, practices, secondary trauma and needs presented by patients and their • Contributing factors communities. (1989, p.5) in the work itself FOR MORE INFORMATION • Contributing factors in the work environment For more information on secondary trauma, see • Contributing factors CHAPTER 6. in the individual

31 3 This general meaning can be further defined continuing disparities in health and socioeco- R T E N . E S in relation to health care by asking if the indi- nomic status between the majority population O T H T N I P

R vidual or organization demonstrates awareness and new immigrant populations, as well as dis- Y B A A L .

W of differences in three key dimensions in various parities between the majority culture and other H W W

C populations and integrates that knowledge into populations of color in the United States. An Oromo man sits practice (Lavizzo-Mourey and Mackenzie, For the torture survivor, lack of cultural com- quietly, saying very 1996). Those dimensions are: petence compounds a natural reluctance to bring little in his psychotherapy up painful past experiences. On the individual session. He is wary of • Health-related beliefs and his interpreter, an cultural values level, this can result in continuing symptoms for Ethiopian who speaks • Disease incidence and prevalence the client and frustration for the professional. his language but is • Treatment efficacy On the community level, the failure to not Oromo. He does address culture impedes the ability of new The word competence, rather than sensitiv- not mention his past immigrant groups to acculturate: learn the new ity, is used in order to tie the learning of cul- involvement with a language, progress in school, find and keep resistance movement tural information, skills, and attitudes to jobs, and rebuild family support systems. and subsequent actions that benefit the client or patient. imprisonment and Competence does not imply a finite level of STANDARDS FOR torture. skill that can be achieved in the same way as CULTURAL COMPETENCE learning to perform open heart surgery or use In March 2001, the Office of Minority a particular therapeutic approach. It is a fluid Health at the U.S. Department of Health and state that is defined in relation to the specific Human Services published a set of national setting and a specific client. The measure of standards defining culturally and linguistically competence is ultimately in the hands of the appropriate services (CLAS) in health care. The beneficiary; the client should perceive the standards focus on the following three areas:

services as relevant to his or her problems and • Cultural competence helpful for achieving the desired outcomes. • Language access services and

HOW CULTURAL • Organizational supports for COMPETENCE AFFECTS CARE cultural competence Lack of cultural competence can affect a Some are mandates based on existing relationship with a refugee or asylum seeker in laws (Standards 4-7), some are guidelines many ways — from the obvious inability to (Standards 1-3 and 8-13), and one is only a communicate across a language barrier to the recommendation (Standard 14). Background subtle ways trust is eroded or never built. information on the CLAS standards can be Insufficient attention to culture can result in found on the Federal Office of Minor- failure to work toward mutual goals. ity Health’s Web site, www. omhrc.gov. On an individual level, the absence of cultural competence in rehabilitation results in TRAINING AND RESOURCES unsatisfactory outcomes for the patient or Often, when health care providers begin to client. On the community level, the result is see numbers of patients or clients from ethnic

32 3

THE THERAPEUTIC TRIANGLE: M PROVIDER, INTERPRETER, AND CLIENT R O C . E Y H P Upon intake, her trau- T A R P G O

Sonia re- T ma. Marta T E A O N . H S

P ported she remained - O F H H T O - N S seldom left I neutral R C R E Y T B S A A

her apart- L and calm . M

W , O ment and W as she D W A G L had no sig- interpreted A S

A nificant relationships Sonia’s ideas as I T S A

B outside of her immedi- precisely as possible E S

© ate family. She told the Marta conveyed a scheduler she would not tone of respect and groups unfamiliar to them, the not be afraid of seeing a patient work with any inter- belief in Sonia’s story. first response is: “Teach us the or client with a cultural back- preter from Guatemala, She consistently first response about this group’s ground that is unfamiliar. Good her home country. matched Sonia’s tone The staff carefully and speech patterns to culture.” This step, based on cross-cultural relationship-build- screened an interpreter, most accurately convey good intentions, is not the only ing skills are not, however, a sub- considering with whom Sonia’s messages. She necessary step toward cross-cul- stitute for actions that increase Sonia would feel most provided an unspoken tural practice. cultural knowledge and seek to comfortable. Prior to support for Sonia, It can lead to stereotyping overcome any barriers to care the first session, the actively contributing therapist and Marta, an to the therapeutic and short-circuit the important that cultural, economic, or lin- interpreter of Mexican process by aiding the process of understanding the guistic differences pose. descent, agreed to dis- communication. Sonia individual patient who has close to Sonia certain eventually began to ORKING WITH come seeking help. Each indi- W details about the inter- open up, beginning INTERPRETERS preter to aid in creating the therapeutic vidual is a unique mix of per- safety and trust. process. sonal, familial, situational, and Many providers must rely on In the initial session, The therapist noted cultural influences. These can the services of interpreters the client, interpreter, that Sonia seemed only be discovered in the when working with survivors. and therapist discussed happy to see both the process of forming a relation- Unfortunately, miscommunica- the role of the inter- therapist and the interpreter, including preter each week, ship with the patient in order to tion occurs because the service Marta’s promise of con- greeting both of them provider, the interpreter, or both provide care. fidentiality, her creden- warmly at the start of The training curricula need to lack training. In response, the tials as a professional each session. Marta be- include not only important content Federal Office of Civil interpreter, and her came the communication about the cultural backgrounds of Rights has issued guidelines for national origin (and bridge between Sonia lack of connection to and the therapist. the torture survivors in particular health and human services the political situation in Over time, she also populations, but also process skills Guatemala). became a model of a FOR MORE INFORMATION that serve to build trusting and effec- In subsequent ses- person whom Sonia For a listing tive cross-cultural relationships. sions, the therapist would choose to trust as of the CLAS moved slowly as she she recovered from The provider who has mas- standards, helped the client trauma and began tered these process skills need see PAGE 38. disclose the details of building relationships.

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SAMPLE VOCABULARY providers on what constitutes compliance SKILLS FOR PROVIDERS R FOR INTERPRETERS

E with Title VI of The Civil Rights Act regard-

T Working with interpreters involves a set (political) asylum P ing people with limited English proficiency. of skills, as does interpreting itself. Frequent

A fingerprint/to get These guidelines are helpful for learning H fingerprinted and thorough communication between

C how to work with interpreters and can be sentence provider and interpreter is required. accessed directly at www.hhs.gov/ocr/lep. charges to detain/ Most training sources stress the impor- detainment/detained Using professional interpreters is often tance of attending three sequential stages of to file (an application) cited as a financial and time burden for work for providers and interpreters: before, hearing nonprofit agencies and other providers. during, and after the use of an interpreter judge However, the price of using ad hoc with a given client or patient. attorney intrepreters (family members, friends, affadavit community members, or other employees) SKILLS FOR INTERPRETERS case and untrained interpreters is high, resulting Interpreting for torture survivors is appeal/to appeal in a denied asylum application, compro- sophisticated work. It requires knowledge passport mised confidentiality for the client, misdiag- of words and concepts commonly transmit- immigration nosis for medical and psychological treat- ted during the course of medical, mental torture ment, or the inability to provide services. health, legal, or social services work affiliation/to be affiliated with and understanding of the cultures of clients THE THERAPEUTIC TRIANGLE: border guards PROVIDER, INTERPRETER, as well as the experiences of clients with AND CLIENT dictator/dictatorship trauma. to smuggle (people) Communication through a trained inter- Sensitivity and resilience in working with persecution preter can function as part of a powerful heal- people (both clients and providers) are essen- electrocution ing process. The process of interpreting pro- tial, as are strong language skills. disappeared vides a unique opportunity to model and While each agency should provide harassment rebuild connection, relationships, and thorough training for its interpreters, it is also to bribe respect. The interpreter becomes part of a the responsibility of each interpreter to seek rape/to be raped therapeutic triangle while linking the to expand his or her knowledge base. nightmare provider and client in communication. A stowaway (See sample vocabulary this page.) relationship of confidence and trust among demonstration Interpreting that is both cross-linguistic those involved helps the survivor to experi- and cross-cultural involves many ence the safety needed to engage effectively components for the effective translation of in treatment. meaning. FOR MORE INFORMATION The core competencies for interpreters

For a summary of basic dos described in the Massachusetts Medical and don’ts for each stage Interpreters Association’s (MMIA) Stan- and for a general guide for providers working dards of Practice have been endorsed by the with interpreters, see National Council on Interpretation in Health FIGURE 3E, PAGES 36-37. Care as the best statement of standards for

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REFERENCES R E

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). T

Toward a culturally competent system of care, Vol. I. P

Washington, D.C.: Georgetown University Child A

Development Center, CASSP Technical Assistance H

Center. C Fischman, Y. (1998). Metaclinical issues in the treatment of political trauma. American Journal of Orthopsychiatry, 68(1), 27-38. Gonsalves, C. (1992). Psychological stages of the

M refugee process. Professional Psychology: Research O C . and Practice, 23, 382-389. N A L P Lavizzo-Mourey, R. & Mackenzie, E. Cultural A K

N competence: Essential measurement of quality for H O J . managed care organizations. Annals of Internal W

W Medicine,124, 919-921. W © Massachusetts Medical Interpreters Association "HER FATHER DISAPPEARED in the attacks on Nyaeudou camp. (1995). Standards of Practice. Retrieved March 4, We don't know where he is." Cumbay Samura, 28, Falabah, 2005, from http://www.mmia.org. Koinadougou district, Sierra Leone. Office of Minority Health (2001). CLAS Standards. Retrieved March 4, 2005, from medical interpreters available. mind, the body, and the spirit. http://www.omhrc. org. van der Veer, G. (1998). Counseling and therapy These standards of practice for Facing the degree of human cruel- with refugees and victims of trauma (2nd ed.). interpreters comprise three major ty experienced by clients is trau- Chichester: John Wiley & Sons. task areas: interpretation, cultural matic and can be life-changing. It ADDITIONAL RESOURCES interface, and ethical behavior. A should be noted that many inter- CULTURAL COMPETENCE code of ethics, derived from preters come from communities THERE ARE NOW MANY EXCELLENT resources for learning more about cultural competence that can be the MMIA standards, stresses affected by torture and may have accessed through online. Some of them are listed the following: heightened sensitivity to the mate- here and provide an entry point for many more. rial transmitted. It is important for 1. National Center for Cultural Competence • Confidentiality http://gucchd.georgetown.edu//nccc/index.html both interpreter and provider to be • Accuracy and complete 2. The Providers’s Guide to Quality and Culture aware of the changes in them- (Management Sciences for Health Electronic interpreting Resource Center). http://erc.msh.org/ selves, in their perspectives of the • Impartiality 3. Diversity Rx. (A joint project of world and the environment, and on The National Conference of State • Respect of client’s privacy Legislatures and Resources for Cross relationships and behaviors toward • Maintenance of Cultural Health Care at the Kaiser Family professional distance oneself and others. The changes Foundation of Menlo Park, CA). www.diversityrx.org/ can range from subtle to very dra- • Professional integrity 4. EthnoMed: Ethnic medical information from • Obligation to deal matic. Harborview Medical Center, Seattle, WA. effectively with Checking in before and after www.ethnomed.org/ INTERPRETING discrimination meetings with clients provides 1. Massachusetts Medical Interpreters SELF-CARE FOR opportunities for interpreters and Association, c/o NEMC Box 271, 800 Washington St., Boston, MA 02111 INTERPRETERS providers to assist each other in 2. Diversity Rx, www.diversityrx.org Interpreting for torture sur- noting any feelings, reactions, and vivors is a taxing endeavor on the responses that may be stressful. I

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37 P R E S S R E L E A S E , 2 0 0 0

T HE CLAS STANDARDS

Health care organizations should ensure that patients/ goals, policies, operational plans, and management account- consumers receive from all staff members effective, under- ability/oversight mechanisms to provide culturally and 11standable, and respectful care that is provided in a manner linguistically appropriate services. compatible with their cultural health beliefs and practices and preferred language. Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related Health care organizations should implement strategies to 9activities9 and are encouraged to integrate cultural and linguis- recruit, retain, and promote at all levels of the organization tic competence-related measures into their internal audits, 2a2 diverse staff and leadership that are representative of the performance improvement programs, patient satisfaction demographic characteristics of the service area. assessments, and outcomes-based evaluations.

Health care organizations should ensure that staff at all Health care organizations should ensure that data on the levels and across all disciplines receive ongoing education individual patient’s/consumer’s race, ethnicity, and 3and3 training in culturally and linguistically appropriate service 11spoken00 and written language are collected in health records, delivery. integrated into the organization’s management information systems, and periodically updated. Health care organizations must offer and provide language assistance services, including bilingual staff and inter- Health care organizations should maintain a current 4preter4 services, at no cost to each patient/consumer with limit- demographic, cultural, and epidemiological profile of ed English proficiency at all points of contact, in a timely man- 11the11 community as well as a needs assessment to accurately ner during all hours of operation. plan for and implement services that respond to the cultural and linguistic characteristics of the service area. Health care organizations must provide to patients/ consumers in their preferred language both verbal offers Health care organizations should develop participatory, 5and5 written notices informing them of their right to receive collaborative partnerships with communities and utilize language assistance services. 1212a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and Health care organizations must assure the competence of implementing CLAS- related activities. language assistance provided to limited English proficient 6patients/consumers6 by interpreters and bilingual staff. Family Health care organizations should ensure that conflict and friends should not be used to provide interpretation and grievance resolution processes are culturally and services (except on request by the patient/consumer). 1313linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by Health care organizations must make available easily patients/consumers. understood patient-related materials and post signage in 77the languages of the commonly encountered groups and/or Health care organizations are encouraged to regularly groups represented in the service area. make available to the public information about their 1414progress and successful innovations in implementing the Health care organizations should develop, implement, CLAS standards and to provide public notice in their 88 and promote a written strategic plan that outlines clear communities about the availability of this information.

S S S S E E E E OTR SURVIVORS TORTURE TORTURE S S S S R R R R O O O O V V C C V V C C EVCSFOR SERVICES EVCSFOR SERVICES H H H H C C C C A A I I A A I I SURVIVORS CREATING CREATING P P P P C C C C I I I I T T T T E E E E A A A A E E E E R R R R S S S S L L L L 4 4 4 4

E SOCIAL SERVICES T P

A IN THIS CHAPTER My community is my support.

H Without my community, I am nothing.

C I SOCIAL WORK Interventions During —SOMALI WOMAN IN MINNESOTA the Resettlement Process

I ROLES OF Social Workers E T I During the Asylum H W

Process O R

orture occurs within a cultural and social A I IMPACT OF TORTURE C © in Accessing and context. It breaks the connections between Providing Social Services Tindividuals and their social environment. LIBERIAN REFUGEES in Sierra Leone. I CULTURAL COMPETENCE bers of other professions. All readers are I WORKING WITH It separates the bonds of communities. Interpreters Social work interventions, therefore, are invited to take what they need from the I PUBLIC POLICY WORK directed at individuals, their families and information offered. immediate environments, community, social, Providing appropriate and effective and functional groups, and policies and sys- services to torture survivors requires a degree tems. These are accomplished through direct of expertise in four core fields:

service, resource development, community • Knowledge of the story of refugees interventions, education and training, research, and asylees — before, during, and and public policy work. after the violence The provision of social services to sur- • Understanding of the nature of torture and its long-term effects vivors of torture is administered by workers on survivors, their families with a wide variety of educational founda- and communities, and the 4 tions and life and work experiences in an professionals who work with them assortment of settings. • Cultural work with traumatized people While this chapter is written for profes- • Best practices for working with interpreters sional social workers, the material is appropriate for social services providers regard- This chapter augments the information less of background, training, or specific concerning the core competencies presented in tasks. Chapter 3. A discussion of social work inter- In addition, some of the material cov- ventions during resettlement and in the politi- ered in this chapter transcends the bound- cal asylum process, sample scenarios illustrat- aries of disciplines and pertains to mem- ing the impact of the effects of torture on accessing social services, and guidelines for FOR MORE INFORMATION cultural competency and for working with

Information for clinical social interpreters and clients are included in this sec- workers can be found in tion. A brief note on policy work and a sum- CHAPTER 6. mary conclude the chapter.

40 OCIAL WORK INTERVENTIONS SOCIAL SUPPORT S 4 DURING RESETTLEMENT Social workers help survivors expand and R

use social support systems to aid in recovery. E

During resettlement, social workers assist T

By building consistent and trustworthy con- P refugees and asylees by establishing trustwor- nections with clients, social workers help them A thy, caring, and healing relationships. H

decrease feelings of mistrust and increase the C Interventions should respect cultural and indi- ability to form meaningful relationships with vidual differences, address survivors’ priorities, others. and give choice and control to the survivors. Most survivors are separated from loved Social work facilitates re-empowerment ones and sometimes social workers can help and capacity-building of survivors in four them locate and safely communicate with fam- main categories of concern: 1) stabilization 2) ily and friends. These connections are critical social support 3) education and 4) personal to survivors’ peace of mind and ongoing and economic independence. recovery. Some survivors say uncertainty STABILIZATION about the fate of their families makes them feel Having a degree of safety and having worse than the torture. access to food, clothing, and housing are Social workers help survivors establish net- essential to stabilization. Laws and works of social support in their new communi- systems in the United States can make provid- ties through service referrals. For example, ing for essential survival needs extremely dif- referrals to English classes provide clients with ficult without support systems; torture sur- opportunities to build friendships with fellow vivors are often completely dependent upon students as well as with the volunteers who others for meeting basic needs. Social workers may offer tutoring or transportation to class. assist survivors in identifying options, com- EDUCATION munity resources, and ways to overcome barri- Survivors come to the United States with ers in their individual stabilization processes varying levels of education, training, work while developing the ability to meet basic experience, and professional rank, which may needs on their own. not be recognized in this country. Pursuing Efforts are focused on helping clients with education in the United States can help build the following: self-esteem and confidence, as well as a foun- • Gaining political asylum to dation for employment. avoid return to country or Social workers offer access to the following situations of danger opportunities to survivors: • Obtaining resources to meet basic needs of food, clothing, • Language classes housing, transportation, etc. • Job training or recertification in a profession or trade • Sustaining personal safety through education and skills • Resources for higher education development. • Systems to support educational

41 T

E efforts (such as financial, cated and arduous process, clients experience 4 N . S

O counseling, and rehabilitative

H considerable stress and anxiety. A social work- T R N I

R aids and referrals). Y E

B er, often as a member of a team, takes on the A L T .

W PERSONAL AND P

W roles of teacher, coach, and advocate/trou-

W ECONOMIC INDEPENDENCE © A bleshooter within the asylum process, alleviat- H “If I give you all Independence is seen from a variety of per-

C ing anxiety for the client and keeping the of my truth, I give spectives—from being able to make choices to process running smoothly. you all of my power.” becoming economically independent. Social

— VIETNAMESE REFUGEE workers assist survivors as they learn about the TEACHER new culture and access employment opportuni- Although attorneys usually explain the asy- ties, job training, higher education, and entitle- lum journey to clients, social workers provide ment programs for those with disabilities. As further definition of the process, while taking survivors gain independence in the various into account limited English, memory prob- facets of their lives, the roles of social workers lems related to trauma, confusion, etc. In addi- diminish. tion, social workers help attorneys understand Examples of client goals in this area include the long-term effects of torture for clients and the following: how those consequences affect attorney-client relationships. • Attaining self-sufficiency and meaningful roles in economic COACH and community life As social workers develop trusting relation- • Enhancing self-identity through relationships and activities that ships with clients, they encourage and support rekindle feelings of pleasure clients’ efforts to tell their stories to the attor- or competence ney and the asylum interviewer. Social workers • Renewing a sense of mastery offer reassurance during the entire process of through the ability to negotiate application, interview, and waiting for the new systems and deal with results. In certain circumstances, a social work- life crises in new setting. er accompanies the client to the interview and ROLES OF SOCIAL WORKERS — with the asylum officer’s approval — sits in DURING THE ASYLUM PROCESS on the interview with the client to provide emo-

Torture survivors who do not come to the tional support.

United States with refugee status may apply for ADVOCATE/TROUBLESHOOTER political asylum. Because asylum is so impor- A social worker helps clients resolve con- tant in a client’s life and because it is a compli- flicts within the process. The client may be

FOR MORE INFORMATION unable to communicate frustration with the attorney and may not be able to resolve the For more discussion of collaboration between conflict for one of the following reasons: attorneys and social • The client sees the attorney in a workers, see CHAPTER 7. position of power and does not want

42 T

to upset the attorney and jeopardize in the community about her. E N 4 . S

their relationship, feeling this might O H T

IMPLICATIONS FOR SOCIAL SERVICES: R N I

endanger the outcome of the case R Y E B A

It can take a long period of interaction in order L T • The client does not want to take . W P W

time from the attorney, who may for a client to be able to talk about needs deep- W © A be providing services pro bono,

er than basic survival needs. Even in a safe, H “My client can’t sleep

and he or she feels indebted to C care-giving environment such as a rehabilita- and I can’t sleep.” the attorney tion center, the process of building a relation- — SOCIAL WORKER AT TORTURE • the client may feel shame and REHABILITATION AGENCY ship may require testing and time. Survivors embarrassment after telling the attorney the details of her or his judge the trustworthiness of the information torture and persecution history. given by the worker in part through the consistency of responses to themselves and to other The social worker helps clients problem-solve clients. or propose strategies to avoid pitfalls within the asylum process. For example, the social worker LEARNED HELPLESSNESS and the client strategize on how to get important A West African client asked the social documents and evidence from the country of worker to do many tasks for him and origin that may be important for the case. showed little initiative in providing for family members. When prompted to contact prospective employers on his own, he did IMPACT OF TORTURE IN ACCESSING not follow through with the phone calls AND PROVIDING SOCIAL SERVICES or visits. Torture affects many relationships by damaging IMPLICATIONS FOR SOCIAL SERVICES: the well-being of its victims and destroying the A survivor may be afraid to act because of the expectation that people relate to each other with previous harsh consequences for any mistake decency and kindness. The long-term effects of such as an incorrect answer. Learned helpless- torture may severely tax the survivor’s capacity ness damages the ability to think for oneself, to access resources and services. In the next sec- express oneself, and take action on behalf tion, several case examples illustrate the effects of one’s needs, desires, and hopes. The social of torture and the corresponding implications worker may respond by offering choices and for social work. opportunities for successful completion of tasks. DAMAGED TRUST A client from a Middle Eastern country DISORIENTATION, CONFUSION, CHRONIC FEAR, AND ANXIETY repeatedly asked the social worker a question concerning family reunification. A client from Laos appeared to lose focus Although she received an appropriate and became bewildered during an asylum answer, she asked another staff member at interview. A Kurdish client was terrified of an the rehabilitation center the same question. interpreter from his home country and did In addition, an interpreter at the center who not show up for subsequent appointments at is from the client’s community informed the the clinic. A torture survivor refused to work social worker that the client checked the at the airport because of the presence of social worker’s credibility by asking others police and others in uniform on the job site.

43 T E IMPLICATIONS FOR SOCIAL SERVICES: and showed up late for class frequently N 4 . S

O although his mother said he went to bed H

T The social worker helps survivors cope R N I

R early each night. Y E B

A with the environment and elements out of L T . W P W their control by helping them to recognize IMPLICATIONS FOR SOCIAL SERVICES: W © A and normalize stress-producing stimuli Symptoms of depression may make language H “None of us had

C and their responses. The worker attempts learning, academic studies, job training, or anticipated how to eliminate potential stressors, such as cultural adjustment tasks difficult. Stressful sit- helpless we would long waits at clinics or social service agencies uations, such as court appearances or asylum be in the face of our interviews, exacerbate symptoms. Medical cultural differences. or encounters in classrooms with others from Words meant one the survivor’s country. intervention or psychotherapy may improve thing to Americans functioning. RAGE and something else to The force of his own rage frightened a Afghans, translations CULTURAL COMPETENCE client from Eastern Europe. A miscommuni- aside.” cation with the instructor in his English class When social workers gain awareness of — AFGHANI REFUGEE put him “over the edge” and he left the class- their culturally derived reactions, assumptions, IN THE UNITED STATES room in an angry state. He hurt himself by and values, cultural competence begins. In banging his head repeatedly against seeking such awareness, workers open them- the wall in the restroom in the building. selves to learning from clients the meaning IMPLICATIONS FOR SOCIAL SERVICES: survivors derive from their past and present Rage is contained under the surface and life experiences, and the meaning they place explodes under trying circumstances. Rage upon new relationships. interferes with the ability to remember, to think Cultural competence is an ongoing process, clearly, or to communicate with others. Clients as the National Association of Social Workers are sensitive to perceptions of differential treat- points out in Standards for Cultural Com- ment within the social service network. While petence in Social Work Practice (2001): acknowledging that anger is understandable given the client’s experiences, the worker helps Cultural competence is never fully clients take actions apart systematically and realized, achieved, or completed, but rather cultural competence is a build a new view of the situation. lifelong practice for social workers who will always encounter diverse clients DEPRESSION and new situations in their A young adult from Southeast Asia was practice. Supervisors and workers not doing well in a job-training program. He must have the expectation that cultural did not retain new information and appeared competence is an ongoing learning to be unmotivated. In addition, he overslept process integral and central to daily supervision. FOR MORE INFORMATION

For more discussion and Social workers should monitor a number of resources related to cultural contextual dimensions during the course of competence, see CHAPTER 3. interactions with clients. These include non-

44 T verbal signals, communication styles, power The following guidelines are helpful for E N 4 . S

O and role differences, gender and age factors, social workers working with interpreters. H T R N I R Y E the physical and environmental settings, and Included are examples of likely scenarios and B A L T . W P the significance of self-disclosure and the conversations among a social worker, a client, W W © expression of feelings. and an interpreter. A A client did not arrive H

In addition, providers should note the ways C 1. TO ENSURE GOOD COMMUNICATION, for scheduled appoint- in which clients perceive problems or chal- take time to introduce everyone and explain ments at the right time lenges and ways in which they view giving or each person’s role. Explain what the role of or even on the right social work is in relation to other professionals receiving assistance. Knowledge of the larger day. The social worker at the agency. relational, historical, political, and religious viewed this as an attempt systems in which clients are set is important. SOCIAL WORKER: Hello, (name of client), to show disrespect for it’s good to meet you. I’m (your name). the social worker’s time BEHAVIORS AND I’m a social worker here. I’ll be working and a lack of interest in CULTURAL DIFFERENCES with you on your everyday needs and con- the rehabilitation effort. cerns, as well as assisting you in reaching Behaviors reveal differences in cultural val- The client, however, some of your future goals. For example, ues. It is not possible to “see” the inner work- operated from a different other clients have been concerned about ings of thought processes but one can observe frame of reference. In places where they can get food, or behaviors. Each person may attribute a differ- understanding the process of getting his country, it is custom- ent meaning to a specific behavior, thereby their work permits, taking language ary to arrive when you arrive. Many circum- creating barriers to building relationships. The classes and finding a job so they can help their families back home. Just as stances can hinder the scenario to the right highlights different per- your doctor assists you with physical speed of the journey, ceptions of time that caused misunderstanding pains or other medical concerns, such as tropical rain, and frustration for client and worker. I’m here to help you with the choices flat tires, or family Using open-ended questions may help facing you here in the United States. obligations. The night gather useful information about the meaning INTRODUCING INTERPRETER: This is before a scheduled of a client’s behavior. For example, “When (interpreter’s name). She or he is here appointment at the clinic, would you come to meetings with someone to help communicate your needs and he had not slept. Falling concerns with me so I can better under- asleep in the early morn- like me if you were back in your country?” and stand and provide you with support or ing, he awoke late and “What would you do in your country before information that can help you to make the came to the clinic past the violence if you were unhappy at work?” choices that you believe are best for you. the appointment time.

2. INFORM THE CLIENT THAT the interpreter On another occasion, WORKING WITH INTERPRETERS will interpret everything said in the room. he came to the clinic on a day when he felt Interpreters are essential to the rehabilita- Try to give an example that illustrates this for the client. If the client does not want most confident facing tion process. They are the voices of both the something to be known, she or he should not the outside world. The clients and social workers, who would not be say it to the interpreter. client operated on a able to communicate clearly otherwise. In SOCIAL WORKER: How are you able to system that valued addition, the method of interpreting provides a meet your financial needs for such things arriving when one unique opportunity to model relationships, as shelter and food? was able to do so. connection, and respect. INTERPRETER: How are you able to

45 4 meet your financial needs for such things as shelter and food? R

E CLIENT: Don’t tell her that the person T

P I live with got me a job with a friend,

A just tell her that my friends help me. H M O C INTERPRETER: Don’t tell her that the C . Y H person I live with got me a job with a P A R G

friend, just tell her that my friends help me. O T O H P - F

3. EXPLAIN TO THE CLIENT THAT THE O - S R E

interpreter will speak as the client. At first this T S A M

may sound odd to the client, especially with , O D

languages that are male/female gendered. A A G L A S male interpreter may be speaking from the O A I T

female perspective or vice versa. S A B E S

SOCIAL WORKER: Are you married? © INTERPRETER: Are you married? trust in human interaction and relationships. CLIENT: Yes, I have a wife and one child. 6. INFORM THE CLIENT THAT INTERPRETERS INTERPRETER: Yes, I have a wife and one are instructed not to introduce their own child. information in a session; they interpret only 4. LET THE CLIENT KNOW INTERPRETERS are what is said by the client and the provider. included in the agency’s confidentiality There may be exceptions to this. For agreement. Make it clear that the social work- instance, an interpreter may know that the er and the interpreter will not share any infor- client has suicidal or homicidal thoughts. mation outside the agency. Clients need to This knowledge is critical for the client’s know that information about their care and care and well-being and needs to be commu- treatment is shared among agency staff who nicated to the social worker immediately. are providing their care and treatment. They may also need to provide a critical Explain clearly the purpose of the release of piece of cultural information to help the information form and why they are asked to provider understand the context and ensure sign the form each time information is to be the meaning is accurately conveyed. shared outside the agency. 7. DEFINE ACCEPTABLE WAYS OF communi- 5. EXPLAIN TO THE CLIENT WHY providers cating between interpreter and client. Explain speaking directly to him or her and not to the to clients it is inappropriate to call interpreters interpreter. The conversation should not focus at home. If the client needs to contact the on the interpreter. The client needs to feel that interpreter, an English-speaking friend can she or he is being helped. phone the agency. That friend may leave a

DO: Do you need help paying this bill? message for the interpreter to call the client, or the client may leave his or her name and phone DON’T: Ask him if he needs help paying number very clearly in her or his own lan- this bill. guage and the interpreter will return the The interpreter is not ignored, however, as client’s call. At times it may be possible to the interpreter is an essential part of the healing arrange a conference call so the client, inter- process. Model with the interpreter a respectful preter, and social worker can talk together. relationship; this can help the client to rebuild 46 direct service workers need to find ways to 8. MODEL SPEAKING IN A NORMAL REFERENCES 4 voice to the client (not too slow or too fast contribute to social change and to feel these Longres, J. F. (1990). R and not too loud or too soft). Explain that efforts have positive impacts on the institu- Human behavior in the social E the following will facilitate mutual under- environment. Itasca: F.E. Peacock. T tional policies that affect their clients. These P standing: National Association of A actions may take place on a local level, Social Workers (2001). H • Talk in short sentences to allow NASW standards for cultural such as advocating for greater community C for accurate interpretation competence in social work prac- resources for low-income workers or for tice. Retrieved on Nov. 12, 2004, • Ask one question at a time from http://www.naswdc.org. pro bono medical services for survivors. • Decide on a convenient Social workers may support agencies ADDITIONAL “stop signal” that everyone RESOURCES can understand and feel that work with state, national, and interna- Barclay, H. H. (1998). Validating comfortable using tional governments to shape public policy torture refugees: Reconnection in that will help torture survivors build better social work policy and practice. 9. USE WORDS, NOT JUST GESTURES, to International Social Work, convey meaning. Take time to explain that lives. They may help clients become active 41(2), 211-226. interpreters need words in order to give the with such organizations. The appendix The Center for Victims of most accurate interpreting of what the directs the reader to some of these Torture Web site: www.cvt.org client wishes to convey. Drachman, D. (1995) resources. Immigration statuses and their 10. DO NOT USE IDIOMS, TECHNICAL influence on service provision, words, or cultural references that are diffi- CONCLUSION access and use. Social Work, cult to interpret or understand. (Some con- 40(2), 188-197. Social work practice is influenced by a cepts may be easy for the interpreter to Engstrom, D. W., & Okamura A., understand but very difficult to interpret.) core set of professional values. These core (2004). A plague of our time: Torture, human rights, and social values are the foundation of the unique per- work, & Working with survivors • Idioms: slow as molasses, spective and mission of the profession and of torture: Approaches to pain in the neck, top dog helping. Families in Society: include: • Technical terms: PTSD, somatic The Journal of Contemporary Social Services, 85(3), 291-309. • Concepts: mental health, • Service Hirayama, H., & Cetingok, M. Social Security, income taxes, • Social justice (1988). Empowerment: A social rental agreements • Dignity and worth of the person work approach for Asian immigrants. Social-Casework, 69(1), • Importance of human 41-47. PUBLIC POLICY WORK relationships Padilla, Y.C. (1997). Immigration Resolution of public policy issues locally, • Integrity policy: Issues for social work practice. Social Work, 4(6), • Competence nationally, and internationally is an essential 595-606. goal of social work with torture survivors. By embracing these core values and Potocky, M. (1996, March). Social workers may choose in their own pro- building knowledge and skills in the four Refugee resettlement in the United States: Implications fessional lives to specialize in direct services core competency areas, social workers pro- for international social welfare. Journal of Sociology and Social work or to focus their efforts exclusively on vide appropriate healing services for tor- Welfare, 23(2), 163-174. social change through policy work. ture survivors. The assistance they offer Ryan, A.S. (1992). Social work However, social workers in direct prac- empowers their clients to rediscover the with immigrants and refugees. Journal of Multicultural tice develop a vision of the larger issues self-esteem, competence, confidence, and Social Work, 2(1). that affect their clients. sense of potential that the torturers tried to

John F. Longres (1990) reminds us that take away. I 47

M M M M S S S S E E E E E E E E R R R R D D D D V V V V C C C C I I I I H H H H I I I I C C C C A A A A C C C C P P P P T T T T A A A A E E E E E E E E R R R R S S S S L L L L 5 5 5 5

5 MEDICAL SERVICES

E his chapter is a resource for physicians T IN THIS CHAPTER

P and nurses working with or planning serv-

A I EFFECTS OF Torture

ices for torture survivors. Preceding chapters / H

T G I ROLES OF Health Care R O . C

Professionals outline the purpose of torture and common R C H

I PROVISION OF Medical N U torture methods. This chapter reviews the .

Treatment W W

I IMPROVING ACCESS long-term effects of torture and describes roles W © to Care Among VIETNAMESE REFUGEE in Thailand. Torture Survivors and responsibilities for physicians, psychia- I CONDUCTING Forensic trists, and nurses who are helping torture sur- Evaluations on Asylum ical and psychological forensic evaluations on Seekers vivors reduce trauma symptoms and rebuild their lives in the United States. These roles and asylum seekers who have been tortured. responsibilities include education, documenta- EFFECTS OF TORTURE tion, assessment, treatment, referral, research, The effects of torture are severe and some- and advocacy. times disabling. A wide range of symptoms While detailed discussion of specific treat- and levels of functioning have been associated ment modalities are beyond the scope of this with individuals experiencing trauma. Many chapter, it will introduce areas deserving fur- factors affect symptom course and prognosis, ther exploration by health care providers. resulting in great variability in how individuals These topics include cultural competence, react to severe stress. working with interpreters, use of medications, and improving access to care. PSYCHOLOGICAL SYMPTOMS 5 Two major meta-analyses (Brewin, 2000; In addition to direct treatment approaches, physicians and psychiatrists are encouraged to Ozer, 2003) of the predictors of posttraumatic integrate preventive components into their stress disorder (PTSD) examined the follow- organization’s programmatic strategies. ing main categories of predictors: Examples of such strategies are discussed in • Historical or static characteristics Chapter 8. Finally, this chapter describes (intelligence, childhood trauma, family resources and training opportunities for physi- psychiatric history, or other prior trauma) cians and nurses interested in conducting med- • Trauma severity • Psychological processes during or immediately after the trauma FOR MORE INFORMATION (including peritraumatic dissociation — For more information dissociative episodes around the time on psychotherapeutic issues, see CHAPTER 6. of the traumatic event) For more information on • Social support and life stress preventative strategies, after the traumatic event see CHAPTER 8. Although all four categories had significant

50 “Social trauma affects predictors of PTSD, the strength of prediction • Appetite disturbance individuals precisely in varied across the categories. Factors closer in • Energy or motivational disturbances their social character; 5 time to the traumatic event showed a stronger • Hopelessness that is, as a totality, as relationship to PTSD than did characteristics a system.” R • Suicidal thoughts E T of the individual or their personal history. Avoidance of thoughts or situations GNACIO ARTIN ARO ESUIT

• — I M -B , J P PSYCHOLOGIST ASSASSINATED BY

Intensity and duration of the trauma experi- that serve as reminders of the trauma THE SALVADORAN MILITARY IN 1989 A ence are two especially important factors. In • Chronic physical complaints H C general, refugees who have endured longer (e.g. headaches, body pain, gastrointestinal problems) periods of torture are more likely to be sympto- matic and/or functionally impaired. Those with Trauma-related symptoms are not always peritraumatic dissociation or a history of child- readily apparent to survivors. Changes in feel- hood trauma also tend to have more difficulties. ings and behavior often occur subtly over time. Those without prior childhood trauma who had Family members or those in close contact with been functioning well prior to their trauma survivors may most clearly observe these experiences generally recover over time. changes. Trauma symptoms may affect a sur- Common psychiatric disorders associated vivor’s relationships, including with family with torture include posttraumatic stress disor- members and in work settings. Survivors’ exis- der, major depressive disorder, substance tential views of the world, of human cruelty, and abuse, other anxiety disorders, and sometimes of God may be severely affected by their experi- paranoia or psychosis (De Jong, 2001; Hinton, ences. They may never again feel the same level 1993; Lavik, 1996; Shrestha, 1998). Examples of trust or connection with human beings or the of common trauma-related symptoms in tor- divine that they had prior to their torture. ture survivors include the following: PHYSICAL CONSEQUENCES • Recurrent intrusive daytime AND SYMPTOMS thoughts or images of the trauma Physical consequences of torture can affect Recurrent traumatic nightmares • all organ systems, as was discovered with tor- Severe emotional distress or • tured prisoners of war in World War II physiological reactions to reminders (Klonoff, 1976). Torture survivors often com- of the trauma plain about physical pain and headaches. • Feeling watchful or on guard without reason Musculoskeletal system complaints are most • Exaggerated startle response commonly reported. • Marked irritability Symptoms and physical findings can vary • Concentration or short-term depending upon which organ system was memory problems affected and how much time has passed since • Feeling distant or cut off from others the torture. Specific types of torture may lead • Numbing of emotions to particular physical findings, such as subcu- • Lack of interest or pleasure taneous fibrosis or compartment syndrome in • Depressed mood the feet from falanga (repetitive beating of the

51 soles of the feet), sexual dysfunction female cutting (female circumcision) in and guidance, survivors can learn to corre- from trauma to the genitals, and nerve or many cultural groups. A full examination late these somatic symptoms with emo-

5 musculoskeletal injuries from body sus- is needed to rule out physical illness, yet tional trauma and stress, knowing that with

R pension or stretching. many times such ‘somatic symptoms’ time, as they begin to feel better emotion- E

T Head trauma with loss of conscious- have an emotional origin or connection to ally, their physical pain may also lessen. P ness is another important injury to assess trauma. Moreover, presenting with somat- A SYMPTOM COURSE H secondary to its potentially profound ic symptoms can also be a more cultural- AND PROGNOSIS C impact on future functioning. This can ly appropriate way of seeking help Symptoms of trauma, including phys- result in changes in memory and atten- Depending upon circumstances, the ical symptoms, fluctuate in severity over tion, as well as affective instability. Some presentation of physical symptoms can be time. A survivor may feel very well for of these effects are acute, while others seen as an index of disease or disorder, an long periods of time before symptoms can be chronic and physically disabling. indication of psychopathology, a symbol- are triggered again by a stressful event or Detailed information on examining ic condensation of emotional conflict, a situation. It is important for trauma sur- torture survivors and the medical effects culturally coded expression of distress, a vivors to understand the common associ- of torture are available in the Physicians medium for expressing social discontent, ation between stresses and symptom for Human Rights (PHR) 2001 publica- or a mechanism through which patients exacerbation so that they do not perceive tion, A Health Professional’s Guide to attempt to reposition themselves within their treatment as ineffective and under- Assisting Asylum Seekers, or from the their local worlds (Kirmayer, 1998). A stand that their increased symptoms will Manual on the Effective Investigation thoughtful discussion of this complex gradually diminish over time. and Documentation of Torture and subject is available in Kirmayer’s article. Of those seeking treatment, some will other Cruel, Inhuman or Degrading Despite possible trauma connections, require one-time treatment, some will Treatment or Punishment (also known as the experience is quite real. The body require intermittent treatment at various the Istanbul Protocol) available on the becomes a metaphor, and emotional pain periods in their life, and others will require PHR web site (www.phrusa.org). is frequently expressed physically. Survivors may complain of frequent ongoing services. When presenting infor- SOMATIC SYMPTOMS headaches or stomach pain while a phys- mation on symptom course, duration of Some torture survivors complain of ical cause of the pain cannot be found medication treatment, and prognosis to unexplained pain and physical symp- with biomedical testing. Torture sur- this third group with chronic impairment, toms for which an organic cause cannot vivors frequently need help in under- it is useful to describe their likely treatment be found. These symptoms may be relat- standing the links among torture, emo- course as analogous to that of other chron- ed to prior experiences of starvation, tional effects, and effects on the body. ic diseases such as diabetes or hyperten- malnutrition, tropical infectious diseases, Survivors are usually relieved to hear sion. Chronic conditions necessitate ongo- head injury, physical assault, or other they are not abnormal, weak, or crazy, ing care and monitoring, and also often untreated chronic illnesses. and their symptoms are a normal human show fluctuations in their clinical course. Health care providers especially need reaction to extreme stress. Like chronic medical conditions, survivors to keep in mind the major infectious dis- It is important to develop links in the with chronic trauma-related impairment eases present in the refugee’s country of survivor’s mind between common pain or will also require ongoing treatment and origin, the prevalence of rape among physical symptoms and their exacerbation can expect periodic exacerbations in refugees, and practices of traditional by psychosocial stressors. With education symptoms and functioning.

52 GRIEF AND LOSS ducted by health care systems or specialized in torture survivors Finally, the loved ones of many torture treatment centers. Individually, physicians • Assisting with care coordination among center providers as well survivors have been killed, or the sur- work to prevent illness through educational 5 as treatment planning vivors are separated from family mem- endeavors, facilitating access to care via R E bers. During the flight to safety, there may health systems change, and pr viding med- PSYCHIATRISTS T P not have been time for refugees to bury ical treatment to torture survivors. With medical and psychiatric train- A their dead in culturally appropriate ways Physicians may direct their education- H ing, psychiatrists assist in deciphering or to mourn for them. Survivors can ben- al efforts toward a number of areas. One C and treating physical and psychological efit from education on the grieving important area includes enhancing com- complaints, which, for torture survivors, process and with encouragement to munity awareness of the effects of torture. are often interwoven. Trained in medical mourn the losses they have endured. A second area involves training other settings, acute psychiatric facilities, and Health care providers need to learn the medical providers to assess and treat sur- psychiatric outpatient clinics, psychia- culturally appropriate means of dealing vivors. Finally, survivors themselves need trists are familiar with providing a range with grief and loss in the survivor’s cul- education to alleviate their fears of med- of services — from handling psychiatric ture. This can be discovered by asking ical illness and disability, help them emergencies to leading multidiscipli- patients and family members. Such infor- understand the need for diagnostic testing nary treatment teams. Outpatient train- mation can be useful in determining when or medications, and promote preventative ing provides psychiatrists with skills to grieving has become inappropriate and information about tuberculosis, HIV, and treat a variety of mental disorders and the individual needs further assistance. other infectious diseases. use multiple treatment modalities. Physicians may also play a central ROLES OF HEALTH CARE Psychiatrists are helpful in disseminat- role in advocating within health sys- PROFESSIONALS ing preventive information to affected tems, HMOs and health insurance PHYSICIANS communities as well as individual clients organizations for the provision of need- Medical treatment by physicians is regarding the medical and psychiatric ed services for torture survivors. They essential to healing torture survivors. effects of torture, focusing on trauma edu- may assist in public and political advo- Lingering body pains and physical cation and coping with trauma (see cacy efforts aimed at increasing general symptoms often create daily reminders “Helping Refugee Trauma Survivors in the resources directed to torture survivors of past torture. Fears of disability and Primary Care Setting” at www.cvt.org). locally, nationally, and internationally. impaired functioning are also common Helping survivors use these coping behav- Finally, the provision of informed, after torture. Similarly, many survivors iors can be essential to their recovery. skillful clinical services by physicians will experience unexplained physical or Trauma education includes describing allows torture survivors to heal from pain symptoms that lead to unnecessary the effects of trauma, normalizing trauma illness and cope with their physical and repetitive diagnostic workups. symptoms, reviewing the course of symp- limitations, by: Medical providers play an important role toms and the prognosis, destigmatizing • Assessing acute and chronic clarifying the nature of physical symp- mental health services, drawing associa- diseases in torture survivors toms in torture survivors and alleviating tions between stress and exacerbated • Providing written and photographic their complaints. documentation of torture-related symptoms, and discussing appropriate Physicians are involved in both planning physical injuries for legal purposes ways to grieve losses. Education on cop- and implementation of interventions con- • Treating acute and chronic diseases ing with trauma includes information on

53 T

E the importance of regular physical activity, prognosis, and completion of N . S

O any disability assessments H relaxation techniques, facilitating religious T N I 5 R needed Y B beliefs or spirituality, strengthening social con- A L . R

W • Utilization of psychiatric rating W

E nections, encouraging employment and hobbies, W

© scales to assess symptom change T finding ways to find new meaning in life, and P A public health nurse • Evaluation of the need for A minimizing negative coping behaviors. visited the home of a psychiatric hospitalization, H Educating survivors about the proper use of psy- including coordinating transfers C refugee woman from Iraq who had recently chotropic medications is another important task of care given birth. During the performed by psychiatrists. • Care coordination among center providers, including facilitating visit, the mother told the Psychiatrists can also be helpful in training nurse that her husband regular multidisciplinary staff on the management of psychiatric emer- treatment planning suffered from anxiety gencies. Moreover, they can train primary care and insomnia and had Psychiatrists are involved in both planning and and psychiatric providers in the community on physical pains for which implementation of interventions conducted by an organic cause could essential aspects of recognizing, assessing, and health care systems or specialized treatment cen- not be found. When the treating torture survivors. Like other physi- ters. Moreover, psychiatrists have the skills and nurse asked the woman cians, psychiatrists may also play an important training to provide multiple treatment modalities if her husband had been role in advocating for treatment, reducing bar- arrested or jailed in their for torture survivors. Treatments include the fol- riers to care, and increasing resources for tor- home country, she began lowing: ture survivors. crying and stated that • Individual, group, or marital/family he had been tortured in A comprehensive psychiatric assessment and psychotherapy prison and that he “has timely treatment facilitates the provision of mul- • Psychotropic medications to never been the same tidisciplinary treatment services. It is essential to alleviate trauma-related symptoms since.” The nurse talked the healing of torture survivors and includes the • Dual medication management with the father about following: and psychotherapy visits when seeking help from appropriate professionals, but he • Standard psychiatric assessment, was adamant about not including: history of present illness, • Motivational interviewing for those needing assistance as trauma history, past psychiatric abusing substances he was not “crazy.” history, review of psychiatric • Crisis management assessment After working with the disorders, substance use history, (e.g., for acutely suicidal clients) family psychiatric history, family for several months, and treatment past medical history, review of the nurse was able to systems, current medications, NURSING make a referral to the mental status exam, pertinent As health care providers, nurses work col- treatment center. During lab findings, bio-psycho-social laboratively within a specialized torture reha- a later visit to the home, formulation, five-axis psychiatric bilitation center or primary care setting. They the father presented diagnoses, and a detailed the nurse with special treatment plan work with physicians and other health care food from his country professionals in achieving identified medical • Evaluation of functional to thank her for helping impairment due to psychiatric goals, such as regularly monitoring blood pres- him to seek help. disorders, determination of sure for those with hypertension and obtaining

54 laboratory testing. and client-satisfaction surveys) medical documentation of torture for asy- Nurses may also work collaboratively lum seekers.

Caring has been identified as the cen- 5 in managing a survivor’s health care. Program evaluation and research are

tral unifying focus of nursing practice; it R essential to improving care for torture

Nursing case management is a process of E is the essence of nursing (Watson, 1999; ensuring that each individual survivor survivors. Research on the effects of tor- T Leininger, 1995). Care is demonstrated P receives appropriate health care services ture, on appropriate measures of clinical A and practiced through the interpersonal both within the torture treatment center or change, and on how to determine treat- H relationship between nurse and client that C primary care facility and in the larger com- ment outcome has been limited thus far. preserves human dignity, wholeness, and munity. The case manager coordinates and Physicians, psychiatrists, and nurses may integrity. Nurses deliver care by respect- monitors the clinical services that the sur- play a vital role by: ing survivors’ priorities, supporting self- vivor receives to assure that the individ- esteem, and minimizing potential stres- • Developing and implementing ual’s unique health care needs are being program evaluation and clinical sors. The nature of the nurse-client rela- met. Responsibilities of the nursing case outcome research strategies tionship concerning the survivor’s physi- manager include the following: • Assuring that such strategies are cal well being allows an opportunity to built into new projects or clinical • Health care service planning rebuild trust. An important article on the programs from their inception. and resource identification role of nurses in torture treatment is “The • Linking clients to needed Fear Is Still in Me: Caring for Survivors PROVISION OF services and coordinating of Torture” (McCullough-Zander and MEDICAL TREATMENT individual client care in the Larson, 2004). CULTURAL COMPETENCE community health care system Treating torture survivors requires • Client advocacy and ALL HEALTH CARE problem-solving with the PROFESSIONALS cultural competence. While it is impossi- health care system Professionals in all areas of health ble to know the norms, behaviors, and • Monitoring service delivery care are involved in documenting the attitudes of all cultures, it is possible to • Evaluating services effects of torture, in making outside refer- approach cross-cultural interchanges with curiosity and an open mind. Such an Nurses educate survivors about rals for clients, and in evaluating treat- approach helps care providers build accessing and navigating the U.S. health ment outcomes for survivors. knowledge and skills over time. care system, including patient rights. As Forensic documentation of the physi- Cultural competence incorporates clinic managers, nurses coordinate health cal effects of torture is an important nonjudgmental questioning of an individ- care services within the torture treatment aspect of providing services for torture ual’s perceptions of culture as well as center or clinic. Responsibilities of the survivors and may include documenting family nuances, sensitive awareness of clinic manager include: the psychological and physical effects of torture in asylum seekers through behaviors and implicit meaning during • Coordinating internal and external history and physical exam, as well as personal interactions, and a commitment health care appointments photo documentation of scars or other to expanding one’s own personal knowl- • Maintaining needed equipment and supplies (such as medications, signs of torture. edge base regarding country conditions physical therapy supplies, etc.) It may be appropriate to create volun- and politics. • Assessing the quality of services teer physician treatment networks or net- Furthermore, working across cultures delivered (e.g., through chart audits works for providing psychological and necessitates re-examination of one’s own

55 attitudes, beliefs, values and prejudices, and 4. Additional detail on working with usually hidden from conscious awareness. interpreters in psychiatry can be found in 5

This awareness can help one work with Westermeyer’s 1989 clinical guide. R torture survivors from a variety of cultures E TRAUMA HISTORY ASSESSMENT T with increasing skill and comfort. P

G When working with refugees, immi- R O . A Prior international experience makes A grants, or asylum seekers, assess for W A H R this process easier. Frequent use of . W

C trauma history. Features that alert clini- W W informational web resources such as © cians to the possibility of a history of Human Rights Watch (www.hrw.org), bership in different or previously adver- torture include the following: Amnesty International (www.aiusa.org), sarial ethnic groups, gender differences, • Status as a refugee, immigrant, the U.S. State Department (www. age differences (e.g., a much younger or an asylum seeker state.gov) and International Crisis Group person interpreting for an older person), • History of civil war in (www.crisisweb.org) provide information and class differences. country of origin about specific groups, their prior experi- Spatial aspects of the client-interpreter- • Reluctance to divulge experiences in country of origin ences, and current country situations. physician triad, as well as the manner and • Client or family member type of questions asked, can be important. WORKING WITH politically active in country AN INTERPRETER Set up the chairs in a triangle so that each of origin When preparing to work together for person can see the others clearly. Take time • Family member who has been the first time, it is helpful for the clinician to observe the interaction and rapport tortured or killed and interpreter to discuss their experi- between interpreter and client. • History of being imprisoned ences, skills, and expectations. The clini- When interviewing, use relatively • Any physical scarring cian should explain the need to know short sentences so the interpreter can • Physical symptoms with no known medical cause everything the client says and the expecta- properly convey the complete content of • Psychiatric symptoms of trauma: tion that the client will be similarly your questions. Do not hesitate to use depression, nightmares, emotional informed. clarifying questions when confused, or numbing, irritability, being easily Consider matching gender whenever summarizing statements to assure prop- startled, difficulty concentrating, possible due to cultural or religious er understanding of a complex story or avoidance, and trouble sleeping issues, potential history of sexual trau- temporal presentation of symptoms. Many torture survivors are reluctant ma, and sociopolitically based mistrust. When attempting to discuss difficult to talk about their trauma history because Factors potentially affecting the inter- concepts such as suicide or hallucina- of the shame of their experiences. They preter-client relationship include mem- tions, work to structure questions so fear they will not be believed, and may they are as unambiguous as possible. attempt to minimize symptoms by trying FOR MORE INFORMATION Sometimes rephrasing a similar ques- not to recall the experiences. For more information on tion later in the interview to recheck cer- In assessing for a torture history, ask working with interpreters and a more detailed tain responses can help verify important an open-ended question about what hap- discussion of working information. pened in the survivor’s country that across cultures, see A more detailed discussion of working forced him or her to leave. If appropriate, CHAPTER 3. with interpreters is provided in Chapters 3 a health care provider can then ask more

56 SAMPLE ASSESSMENT direct questions about a history of being examination are performed or how diagnostic QUESTIONS TO BE imprisoned, beaten, or attacked by soldiers or tests are administered is essential. Torture INCORPORATED INTO

STANDARD ASSESSMENTS 5 rebel groups. survivors benefit from knowing that they can FOR NEW PATIENTS stop or delay medical procedures when nec- R MEDICAL ASSESSMENT E T essary. For some, certain procedures are best IN WHAT COUNTRY Torture survivors want to know what is P were you born? wrong with them physically, which symptoms done under anesthesia. A

CAN YOU TELL ME H they can expect will improve, and what symp- PSYCHOSOCIAL STRESSORS what made you leave C toms they should learn to live with. The rec- Torture survivors benefit from under- your country? ommended medical assessment of all refugees standing the role of current psychosocial HAVE YOU EVER HAD problems because of includes the following: stressors in increasing symptoms. Most your culture or tribe? Your political belief? • History and complete physical refugees have the expectation that once they Your religion? exam, including genitourinary are in the United States their problems will be Your gender? system eliminated. There is widespread perception HAVE YOU EVER BEEN arrested or put in jail? • Skin test for tuberculosis, and/or of the United States as a safe place and one of chest X-ray HAVE YOU EVER BEEN easy opportunity. beaten or attacked by • Vision and hearing screening soldiers, police, or Many torture survivors are therefore dis- rebel groups? • Dental evaluation mayed to find that their psychological and HAVE YOU EVER SEEN • Stool test for ova and parasites physical symptoms often are worse during or heard others being • Urinalysis beaten or attacked? their first few years in the United States • Hemoglobin HAVE ANY MEMBERS because of the additional stressors of rebuild- of your family been • Cholesterol arrested or attacked ing their lives in a new place. Examples of because of their • Serological test for syphilis acculturation stressors for refugees and asy- culture, tribe, political • Hepatitis B screening tests; beliefs, or religion? lum seekers include: possibly hepatitis A and IF A HISTORY OF hepatitis C screening tests • Learning a new culture and possibly torture or trauma is indicated, what a new language • Explanation of and offer of HIV testing problems are you • Lack of social and family networks having now from being • Explanation of and offer of STD testing beaten or attacked? other than syphilis • Financial and work difficulties • Immunization assessment • Concerns about their legal immigration status • Thyroid function testing • Worries about family back home Routine events in a clinic or hospital such • Loss of previous social status as electrocardiogram testing for a survivor of • Changes in family members’ roles electrical torture, or a gynecologic exam for a (e.g., children adopting American rape survivor can be very stressful. Torture value of independence; wife now survivors can better tolerate tests and proce- working outside of the home) dures without being severely stressed if they SOCIAL STIGMA OF are given emotional support and prior educa- MENTAL ILLNESS tion on what to expect. Emphasizing that they Torture survivors and refugees in general are have control over which aspects of a physical often reluctant to seek mental health services.

57 This is usually due to social stigma sur- when they feel better or if they have not apeutic, both emotionally and physically. rounding mental illness and potential impli- noticed any effects within several days.

5 CONDUCTING cations for themselves or their families for With the use of antidepressants for exam- FORENSIC EVALUATIONS R

E seeking mental health treatment. Such ple, patients need to understand that it ON ASYLUM SEEKERS T

P views are common throughout the world. takes several weeks to notice effects. A growing number of physician vol-

A To most refugees, “mental illness” However any side effects that might occur unteers are becoming involved in con- H refers to persistent and usually psychotic usually happen in the first two weeks and ducting forensic evaluations on torture C states that they might call “crazy.” In some then likely resolve. Patients need to under- survivors seeking asylum. Volunteer net- cultures having a family member with stand that if side effects occur, dosages can works have sprung up throughout the severe mental illness brings shame on the be adjusted or medications changed. United States, encouraged and often facil- entire family and may diminish family Understanding how a torture survivor itated by Physicians for Human Rights. members’ opportunities for marriage. discusses and explains illness can help in Physicians conducting psychiatric or Psychotherapy and psychiatric treat- comprehending his or her reasons for not medical evaluations provide objective, ments are generally unknown in most coun- taking medications as directed. Deve- unbiased documentation of the physical tries, which typically have only one psychi- loping a mutual understanding of ratio- and psychological effects of torture. atric institution for the severely mentally ill. nales for using medications is essential A Health Professional’s Guide to Education is required to modify survivors’ to ongoing compliance. Begin follow-up Assisting Asylum Seekers (Physicians for views of mental illness. Presenting emo- appointments with a nonjudgmental Human Rights, 2001) provides an excel- tional problems as a continuum of severity determination of which medications lent resource for physicians and mental from low-level to severe mental health clients are presently taking and why they health professionals seeking to develop problems can be useful. Recognizing that have chosen to discontinue other ones. the knowledge and skills needed to per- each of us moves back and forth on this form clinical evaluations on asylum seek- PHYSICAL THERAPY continuum depending upon current stres- AND MASSAGE ers. It details United States asylum law, sors such as divorce, death of a child or even Specialized torture treatment centers general interview considerations, physi- severe trauma facilitates understanding of have observed benefit among their cal evidence of torture, psychological evi- mental health concepts. patients from physical treatment modali- dence of torture, issues in the assessment MEDICATIONS ties such as physical therapy or massage. of children that have been tortured, how Compliance with medications is a com- Primary care or other clinics treating tor- to provide written documentation of mon barrier to treating torture survivors ture survivors may consider such inter- medical and psychological findings, and and refugees in general. Many refugees ventions when addressing complaints of how to provide oral testimony in court. have either never taken Western medica- chronic pain and physical symptoms. Much of this resource is based on recent tions or, as with antibiotics, have taken Volunteer massage and physical thera- international guidelines for medical-legal them for only short periods of time. They pists now conduct regular sessions for CVT documentation of torture contained in the may lack an understanding of why medica- clients referred because of chronic pain, Istanbul Protocol (found on the PHR Web tions may need to be taken for extended headaches, or other sequelae from injuries. site). The 1999 Istanbul Protocol was the periods of time. Patient education on the Because torture is usually directed in part first document to provide international long-term use of medications is required. toward the physical being of the victim, guidelines for documenting torture and Many refugees stop taking medications attention to the body can be especially ther- was the product of three years of research,

58 analysis, and drafting by more themselves play an active role in REFERENCES than 75 forensic specialists, their rehabilitation. Alleviating Brewin, C.R., Andrews, B., & Valentine, J.D. (2000).

Meta-analysis of risk factors for posttraumatic stress 5 physicians, psychiatrists, psy- misinformed fears of chronic disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766. R

chologists, lawyers, and human impairment and offering words E rights monitors. This group repre- of encouragement are powerful De Jong, J.T.V.M., Komproe, I.H., Van Ommeren, M. et al. T (2001). Lifetime events and posttraumatic stress disorder P sented 40 organizations from 15 tools in regaining hope and in four post conflict settings. Journal of the American A

Medical Association, 286, 555-562. H countries. facilitating recovery. Moreover, Hinton, W.L., Chen Y.C.J., & Du, N. (1993). DSM-III-R C prescription of psychotropic The overall goal of medical disorders in Vietnamese refugees: Prevalence and and psychological evaluation of medications also facilitates sta- correlates. The Journal of Nervous and Mental Disease, 181(2),113-122. torture survivors is to assess the bilization of acute psychiatric Klonoff, H., McDougall, G., Clark, C., Kramer, P., degree of consistency between symptoms and improvement in Horgan, J. (1976). The neuropsychological, psychiatric, an individual’s account of torture overall functioning for many and physical effects of prolonged and severe stress: Thirty years later. The Journal of Nervous and Mental Disease, and the medical and psychologi- torture survivors. 163(4), 246-252. cal findings observed during the In addition to direct service Lavik, N.J., Hauff, E., Skrondal, A., & Solberg, O. (1996). Mental disorder among refugees and the impact of provision, health care profes- evaluation. Both Physicians for persecution and exile: Some findings from the outpatient Human Rights and Doctors of sionals need to consider a broad population. British Journal of Psychiatry, 169(6), 726-732. the World (www.doctorsofthe array of factors that limit torture Leininger, M. (1995). Transcultural nursing: Concepts, theories, and practice. Columbus: McGraw-Hill. world.org) offer training to survivors from availing them- McCullough-Zander K., Larson, S. (2004). The fear is organizations or networks of selves of needed treatments. still in me: Caring for survivors of torture. American Journal of Nursing, 104(10), 54-64. health professionals interested in Programs and services Manual on the effective investigation and documentation developed to educate high-risk conducting this work. of torture and other cruel, inhuman or degrading Professionals may contact communities, to minimize treatment or punishment (The Istanbul Protocol). (1999). (Submitted to the United Nations High Commissioner PHR to find out whether exist- barriers to seeking appropriate for Human Rights). ing networks for assisting asy- care, and to facilitate the recog- Ozer, E.J, Best, S.R., Lipsey, T.I., & Weiss, D.S. (2003). lum seekers are functioning in nition of torture survivors in Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, their area. It is possible to create settings where they are likely to 52-73. a new network of health profes- present are important adjuncts Physicians for Human Rights (2001). Examining asylum seekers: A health professional’s guide to medical and sionals if one is not available. to direct services that can be psychological evaluations of torture. Boston: PHR guided by physicians and Publications. ONCLUSION C nurses. Finally, the forensic Shrestha, N.M., Sharma, B., Van Ommeren, M., Regmi, S., Makaju, R., Kompro, I., Shrestha, G., & de Jong, J. Health care professionals documentation of torture (1998). Impact of torture on refugees displaced within the provide a wide array of expert- among asylum seekers, developing world: Symptomatology among Bhutanese refugees in Nepal. Journal of the American Medical ise and experiences essential to advocacy for appropriate health Association, 280 (5), 443-448. the care of torture survivors. care, and preventing Westermeyer, J. (1989). The psychiatric care of migrants: A clinical guide. Washington, D.C.: American Psychiatric Through their care and leader- torture are also essential com- Press. ship, they strive to encourage ponents in the holistic provi- Watson, J. (1999). Postmodern nursing and beyond. resilience among torture sur- sion of professional health care Edinburgh: Churchill Livingstone. vivors and assure that survivors for survivors of torture. I

59 5 MPROVING CCESS TO ARE MONG ORTURE URVIVORS R IMPROVING ACCESS TO CARE AMONG TORTURE SURVIVORS E T

P orture survivors are often appointments is important for

A reluctant to seek medical and many in low-paying jobs with dif- H mental health services. Several key ficulties taking time off work. C T areas (including health systems Helping women to problem-solve around child care issues or provid- and logistical barriers) have been ing child care at the clinic can also identified as targets for improving

M be helpful. O C the willingness of torture survivors . N A L TRANSPORTATION P

to access appropriate treatments. A K N

H Lack of transportation is another O J

Some examples of issues and . W

W common logistical barrier. Taking

strategies to improve access to care W

© the bus to appointments, especially are described below. U.S. health care clinics are begin- with children, in the winter, or MENTAL HEALTH SERVICES when in pain, is difficult. Helping IN PRIMARY CARE CLINICS ning to accommodate same-day patient visits. survivors to explore community Some primary care clinics, which programs or health care plans pro- PATIENT EDUCATION are a part of the health system most viding alternative transportation, or people are comfortable using, are Education about the effects of even using community or church beginning to incorporate mental trauma and ways of coping is volunteers to provide transporta- health services into their clinics. essential to recovery. Primary care tion can help alleviate this com- Torture survivors may have less clinics are often a major interven- mon problem. resistance to mental health care tion point where large numbers of MUTUAL ASSISTANCE when these services are in the same torture survivors can be reached. ASSOCIATIONS location and not differentiated As such, it may be helpful for pri- Establishing long-term relation- from other health care. mary care clinics to allot 45 to ships with staff at local refugee 60 minutes for the provision SAME-DAY PATIENT VISITS community organizations can of individual or group trauma In many countries, health care vis- sometimes improve a survivor education by appropriate staff. its are not scheduled in advance. communities’ willingness to access As with diabetes education, using Individuals travel to their provider care. Moreover, mutual assistance a designated staff member to on the day they wish to be seen, associations (MAAs) may provide conduct patient education sessions arriving as early as possible, and important adjunct services to their can be helpful. wait their turn. Despite sometimes community members and become waiting many hours, patients CHILD CARE an important referral source for at least know they can be seen on Logistical barriers often prevent health care providers. Staff at the day when their symptoms torture survivors from receiving MAAs can also serve as a cultural or concerns are greatest. Some care. The availability of evening resource to health care clinics.

60 PSYCHOLOGICAL PSYCHOLOGICAL SERVICES SERVICES CHAPTER CHAPTER 6 6

©WWW.JOHNKAPLAN.COM CHAPTER 6

PSYCHOLOGICAL SERVICES

IN THIS CHAPTER orture survivors engage in psychological services to pursue a wide range of goals, ■ CHALLENGES AND rewards of working from single symptom reduction to addressing CHAPTER 6 T with survivors ■ THEORETICAL the complex effects of torture on their families frameworks and communities. Psychological effects of tor- ■ ADAPTING EXISTING ture vary considerably. Likewise, there is wide services for survivors .JOHNKAPLAN.COM ■ EFFECTS OF THE WORK variation in the types of assistance sought to

on the provider ©WWW address such effects, depending on a host of ■ WORKING WITH interpreters factors ranging from service accessibility to Empowerment is a fundamental principle of beliefs about health and healing. psychological recovery, as it is with survivors of Some survivors will have very specific other types of trauma. Through this approach, needs, such as getting a good night's sleep or the provider and client work collaboratively in receiving an evaluation of the psychological choosing psychological services and interven- effects of torture for their political asylum appli- tions that match the survivor’s self-defined cation. Others may address mental health needs recovery needs, goals, and preferences. through community activities and institutions The range of potential interventions is consid- that focus on spiritual or physical health. Still erable. It is beyond the scope of this chapter to pro- others may benefit from a variety of psycholog- vide a comprehensive account of psychological ical or multidisciplinary interventions as they services that may be helpful for torture survivors. progress through a psychosocial recovery This chapter focuses on identifying basic 6 process that involves any of the following: principles and areas of learning needed to begin providing mental health care to torture • Stabilizing and reducing symptoms survivors living in the United States. The • Mourning multiple losses (family, friends, country, status, chapter is written for mental health providers culture, etc.) who are relatively new to working with torture • Coming to terms with the survivors. Providers may be called upon to torture trauma and integrating offer any of a variety of psychological servic- it into one’s life story es to individuals, families, groups, or commu- • Mourning losses nities affected by torture, including crisis inter- • Repairing relationships affected vention, counseling, assessment, consultation, by torture, including the survivors’ facilitation, supervision, and short- and long- relationship to themselves, family, community, and term therapy. even all humanity This chapter is not intended as a “how to”

62 manual. Rather, it serves as a point of depar- The challenges of providing appropriate, ture to help providers determine which types effective psychological services to torture of knowledge or training they need to give survivors exist side by side with both the necessity qualified care. In addition, the authors offer a and the rewards of doing so. Like other popula- number of references of resources for learning. tions, torture survivors deserve access to informed, relevant psychological services in addressing their CHALLENGES AND REWARDS OF WORKING mental-health needs and concerns. Working with survivors, who demonstrate

WITH TORTURE SURVIVORS CHAPTER 6 strength and resiliency in their ability to sur- Mental health providers commonly feel vive torture and the flight from their countries, overwhelmed when they first face the chal- presents providers an opportunity to facilitate lenges of serving torture survivors. The num- the survivors’ efforts to reclaim and rebuild ber and severity of life-threatening traumatic their lives. Many providers say serving torture events experienced by torture survivors, as survivors is a profound experience of mutual well as the human design and perpetration of learning, one that ranks among their most such events, fall outside the spectrum of trau- valuable professional experiences. With ma most providers feel prepared to confront. enough resources and meaningful support, tor- Issues of secondary trauma and counter- ture survivors can recover from their ordeals transference take on new degrees of intensity and go on to thrive. and depth. Providers grapple not only with tor- Working with torture survivors is about ture as an extreme form of trauma but also working with extremes, such as confronting sociopolitical, historical, and ethnocultural the best and worst of what humanity is capable dimensions of survivors’ experiences. of doing. Torture survivors, as a population, Added to this mix are the pressing needs of are highly resilient and resourceful and, at the many torture survivors for medical, legal, and same time, highly vulnerable and affected by social services. At the same time, their eligi- their experiences. The challenge for psycho- bility for such services is limited. This is par- logical services involves questions of how to ticularly true for survivors who are applying address both of these realities without ignoring for political asylum — a complex and stressful or minimizing one at the expense of the other. process by itself. Transportation needs, lan- THEORETICAL FRAMEWORKS guage barriers, and cultural differences pose additional challenges. Due to the sociopolitical context of torture Clearly, this unique population with and the cross-cultural nature of most service many complex needs requires specialized delivery in exile, it is important for mental health expertise. As a result, mental health providers care providers to draw from frameworks both may need to expand their traditional roles within and outside of their field. For example, a to include more case management, advocacy, study-group curriculum developed for commu- and accompaniment. nity psychotherapists at CVT utilizes readings

from not only psychology and psychiatry, of a psychosocial treatment method vivor are as follows: but also cultural anthropology, journalism, developed specifically for torture sur- • Respect literature, and liberation movements. vivors. This method, which originated in • Information Most trauma treatment today is Latin America, draws on truth telling as • Connection based on an understanding of the a ritual of healing. It combines elements • Hope recovery process that emphasizes of exposure, re-telling, re-framing, and reduction and management of posttrau- denunciation/justice-seeking. (For a ADAPTING EXISTING SERVICES FOR TORTURE SURVIVORS matic stress disorder and other trauma- description, see Cienfuegos & Monelli, CHAPTER 6 related symptoms. Judith Herman’s 1983, or Agger & Jensen, 1990). The current dominant system for deliv- classic 1992 work, Trauma and Current clinical trends in the mental ering health care and social services in the Recovery, describes common processes health treatment of torture survivors in United States has its own culture and defin- relevant for many torture survivors that the United States include: ing features. Health care is fast-paced, unfold in this model for recovery. • Group treatment (Victorian time-limited, and organized according to a Many providers use standard trauma Foundation for Survivors Western medical model that focuses on the treatments and approaches developed of Torture, 1996) identification, isolation, and treatment of • on other populations, such as cognitive- Family-focused services specific symptoms or disorders. (Weine et al., 2004) behavioral, psychodynamic, and pharma- Providers in the health care system in • cological to treat torture survivors. For an Integration of somatic the United States developed the follow- psychotherapeutic techniques early review, see Metin Basoglu’s 1992 ing adaptations for mental health service with more established edited volume, Torture and Its Conse- treatments (Gray, 2001). delivery to torture survivors. They refer quences: Current Treatment Approaches. to an existing way of practice that needs As with other types of therapy, the Beyond learning how providers use to be adapted in serving this population. quality of the therapist-client relation- standard treatement with torture sur- Among the different practice contexts ship is more important than the theoreti- vivors, it is important to introduce one- represented by readers of this manual, cal orientation in providing a healing self to conceptual frameworks within some of these adaptations may be more experience for torture survivors. The psychology that are broader than a DSM or less relevant to the provider’s setting Sidran Foundation’s online consumer’s (Diagnostic and Statistical Manual of and its professional culture. Mental Disorders) model of trauma. An guide for choosing a therapist for post- ATTEND TO CULTURAL ISSUES example of a postmodern approach to traumatic stress and dissociative condi- Culture is said to refer to where the psychotherapy that is relevant to work- tions is applicable to torture survivors: survivor is from as well as the general ing with survivors in exile is described in . . . good trauma therapists come culture of fear that develops in societies Bracken’s (2002) Trauma: Culture, from every discipline, work in all where torture is widespread (see Chapter Meaning, and Philosophy. settings, use a variety of approaches and techniques, and have a wide 2). Cultural issues for survivors in exile The testimony method is an example range of credentials and experi- tend to be central regardless of a FOR MORE INFORMATION ence…The dual formulation of vali- provider’s cultural framework or expert- dation and empowerment seems to For resources on ise. No matter how much the providers trauma treatment, see be fundamental to post-traumatic APPENDIX, PAGE 103. therapy…The four most important know about given cultures, they must things a therapist has to offer a sur- always find out what culture means to

64 NOTEWORTHY BOOKS particular survivors and families. time, help survivors understand Survivors’ experiences and beliefs differ that they are not the sole source THE FOLLOWING of information on their culture. autobiographies and widely within cultural groups. Providers field-based journalism offer • Find out who the survivor was valuable insight into survivors’ who fail to grasp this reality can develop before the torture. What would the psychological realities and clinical blind spots and false assumptions. dilemmas. (For instructive survivor be doing to heal if he or examples, see Cohen, 1998; Guidelines for developing cultural she were in his or her home country? Gourevitch, 1998; and Ortiz, 2002). understanding include the following: • Depending on the culture and Anne Fadiman’s 1997 book,

• Learn to identify and articulate background of the survivor, The Spirit Catches You and CHAPTER 6 one’s own cultural beliefs, be prepared to work with You Fall Down: A Hmong Child, survivors who think and express Her American Doctors, and practices, and assumptions. the Collision of Two Cultures Without this skill, the provider themselves at the collective provides an insightful description may make culturally based level (i.e., survivors talking in of how well-meaning terms of “we,” “my people” providers can miss assumptions that are automatic the mark. or unconscious. rather than “I”), or using means of dialogue common to oral EXAMPLES OF • Investigate ways to address integrative work traditions (e.g., proverbs, cultural difference/sameness about the experi- parables, riddles, storytelling). ences of torture among therapist, client, and survivors include: • Incorporate discussions of the interpreter. Have discussions Honoring with all members of the team survivor’s political context into Differences: on how to address these. treatment, particularly as it Cultural Issues in the intersects with culture. For Treatment of Trauma and Loss • Learn from multiple sources by Kathleen Nader, edited by N. example, survivors may use and perspectives about the Dubrow and B.H. Stamm (1999) passionate political discourse in Philadelphia: Brunner/Mazel. countries, cultures, and therapy as a culturally acceptable Serving Survivors of Torture subcultures of survivors the method of expressing strong by Glenn Randall and Ellen provider is serving. Lutz (1991) Washington, D.C.: emotions that are unacceptable • American Association for Learn about other components to express through other means. the Advancement of Science. of the lifelong developmental PROVIDE CLIENT-TAILORED The Mental Health of Refugees: learning process that are involved INFORMATION, EXPLANATION, Ecological Approaches to in cultural competence (e.g., see AND CHOICE Healing and Adaptation by Kenneth E. Miller and Sue, 1998). Culture-specific Torture survivors often are unfamiliar Lisa M. Rasco (2004). expertise is only one aspect of New York: Lawrence culturally responsive services. with health care institutions in the United Erlbaum Associates Inc. • States, social and professional norms, Counseling and Therapy Assess and address culturally With Refugees and Victims relevant variables such as mental health services, and concepts such of Trauma, by Guus van der spirituality and religious as confidentiality and privacy. Not know- Veer (1998) 2nd ed. Chichester, England: John Wiley & Sons. practices, family and social ing what to expect or how things work in roles, stages of resettlement a new land is frightening for many sur- and/or acculturation. vivors and can contribute to a sense of • Use tools designed for cross-cultural dialogue loss of personal power. (Kleinman’s [1978]). In addition, survivors typically come from • Ask survivors what their culture contexts where authorities, including health means to them. At the same care providers, are associated with the unlim-

65 GUIDELINES FOR ADAPTING SERVICES ited abuse of power. Many survivors experi- how confidentiality applies to each enced this abuse directly and intimately. role (interpreter, client, provider, SLOW DOWN OR BECOME bicultural worker, receptionist, etc.). more comfortable with a slower Understandably, they often fear engaging in pace. Information that a provider Often torture survivors wonder is accustomed to getting quickly any kind of healing relationship. about possible connections (e.g., a person’s age) takes Issues of power, control, and trust are between the provider or clinic much longer due to factors such as interpreting time, cultural paramount for torture survivors. Providing and governmental or immigration differences, and psychological authorities, and it is helpful to symptoms. client-tailored information, explanations, address this openly. Asking and choices wherever possible and appro- CHAPTER 6 MONITOR AND/OR REDUCE clients what they would like the the number of questions asked, priate throughout treatment helps the sur- especially in the beginning of interpreter/provider to do if they treatment, in consultation with vivor restore a sense of control and power. see each other in the community is the client. Being asked many questions reminds some clients Providers must be careful not to over- one of many clinical opportunities of the interrogation experience. for client empowerment whelm survivors with too much informa- CHECK IN WITH CLIENTS PURPOSE: What are the goals of the regularly to see how they tion at once. However, the cursory in-per- work together? are doing and offer breaks, son explanations and lengthy documents especially during initial PSYCHOLOGICAL SERVICES: interviews. (e.g., data privacy notices) that are typical What it is, how it works, how it can help HELP CLIENTS MODERATE with mental health clinics in the United the pace of telling their trauma the survivor achieve their goals. States are insufficient and potentially stories. PSYCHIATRIC MEDICATIONS: ACTIVELY ADDRESS ANY damaging in building trusting relation- evidence of re-experiencing Common issues include concerns symptoms or other distress, ships with torture survivors. Listed below about addiction or dependency, dis- allowing as much time as are examples of key areas in which tor- continuing meds once one starts to it takes for clients to feel comfortable enough to ture survivors benefit from personalized feel better, sharing meds with others, proceed. This often means changing one’s dosage, difficulty letting go of interview protocol. information, explanation, discussion, and paying for meds or knowing how ALLOW AT LEAST TWICE AS collaborative problem solving: to use a pharmacy, etc. much time for sessions with interpreters. ROLES AND RESPONSIBILITIES OF CLIENTS’ RIGHTS: Torture CLIENT, PROVIDER, INTERPRETER, ALLOW ADEQUATE TIME AT survivors may or may not be AND OTHER STAFF: the end of sessions for closure For torture familiar with the concept of and for joint planning regarding self-care of clients after meetings survivors, who may attribute enor- “rights.” What are they? and between sessions. mous amounts of power to authori- SYSTEMS AND INSTITUTIONS: ADAPT TREATMENT GOALS ties, it is important to clarify the How they (e.g., social services, to the long processes many provider role, i.e., limits of power survivors face in rebuilding health care, education, employment, and what the provider offers. It is their lives in a new country. legal services, etc.) relate to working For example, the establishment critical to explain who the provider together is an important issue for of safety can take years as is and how they can help in terms clients move through the clients. process of obtaining political directly linked to the survivor’s situ- asylum, locating and supporting ation and/or needs. SLOW THE PACE family members, and bringing EXPECTATIONS: What can the families to safety. The fast pace of health care interac- survivor can expect next? What tions in the United States, with 15-minute does the provider expect next? doctor appointments and single-session CONFIDENTIALITY: What is it and how does it work? What are its psychological assessments, may re-trau- limits. It is important to discuss matize a torture survivor. A core effect of

66 STAGES OF trauma is that the body and mind are over- human rights violations as TRAUMA RECOVERY whelmed and accelerated; too much is hap- strategic, intentional sociopolitical acts in terms that have meaning pening too fast. DRAWING ON COMMON for survivors. elements found across A corrective, healing experience for a different theorists and • Interpreting symptoms or types of trauma, Herman torture survivor involves adapting oneself to torture-related behaviors as the (1992) described the a pace that is tolerable for the survivor. This following broad stages results of pathological systems in trauma recovery: pace may change throughout treatment and of oppression and injustice. 1) ESTABLISHMENT OF needs continuous monitoring. • safety and stabilization Understanding that politics have CHAPTER 6 played a formative role in the 2) REMEMBRANCE AND SITUATE PROBLEMS mourning: coming to IN HISTORICAL AND lives of many torture survivors. terms with trauma and POLITICAL CONTEXTS Survivors need to be able to its effect on one’s life discuss political issues in treatment 3) RECONNECTION: Torture survivors in exile are often aware Rebuilding one’s — the political is personal. life and future their problems are political and historical Survivors commonly recount in PROGRESS THROUGH in origin. They probably would not be in detail political and historical events these stages is not linear this country, let alone the therapist’s office, in their country. They may begin or unidirectional and is affected by ongoing if not for the political situations back home. their stories long before their stress. Moving through individual births. Again, political the stages can take If providers do not clearly demonstrate and cultural factors intertwine in anywhere from months to years. As Herman notes, each an understanding of the context of the sur- work with torture survivors. survivor “must be vivor’s experiences, survivors feel misun- the author and arbiter DE-STIGMATIZE of her own recovery.” derstood, alienated, and misrepresented in (p.133). A torture Torture survivors may feel they are going survivor may define a whatever treatment plan follows. successful recovery as crazy or are the only ones who have prob- Providers should frame problems within constituting one, two, or lems. This is a key reason why many torture all three of these stages. larger contexts in a manner that does not rehabilitation programs use group treatment. minimize the very real psychological Most of the time, torture is a highly soli- problems and distress caused by torture tary trauma. Many aspects of the interroga- and exile. Rather, validating symptoms tion environment are deliberately controlled and other psychological effects as a and manipulated to convince detainees they normal, understandable result of a deliber- are utterly alone and beyond any help. ate political strategy is a key aspect of Cultural and social factors contribute empowerment. At a minimum, this adap- toward stigmatization of mental health tation involves the following: problems in this country and in others. • Conducting assessments and Many survivors are from countries that interventions in a manner that reserve scarce mental health services for demonstrates some understanding the seriously and persistently mentally ill, of the common life experiences of refugees /asylees, the struggle such as persons with schizophrenia. Those of the survivor’s people, and the seeking services for mental health prob- effects of war. lems are labeled “crazy” and, in their • Discussing torture and other countries of origin, suffer serious social

67 stigma and negative economic consequences. can prevent a survivor from remembering or However, torture treatment programs do not re-experiencing torture. find stigma to be an insurmountable barrier. However, a provider should become familiar The following examples are effective ways to with common elements of service environments de-stigmatize the effects of torture and to that can be traumatic reminders for torture sur- uphold the rights of all survivors to receive vivors. These elements include the following: supportive assistance and care: • Lengthy waiting periods to meet • with someone — victims often wait CHAPTER 6 Emphasize problems as normal, to be interrogated and tortured common, expected, solvable, • impermanent, appropriate Room characteristics that are similar and valid. to interrogation cells — small or large, crowded, private/enclosed, windowless, • Use educational materials to dimly lit, bright overhead light normalize effects of torture — videos, printed materials, such as • Uniformed personnel in the building, brochures, checklists, handouts. medical staff and instruments • Consult with interpreters, clients sitting in the same position bicultural workers, and other for long periods of time. cultural liaisons to determine • Clients asked many questions culturally congruent, nonshaming At the first interview, providers should explanations and concepts. explain their awareness of the potential for sur- • Express openness to consulting with others from whom the client vivors to encounter traumatic reminders and seeks healing or assistance. should develop a mutually agreed-upon plan for • Emphasize that clients deserve how clients and providers will address the prob- services and explain any differences in lem. If one is not sure, but suspects something is cultural norms regarding what it means a reminder or is distressing the survivor, address to seek mental health services for trauma the issue directly with the survivor. Ask, express recovery (e.g., “normal” people receive psychotherapy in the United States). understanding, validate and normalize, and negotiate a mutually agreeable solution. ADDRESS THE POTENTIAL FOR RE-TRAUMATIZATION For example, in one instance, a small windowless office reminded a survivor of her tor- There is no exhaustive list of the sights, ture cell. The provider arranged to provide ses- smells, sounds, and other experiences that sions in a larger family therapy room that had trigger intrusive post-trauma symptoms or ample natural light. lead survivors to re-experience aspects of the torture. Anything can be a reminder: ordinary TRAUMATIC MATERIAL objects such as an office stapler or a broom Concerns about re-traumatization are com- handle, and ordinary experiences such as wait- plex; probing into traumatic material is likely ing for an appointment or being questioned. to raise difficult feelings and issues for Likewise, there is no list of objects to providers, clients, and interpreters. remove from the office or things not to do that For example, mental health providers may

68 RESOURCES FOR fear that clients will experience them as tor- ity with pencil-paper measures or the kinds PSYCHOLOGICAL turers. Strong counter-transference is nor- of questions asked on personality invento- ASSESSMENT mative in working with torture survivors. It ries. Clients also may be preliterate, which FOR PSYCHOLOGICAL is vital that providers have access to educa- providers might not know at intake. evaluation of asylum seekers and/or assessment of psycho- tional and training resources as well as pro- If these tools are used, providers logical evidence of torture, the fessional consultation. An excellent should incorporate extra client prepara- following may be useful: resource for increased understanding of tion time to explain, obtain informed con- PHYSICIANS FOR HUMAN RIGHTS (2001) clinical issues involved in treating trauma sent, and reassure. This is particularly true Examining Asylum Seekers: A Health Professional’s CHAPTER 6 is Countertransference and the Treatment if the client does not know how to read or Guide to Medical and of Trauma (Dalenberg, 2000). write and providers must administer the Psychological Evaluations of Torture. Boston: Physicians Because of the nature of torture trauma, measure orally (if it is considered valid for Human Rights. providers need to collaborate carefully with when orally administered). At the end UNITED NATIONS of the session, providers need time to (1999) The Manual on clients in the use of any exposure-based the Effective Investigation techniques, including telling one’s story. In debrief with survivors about the process and Documentation of Torture and Other Cruel, addition, providers must work closely with of completing the measures. Inhuman or Degrading Privacy issues are extremely important Treatment or Punishment clients in using interventions that aim to (The Istanbul Protocol). change thoughts, beliefs, or ways of think- to torture survivors. Providers should New York: United Nations. ing, because that is also the aim of torturers. carefully explain any collection of data for POTENTIAL FOR the purposes of assessment or research. RE-TRAUMATIZATION Providers should find ways to maximize THROUGH ASSESSMENT privacy (e.g., use ID numbers instead Assessment deserves special mention, of names). HIPAA now mandates client because many clinics use standardized privacy. assessment tools and measures. Aside from serious validity problems for meas- WORK HOLISTICALLY ures lacking appropriate translations and The many urgent needs of torture sur- normative data on persons from survivors in exile confront mental health vivors’ countries, the responsible use of providers with direct confirmation of questionnaires and tests with torture sur- Maslow’s hierarchy. Psychological con- vivors takes into account the potential for cerns must often take a backseat to more re-traumatization. primary survival needs such as food, cloth- Survivors may be suspicious about the ing, housing, physical safety, income, and reasons providers are asking them to com- location of missing family members. plete written measures. Questions about In addition, due to culture and other past trauma and current symptoms may be FOR MORE INFORMATION very evocative for survivors. Survivors For a description of may be unfamiliar with many aspects of HIPAA regulations, the procedure of filling out multiple forms see PAGE 70. in a waiting room. They may lack familiar-

69 HIPAA AND FEDERAL PRIVACY REGULATIONS factors, health can take on an absolute medical concerns quality and meaning for torture survivors • Talk about mental health within the ALL HEALTH CARE PROVIDERS that encompasses physical, mental, and client’s frame of reference, which have both an ethical and legal may be holistic (i.e., do not duty to protect the confidentiality spiritual health. Providers must address and security of client health care separate mental from the spiritual survivors’ health in a holistic manner. information. The Health Insurance and/or physical domains) Portability and Accountability Act Mental health providers must address (HIPAA) became a law in 1996. • In collaboration with the client, This law requires, among other the mental health issues of torture survivors work with other services and things, that the vast majority of all health care entities nationwide, within the broader social, political, and eco- significant persons of influence in CHAPTER 6 including health care providers, the client’s life, both stateside and health insurance plans, HMOs, nomic environments affecting their physical abroad (e.g., social, legal, medical health care clearinghouse, and and mental health. That typically involves business associates of those service providers, family members, entities, take steps to protect the expansion of the provider’s traditional serv- elders, traditional healers, religious privacy and confidentiality of all clients’ health records. ice delivery role as well as widening the cir- leaders, other community or cultural AS OF APRIL 2003, AGENCIES cle of those with whom one collaborates. liaisons, embassies and immigration are required to comply with new In psychotherapy, examples of this officials, non-governmental federal privacy regulations that organizations working in the were issued under the Federal adaptation include the following: Health Insurance Portability and country of origin, etc.) Accountability Act (HIPAA). • When state laws for privacy Collaborate closely with the client’s protections are more restrictive social service providers. If a client EFFECTS OF THE than HIPAA, those provisions of does not have a social service WORK ON THE PROVIDER state law generally takes prece- dence over HIPAA provisions. provider, establish relationships Psychological services involve inti- A CD WITH CVT’s HIPAA with community agencies that policies and employee training provide case management services. mate contact with stories of torture and manual is available to members Expand the traditional role of the of the National Consortium of associated reactions such as changes in Torture Treatment Programs. therapist to include advocacy thoughts, feelings, bodily sensations, and (even when there are other advocates), and accompaniment belief systems and worldviews. Providing (e.g., accompanying a client to psychological services to torture survivors an asylum interview as a requires providers to tolerate immense supportive presence) pain and to come to terms with the human • Provide some concrete assistance capacity for evil in a manner that goes at the first interview and establish beyond psychological explanations. There yourself as a resource in addressing are fundamental moral questions when the client’s immediate needs (i.e., do not just ask questions but dealing with the extremes of human cruel- also offer suggestions, referrals, ty and sadism as well as extremes of or other resources during an initial human resiliency and strength of spirit. assessment interview) By design, torture is incomprehensible, • Address mental health within the unspeakable; its horrors take one beyond context of primary survival needs social science into the realms of faith, phi- such as food, security, housing, losophy, and other age-old ways that location of and communication with loved ones, treatment of human beings have tried to find meaning physical injuries and serious in suffering and evil. Simply put, working

70 RESOURCES THAT ADDRESS with torture changes providers. It is fool- endless, but common examples include THE IMPACT OF THE hardy to imagine otherwise and yet breath work, meditation, physical exercise, WORK ON THERAPISTS impossible to anticipate how one is and sports, spiritual and religious prac- GENERAL RESOURCES FOR changed in advance — a reality that many tices, movement-based practices such as therapists in addressing the effects of the work include therapists beginning with this population dance and yoga, massage, and gardening. the following: understandably find daunting. Relative to working with other forms of Countertransference and trauma, torture trauma can be particularly the Treatment of Trauma The effects of working closely with by Constance J. Dalenberg isolating. Psychotherapists working with (2000) American Psychological trauma are covered extensively in the lit- CHAPTER 6 Association: Washington, D.C. erature and are called by various names, torture commonly feel as though they do Treating Compassion Fatigue such as secondary trauma, vicarious trau- not have access to peers who understand by Charles R. Figley (2002) New York: Brunner-Routledge. ma, and compassion fatigue. Since sec- them or can relate to their particular Trauma and the Therapist by ondary trauma is affected by individual stresses, struggles, and dilemmas. Sustain- Laurie Anne Pearlman and ing connection with sources of professional Karen W. Saakvitne (1995). factors and the work environment itself, it London: Norton. is important that providers receive ongo- and personal support is extremely important Transforming the Pain: in attending to the effects of the work on the A Workbook on Vicarious ing training and consultation tailored to Traumatization by Karen W. their particular work setting. mental health provider. Developing colle- Saakvitne and Laurie Anne Pearlman (1996) New York: gial relationships with other therapists from Secondary trauma in psychological W.W. Norton. torture treatment programs around the service delivery is an issue for everyone Secondary Traumatic Stress: country is uniquely and profoundly helpful Self-Care Issues for Clinicians, involved: especially interpreters, bicul- Researchers and Educators in addressing the reality of professional iso- edited by B. Hudnall Stamm tural workers, and others from affected (1995) Lutherville, Maryland: lation. communities who have their own trau- Sidran Press. matic history, collective traumatic histo- WORKING WITH INTERPRETERS ry, and ongoing trauma back home. Interpreters are in the position of hearing For clinicians who do not speak the the trauma twice (in both languages) and same language as the torture survivor, an having to simultaneously absorb and interpreter will be part of the therapeutic interpret the trauma story. Establishing relationship. Providers of psychological processes and procedures for screening, services need ongoing training on the training, supporting, debriefing, and col- unique impact and role of interpreters in laborating with interpreters in addressing psychological assessment and treatment. secondary trauma is essential in provid- The presence of an interpreter changes ing interpreted psychological services to the dyadic relationship between torture torture survivors. survivor and clinician to a triadic relation- Many therapists who work with torture al system. Interpreters take on a powerful trauma find it helpful to develop regular role in the treatment process, as they give self-care practices that address the effects voice to the experiences of the survivor of the work on their bodies, minds, and and to the reactions and responses of the spirits. The list of potential practices is clinician. Only they understand every-

71 thing said. Various mental health con- FAMILIAR STRATEGIES USED plans, familial roles, and BY PSYCHOLOGICAL SERVICES responsibilities. cepts do not translate readily into other TO HELP TORTURE SURVIVORS • languages, making pre-session collabo- Help survivors anticipate and cope Providing torture survivors with psy- with potentially re-traumatizing ration and post-session debriefing with chological services requires new skills and experiences (e.g., asylum inter- interpreters essential in providing knowledge. However, it is important for view or hearing) or with unex- responsible, ethical service delivery to therapists new to this work to understand pected experiences of re-victim- ization (e.g., crime, racism, etc.). torture survivors. Many therapists that much of their previous repertoire and • beginning to work with interpreters find Foster the connection of thoughts, CHAPTER 6 training is relevant. The following strate- feelings, bodily sensations, and it challenging to have a third person gies or interventions used by psychothera- other responses to the trauma present and to work with the complexi- pists in their work with torture survivors from which they originated; ties of a triadic relationship. may sound familiar to those who have normalize these experiences. Issues related to the interpreter-client worked with other forms of trauma: • Foster the establishment or match can profoundly affect how the re-establishment of trust in • Provide information to survivors others and in the world, to provider and client address (or fail to about posttraumatic reactions, whatever extent possible. address) trust, dependency, shame and such as PTSD and depression, • Promote positive connection or other common issues in therapy. The and provide information about the psychological effects of reconnection with others. therapist may or may not be aware of trauma; normalize and validate • Address pre- and post-torture how various dimensions of the match these reactions. trauma experiences which may affect the relationship: gender, age, • Provide a safe, therapeutic also be of significance. social class, political affiliation, tribe, environment for the emotions • Foster the eventual connection ethnicity, religion, education, and geo- that survivors feel; listen, receive, or reconnection with meaningful and endure the emotions with graphic region of origin. Consult with return to one’s social, cultural, the survivor. political, and economic roles, the client — ideally, before the first • Help survivors learn to calm and to whatever extent is desired appointment — on relevant dimensions soothe themselves by teaching by the client. of the match for a given client. specific anxiety-management As mentioned earlier, the therapist For an introduction to the dynamics of strategies and through internaliza- tion of the therapeutic relationship. variable is widely regarded in effective working in a triadic system, review Haenel • Help survivors identify their trauma therapy. For a discussion of this (1997). For an introduction to building beliefs about experiences of factor in psychotherapy for severely effective professional partnerships with torture and persecution and traumatized refugees, see Kinzie (2001). interpreters and learning about the inter- begin to examine those beliefs All qualities demonstrated by a good preter’s role in mental health service deliv- imposed under torture (e.g., “I was responsible for what therapist — genuineness, warmth, high ery, see Lee (1997). Another general was done to my family.”). positive regard, responsiveness, consis- resource is Working With Interpreters in • Assist survivors through the tency, and respect — are as important in Mental Health (Tribe, 2003). grieving and mourning of working with torture survivors as with FOR MORE INFORMATION multiple losses. any other clients. • Assist survivors with their overall General guidelines for Many survivors highlight the value working with interpreters adjustment to a new environment can be found in CHAPTER 3. and the re-establishment of of feeling heard and believed as the ■ occupational and educational most healing aspect of their treatment.

72 REFERENCES

Agger, I., & Jensen, S. (1990). Testimony cation: Therapeutic use of interpreters. http://www.sidran.org/howtochoose. as ritual and evidence in psychotherapy In E. Lee (Ed.), Working with Asian Tribe, R. & Raval, H. (2003). Working for political refugees. Journal of Americans: A guide for clinicians. with interpreters in mental health. Traumatic Stress, 3, 115-130. New York: Guilford Press. London: Brunner-Routledge. Basoglu, M. (Ed.). (1992). Torture and Manual on the effective investigation and van der Veer, G. (1998). Counseling and its consequences: Current documentation of torture and other cruel, therapy with refugees and victims of treatment approaches. Cambridge: inhuman or degrading treatment or pun- trauma, 2nd ed. Chichester, England: Cambridge University Press. ishment (The Istanbul Protocol). (1999). John Wiley & Sons. Bracken, P. (2002). Trauma: Culture, (Submitted to the United Nations High Commissioner for Human Rights). Victorian Foundation for Survivors of meaning, and philosophy. London & Torture. (1996). A guide to working CHAPTER 6 Philadelphia: Whurr Publishers. Miller, K., & Rasco, L. (Eds.). (2004). with young people who are refugees: Cienfuegos, A. J., & Monelli, C. (1983). The mental health of refugees: Strategies for providing individual The testimony of political repression as a ecological approaches to healing counseling and group work. therapeutic instrument. American Journal and adaptation. New York: Lawrence Victoria, Australia: Victorian of Orthopsychiatry, 53, 43-51. Erlbaum Associates Inc. Foundation for Survivors of Torture. Cohen, R. (1998). Hearts grown brutal: Nader, K., Dubrow, N., & Stamm, B. H. Weine, S.; Feetham, S.; Kulauzovic, Y;, Sagas of Sarajevo. New York: (Ed.). (1999). Honoring differences: Besic, S.; Lezic, A.; Mujagic, A.; Random House. Cultural issues in the treatment of trauma Muzurovic, J.; Spahovic, D.; Zhubi, M.; and loss. Philadelphia: Brunner/Mazel. Dalenberg, C. (2000). Rolland, J.; and Pavkovic, I. (2004). Countertransference and the treatment of Ortiz, D. (2001). The Survivors’ Bosnian and Kosovar refugees in the trauma. American Psychological Perspective: Voices From the Center. United States: Family interventions in a Association: Washington, D.C. In E. Gerrity, T. M. Keane, & F. Tuma services framework. In K. Miller and (Eds.), The mental health consequences L. Rasco (Eds.) The mental health of Fadiman, A. (1997). The spirit of torture (pp. 13-34). New York: refugees: Ecological approaches to catches you and you fall down: Plenum Press. healing and adaptation (pp. 263-293). A Hmong child, her American doctors, New York: Lawrence Erlbaum and the collision of two cultures. Pearlman, L.A., & Saakvitne, K. W. Associates Inc. New York: Noonday Press. (1995). Trauma and the therapist. London: Norton. Figley, C. (2002). Treating compassion ONLINE RESOURCES fatigue. New York: Brunner-Routledge. Physicians for Human Rights. (2001). Examining asylum seekers: A health The following tips on online resources and Gourevitch, P. (1998). We wish to inform professional’s guide to medical and their use is adapted from the Center for you that tomorrow we will be killed with psychological evaluations of torture. Victims of Torture online resource manual our families: Stories from Rwanda. New Boston: Physicians for Human Rights. created by Wendy L. Roehlke, library vol- York: Farrar Straus & Giroux. unteer at the Center for Victims of Torture. Randall, G. R., & Lutz, E. (1991). Gray, A. (2001). The body remembers: Serving survivors of torture. Washington, http://www.apa.org/psycinfo/ Dance/movement therapy with an adult D.C.: American Association for the PsycINFO®, available from the American survivor of torture. American Journal of Advancement of Science. Psychological Association (APA) is an Dance Therapy, 23, 29-43. Saakvitne, K.W., & Pearlman, L.A. excellent online resource because of its Haenel, F. (1997). Aspects and problems (1996). Transforming the pain: A coverage of the field. The drawback: associated with the use of interpreters workbook on vicarious traumatization. It requires someone to pay for the access. in psychotherapy of victims of torture. New York: W.W. Norton. In some instances, the database may be used Torture, 7(3), pp. 68-71. in university or public libraries at no charge. Stamm, B. H., (Ed.) (1995). Secondary Herman, J. (1992). Trauma and traumatic stress: Self-care issues for http://www.apa.org/psycinfo/ recovery. New York: Basic Books. clinicians, researchers & educators. products/psycfirst.htm Kinzie, J. D. (2001). Psychotherapy Lutherville, Maryland: Sidran Press The APA also produces PsycFIRST®, for massively traumatized refugees: Sue, S. (1998). In search of cultural containing PsycINFO’s current year The therapist variable. American Journal competence in psychotherapy and of data plus that from the three previous of Psychotherapy, 55(4), 475-490. counseling. American Psychologist, years. This database is helpful in Kleinman, A. (1978) Culture, illness and 53, 440-448. searching for the most recent materials. care: Clinical lessons from anthropologic It requires someone to pay for the access Therapy for post traumatic stress and and cross-cultural research. Annals of but may be available through university dissociative conditions: What to look Internal Medicine, 88, 251-258. or public libraries. for and how to choose a therapist. Lee, E. (1997). Cross-cultural communi- Retrieved Feb. 28, 2005, from

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legal representation. U A . L W P H BUILDING A I W K W Attorneys encounter torture survivors with H

C cultural competence O © J

I EFFECTIVE LEGAL a variety of legal needs. Frequently, however, © representation with an interpreter the survivor’s initial and most pressing legal Most survivors of torture are newcomers to problem involves immigration matters, such as the United States. They share with other new- asylum, family reunification, or defense from comers the challenges of unfamiliarity with removal (deportation). Because safety is cru- the United States legal system and lack of flu- cial to the survivor’s ability to engage fully in ency in the English language. torture treatment services, the asylum process Survivors often face specific trauma-relat- is integral to rehabilitation. ed challenges—depression, post-traumatic Other related immigration legal services, stress disorder, anxiety, and fear of authority, including family reunification and obtaining including lawyers and the judicial system. The lawful permanent resident status, may also be client’s relationship with an attorney, prosecu- vital to the survivor’s steps toward rehabilita- tor, or judge may be problematic if legal pro- tion. Survivors with a variety of immigration fessionals participated in the client’s torture or statuses may find themselves in need of repre- persecution. sentation in these matters. Without a lawyer’s careful attention, these When feasible, torture treatment centers issues may interfere substantially with clients’ 7and immigration legal services professionals ability to participate in their representation. work in cooperation. Lawyers, however, are In these situations, attorneys must diligent- rarely trained to work with survivors of torture ly practice the basics of good lawyering: build- and may be overwhelmed by many challenges ing a solid attorney-client relationship, com- presented during representation. municating effectively with the client through- The goal of legal representation is decep- out representation, and, at all times, treating tively straightforward: to provide sound legal the client with dignity and respect. advice that enables the client to make an informed choice of action, and to represent the LIFE EXPERIENCES AND RESETTLEMENT ISSUES client in achieving his or her legal objective. Realizing that goal can be far from simple, A survivor’s life experiences and issues especially when the lawyer represents a client unique to resettlement in a new country may who has survived the trauma of torture. create obstacles to the effective delivery of

76 legal services. The client, lawyer, and other short, it is critical that the attorney take time to service providers may need to address these ask questions about the client’s background, experiences and issues before representation explain basic concepts, and remain open to the can move forward. client’s questions throughout the process. 7

AVOIDING ASSUMPTIONS DEALING WITH IMMEDIATE NEEDS

The lawyer cannot assume a torture sur- Torture survivors deal with complicated R E vivor is familiar with basic U.S. legal concepts, and emotionally stressful resettlement con- T P

which are often learned by those who grow up cerns. Unfortunately, many legal issues arise A in this country through high school civics during one of the most stressful periods in the H C classes and television courtroom dramas. client’s life. While the lawyer must clarify the attorney- Often clients will turn to their attorneys to client relationship with all clients, it is espe- solve the many problems they are facing, cially important when representing torture sur- including lack of adequate housing, unem- vivors that the attorney avoids making ployment, isolation, medical problems, or lack assumptions and takes time to start at the of transportation. Some of these issues—such beginning. as obtaining employment or petitioning to Concepts like the adversarial process and bring family members to the United States— the independence of the judiciary may be may not be solvable until asylum is granted, unfamiliar. Confidentiality of communica- making it particularly important that the attor- tions and attorney-client privilege — the foun- ney act promptly to establish realistic expecta- dation of the relationship — must be carefully tions for time frames and the likelihood of suc- explained. cess. Other issues, most obviously medical Attorneys working with torture survivors, problems, should be referred to the appropriate whether providing free legal services or work- professionals. ing for a fee, must take care to draft clear Still other issues may require effort, atten- retainer agreements specifying the legal fees, tion, and creativity on the attorney’s part. For the costs for which the client will be responsi- example, if the client cannot travel to the attor- ble, and the scope of the legal work to be ney’s office, the attorney may need to consider undertaken. The attorney must explain these meeting in a location nearer the client’s home, agreements to the client at the outset to ensure conducting some business by telephone, and the client understands the services. coordinating meetings with other appoint- While some clients may not know the U.S. ments the client has in order to minimize trans- legal system, it is a mistake to assume clients portation problems. are unfamiliar with legal concepts or lack For asylum seekers, many other issues, in sophistication or education. Clients come from addition to securing legal immigration status, all backgrounds and may be attorneys, judges, hinge on obtaining asylum: release from physicians, government officials, scientists, detention, employment authorization, and eli- professors, journalists, or business owners. In gibility for government assistance, housing

77 BALANCING NEEDS: programs, job-training services, and the ability that will benefit their families. LEGAL DEADLINES VS. IMMINENT NEEDS to reunite with family members. Refugees entering the United States REUNIFICATION WITH FAMILY through the refugee resettlement system face SCHEDULE REGULAR, enormous stress in the refugee camps, long periodic meetings Concerns for the safety of family members 7 with the client. This waits for permission to enter the United States, left behind and efforts to be reunited with them

R allows the client to are of critical importance to the asylum seeker. and a lack of access to sound legal advice while E schedule regular T transportation and Attorneys working with asylum seekers should in the refugee camps. Attorneys working with P coordinate the visit refugees need to be aware of the contents of A with the lawyer with explain realistic time frames to avoid giving H other appointments. false expectations. Deadlines, such as for filing their clients’ refugee files. C Most importantly, Attorneys must pay particular attention to this keeps the a petition for refugee or asylee family mem- preparation of the bers, should be clearly explained. refugees who enter the United States as deriv- case on schedule even when some Lawyers should also think about how to ative beneficiaries of a parent’s refugee appli- meetings are less minimize delays. For example, in order for an cation before filing other applications or peti- productive due to the client’s asylee to petition to bring his or her spouse and tions. In some cases, the child, called the deriv- attention to ative refugee, may not be the biological child immediate children to the United States, the asylee must concerns. submit proof of the relationship (such as the of the parent, or principal refugee. birth certificate or marriage certificate) and a Immigration authorities often discover this photograph of each family member. These doc- when the child applies for naturalization and a uments may take months to obtain. Asylum request is made for a change of name to the seekers can begin gathering this documenta- child’s true name, which was concealed at the tion while waiting for their asylum decisions, time of refugee processing. Because this rela- so they can file petitions for the family mem- tionship was misrepresented, the child’s refugee bers immediately upon obtaining asylum. status may be terminated and removal proceed- Similarly, attorneys or other legal workers ings initiated. While there is little corrective helping refugees reunify with family members action that can be taken once the misrepresenta- abroad should take care to lay out necessary tion happens, it is crucial that the attorney dis- steps and convey accurate information about cuss these possibilities with the refugee before deadlines and expected adjudication times. filing petitions for relatives or applications for Torture survivors applying for lawful perma- adjustment of status or naturalization.

nent resident status or naturalization may be BALANCING LEGAL DEADLINES AND relying on that status to petition to immigrate CLIENTS’ IMMEDIATE NEEDS other family members, including adult sons Dealing with legal realities in an empathet- and daughters, siblings, and parents, to the ic and productive way is essential. The client United States. needs to know the attorney cares, while under- Other survivors may be unaware of the ben- standing that the attorney may be unable to efits of lawful permanent residence or of citi- solve all problems and that there are bound- zenship. Careful advice from immigration aries to the attorney-client relationship. attorneys helps survivors make sound choices When the client is working with profession-

78 T als at a torture treatment center, their care team itself. The Triple Trauma Paradigm, identifies E N . S O may include a social worker skilled in helping trauma the client has likely experienced at dif- H T N I R Y the client find solutions to immediate needs. If ferent phases: pre-flight, flight, and post-flight. B A L . W

the client does not have access to such compre- In each stage, clients will experience fears and W W © hensive services, the attorney should make, losses that influence their ability to participate 7 A uniformed police when possible, appropriate referrals to other in legal proceedings. R officer passed by David E service providers. The unfortunate fact, howev- T THE TORTURE SURVIVOR’S and his attorney in the P er, is that services may not be readily available RESPONSE TO THE LEGAL SYSTEM law office building. A to clients without immigration status. In some instances, members of the home The attorney’s response H C Ideally, the client’s immediate needs are country’s legal system were involved in the was one of mild curiosity met before they must deal with legal problems. repression and torture survived by the asylum about where the officer In reality, the lawyer must balance legal dead- seeker. Understandably, this may create an was going. David, who is a torture survivor, lines and the need to prepare the case with the immediate barrier to developing a trusting on the other hand, client’s desire to focus on immediate, day-to- relationship between the client and the attor- became silent and day concerns. ney. Clear explanations of the role and duties began sweating. His Clients may be in such distress over housing, of the lawyer in the United States legal system assumption, based financial, or medical concerns that they are may alleviate this concern. on his experience, unable to concentrate on legal issues. In such sit- Traumatized clients may be reluctant to was that someone — uations, preparing the case will take more time. work on the details of their asylum claims, perhaps he — would The lawyer must keep case deadlines clearly in which involve recalling and recounting be taken away by the police without charge the client’s mind while remaining aware of other extremely painful events. They may deflect or explanation. important issues facing the client. these discussions by focusing on other issues. Fear of authority figures, including the COMPREHENDING TORTURE client’s own attorney, immigration officials, Inherent in the asylum process is the telling and judges may interfere with the attorney- and retelling of the client’s story of torture, client relationship or with the client’s ability to trauma, and persecution. While obtaining the go forward with the legal case. story, the attorney must avoid re-traumatizing The response of the United States govern- the client. The client must confront issues of ment to asylum seekers exacerbates the client’s loss—especially the loss of family, home, fears. Many asylum seekers, including torture work, and community—during the asylum survivors, are detained in U.S. jails, prisons, process in order to present the case to the adju- and immigration detention centers throughout dicator (asylum officer or judge). An attor- their cases. Often conditions of detention mir- ney’s ability to address these complex issues while assisting the client with his or her legal FOR MORE INFORMATION needs is critical to effective representation. For more information on An attorney needs to be aware that the the Triple Trauma Paradigm, see CHAPTER 3. client’s trauma is not confined to the torture

79 T

E ror those the asylum seeker fled. Asylum seekers are held to an extremely N . S O

H Lawyers working with detained torture high standard. They must recount every T N I R Y

B survivors need to establish that they do not material detail of their case, including dates, A L . W

W work for the government and that communi- times, places, and people. They must recount W ©

7 cations with clients will remain confidential. their stories in a coherent manner, enabling

Birana, a medical

R Attorneys may be the only contact clients the adjudicator to understand what took

E doctor from Nepal, have with the outside world. They must be place and why. They must answer questions T developed what seemed P alert to the clients’ medical and psychologi- about why the persecution or torture took to be a good rapport A cal needs, advocating for clients with deten- place, why they were targeted, and why they H with her volunteer attorney,

C who was working with a tion facilities or immigration authorities to were able to escape to safety. torture survivor for the ensure clients are receiving appropriate care. The client’s account of events must be first time. They enjoyed detailed, consistent, and complete from the GATHERING FORENSIC lively discussions about DOCUMENTATION outset. Once the written claim is filed, adding Birana’s profession and The attorney will need to coordinate the information later remembered or shared with observations about the gathering of forensic documentation related to the lawyer may be seen as embellishment and U.S. medical system. When the client’s asylum case, including medical lead to a finding that the client is not credible. the attorney’s questions At the same time, asylum seekers must turned to the client’s incar- and psychological assessments. Procedures ceration in her home coun- governing the client’s access to outside med- file their claims within one year of arrival in try, however, Birana grew ical and psychological personnel may be diffi- the United States. Few exceptions apply to unresponsive. Applying cult to navigate, and will vary depending on the one-year deadline and claims that the traditional credibility his or her location. Often the attorney will be client was too traumatized to immediately indicators, the attorney called upon to obtain documentary evidence pursue the case often will be rejected. If asy- became concerned Birana from the client’s home country. Efforts must lum seekers are in removal proceedings, their was fabricating her claim. be made to ensure the detained client is able to applications and evidence must be filed in After a meeting at the accordance with court filing deadlines. referring legal services carry the burden of proof in the asylum case. Developing the torture survivor’s asylum organization, the volunteer DEVELOPING THE CASE: attorney concluded Birana’s AVOIDING RE-TRAUMATIZATION case cannot be completed in one sitting. trauma was probably severe WHILE GETTING THE FACTS Lawyers must plan to work with the client and referred her to the A successful asylum case depends upon closely throughout the available time to best local torture treatment the client’s accurate written and oral testimo- develop the case. The client and attorney center. Birana received ny about the experiences leading to flight must build sufficient rapport and trust for the treatment while the volun- from the country of persecution. Cases hinge client to be able to reveal all aspects of the teer attorney continued on two interdependent items: first, the con- story, including embarrassing or humiliating working with her. After sistent, complete, and accurate retelling of learning the extent of details. Frequently relevant information is Birana’s suffering, the the client’s story, both in the written revealed only after the attorney and client attorney described her application and in person; and, second, the have been working together for an extensive as the bravest individual client’s credibility as indicated by demeanor, period. she knew. Eventually specificity, detail, and consistency while To present the case persuasively, the attor- asylum was granted. retelling the story. ney must become familiar with the client’s

80 own story and the context in which the vivor is lying. Counsel for the asylum dence in support of their claims. events unfolded, in addition to seeker must understand the sequelae, or Evidence of physical injury and psycho- gathering documentary and forensic aftereffects, that result from torture. The logical condition, together with an expert evidence. attorney also must develop evidence to opinion regarding the likely cause, may

Rushed preparation of the case risks present to the adjudicator that offsets a be persuasive. Obtaining evaluations in 7

leaving important elements undeveloped. negative credibility finding. advance of the asylum interview or R E

Because so much hinges on the grant of removal hearing enters this information T COORDINATING CARE: asylum, the client may be understandably WORKING EFFECTIVELY into the record. Professionals preparing P WITH TORTURE TREATMENT A anxious for the case to proceed quickly. these evaluations may be called upon to H PROFESSIONALS While the attorney needs to avoid unnec- serve as expert witnesses at trial. C As discussed earlier, the effects of tor- essary delays, he or she also must keep the Attorneys should never assume that ture can interfere with the client’s full bigger picture of case development and the client’s treating physician or therapist participation in the legal case. There is no evidence production in mind. will provide an evaluation or serve as an substitute for a care team trained in work- Symptoms suffered by survivors, expert witness. Practice will vary ing with torture survivors to help meet including depression, anxiety, and post- depending on the torture treatment cen- the client’s medical, psychological, and ter’s policies and on the needs of the indi- traumatic stress disorder, may interfere social needs. Where such expertise is not vidual client. with clients’ ability to participate in their available, attorneys need to research At the onset of representation, the cases. Clients may have difficulty remem- providers who have sufficient training to attorney and members of the client’s care bering details of events. Their emotional assist their clients. team should discuss whether the provider reactions when recounting traumatic All members of the care team will bet- will be able to serve as an expert witness events may seem inappropriate. ter serve the needs of the client when they in support of the asylum case or whether They may avoid discussing the torture work together. For example, the attorney an outside assessment will be required. or other traumatic events or begin miss- may benefit from understanding the Also, the attorney must develop a plan ing appointments with the attorney when effects of torture as they relate to the and timeline for developing expert they anticipate the discussion will be too client’s memory of the event. The psychol- assessments and witnesses. painful. Clients may not recount torture ogist may benefit from knowing about an events in a linear fashion; they may jump upcoming asylum hearing that may be BUILDING from one event to the next or omit details. causing the client anxiety. The social CULTURAL COMPETENCE This may be particularly true for individ- worker, trying to arrange housing, may Cultural competence is ever-develop- uals who have endured multiple arrests or need to know the status of the client’s ing and is a critical tool to building a for whom torture started at an early age. immigration case to determine eligibility sound, productive, and ethical attorney- Traditional indicators of credibility in for programs. Regular communication client relationship. Cultural experiences U.S. courts—demeanor, eye contact, con- among team members facilitates care. affect many aspects of this interaction. sistent recall of events—may not be valid In addition, medical and psychologi- These include building trusting rela- indicators in the client’s culture or may be cal assessments by experts may provide tionships, evaluating credibility, develop- affected by shame surrounding the torture documentation in support of the asylum ing client-centered case strategies and itself. Both attorneys and adjudicators may claim. Asylum seekers have the burden of solutions, and gathering information. jump to the conclusion that a torture sur- producing all reasonably available evi- Cultural competence is largely a matter

81 T

E of common sense, awareness, and will- arrested three times, but in the course of N . S O

H ingness to learn new information. discussion with the attorney preparing his T N I R Y

B asylum application, he mentioned many A L . DEVELOPING W

7 police. Eventually the client explained

Communicating effectively with a When sought as a witness in R person from another culture is challeng- that when the attorney asked about

E a criminal investigation,

T “arrests,” he thought only of the three Beatrice, an asylum seeker, ing. Body language, gestures, gender P and her attorney met with the times he was held in prison for extended A roles, communication, and story-telling

H criminal defense attorney. styles may vary dramatically. periods of time. The dozens of other times

C The defense attorney carefully Building cultural competence he was stopped by the police and detained laid out Beatrice’s options: to talk for a few hours or days he regarded as to the police without assurances involves learning about differences that the conversation would not be can stand in the way of clear understand- “routine” and not worthy of mention. used against her in later criminal ing. For example, gestures such as nod- Basic understanding of the client’s charges, to seek assurances the ding may convey a different meaning home country can greatly facilitate com- conversation would not be used munication. For example, interviewing against her later, or to refuse to than that assumed by the listener. Paying clients from Ethiopia can be challenging if talk to the police. When Beatrice close attention to the client’s eye contact, asked what would happen if she tone of voice and manner of answering the attorney does not know the Ethiopian refused to speak to the police, questions provides cues as to the client’s calendar is approximately seven years and the attorney replied “the govern- comfort with the relationship and the eight months behind the Julian calendar ment might try to make things commonly used by the rest of the world. difficult.” Beatrice, a survivor of process of obtaining legal services. As Professor Angela McCaffrey dis- torture, went pale, believing the DEFINING FAMILY attorney meant she would face cusses in her article, “Don’t Get Lost in RELATIONSHIPS the same torture she had suffered Translation: Teaching Students to Work Cross-cultural communication skills in her home country. The With Interpreters,” (2000) taking time to are never more relevant than when the immigration attorney, aware of the torture, explained she would learn the basics of the home country’s attorney and client are discussing family absolutely not be tortured or legal system and the client’s social and relationships for immigration purposes. otherwise physically harmed by political background helps avoid misun- Attorneys working in the field of immi- the police for exercising her derstandings, saves time and frustration, gration understand the precise, technical constitutional right against self-incrimination. The defense and more accurately conveys the client’s definitions given to various family attorney then detailed what sort story. relationships under the Immigration of pressure the police might bring Make sure that lawyer and client are and Nationality Act. Definitions of against her in that situation. Had using the same definition of a term. For “spouse,” “parent,” and “child” all may the miscommunication not been example, a client maintained he had been be found at 8 U.S.C., Section 1101. discovered, Beatrice would have been unnecessarily frightened These definitions are substantially dif- and would have been unable to FOR MORE INFORMATION ferent from those used in standard make an informed decision because For more information American English, and may be radically she would have based her decision on cultural competence, different from the definition commonly on a critical misunderstanding. see CHAPTER 3. understood in the client’s culture.

82 Unfortunately, misunderstandings or Avoid assumptions about family rela- be used throughout the preparation and inaccurate descriptions of the family relationships. Ask questions about the rela- presentation of the case. Failure to use tionship described by the immigrant tionship rather than relying on the descrip- competent and impartial interpreters client may have grave consequences: tor of uncle or sister to make assumptions. risks errors, omissions, and inaccuracy

negative credibility findings, denial of Draw family trees to understand all the rel- that later may be insurmountable. 7

family reunification petitions, and revo- evant characters in the client’s story. Nowhere is accurate interpretation R E

cation of status and removal from the It is particularly important for the more crucial than in the asylum case. The T United States. attorney to apply the basic concepts of asylum seeker’s credibility will be judged P A

There simply is no room for error in cultural communication skills in this on the consistency of specific, and often H identifying the family relationship on area. The attorney must recognize that minute, details of the case. C immigration forms. Misrepresentations, not all cultures define family relation- Asylum seekers in the United States whether intentional or not, made by torture ships in the same way. Without this must provide their own interpreters at survivors on their immigration forms may recognition, the attorney may fail to their Asylum Office interviews. come back to haunt them years later when adequately question the client about the Interpreters at asylum interviews are immigration authorities demand authenti- relationships and may not elicit sufficient rarely certified, professional interpreters cated birth certificates or paternity testing. information to accurately analyze the and are often friends, family, or commu- relationship under the relevant legal Because of the potentially tragic conse- nity members. definition. quences of inaccuracies when listing fam- Asylum seekers and others appearing in Equally important, the attorney must ily members on immigration forms, attor- the U.S. Immigration Court are provided remain nonjudgmental when the client neys working with torture survivors must with a court interpreter, who is either an describes family relationships that are not elicit accurate descriptions of the relation- employee of the court or under contract to commonly recognized in the United States. ship between the client and the family provide interpreting services. While many For example, a male client may indicate that members. Simply asking the client to list Immigration Court interpreters provide he has more than one wife. While the prac- their children, for example, without excellent interpretations, failure to detect tice of polygamy is not permitted in the explaining the definition of the term child and correct errors threatens the non- United States and the client may be unable and without questioning the client about English-speaker’s access to the justice sys- to obtain immigration status on behalf of the precise parentage of their children may tem. his entire family because of this, it is critical yield an inaccurate or incomplete list. that the attorney learns this information in THE CHALLENGE Clients asked about their children may OF INTERPRETING order to represent the client effectively. think broadly, applying the practical defini- Interpreting and translation are difficult tion of child used in their country, and EFFECTIVE LEGAL tasks, requiring interpreters and translators include the children of relatives or neigh- REPRESENTATION to be competent in both languages. In addi- bors left in their care at the outbreak of war WITH AN INTERPRETER tion, they must be familiar with the cultur- or the disappearance of a child’s biological Effective legal representation depends al backgrounds of the client and attorney, parents. On the other hand, clients may on clear and accurate communication. the particular dialects used, and any think very narrowly, assuming the attorney For those not fluent in American English, required technical language. is asking only for those children living in interpreting is essential. If interpreting is In one case cited by McCaffrey, the the client’s household. necessary, a competent interpreter must Spanish sentence “!Hombre, ni tengo diez

83 T kilos!” was interpreted by the court interpreter as and complicated personal experiences of a E N . S

O “Man, I don’t even have 10 kilos [of drugs],” traumatic nature are discussed. Discuss with H T N I R

Y rather than “Man, I don’t even have ten cents.” clients whether they would feel better able B A L .

7 mistaken drug conviction of a Cuban man. first language.

R An attorney prepared Interpreting is even more complex if legal Next, it is important to select an interpreter E an asylum application or other specialized language is used. When T who will be effective in the particular situa- P using the interpreter who working with torture victims seeking asylum or tion. While there is no set rule for which inter- A initially accompanied the in any immigration matter, the interpreter H preter will be best, certain considerations client to his office. The C needs to be familiar with specialized terminol- should be taken into account. For example, if client spoke and read ogy, including technical legal language no English and the case the interpreter will be called upon to appear at explaining the asylum and immigration laws, was prepared entirely an interview with the Asylum Office, it is through the same place names from the home country, and terms important to work with an interpreter who is for torture techniques. interpreter. The asylum both unrelated to the asylum applicant and case was not called for STEPS FOR SELECTING who has lawful immigration status in the interview for several AN INTERPRETER United States. years. During that time, First determine whether the client needs an It is important to find a neutral, qualified the interpreter died. interpreter. If an interpreter is needed, then When finally scheduled, interpreter rather than a family member or determine in what situations. the client brought a new friend. Immediate family members may not be The client may be able to speak sufficient interpreter to prepare permitted to interpret at official immigration English to schedule appointments by tele- for the interview. It was interviews, such as the asylum interview. discovered that many phone but be unable to understand questions Interpreting by family or friends may inhibit of the incidents included or convey important information. Be alert for open communication between the attorney and in the asylum application clients who seem to latch onto nouns in a sen- the client. never happened to the tence but who are unable to distinguish more client, but rather For example, a woman who was raped in complex concepts, such as time or direction. were inserted by the prison is unlikely to discuss this with the attor- The client may be able to speak English, but interpreter to bolster ney if her husband is interpreting for her and not read or write important documents, so pro- the case. does not know of the incident. Or, the husband viding either translated documents or making may leave out this information, not wanting to an interpreter available to read the documents share his wife’s rape with the attorney. Such in the client’s language is required. omissions obviously may have profound conse- Partial knowledge of a new or second lan- quences on the asylum claim. guage is limiting when emotionally sensitive A shared cultural background between the

FOR MORE INFORMATION client and the interpreter may assist in effective communication. But in some cases, the value of For more on overcoming challenges of language that shared cultural background may be out- interpreting, see weighed by other considerations. CHAPTERS 3 and 5. Some clients fear discussing their case in

84 front of a person from their own country. They fear the REFERENCES interpreter will not maintain confidentiality of the infor- Abbott C. & Bubany, C. (1996). The anatomy of a client interview. mation and that others in the community will learn The Practical Lawyer, 42, 61-78. Aron, A. (2001, February). Refugee psychology 101: A crash course embarrassing, humiliating or simply private information. for attorneys. Torture Survivors Network. Professional Papers. Bryant, S. (2001). The five habits: Building cross-cultural Other clients may fear that the interpreter will convey 7

competence in lawyers. Clinical Law Review, 8, 33.

information about their political activities to the govern- R McCaffrey, A. (2000). Don’t get lost in translation: Teaching law ment of the home country. E

students to work with language interpreters. Clinical Law Review, T

When political, ethnic, and clan disputes from the 6, 347. P

Yale-Loehr, S. (2004). Initial interviews. In S. Browning (Ed.), A home country continue to be problematic in immigrant 2004-2005 Immigration & nationality law handbook. H communities in the United States, an interpreter from Washington, D.C. American Immigration Lawyers Association. C another faction may be perceived by the torture survivor as ADDITIONAL RESOURCES someone with a bias against them. The value of a shared www.humanrightsfirst.org Human Rights First (formerly Lawyer’s Committee for cultural background is lost, and an interpreter from outside Human Rights) the client’s immediate community is more appropriate. www.lirs.org/What/ Work with the client to find an interpreter who will, in that par- programs/torturesurvivor.htm The Detained Torture Survivor Legal Support Network is a ticular situation, provide the best means of open communication. nationwide network of legal service hubs for torture survivors held Finally, the cost of interpreting should not be over- in immigration detention. They have produced Pocket Knowledge, a 40-page booklet with practical information for individuals released looked. It is customary for attorneys in private practice to from immigration detention. Available online in French, English, bill interpreter costs to clients. Clients and attorneys should Spanish, and Arabic. www.aila.org clearly understand who is to bear the cost of hiring an inter- www.ailf.org preter. Responsibility for such costs should be specified in The American Immigration Lawyers Association and the American Immigration Law Foundation provide excellent the retainer agreement. While the use of competent inter- resources to attorneys practicing in the area of immigration law, preters is essential, the use of paid professional interpreters including practice advisories and litigation support. may not be. Attorneys should explore options for volun- www.asylumlaw.org Free Web site run by an international consortium of agencies that teers when possible. help asylum seekers in Australia, Canada, the United States, and several countries in Europe. Provides links to legal and human rights CONCLUSION resources, experts, and other information valuable for asylum seekers. Legal work on behalf of torture survivors provides both www.ilrc.org enormous professional satisfaction and great challenges. The Immigrant Legal Resource Center provides technical support The basic tenets of professional responsibility will help and publications designed for nonprofits working in the area of immigration law. build a successful working relationship with clients who www.uscis.gov have survived torture. In addition, by tailoring legal repre- Web site for the U.S. Citizenship and Immigration Services. This site has location and filing information for immigration benefits, sentation programs for torture survivors, structural barriers including asylum. Free immigration forms may be downloaded or can be reduced to provide survivors with the greatest filed from this site. Case status information for cases pending with USCIS may be obtained. access to legal services. For those attorneys providing even www.usdoj.gov/eoir occasional services to torture survivors, careful considera- The U.S. Immigration Court system and the Board of Immigration tion of the particular needs of the survivor can enhance Appeals. This site has court and BIA location and filing information, a Virtual Law Library, and information about free immigration attorney-client communication, strengthen the record, and legal services around the United States. ultimately contribute to the success of the case. I

P P P P S S S S S S S S U U U U L L L L T T T T E E E FOR E R R R R A A A A O O O O R R R R V V V V N N N N R R R R V V V V I I I I C C C C N N N N V V V V T T T T H H H H I I I I A A A A C C C C O O O O U U U U I I I I P P P P N N N N T T T T R R R R E E E E R R R R E E E E R R R R G G G G S S S S S S S S E E E E 8 8 8 8

PLANNING SERVICES FOR TORTURE SURVIVORS

he existing programs for torture survivors

8 IN THIS CHAPTER

in the United States represent a wide vari- G R R

I STEPS IN PLANNING O . C E

ety of models for structuring services for tor- S Services T F A T .

I ASSESSING THE NEEDS W P

ture survivors. Each program became aware of W W

of Survivors and Resources A © I FINANCIAL SUPPORT the needs of torture survivors in its own way. H for Services ABEER AND OMAR, now living in Amman, C Some have been providing services for two Jordan, were forced to leave Baghdad after I DECIDING ON THE the fall of Saddam Hussein. Range and Model of decades and others are just entering the field. Services to Provide Although the field of torture treatment is I INCLUDING ties affected by torture who might be benefi- Prevention Strategies in its infancy, a body of knowledge has been ciaries of increased or enhanced services for I TRAINING AND developing over the last twenty years through Supporting Staff their views on needs. accumulated clinical experience and Inventory the agencies and individuals in research. Chapter 1 outlines the history of the the community who are already providing torture treatment movement. Chapters 3 services to refugees and other immigrants and assess how their missions and practice through 7 describe in some detail the major may or may not make them logical partners. service components of programs for torture survivors: social services, psychological 2. DETERMINE THE POSSIBLE sources of financial support for services for torture services, legal services and medical services. survivors and the challenges in financing This chapter gives additional information these services. for program planners on needs and resource 3. DECIDE THE RANGE AND LIKELY model of assessment, financing, choices in structuring services. If planning to provide only one type 8 services, and training and supporting staff in of service, make a plan for how a torture sur- this demanding work. vivor can be connected to other needed serv- This information can be used to plan special- ices. Keep in mind that many programs have begun based on available professions or ized programs for torture survivors. It can also funding, and expanded those services as part be used by mainstream health, social service, or of a vision for integrated services when new legal service providers who want to adapt their resources became available. existing services to serve torture survivors. 4. DECIDE WHETHER TO INCORPORATE approaches for preventing torture into the STEPS IN PLANNING SERVICES program plan.

The major tasks involved in planning to pro- 5. DECIDE HOW PROGRAM STAFF will vide services are: receive the training and support on the job they need in order to carry out their roles 1. ASSESS NEEDS AND existing resources. effectively. In particular, program leaders Interview key stakeholders from communi- must develop a plan for managing vicarious

88 A SURVIVOR PERSPECTIVE trauma and its impact on clients, staff, and torture treatment programs ON SERVICES the organization. • Treatment services for a particular G

Dianna R O

Details on pursuing each step follow. .

group, e.g. Khmers, Bosnians E N I

Ortiz, an Z A G

• Immigrant services, e.g. resettlement A M

American N

ASSESSING THE NEEDS A C agencies I R E

who was M

OF SURVIVORS AND A .

• Human rights advocacy, e.g. legal W tortured in W

EXISTING RESOURCES W © advocacy organizations 8 Guatemala, Before designing a program it is impor- • Services based on a specific discipline, writes in The Mental R E tant to find out who are the torture survivors e.g., cultural psychiatry, legal aid Health Consequences T

for the poor P in the community, what kinds of needs they of Torture from the A • Services for a designated have, and who is already trying to address perspective of survivors: H

patient population, e.g. C those needs and with what success. If this “Talk therapy is not the mainstream clinics in areas only form of treatment step is omitted, you may find that few people with high immigrant populations that has proved useful. are knocking at the door for services, too Each mission offers strengths and weak- Some survivors use many agencies are competing for the same nesses in providing services for torture traditional medicines, few funding dollars, and/or you repeat mis- survivors. Most important, an organization such as natural remedies takes already made by others. prepared by traditional or individual interested in developing healers. Others favor INVENTORY AGENCIES AND services for torture survivors must find INDIVIDUALS IN THE COMMUNITY techniques such as body an honest basis in mission for doing the work, massage, aroma Who else in the community also works work and anticipate where the mission may and sound therapy, with refugees or torture survivors? By col- pose limits on or contradictions with what special breathing and laborating with others who share a common is needed to help. relaxation exercises, vision, you can avoid competing for limited If there are not many organizational or the ancient spiritual funds, duplicating services, and putting tradition of shamanism.” resources in your community, are there inter- unnecessary limits on services. State refugee ested individuals? Many existing programs coordinators are a good starting point for the started with committed individuals, taking inventory process. They can be located via time from their primary jobs to assist torture the Web site of the Office of Refugee survivors or asylum seekers. Resettlement, www.acf.dhhs.gov. Look for programs that are already serving immi- INTERVIEW KEY STAKEHOLDERS FROM THOSE COMMUNITIES grants from affected communities and pro- AFFECTED BY TORTURE grams whose missions seem compatible. It is imperative to collaborate with affect- Existing programs for torture survivors ed communities to determine their needs. Ask in the United States reflect a wide range the following questions of members of such of missions. Organizations’ missions are communities: What is the range of ethnicities focused on the following types of services torture survivors are likely to come from in and programs: your community? Does the program plan to

• Treatment services exclusively serve everyone who is eligible for services, for torture survivors, i.e., stand-alone depending on capacity, or does the program

89 plan to serve particular ethnic commu- them? If services are intended for just approaches to psychological services nities? If the torture treatment program one or a few linguistic groups, the pro- may be very popular with some people grows out of one serving a specific eth- gram may need fewer interpreters and not well accepted by others. Torture nic community, is it open to serving tor- because it can use staff who speak the survivors from countries with no history ture survivors from other countries with languages of its clients. If services are of mental health services may be reluc- varying linguistic needs? open to a wide range of ethnicities, you tant to access those services without addi- 8 In order to obtain accurate demo- will need to think through the linguistic tional education about what they are, how R

E graphic information, program planners needs of prospective clients and how to privacy is assured, and how their health T

P need to go beyond state refugee admis- meet them. beliefs about certain symptoms and their A sions or the usual sources for public Programs that move into torture causes match up with the provider’s. H

C health information. Refugee admis- treatment from a base in serving a par- Existing programs that serve torture sions vastly underestimate the actual ticular ethnic group may assume that survivors differ in range of served pop- number of refugees because they do not they can continue to serve only that ulations. Some programs limit services include secondary migration. group. However, there are several to specific ethnic groups. Other pro- They also do not include immigrants potential problems with that approach. grams are based in a particular geo- who did not officially come as refugees First, if a program receives funding graphic area with one or several new but who may be torture survivors. School from the Torture Victims Relief Act, immigrant groups. The majority of pro- districts’ English-language-learner statis- those funds are earmarked for torture grams serve a multiethnic population tics provide good proxy information on survivors, and not particular ethnic based on their status as torture sur- actual immigrants with children from groups. If yours is the only such pro- vivors. In addition to interviewing key various language groups in the communi- gram in your city, you may not exclude stakeholders from affected community, but may exclude highly affected popu- a client based on ethnicity alone. ties, consult with existing programs lations such as Liberians, whose primary Second, many torture survivors have that serve the same ethnic groups the language is often listed as English. deep mistrust of people from their own proposed program plans to serve. There is little local epidemiological country, based on the particular condi- FINANCIAL information on torture prevalence tions in which the torture occurred. SUPPORT FOR SERVICES because immigrants are usually not (See Chapter 2 for more information.) Torture survivors often have limited questioned about this exposure by Some ethnic-specific programs may financial resources; their life’s health professionals. Mutual aid associ- replicate the divisions that developed accumulations may have been stolen or ations, churches and mosques serving during conflicts in the home country. lost through exile, and the immigrants, and literature searches for How receptive are key stakeholders to symptoms of torture and the limita- studies of similar populations abroad the ways in which you plan to organize tions of their immigration status may may provide information and numbers services? Do your program goals fit

on populations that have experienced within culturally acceptable limits? If the FOR MORE INFORMATION higher levels of torture and war trauma. proposed program serves clients from For more information Once you have assessed who the tor- many ethnic groups with differing cul- on how torture affects ture survivors are in your community, tural needs, how flexible can it be when communities, see CHAPTER 2. how best can you provide services to providing services? For example, group

90 CASE STORY

BUILDING SERVICES USING A DECENTRALIZED NETWORK MODEL

program serving torture sur- Services for torture survivors 8

vivors in the Midwest began flowed from a more general mis- R

in 1998, arising out of the refugee sion — to help refugees function E

A T P T

resettlement process. One of the E at the highest level possible, thus N . A S

early program organizers worked O enabling them to adjust success- H T H N I R Y as a counselor at a local counsel- fully to life in a safe environment. C B A L .

ing program. W Key staff were the clinical direc- W W She had been involved in the © tor and the administrative direc- Sanctuary movement of faith- educational, medical, and mental tor. based organizations providing aid health professionals serving This functioning network did and comfort to Latin American survivors. Referrals came from not receive funding from the refugees fleeing torture and perse- the local International Institute, Office of Refugee Resettlement cution in the political upheaval of medical clinics, friends and (ORR) as authorized in the the 1980s. former clients, and other mental Torture Victims Relief Act By the early 1990s, she began health providers. (TVRA) in 2003, but received identifying refugees who were Clients came from many coun- some TVRA funding through the suffering from posttraumatic tries, and the project contracted United Nations Voluntary Fund stress disorder. She organized a interpreters as needed. Grants for Survivors of Torture. With lim- local coalition of agencies and funded staff, who were paid a ited funding, the network was still individuals already providing nominal amount. The clinical able to provide services to about services to refugees who could director reported the advantage of 40 torture survivors per year. address their need for mental their informal network was a In 2004, the network joined health services. focus on delivering services, with their county’s Mental Health The partners included a psy- despite limited funding. Board, one other treatment pro- chiatrist, in-home services, emer- The disadvantage was the gram, and four legal/asylum gency outreach programs, and ability of partners to withdraw: organizations to apply for TVRA counseling programs. Using a “more freedom, more vulnerability.” funding under ORR. case management model and a In the summer of 2001, the They collaborated in order to decentralized network of services, service network incorporated as a avoid competing with each other the informal network then began nonprofit public benefit corpora- for limited funds. They were one applying for funding as a group. tion. That status enabled it to initi- of eight programs to receive new Clinical members of the ate projects on its own and to seek ORR funds in late 2004. network provided training for grant funds.

91 prevent them from working. Direct client Services may provide grants to programs in billing will be one of the least likely sources of the United States to cover the costs of the funding for an agency working with survivors following services: of torture, although it maybe possible with • Services for the rehabilitation of some individuals who still have personal finan- victims of torture, including treatment of the physical and psychological cial resources or insurance. 8 effects of torture Individuals and organizations who are inter- R • Social and legal services for E ested in developing services for torture sur-

T victims of torture

P vivors will need to consider multiple sources of • Research and training for health care A funding: individual donors and charitable foun- providers outside of treatment centers, H

C dations, medical insurance, funding from state or programs for the purpose of programs and legislatures, and federal funding enabling such providers to provide the services described in Paragraph 1 that is both targeted for torture victims and of the legislation available more generally. As in any nonprofit When the TVRA was reauthorized in organization, a diversified base of donors 2003, it acknowledged differences between insures long-term financial stability. the United Nations and the World Medical This section begins by describing the Association in defining torture. (See chapter Torture Victims Relief Act of 1998, not only one for these definitions.) For purposes of because it is a dedicated pool of funding specif- determining eligibility for funding, the U.S. ically for services for torture survivors, but also legislation used a definition given in Section because it provides a legal description of what 2340(1) in Title 18, United States Code: “services for torture survivors” comprise. Unfortunately, the amounts appropriated by …an act committed by a person acting Congress do not meet the needs of current pro- under the color of law specifically intended to inflict severe physical pain or suffering grams, so TVRA funds should not be seen as a (other than pain or suffering incidental to likely source of funding for new programs. lawful sanctions) upon another person TORTURE VICTIMS RELIEF ACT within his custody or physical control.

The Center for Victims of Torture worked This definition encompasses the use of closely with key members of the United rape or other forms of sexual violence. The States Congress to enact the Torture Victims term “under color of law” is defined as when Relief Act (TVRA) of 1998, which provides: a person acts or purports to act in the per- Assistance for treatment of torture vic- formance of official duties under any law, tims — the Secretary of Health and Human ordinance, or regulation. As in the case of many recent conflicts in Africa (e.g. in FOR MORE INFORMATION Liberia, Sierra Leone, Congo, Rwanda) Current torture treatment where there are competing rebel groups and programs are listed in the semiautonomous militias that engage in tor- Appendix on PAGE 103. ture as a weapon of war — human rights

92 organizations have generally understood TVRA. Some had been providing services for those groups to have pretentions of gover- more than 10 years before the Act was passed. nance or be sub rosa proxies for official gov- UNITED NATIONS VOLUNTARY ernment action, and thus covered by the law. FUND FOR VICTIMS OF TORTURE The TVRA funding guidelines allow the About 20 percent of TVRA funds are rout- following activities to be deemed eligible for

ed through the United Nations Voluntary Fund 8 funding, either as a whole or in varying com- for Victims of Torture, which was established R binations: medical, psychological, social, and E

by the General Assembly in 1982. These funds T legal services. If the applicant does not pro- are distributed internationally, with a small P A pose to provide all allowable services, then it

amount going to existing United States torture H is expected to show how the missing services treatment programs. C can be accessed by a client. Partnerships with The UN Voluntary Fund collects voluntary other providers are allowed as a means to contributions from UN member nations, then insure all components are available. TVRA distributes those contributions to nongovern- legislation also allows funds to be used for mental organizations and treatment centers for training service providers outside of treatment the purpose of assisting victims of torture and centers. As a result, those services (in theory) their relatives whose human rights have been enable the building of networks of individuals severely violated as a result of torture. The and organizations as well as full-service treat- Fund also may provide limited support to proj- ment centers. The domestic portion of the ects for training health care professionals spe- funding is routed through the Office of cializing in the treatment of victims of torture. Refugee Resettlement, housed in the U.S. FUNDING LEGAL SERVICES Department of Health and Human Services. FOR TORTURE SURVIVORS Without a substantial increase in current Some legal services for torture survivors appropriation levels, TVRA funds are not who are eligible by income guidelines are fund- large enough to maintain existing treatment ed through general funds for legal aid under the centers, much less establish new treatment Legal Services Corporation. However, the centers in high-need areas and also support Illegal Immigration and Reform Responsibility dissemination activities for networks and Act of 1996 made undocumented immigrants, mainstream providers. including asylum seekers, often not eligible for Individuals and organizations who are inter- services through Legal Aid, unless they meet ested in developing services for torture sur- one of several technical categories specified in vivors will need to consider many other, often a policy document that was released in 2003 creative, sources of funding. Some programs (Federal Register, 2003). An example of this have succeeded in garnering funds from med- model of legal services for torture survivors is ical billing, state funding, private foundations, the Legal Aid Foundation of Los Angeles. and individual donors. Not all current treatment In some states, legal services for indigent programs receive federal funding under the immigrants seeking protection in the United

93 States are provided by private attorneys working on a pro bono (donated services) basis. Pro bono work is encouraged by many state bar associations. Examples of this model are Human Rights First and Minnesota Advocates 8

for Human Rights. Chapter seven was R

E written by attorneys working for T E P Minnesota Advocates for Human R U T R A

Rights, which has worked in partner- O T

F H O

ship with CVT since its formation. S C M I T C I V

A third funding source for legal serv- R O F

ices is law schools. A number have E T N E C established pro bono clinics in immi- E H T

grant law for student-training purposes © and may be staffed by very experienced THE CENTER FOR VICTIMS of Torture headquarters in Minneapolis, Minn. immigration attorneys on the faculty. Volunteers and donated services orienting any volunteers. This includes Examples of programs embedded in law serve several aims. First, they keep the writing job descriptions and determin- schools are at Georgetown, Villanova, cost of providing comprehensive servic- ing how liability issues will be handled. Harvard, and St. Mary’s in Houston. es down. Second, if you are careful to Confidentiality and boundary issues VOLUNTEERS AND IN-KIND SERVICES track the number of hours provided by need to be addressed. Consult with a Many existing torture services pro- volunteers and the value of donated serv- local program that has a well-devel- grams make extensive use of volun- ices, these may sometimes be used as oped volunteer program. Many state teers. The Center for Victims of matching funds for other grants. Third, governments also maintain an office to Torture uses over 300 volunteers a year volunteers are a visible means of demon- encourage and support volunteerism. and has a dedicated staff person to strating the support you and your mis- There are also issues specific to manage this program. Examples of sion enjoy in the community, which can programs for torture survivors in using non-clinical roles include “community serve to attract local funding. Finally, volunteers, such as managing volun- guides” for clients, ESL tutors, drivers, volunteers are likely to become program teers who may have their own trauma speakers bureau members, office assis- donors or advocates themselves. They histories and avoiding any religious tants, and research assistants. help to create a local constituency for proselytizing with vulnerable clients Examples of clinical roles include torture victims and the program. from diverse religious backgrounds. forensic evaluators, surgeons and other Volunteers should be treated as staff, For this reason, it is important to con- specialists, dentists, therapists, and subject to the same standards, account- sult with other torture treatment pro- physical and massage therapists. A ability, and assistance as paid staff. grams that use volunteers by contact- clinical volunteer program requires a Before starting to use volunteers a pro- ing them directly or by contacting the higher level of screening, training, and gram must develop policies and proce- CVT National Capacity Building ongoing supervision. dures for recruitment, screening, and Project staff for a recommendation.

94 BUILDING A SUSTAINABLE policy issues that will affect its working CVT’S PROGRAM MODEL ORGANIZATION THROUGH environment; media and communica- THE GOVERNANCE STRUCTURE THE CENTER FOR VICTIMS OF tions specialists; lawyers; business and In creating a robust and durable Torture (CVT) in Minnesota is political leaders; and top-level govern- a stand-alone, multi-discipli- organization, special attention should be nary treatment center serving ment administrators. Effort is made to primarily asylum seekers from paid to creating a strong governance a large number of countries. create a nonpartisan board by assuring CVT’s integrated approach

structure or board of directors. Some 8 to treatment includes the fol-

voices from varying political persua- lowing services: medical treat- organizations treat board development R ment, nursing care, psycho- sions within the board. E

as a pro forma legal requirement, per- therapy, physical therapy, T

Every community faces an extraordi- social work, and massage P haps filling it with staff members or therapy. A nary array of needs competing for atten- Clients are guided through inexperienced volunteers. This misses an H three stages of healing either

tion and resources. An independent C important mechanism for building new individually or through a board of directors makes its own judg- group model. These stages ties to the community and deprives the are: ments about how the rehabilitation of tor- organization of a stabilizing influence SAFETY AND STABILIZATION: ture survivors fits into the mix of neces- that can help mitigate the internal Re-establishing sary services that must exist to create health and trust dynamics of vicarious trauma. GRIEF AND MOURNING: successful communities. The payoff for Working through Organizational consultants often the organization is that, having made that what happened emphasize recruiting board members RECONNECTION: judgment, the board is the bridge back to Getting back to community, who, in their mix, supply the three W’s: love and work. the rest of the community to testify to the wealth, wisdom, and work. Wealth importance of this problem and the role All services are provided includes personal philanthropy by the on an outpatient basis in the organization plays to solve it on facilities in Minneapolis board members, but also those who have and St. Paul. CVT’s clinics behalf of the whole community. Rather are located in renovated connections to resources the organiza- older homes, in environments than giving up power to a strong board, a tion will need to carry out its mission. that are as home-like and staff is thus greatly strengthened in its welcoming as possible. Wisdom may include those who know An estimated 50% to capacity to achieve its mission. 60% of client visits require the field of trauma, but in most commu- the services of skilled interpreters trained at CVT. If a nities the staff will become the experts in DECIDING ON THE RANGE AND client needs additional med- this field and outgrow such oversight MODEL OF SERVICES TO PROVIDE ical or specialty services, they are referred to commu- from the board. Rather than using the Over the several decades that torture nity providers. Resource access issues are board to create a superstaff, it is impor- treatment programs have existed in the facilitated by a large number tant to include those with expertise in of volunteers, such as drivers, United States, many different models of befrienders, ELL instructors, fields of importance to the organization intervention have been created to and job counselors, etc. CVT works closely with pro bono but which may not exist on staff, espe- respond to the diverse needs of torture attorneys who are recruited and trained by a local legal cially not on a full-time basis. CVT has survivors. Differences in models can human rights organization. found it very useful to include health result from a number of factors: needs CVT provides direct services to about 225 people administrators, especially CEOs and and desires of specific ethnic groups a year, roughly two-thirds of whom are continuing clients. other high-level administrators, who served, theories of practice in treatment, About the same number of understand the dynamics of the health available resources, special expertise, people are referred to other services in the community. care delivery business and the public and clinical experience.

95 SAMPLE CASE MANAGEMENT MODEL MODELS OF TREATMENT culty accumulating knowledge and FOR MULTIDISCIPLINARY SERVICES AND SERVICE PROVISION improving clinical skills. IN THE UNITED STATES INITIAL AND ONGOING CONTACT 2. MODELS BY RANGE OF SERVICES: between a client and a case manager can Below are the primary types of Multidisciplinary centers have be very helpful. The case manager documents models categorized by organiza- trauma history, builds and maintains rapport developed successful trauma treat- tional structure and range of servic- throughout the client’s treatment, is aware of ment models that integrate medical,

8 ongoing needs and barriers, and serves as a es, drawn from current program psychological, social, somatic, and general resource for the survivor. R examples. The Web site for the legal components. A variety of treat-

E INFORMED BY ONGOING case-planning ment models may be applied

T National Capacity Building Project discussions with the treatment team, the case

P in treating survivors of torture. The manager can assist with scheduling or refer- contains organizational profiles and A essential components involve creat- rals to the appropriate multidisciplinary health H updated contact information on par- ing a supportive environment, estab- care providers. C ticipating programs. Go to lishing a trusting relationship, and FOR EXAMPLE, torture survivors are often providing appropriate multidiscipli- unable to benefit initially from in-depth www.cvt.org and click on Building nary services at a time when the psychotherapy due to their multiple psycho- Healing Communities. social needs. Case managers may assist individual may best avail him or her- survivors with such psychosocial needs, teach 1. MODELS BY ORGANIZATIONAL self of that treatment. relaxation strategies either individually or in STRUCTURE: The choice of organi- Decentralized referral networks groups, and refer them to a psychotherapist at zational structure often follows offer a choice, especially when a full- the time they are most able to take advantage from the mission. Stand-alone pro- service specialized torture treatment of this modality. grams bear all the burdens and ben- program may not be financially fea- SIMILARLY, SURVIVORS WITH SEVERE efits of independence: building a sible for your community. A program depression or intrusive and hyperarousal symptoms of PTSD can be referred directly to board of directors, finding and that links together different agencies a psychiatrist for treatment. Those with physical maintaining resources, strategic and individuals can leverage existing symptoms or sequelae from their torture can planning and leadership. But these resources and start providing inten- be referred first to primary care physicians. centers provide most services need- tional services for torture survivors CASE-MANAGEMENT DUTIES may be ed by torture survivors in a “one- with less funding. Many programs shared among the multidisciplinary treatment stop shopping” framework. have started with the vision and ener- team, which often includes social workers, Hospital or university-based pro- gy of committed individuals and later nurses, psychologists, and psychiatrists, grams may draw upon academic expanded as more resources became depending on availability. expertise and institutional strength. available. THE CASE MANAGER HAS PRIMARY Programs embedded in larger agen- Single-service programs have responsibility for coordinating the survivor’s care needs and informing others of changes in cies may encompass a greater range developed a special expertise that is these needs. Similarly, it is helpful to share of services for the client or reflect a of vital importance to torture sur- group educational and therapeutic services particular ethnic expertise, but may vivors and may serve as a source of among team members who are able to pro- suffer from a lack of attention or learning for others in the torture vide them. compete internally for funding. treatment movement. Currently, STRUCTURING TRAUMA TREATMENT Decentralized collaborations are a programs that provide legal teams in this manner also allows for more way to share scarce resources and services for asylum seekers are the time-intensive resources requiring highly still provide all or most components most common examples of single- trained staff, such as individual psychotherapy, to be used in a more efficient manner, as of healing. They may also be a means service programs receiving TVRA clients will begin this intervention once their to increase community support in funding. These programs have close immediate psychosocial needs have stabilized. welcoming new refugee groups. relationships with agencies providing They may, however, lack enough of a torture treatment services so that strong center to grow or mature and their clients have access both to eval- may, in particular, have more diffi- uation services and treatment.

96 traumatic events, they are more likely to PREVENTION STRATEGIES seek help. Also, community education In addition to direct services for torture builds awareness of available treatments survivors, torture treatment programs and for survivors and their families. human rights organizations may include Trauma coping strategies are behaviors that have helped other trauma sur- preventing torture in their mission state- vivors to feel better. Trauma survivors ments. For example, the mission of the 8 may consider exploring one or more of

Center for Victims of Torture is “to heal these strategies in order to facilitate their R E the wounds of torture on individuals, their own recovery. T P M O families, and their communities and to A

C 3. SCREENING, ASSESSMENT, AND . N H A stop torture worldwide.” L EARLY TREATMENT OR REFERRAL IN P A C K

N THE PRIM ARY CAR E S ETT ING : In the field of public health, preven- H O J .

W Despite ongoing needs and the potential

tion is generally categorized as primary W

W for great benefit from mental health serv- prevention, directed at averting a poten- © “THEY ASKED ME to give them a sewing ices, many refugees do not perceive they tial health problem; secondary preven- machine,” said Morie Momah, 50, of are in need of treatment, nor do they con- Gbalahun, Kailahun district in Sierra tion, directed at early detection and Leone. “I said, ‘I don't have one ...’ ceptualize their trauma symptoms in He was a tall man. I could not know terms of Western mental health concepts. intervention to delay onset or mitigate a his name ... He cut my arm off and Many are reluctant to access mental health problem; or tertiary prevention, they ran into the bush.” health services even when referred. directed at minimizing disability and For these reasons, primary care 1. LEGAL ADVOCACY FOR JUSTICE avoiding relapse. Tertiary prevention providers are often the only health care AND ACCOUNTABILITY OF PERSE - can take place within the context of professionals available to detect and treat CUTORS : The Center for Justice & the problems resulting from trauma. The individual treatment or within a com- Accountability (CJA, www.cja.org) in roles of physicians and nurses are well munity setting targeting an affected San Francisco works to deter torture and known and accepted across cultures. other severe human rights abuses around population. Thus, primary care providers provide a the world by helping survivors hold their Prevention, as it applies to torture, critical entry point for identifying trauma persecutors accountable. CJA represents survivors needing help, providing treat- may operate outside the usual bound- survivors in civil suits against persecutors ment in the primary care setting, if appro- aries of health and include a wide range who live in or visit the United States. CJA priate, and using their ongoing relation- is pioneering an integrated approach to of tactics and targets. The New Tactics ship to facilitate successful mental health the quest for justice that combines legal in Human Rights Project, coordinated referrals. Early intervention in treating representation with referrals for needed by the Center for Victims of Torture, trauma symptoms is important in pre- medical and psychosocial services, and venting future disability and prolonged encourages creative use of tactics, outreach to schools, community organi- suffering. drawing from many sectors, to protect zations, and the general public. Torture treatment specialists, such as and extend human rights around the 2. COMMUNITY EDUCATION ON psychologists and psychiatrists, may world and is an example of prevention TRAUMA EFFECTS AND COPING: work with primary care providers in clin- of torture. A workbook and series of Education in communities affected by ics that see high numbers of refugees likely to have experienced torture. These tactical notebooks are available online torture is a key secondary prevention strategy. When survivors recognize the specialists help providers to recognize the at www.newtactics.org. common aftereffects of torture and effects of torture and provide treatment The following are examples of pri- understand that their symptoms and cop- when possible. They also work to mini- mary and secondary prevention strategies: ing responses are a normal response to mize stigma regarding seeking mental

97 TRAUMA EDUCATION INCLUDES health treatment and may facilitate success- have trained police or military officials as a INFORMATION THAT: ful referrals of torture survivors to mental strategy to prevent torture. Through sensiti- health professionals. zation about human rights, the effects of NORMALIZES TRAUMA physical and psychological abuse, and legal experiences and 4. PREVENTION STRATEGIES USED BY statutes, centers have been helpful in chang- symptoms TREATMENT CENTERS OUTSIDE THE ing norms of behavior among police and REVIEWS SYMPTOM UNITED STATES: Some torture rehabilita- military officials. Trainings have also been 8 course and prognosis tion centers outside of the United States conducted among the judiciary on the prac- R DESTIGMATIZES conduct a variety of preventative efforts. tice of torture in a specific country, E mental health care While many are specific to their settings T its effects on victims, and how this

P REVIEWS THE EFFECTS and not directly applicable to the United may affect their testimony or willingness

A of additional stress in States, they may stimulate ideas of to press charges. These approaches and

H exacerbating symptoms approaches in your community. many others can be found through the C RELATES TRAUMA, One such effort in East Asia involves stress, and somatic New Tactics in Human Rights Project symptoms outreach to isolated, rural areas using (www.newtactics.org). mobile clinics. A physician and legal staff FACILITATES TRAINING AND appropriate grieving member travel to the rural site and conduct general sensitization trainings regarding the SUPPORTING STAFF PROVIDES AWARENESS of successful trauma effects of torture and treatments available. Working with torture survivors is special- treatment methods They also document abuse reported by local ized and challenging work. Staff who work populations for use in their advocacy efforts EMPHASIZES in torture treatment programs are mission- medication compliance against those who perpetrate, sponsor, and driven individuals. However, many in the REVIEWS IMPORTANT condone torture. Moreover, these mobile self-healing or coping clinics inform the public as well as torture field have written about the effects that work- strategies survivors of their rights and redress availing intimately with clients who have been able to those who have been harmed. severely traumatized can have on the care- In many countries, torture occurs in pris- givers. The effects have been summarized as ons and police detention centers. Many torture rehabilitation centers target such places vicarious traumatization or secondary trau- by providing medical services to prisoners. ma. Vicarious traumatization has been Through these visits they are able to treat defined as “a transformation in one’s inner torture survivors, document additional tor- experience resulting from empathic engage- ture, educate guards about the effects of ment with clients’ traumatic material” their actions, and use their documentation to advocate changing institutional policies (Pearlman and Saakvitne, 1995). The effects with appropriate decision-makers. on the provider have been discussed in earli- Some treatment centers in East Africa er chapters of this book, along with sugges-

FOR MORE INFORMATION tions for self-care. (See Chapters 3 and 6.) Besides self-care, an organization needs For more information on public education to manage the effects of secondary trauma strategies, see CHAPTER 5. on staff, clients, and the organization as a Another source is CVT’s publication, Helping whole. Secondary trauma can affect staff Refugee Trauma Survivors morale, staff retention, and the quality of in the Primary Care Setting, services to clients. online at www.cvt.org. For the program planner, two aspects of

98 TRAUMA-COPING minimizing and managing vicarious or sec- issues of refugees and asylees STRATEGIES ondary trauma are especially relevant. One • Understanding the dynamics is adequate training; the other is institution- of torture and the long-term REDISCOVERING effects of torture innate resiliency al policies and mechanisms to support staff • Cultural competence in working INCORPORATING in their work. regular physical with traumatized people exercise

RESOURCES FOR • Working with effectively with 8 TRAINING STAFF IN DEVELOPING HELPFUL

skilled interpreters relaxation techniques R TORTURE TREATMENT PROGRAMS E

FACILITATING T Training staff in the skills and knowledge These core areas form the general foun- spirituality and P needed to provide effective interventions with dation for training content. religious beliefs A torture survivors happens at various points in The field of torture treatment is in its RECREATING H meaning in life C a program’s development. In a new organiza- early stages, pulling in expertise from earli- ENCOURAGING tion, staff who will be working primarily with er work on posttraumatic stress disorder and employment and hobbies torture survivors will need in-depth training trauma in veterans, battered women, and and orientation to the history and issues of the abused children. Only a few higher educa- STRENGTHENING social connections torture treatment and human rights move- tion programs and traumatic stress institutes MINIMIZING ments across the globe, as well as focus on exist that prepare clinicians to provide treat- maladaptive coping the research base and clinical skills needed to ment to victims of extreme political vio- LIMITING EXPOSURE to trauma reminders provide effective care. lence. Torture treatment programs have Volunteers, pro bono professionals, and needed to provide internal training and specialty providers within a referral network capacity-building to supplement the training will need sensitization and skills training. available in traditional higher education. Once a program has developed a level of The Torture Victims Relief Act also expertise through experience working with funds training activities. Since 2000, the survivors of torture, it may seek to dissemi- Center for Victims of Torture has received nate its expertise to others whose work TVRA funds to organize training and capac- includes but does not focus exclusively on ity-building activities for programs provid- torture survivors — students, other profes- ing services to torture survivors that are sionals interested in taking up the work, and funded by TVRA, or are members of the refugee leaders. Training curricula and National Consortium of Torture Treatment approaches must be tailored to the audience Programs. CVT maintains a parallel project and trainers must be clear about what they working with specialized treatment centers expect from participants as an outcome of in countries where torture is prevalent. the training offered. Training and capacity-building strategies As outlined in Chapter 3, providers need include two-day institutes, conference calls, to develop the following four core compe- small subgrants, self-assessment tools, web tencies when working with torture survivors: resources, and phone consultation with var- • Knowledge of the life ious content experts. For more information experiences and resettlement visit the Center’s National Capacity

99 Building Project Web Resource Center at opportunities to notice symptoms within one- www.cvt.org. self or in other group members. A number of programs have developed Support groups can form among mem- training materials, videos, and web content bers of a profession, such as the organiza- as part of this process. All are available to tions’ social workers, or develop others either for a cost or for no charge via from multidisciplinary work teams. 8 their organizations’ Web sites. Current pro- Debriefings can take place in large groups, R

E grams and their sites are listed in the such as staff meetings, or in meetings as T

P Appendix of this guide. small as one-to-one discussions with a A POLICIES TO MINIMIZE co-worker, supervisor, or senior clinician. H EFFECTS OF SECONDARY C Building these components into a pro- TRAUMA ON STAFF gram for torture survivors has budgetary It is important that organizations inter- and structural implications that must be nally practice the democratic and human rights principles that they support and pro- taken into account. vide fair treatment to their employees. The Funding is often unpredictable in the components of an institutional approach world of nonprofit organizations, and this to reducing staff stress and secondary can add to the stress within an organization trauma include adequate health insurance, working with trauma survivors. Clinicians paid time off, continuing education, must build long-term relationships of trust and resources with which to do the work to help survivors recover. Therefore, with clients. economic instability, staff reductions, and Opportunities for staff members to con- other fluctuations in staffing have profes- trol aspects of their work and opportunities sional and moral implications, as well as for job variation and breaks from direct trau- personal ones. ma client work also help minimize The organization should invest in sound the results of secondary trauma. An financial systems and personnel to improve excellent article to read on this subject is planning and minimize disruptions. That “Helpers’ Responses to Trauma Work: should include building a cash reserve that Understanding and Intervening in an would allow the organization to fulfill its Organization” (1995) by Rosenbloom, Pratt, commitment to its clients despite sudden and Pearlman. downturns. Supportive connections among staff mem- Torture survivors carry a great deal of bers are established with structured, planned fear and transmit it to the organization. means of talking about stress and secondary Earlier chapters have discussed how to trauma built into the workplace. These means handle this clinically. Managerial leader- including procedures for debriefing after ship can help the process by creating crises, critical incidents, or difficult work situ- an organization that is well connected to ations. On-going support groups provide the community and to powerful stakehold-

100 ers who will support its mission and gram donors, program advocates, and REFERENCES encourage its success. advocates for human rights in general. Pearlman, L.A. & Saakvitne, The clinical process is enhanced when Another approach to training is to cre- K.W. (1995). Trauma and the therapist: Countertransference torture survivors perceive that the organi- ate indepth, ongoing interactions with and vicarious traumatization zation works to protect them and their refugee-led mutual assistance associa- in psychotherapy with incest survivors. New York: W.W. families. Strong ties to members of tions, or refugee-focused nonprofit organ-

Norton & Co. 8 Congress, for example, can often be built izations that offer special services benefi- Rosenbloom, D., Pratt, A., & R Pearlman, L. A. (1995). through their local staff who provide con- cial to torture survivors. E

Helpers’ responses to trauma T stituency services, such as refugee reset- Refugee-led organizations typically work: Understanding and P

intervening in an organization. A tlement and asylum cases. Visits to the assist torture survivors with a variety of

In B. Stamm (Ed.), Secondary H

center with staff and clients by public offi- needs. Some conduct health education or traumatic stress: Self-care issues C for clinicians, researchers, and cials (mayors, governors, members of trauma education efforts, while others pro- educators (pp. 65-79). Congress, etc.) can develop strong bonds vide supportive or educational groups for Lutherville, MD: Sidran to the organization, but also give clients survivors. ADDITIONAL RESOURCES the opportunity to be listened to and Such services are greatly enhanced by http://www.compasspoint.org CompassPoint Nonprofit Services respected by people with power. ongoing consultation with torture rehabil- Many publications and itation center staff. Collaborations CompassPoint Board Café TRAINING TO BUILD e-newsletter are “short enough to NETWORKS OF SUPPORT between refugee-focused organizations be read over a cup of coffee.” FOR TORTURE SURVIVORS and torture treatment programs are mutu- IN LOCAL COMMUNITIES http://www.mncn.org Most mature torture treatment pro- ally beneficial, allowing the exchange of Minnesota Council of Nonprofits specialized knowledge about certain This organization sells a variety grams have begun to offer training and of publications at low prices outreach to health and social services pro- issues and referrals for specialized servic- that are useful for nonprofits across the country, such as es (e.g., with a legal organization serving fessionals and policy-makers. Such main- No Surprises: Harmonizing stream training can increase the number refugees and/or asylum seekers). Risk and Reward in Volunteer Management, Handbook for of torture survivors able to receive servic- Training an ever wider audience has Starting a Successful Nonprofit the obvious appeal of stretching limited es and educate the next generation of pro- http://www.nonprofitrisk.org fessionals about the special needs of funds to cover a greater number of torture Nonprofit Risk Management Center immigrant populations. Also, influential survivors. Specialized torture treatment The mission of this organization members of the community can be sensi- programs, through years of engagement is to help nonprofits cope with uncertainty. It offers a wide tized to the problem of torture and can with torture survivors from many differ- range of services (from technical play active roles in defending and expand- ent countries, create a knowledge base of assistance to software to training and consulting help) on a vast ing human rights. best practices. array of risk management topics (from employment practices, to More established torture treatment pro- Knowledge dissemination can only insurance purchasing to internal grams also train volunteers as a strategy for work if the specialized torture treatment controls and preventing child abuse). The Nonprofit Risk expanding support for torture survivors. programs continue to grow and learn. Management Center does not Volunteers, in addition to expanding These programs serve as “centers of excel- sell insurance or endorse organizations that do. the quantity and breadth of services avail- lence” and visible beacons of hope for sur- able to survivors, may also become pro- vivors of torture around the world. I

101

A A A A P P P P P P P P E E E E N N N N D D D D I I I I X X X X

nformation on providing services to torture IN THIS SECTION survivors is available from a variety of I COUNTRY information Isources. There are many books and journals I LANGUAGES accessible from libraries as well as numerous I TORTURE TREATMENT / A

Programs in the W

online resources. The following is not a com- R N

United States U / G I HUMAN RIGHTS prehensive list of resources but provides a R O . N U I COMMUNITY RESOURCES good starting point for those seeking more . W X W

I I ORGANIZATIONS WITH information. W Developed Training © D CAMP FOR PALESTINIAN refugees in Lebanon Curricula Reference help from many libraries is in 1999. N I ONLINE TRAINING E Courses available online through email and real-time P www.amnesty.org P I OTHER LINKS interactive chat. Library catalogs and data- Amnesty International’s (AI) Web site A bases of journals are also available online. embraces information on current human Librarians, trained in resources of all types, rights issues, AI publications, and reports will help with research. in a range of languages, as well as links to other human rights-related Web sites. OUNTRY INFORMATION C www.un.org Many sources of information on countries Web site of the United Nations are online. Some present only facts and www.incore.ulst.ac.uk figures, while others provide images or The Web site of INCORE (International Conflict Research) constitutes a set of A information with a definite viewpoint. Four of country portals focusing on conflict and the following sources are portals containing ethnicity, with emphasis on online news links to many other worthwhile sites and two sources of various types. Judgment of are map sites. They are reliable and generally content is left to the reader. well maintained. The information they contain www.lib.umich.edu/govdocs/foreign.html is up to date. Several individual sites are also University of Michigan Documents Center: included. Foreign Government Resources on the Web. An authoritative site of government document www.cia.gov/cia/publications/factbook links, many of which are not on other lists. It The CIA World FactBook contains serves as a central reference and geographic, political, and demographic referral point for government information, information as well as reference maps whether local, state, federal, foreign or inter- and other information. national, with emphasis on the areas of government, political science, statistical data, www.state.gov/r/pa/ei/bgn and news. The United States State Department’s Country Background Notes. Includes www.un.org/Depts/Cartographic/english/ information about people, history, htmain.htm government, political conditions, UN Cartographic Section: economy, and foreign relations of A team of experienced mapping and various countries. GIS specialists at the cartographic authority

104 There are35memberorganizations in21 collectively toprevent worldwide. torture survivorsed tothecareoftorture andacts ledge, technicalcapacitiesand resources devot- Resettlement. The NCTTPadvances theknow- recei (NCTTP), aswell asorganizations thathave of Consortium Torture Treatment Programs sive. It includesmembersoftheNational on Pages 108-111. This listisnotcomprehen- States whowork survivors withtorture is STATES UNITED THE IN T a and CD-ROM versions ofthe14theditionare special featureisthelanguagemaps.Print research intolesser-known languages. A of theworld, theresultofover 50years of comprehensive Web siteaboutlanguages Ethnologue ispotentially themost www.ethnologue.com L and includehistoricalnauticalmaps. re The mapsavailable or country foraparticular maps have lessdetailthanthosefromtheUN. freely downloaded andprinted. The country They areinthepublic domainandcanbe duced themaps,unlessotherwiseindicated. The U.S. CentralIntelligence Agency pro- has5,715ofitsmapimagesonline. currently The University of Texas mapcollection www.lib.utexas.edu/maps d by theSecurityCouncilandnotforgeneral d ofUN part the Sectionareanintegral d for theUnitedNationscreatesvery v istribution. istribution. The contentisupdatedregularly. ocuments andothersarepreparedforuse etailed maps.Many mapsproducedby ANGUAGES RUETETETPROGRAMS TREATMENT ORTURE gion vary fromfew tomany ailab A list of service providersA listofservice intheUnited v ed fundingfromtheOf le forpurchase. fice ofRefugee fice programs canbefoundattheNCTTP Web site onmanyMore information ofthese states. database oftacticstohelpend humanrights along theway. This Web sitehasasearchable ing theiruse,andthechallenges thatsurf mentation ofv Tactical Notebooksthatdescribetheimple- approaches toprotectinghumanrights,and book thatdescribesseveral innovative Resource for Practitioners site are leadership. oneofhealingandreclaimingcivic tion — tection ofhumanrightsfromauniqueposi- ment centerthatalsoadvocates forthepro- ence asacreatorofne Victims of Torture andgrew outofitsexperi- The projectiscoordinatedb tions andpractitionersfromaroundtheworld. initiative ledby adiverse oforganiza- group The New Tactics Projectisaninternational www.newtactics.org Commissioner forHumanRights The UnitedNationsOf www.ohchr.org 300 languages. Human Rightstranslatedintomorethan The UnitedNationalDeclarationof www.unhchr.ch/udhr Human Rights United NationsUniversal Declarationof www.un.org/Overview/rights.html protection andassistanceagencies. and rights atstake, humanrightsinstruments, keyissues. The guidespresentdefinitions, offering introductionstovarious humanrights produceshumanrightstopicguides Library The University ofMinnesotaHumanRights www1.umn.edu/humanrts H http://ncttp.westside.com. MNRIGHTS UMAN Accessib New Tactics inHumanRights: A le toreadordo arious tactics,f w tacticsandasatreat fice oftheHigh fice , a200-page wnload onthis y theCenterfor actors influenc aced - - 105

APPENDIX abuses. The site hosts a discussion forum conducted in French, Russian, Spanish, and Turkish as well as English.

COMMUNITY RESOURCES www.searac.org The Southeast Asia Resource Action Center began operation in 1979. It is a national

organization working to advance the interests M O C .

of Cambodian, Laotian, and Vietnamese Y H P A R X Americans through leadership development, G I O T

capacity building and community empower- O H D P - F

ment. The organization recently compiled O - N S R E E the Southeast Asian American Statistical T S A P M

Profile, found at www.searac.orgseastat , P O D A G A profilemay04.pdf L A S

O Â

www.acf.hhs.gov/programs/orr I T S A

The Office of Refugee Resettlement plans, B E S

develops and directs implementation of a © comprehensive program for domestic (USCR) site introduces information on refugee and entrant resettlement assistance. global refugee issues. The USCR publishes It develops, recommends, and issues program Refugee Reports, a monthly information policies, procedures and interpretations to service providing in-depth coverage of: provide program direction Search this site refugee resettlement in the United States, for funding opportunities and links to organi- federal legislation affecting refugees and zations and programs that provide services to asylum seekers, analysis of court decisions refugees and immigrants. that affect refugees, conditions in first www.acf.dhhs.gov/programs/orr/ asylum camps around the world, annual partners/coordina.htm statistics on refugees, internally displaced Contact information for state refugee persons, and asylum seekers. They publish coordinators. These offices help locate the Annual Refugee Survey, an authoritative resettlement agencies in each state or region. report that reviews refugee conditions and This page has links to national mutual assis- government policies affecting refugees, tance organizations. asylum seekers, and displaced persons.

www.211.org (or, by telephone, dial 2-1-1) ORGANIZATIONS WITH 211 is a service active in 31 states that can DEVELOPED TRAINING CURRICULA help with information and referrals on a wide variety of topics. While services offered Many of the established torture treatment through 211 vary from community to commu- centers in the United States have developed nity, it provides access to services such as training curricula on various topics related to basic human needs (food banks, shelters, and rent assistance), physical and mental health providing services to torture survivors such as resources, and employment supports. identifying and treating torture survivors, sec-

www.refugees.org ondary traumatization, the social effects of United States Committee for Refugees torture and more culturally-specific informa-

106 tion on certain groups. Istanbul Protocol: Manual on OTHER LINKS The Center for Victims of Torture in the Effective Investigation and www.irct.org Documentation of Torture and Minneapolis offers a self-study course for International Rehabilitation Council Other Cruel, Inhuman or Degrading primary care physicians based on the for Torture Victims. This site links to Treatment or Punishment United videos From Terror to Healing. This two- human rights and torture treatment Nations Document, August 1999 part video and study guide can be pur- programs around the world. The IRCT Examining Asylum Seekers: A Health maintains a documentation center with chased through the Center for Victims of Professional’s Guide to Medical and torture at www.cvt.org. a searchable database and hosts an Psychological Evaluation of Torture online forum on torture-related topics. For in-depth training, the International www.crisisgroup.org X Trauma Studies Program in New York http://kspope.com/torvic/torture.php I

The International Crisis Group Web D Resources for Torture Survivors, offers a Postgraduate Certificate Training site updates information on conflict N

Refugees, Asylum-Seekers, and E Program in International Trauma Studies. situations around the world. The site People Affected by War. This site accom- P

offers reports and briefings, as well P This is a nine-month training program for modates links to treatment as searchable databases of conflict A professionals working with survivors of centers, online training, information histories, maps and other information. domestic and communal violence, war and about asylum and refuge and other refugee trauma, natural and human-made information. www.afpnet.org The Association of Fundraising disasters. More information is available at www.phrusa.org Professionals Web site gives Physicians for Human Rights Includes www.nyu.edu/trauma.studies/programs_ information about fundraising, access to two publications on torture description.htm online handbooks, and a searchable evaluation that can be ordered or down- directory of consultants and resource loaded as PDF (portable document ONLINE TRAINING COURSES partners. I format) files: The Boston Center for Refugee Health and Human Rights at www.bcrhhr.org offers the online course “Caring for Refugees and Survivors of Torture.” An introductory Internet-based human rights course for health professionals (physicians, nurses, social and public health workers, psychologists), lawyers, trainees, and human rights advocates who want to learn about survivors of torture and refugee trauma. The Manager’s Resource Center offers G R

the online course “The Providers Guide to O . A W A

Quality and Culture” at R

http://erc. . W W

This course is designed to assist W msh.org. @

N health care organizations in providing E N O M I U high-quality, culturally competent ser- A K K I

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110 ORGANIZATION PHONE FAX ADDRESS CITY STATE ZIP WEBSITE

Safe Horizon / Solace 646-825-2227 718-457-6071 74-09 37th Ave., Jackson Heights NY 11372 www.safehorizon.org Room #412

Center for Victims of 614-559-0169 614-231-4978 1151 College Ave. Columbus OH 43209 www.jfscolumbus.org Torture at Jewish Family Services

Amigos Multicultural 541-484-2450 541-485-7293 P.O. Box 50473 Eugene OR 97405 www.amigosmsc.org Services Center

Torture Treatment 503-494-6148 503-494-6143 OHSU Portland OR 97201- Center of Oregon 3181 S.W. Sam 3098 Jackson Park Road UHN 88

Liberty Center for 215-747-7500 215-276-5533 231 N. 63rd St. Philadelphia PA 19139- Survivors of Torture Ext. 249 1111

Center for Survivors 218-887-4101 214-827-9246 4123 Junius Dallas TX 75206 www.cstdallas.org of Torture

Boat People SOS 281-530-6888 281-530-6838 11205 Bellaire Blvd., Houston TX 77072 www.bpsos.org Suite B22

Asian Association 801-467-6060 801-486-3007 1588 S. Major St. Salt Lake City UT 84115 www.aau-slc.org of Utah

Utah Health and 801-363-4596 801-363-6068 309 E. 100 South, Salt Lake City UT 84112 www.uhhp.org Human Rights Project Suite #11

Program for Survivors 703-533-3302 703-237-2083 701 W. Broad St. Falls Church VA 22046 www.cmhsweb.org of Torture and Severe Suite #305 Trauma (PSTT) at CMHS 111

APPENDIX