Torture Survivors: Recognizing Special Needs

This post will be a summary of a lecture given my Mary Fabri. (Here is a NPR story on the Kovler Center! Mario is my supervisor and Mary (the lecturer) is my major boss. http://www.chicagopublicradio.org/Program_WV.aspx?episode=13687 )

Mary Fabri is the Senior Clinical Director at Marjorie Kovler Center and is considered an international expert in torture treatment. She's a pretty incredible person and been an advocate for survivors for years and years. Here is a summary of her lecture with my own thoughts added in italics.

1. Types of Torture
a. Physical- How it's usually depicted in TV and films.
b. Psychological- Much more effective and longer lasting.
c. Sexual-common in both genders
d. Deprivation (social, sensory, sleep, hygiene, health, nutrition)


2. Realities for Refugees and Asylum Seekers


a. There are no safe places
(1) One thing to keep in mind with torture survivors is that they have forever loss their sense of home. Picture your own government betraying your trust by torturing you and forcing you into exile. Your sense of homeland, motherland, fatherland is lost forever. Torture survivors have serious trust issues. This fact adds a lot of pressure. When you forget to call a client to remind him/her of an appointment, it's a small act of betrayal. On the other hand, trust doesn't just come from being polite and smiling a lot. It takes years of kindness and support.

b. Separation from family, friends, community- Imagine leaving your family for a weekend. Now picture leaving for 6-12 years (the typical average for our clients). Just imagine the stress. When families are reunited, it can actually be immensely stressful for everyone involved.

c. Deep sense of being different
(1) 90% of our female clients have been raped. Rape victims often feel perpetually violated.
(2) Psychological torture involves dehumanization. When you are screaming at and described as nothing more than a cockroach, some part of you believes it. After all, how could any normal human be treated like that? Torture is so effective because the horrific acts humans do is beyond cruel. It's simply unimaginable.



3. Triple Trauma Paradigm

a. Traumatic event- As Westerns, the diagnosis for our clients is Post-Traumatic Stress Disorder. Well the diagnosis is helpful, there are several problems with this diagnosis for torture survivors:
(a) First of all, the diagnosis criteria for PTSD were made from studies involving American rape victims or American veterans returning from war. The diagnosis criteria was not involve a wide variety of cultures and situations.
(b) The use of the word "post" is highly misleading. As will see in the triple paradigm, trauma persists beyond the actual torture.
(c) The use of "disorder" is also misleading. These reactions are not a disorder but a normal, biological reaction. The experience of torture is so surreal the brain really struggles to cope with it. A common reaction to torture survivors is "flashbacks." Flashbacks can strike after the smallest stimulus and are so vivid the survivor believes he/she is re-experiencing the torture. Psychologists tell us the brain is replaying the event in an attempt to understand what happened.

b. Flight- Think of how traumatic hiring a human smuggler would be. Imagine putting thousands of dollars into a man's hand who could easily kill you, rob you, rape you or even sell you. Also, think of victims of domestic abuse; actually leaving the abusive spouse is considered to be one of the most difficult parts of spousal abuse. The flight itself is traumatic.
c. Resettlement and acculturation- I think you can imagine with this part. I've tried in my previous posts and will continue to attempt to explain the traumatic difficulties of asylum seekers on a daily basis while they attempt to resettle.



4. Three major Sequelae of Torture- These are the three abnormal conditions commonly found in torture survivors.


a. Avoidance- A very common tactic used by many people in a wide variety of traumas. Painful memories are difficult to burden so many people attempt to shed them. Survivors avoid talking about the experiences or even their home country in general. Survivors also withdraw emotionally from their surroundings (CAT scans of survivors' brains have found the pre-frontal cortex and hippocampus (where emotions are relayed through out the brain) actually shrink). Many survivors begin actively destroying their memory. Testifying in court as to what occurred in their past is often impossible. In addition, many of my clients consistently forget to come to doctor's appointments. I used to think it was just a cultural thing for some or even just common memory problems many people have. In reality, some clients spend so much time actively destroying their memory that the memory ceases to properly function.

b. Hyperarousal. In addition to the shrinkage of the prefrontal cortex, CAT scans have found that the amygdala (fear center in brain) in survivors are abnormally large. Many clients rarely sleep. Some clients never sleep normally again for the rest of their life. In Long Way Gone (memoir of a child soldier) he admits to never sleeping more than 3 hours a night (in addition to all their other problems, fear and anxiety become way worse without sleep). Hyperarousal is a biological response to a threat to the survival of the body. The problem with many survivors is they were persecuted for years so they can't quit that state. Concentration is difficult and GI problems are VERY common (I see it all the time when scheduling medical appointments).

c. Depression. Many survivors find no joy in life anymore. A common experience for our clients is a professional with a family is forced to flee. They left their family behind (if they're alive at all) and are forced to live in a country where they know almost no one, don't speak the language, and if they're employed at all work in a job way below their skill level. The simple fact is many survivors of torture wish they had died at the hands of their torturers. The sense of loss is simply too great.


5. Altered Self-Concept. Many survivors no longer know themselves. Many describe undergoing a personality change or feel damaged and contaminated. This loss of personality is the lasting damage of psychological torture.


Feel free to ask any questions! I'll post the answers in the comment section.

My Education in Mental Health

One of the unique opportunities this year at my site is that the Kovler Center has hired two therapist intern. With their hiring comes about 10 orientation sessions to help them learn more about counseling torture victims. One of my supervisors asked Phil (the other Amate volunteer) and me to join. We have and have learned a lot! I am going to summarize a bit from my sessions.

1. Working with Interpreters

One of the difficulties about therapy in this line of work is significant language barriers. Any professional that works with clients opens up a dangerous possibility of misinterpretation. Lawyers talk through interpreters when building an immigration case; doctors talk through interpreters when attempting to diagnose (which makes tests such as Alzheimer's exams nearly impossible); therapists talk through interpreters to help clients suffering from Post-Traumatic Stress Disorder (PTSD).

When watching a movie on the asylum process, a big component of that movie was showing the danger of poor interpreters. Immigration cases hinge on details and a sloppy or an untrained interpreter can ruin an entire case.

Dates and details can be essential. For example (this story isn't really about interpreting exactly, but it will help paint a bigger picture), one woman from Eastern Europe immigrated to the United States and applied for asylum. She claimed she was persecuted because she was an Anglican. The Asylum Officer (AO) asked her who the head of the Anglican Church was. She responded Bishop George. The AO deferred her appeal for asylum to an immigration judge (essentially a "no" that gets appealed). The AO said in the video that any Anglican would know the Archbishop of Canterbury is the head of the Anglican Church. In fact, Bishop George was the head of the Anglican Church in Eastern Europe. She was delayed several years due to a misunderstanding.

Interpreting is extremely difficult because it's very subjective. When people ask for language skills, people with a basic proficiency will often claim fluency and volunteer to interpret. However, the amount of skill required by interpreting is way beyond mere proficiency. The subtleties of languages are immense and diagnosing PTSD relies on those nuances. (For example, a common question is whether the patient experiences feelings of nervousness. In French, a common translation of nervous is "nerveuse" when in reality "inquiet" would be more accurate. Nerveuse could best be translated as "highly strung" which is not what we understand nervousness to be. Nervousness is more correctly thought of as a discomfort instead of a severe anxiety. Sorry, long diatribe.) A professional in this line of work needs to be frank with interpreters and be aware. Obvious omissions or false interpretations should be confronted A lot is at stake.

2. Immigration Law

Depaul Law School invited us to attend an immigration class. If you bore easily, feel free to skip this section.

I forget whether I described this path earlier but a typical torture survivor flees his (or her, I'm going to just say his for ease) country illegally because the gov't would forbid them from leaving.

Typically, smuggling a human costs anywhere up to $10,000. Upon entering illegally, if they are detained but they present a "credible fear" of returning to home country the US will ask if they would like to seek asylum. They apply usually with a pro bono lawyer. The client needs to show an immigration judge that his life would be at risk by returning. When building a case, the lawyer needs an affidavit. If it becomes apparent to the lawyer that tortured occurred, the client will be referred to us.
The basic guide for a successful asylum case is ensuring that evidence of persecution or future persecution is presented and there is a cohesive story. To provide evidence of trauma, professionals collect physiological and/or medical forensic evidence. If the lawyer can show a "well-founded fear" of returning, the judge will grant the client asylum, and he will be on the path to citizenship.


3. Cross Cultural Boundaries

One of the difficulties with therapy is that it mimics interrogation. Picture the two scenarios, both involve the client facing an authoritative figure who asks probing questions. Therefore, it is essential that therapists let clients control the meeting. Where do you meet, sit, etc. Control needs to be in the clients hands.

4. Occupational Therapy

Surprisingly one of the best sessions was on occupational therapy. I had never heard of occupational therapy before, but I learned that it's about more than jobs. One of the hardest things for immigrants in general is returning to a sense of "normalcy." I shall say this story as an example.

In the early stages of the Kovler Center, the therapists encountered a large scale problem. Some Latino immigrants were unable to raise their kids effectively due to their trauma. They were so afraid of burdening their kids they kept their distance.

(As a side note, a really difficult aspect of immigration is kids learn languages much faster. As a result, it is common to see a role reversal in parenthood. Kids often are taking their parents to appointments and translating. It creates a very difficult dynamic because rather having the kids grow, they need to provide and essentially parent their parents. It's difficult to see).

So back to the Latino family: as a result of the parents coping with their own trauma, the children were falling into bad habits. There days were spent either in front of the TV or roaming the streets with unsavory characters. During therapy sessions, the parents confessed their anguish over the very likely possibility that their children would soon join gangs. The therapists turned to an occupational therapist.

After severe shifts such as immigration, torture (or even graduating from college for that matter) it requires observing oneself to establish how to spend one's time. To all my fellow grads, I think we could really learn a lot from an occupational therapist. So many of my weekends in college were spent clustering with friends, homework, or regular extracurricular activities. When you lose the regularity of school and band practices you lose your identity in a sense. Weekends here are occasionally aimlessly spent waiting for the week to start. Occupational therapists work to help clients realize their own power of situations. Children don't have to resort to TV just because they are no longer in their own country. The therapist worked with the children and helped them recreate their childhood in a new location. They began to play sports and celebrate festivals. By realizing that they can control their environment, the children could build their life back.

5. Psychological effects of torture

I will write on this subject tomorrow. There's a lot to it!