Counseling Today, Features

A reality too horrible to consider

Jonathan Rollins February 14, 2009

Kathi Anderson has grown accustomed to the often-involuntary reaction that many people have upon hearing that she works with survivors of torture. “The word torture sticks in people’s minds more so than survivor,” says Anderson, a National Certified Counselor and member of the American Counseling Association. “They step back from me like it’s a disease, so can you imagine what it must be like for a survivor to reveal that to someone?”

Even in a post-9/11 world, the prominence of politically motivated torture is too awful or seems too far removed for most Americans to consider, and the thought that more than a handful of torture survivors might be living in the United States is to most, well, a “foreign” concept. But according to government estimates, the number of torture survivors residing in this country approaches half a million.

“This continues to be a virtually invisible population — very, very marginalized,” says Anderson, who, along with Rev. William Radatz and Rev. George Falk, founded Survivors of Torture International (notorture.org) in San Diego in 1997. She serves as executive director of the nonprofit organization, which provides a holistic program of psychological, medical, dental, legal and social services.

“What I have learned is that with therapeutic interventions, survivors can and do heal, which minimizes the possibility of the trauma being transmitted to subsequent generations,” says Anderson, who has a bachelor’s degree in international relations and a master’s in counseling. “Many counselors to this day don’t consider the possibility that the clients they are serving may be torture survivors and, as a result, aren’t as effective as they could be. Torturers oftentimes tell their victims that no one will care or that no one will believe them when they are released. We, as counselors, have an opportunity to both counteract the torturers and
assist the survivors who are in need of
our services.”

Coming to America

Worldwide, individuals are tortured because of their ethnicity, political or religious affiliations, sexual orientation, gender or involvement in causes opposed by ruling powers. Many survivors of torture are exiled from their home countries and separated from their families. For some, escape is the only option, even if they possess only the vaguest notion of where or what they might be escaping to.

Andersonrecounts the story of an
Afghan woman who was a teacher. When the Taliban took power, she was no longer permitted to work because of her gender. She lost not only part of her identity but, being unmarried, her means of supporting herself. Several of her neighbors asked her to continue teaching their daughters in secret in her home because the Taliban had also outlawed the education of girls. The Taliban eventually found out what was happening and raided the woman’s home. She was incarcerated, tortured and released back into the community to serve as a visible example of what would happen to those who disobeyed the Taliban’s orders.

To show their gratitude for the woman and because they didn’t want to see her life further put at risk, her neighbors collected money, gave it to her and encouraged her to escape. She took a circuitous route from Afghanistan to San Diego (pre-9/11), finally crossing the porous border into the United States. Upon seeing a taxi driver who had emigrated from Afghanistan, she presented him with the address she had been given — an address that happened to be for a city on the East Coast, on the other side of the country. Fortunately, the taxi driver called his sister and told her the woman needed a place to stay. The sister took the stranger into her home without question and allowed her to stay until she was granted asylum. Today, the woman is once again teaching, helping Afghan children who are growing up in the United States to learn the customs and native tongue of their mother country.

Kerstin Palmer, an LPC, tells similar stories about the asylum seekers who come to Denver’s Rocky Mountain Survivors Center (rmscdenver.org), where she serves as director of therapeutic counseling. She talks about a young Ethiopian woman who was tortured before a group of people raised money and bought her a plane ticket to South America. For the next three months, she rode in the back of a pickup truck, slowly making her way north. After being smuggled into Mexico, she finally crossed the river into the United States, where she was promptly picked up by the Border Patrol. Housed in a detention facility for several months, she had little idea of what might happen to her next because she couldn’t speak English and most of her fellow detainees spoke only Spanish. She was released only after an attorney engaged in asylum work volunteered to help her. She eventually moved to Colorado and obtained assistance from the Rocky Mountain Survivors Center.

“These survivors are amazingly courageous and resilient people,” says Palmer, who has specialized in the treatment of trauma throughout her career, including working with abused children and their families. “Being an immigrant myself (she moved from Sweden to Colorado in 1983), I understand what it’s like to change countries, and even under the best of circumstances, it’s hard.”

In fact, she says, helping torture survivors deal with issues centered on identity change is no less important than working through issues of trauma and grief. “We have to help this population with social reconnection as they struggle with becoming a different person in a different land,” she explains.

Andersonsays torture survivors often experience nightmares, night terrors, sleep deprivation, intense anxiety and other symptoms related to post-traumatic stress disorder. Depression is another common struggle. “The psychological scars from being tortured take much longer to heal than the physical scars,” she says.

Some effects of torture aren’t necessarily visible to the eye but potentially are more debilitating, Palmer says. “Survivors of torture often feel like failures and can become preoccupied with ‘Why didn’t I do something differently?’” she says. “They often feel like they’re dirtied somehow. Their shame issues are high, and they sometimes feel contagious. As counselors, when you hear what they have gone through, you have to be careful of your reaction to the severity of the trauma, or they might think, ‘Even my therapist can’t handle this. Now I’ve made her feel bad, too.’”

Survivors’ assessment of the “contagiousness” factor aren’t necessarily off base if the aftereffects of torture are left unchecked. According to Anderson, research shows that if torture survivors don’t receive therapeutic interventions, their children and grandchildren have higher incidences of mental health disorders and face greater risk of school failure and family violence. “Torture has a ripple effect on families and even communities,” she says. “It can be toxic.”

As Palmer explains, survivors of torture often live their lives on edge. This sense of unease can easily transfer to their families if left untreated. “There is more fear present in the room with survivors, in part because they are so hypervigilant,” she says. “They are constantly geared toward fight or flight. It is a different operation for them to concentrate or to simply do boring things because they never feel totally safe.”

Both Palmer and Anderson say that, thankfully, therapeutic interventions can decrease the anxiety levels experienced by survivors and help them to restore their sense of self-worth, dignity and hope.

Multicultural competence

While counselors should have training in trauma work before treating torture survivors, practicing with multicultural competence is also a must. When she helped to found Survivors of Torture International, Anderson assumed the majority of its clients would come from Latin America, given the organization’s location in San Diego. In actuality, most hail from African and Middle Eastern nations. Overall, the organization has served approximately 800 clients from nearly 60 countries.

A hallway at Survivors of Torture International features a map that indicates the country of origin of each of its clients. That visual aid helps clients realize that, “‘Oh my gosh, it’s not just me’ or ‘It’s not just my country,’” Anderson says. “It makes their experience a lot less isolating.”

Offering therapeutic groups is another consideration, both for helping survivors to normalize their experience and to show sensitivity to their cultural norms. “When working with people from diverse cultures, one-on-one work can be foreign to them,” Anderson says. “In many cases, doing group work makes much more sense to them and makes them feel more comfortable.”

Likewise, counselors may have to take steps to decrease survivors’ suspiciousness of therapeutic services and entice them to participate. “As care providers, it’s really incumbent on us to meet them more than halfway,” Anderson says. For example, her organization doesn’t publicize its physical address (using a P.O. box instead) and is located away from a main street so clients can guard their privacy. In addition, her organization rarely uses the term “mental health” in describing its services. Many torture survivors already are burdened with a sense of shame or guilt, she explains, and in most of their countries of origin, a strong stigma is attached to mental health services. “So when providing counseling services to this population,” she says, “we might just call it ‘help’ or even ‘going on a nature walk to talk.’”

The Rocky Mountain Survivors Center is also careful about the way it presents available services to clients — asylum seekers who otherwise receive absolutely no services from other sources. “Most of the world doesn’t have counseling as it is practiced in the United States,” Palmer says. “Many of (our clients) don’t know what counseling is, so we explain it to them in simple language that makes sense. But they do know about ‘insane asylums’ and that those people are never accepted back into society in their culture, so they fear anything labeled ‘mental health.’ We present ourselves as people others can come and safely talk to about what has happened to them, much like the role elders serve in their culture. We try to describe their condition as being more like an injury instead of an illness that we are going to help them ‘heal’ from.”

Palmer has learned a couple of other interesting cultural lessons while working at the nonprofit survivors center. First, she says, some clients, particularly those from Africa, regard anything offered for free — including legal representation, health care or psychosocial services — as being “bad,” or at the very least view the offer with suspicion.

Palmer also noted that clients from Africa were more likely to accept offers for help but then not show up to take advantage of the services. She finally had an African client tell her, “We are ‘yes’ people.” He explained that people from his culture automatically answer “yes” to any offer, whether they want to accept or not; to decline the offer in front of the person is considered rude. From this encounter, Palmer learned to give clients from Africa specific options. For example, instead of asking, “Would you like to come in for an appointment?” she will now ask, “Would you like to have your appointment in a week, in two weeks, or would you like to call me when you are ready?”

When it comes to multicultural competence and sensitivity, Palmer says, “There are two key words to remember: respect and curiosity. Be respectfully curious about the person.” She also gives counselors another piece of advice: Don’t have preconceived notions about what is “right” or “wrong” based on an exclusively Western point of view. She admits this is sometimes easier said than done.

Palmer recalls one instance in which a 63-year-old woman from Sudan arrived at the survivors center. She had been in slavery and had been tortured (“The fact that she reached age 63 is a miracle,” Palmer says as an aside). Fellow villagers had raised money to help her escape and reunite with her daughter, who was married and living in Denver. The therapists and other service providers at the survivors center ran into a roadblock, however, when they tried to help the woman. “In her culture,” Palmer explains, “women cannot speak until the man tells them they can. We don’t like that thought here in the West.”

Palmer respectfully asked the son-in-law if she could meet with the woman one-on-one, but the woman said she would refuse to speak unless her son-in-law was present. The initial session eventually was carried out with a therapist asking the son-in-law for permission each time before the woman spoke. “It didn’t seem like a big power trip,” Palmer says. “It just seemed like, ‘This is how we do it in our culture.’”

After that first session, the woman was comfortable enough to meet with a male therapist and an interpreter by herself. “Because she had been a slave and been tortured, we were trying to teach her self-empowerment,” Palmer says, “but we first had to understand that we weren’t starting from the same point culturally.”

Meeting needs

When treating survivors of torture, “therapy” can take many forms, much of it extending beyond the traditional realm of counseling, says Anderson. She points to a cooking class that Survivors of Torture International offers its clients. “This is a nontraditional approach,” she says, “but everybody likes food, so you can pull a lot of people and a lot of cultures in. It’s therapeutic because they are preparing and eating a meal together, reestablishing human connections, laughing and having joy. But it’s also practical because they are learning how to cook for themselves, which many of the men don’t necessarily do in their cultures. We try to meet our clients where their needs are. As they learn to trust us through these experiences, they often open themselves up to other kinds of therapy.”

The best treatment/intervention techniques vary from person to person, Anderson says. She sees similarities between working with survivors of torture and individuals who have been raped because both groups have had their sense of control taken from them. For that reason, she says, counselors should collaborate with torture survivors on their treatment plans, both to restore some sense of control to them and to ensure the plan is a good fit.

“We’re also not proponents of these survivors having to tell their entire story to be healed,” Anderson says. “They may reveal pieces of it little by little, and that’s OK. As counselors, we have to go at their pace.” She has found torture survivors to be extremely appreciative of counselors and therapists who can help them put the feelings they have been carrying around inside of them into words.

This process is aided greatly by making survivors feel safe in their sharing. For example, Anderson says, when her organization does an intake with a client and takes down the person’s history, “We make it more of a conversation rather than an interview because we don’t want them to feel like they are going through an interrogation again.” Likewise, all the offices have windows that open so survivors won’t have flashbacks to when they were confined by their torturers. “We try to make the environment as warm and inviting as possible for them,” Anderson says. “We might even begin with tea in the kitchen rather than heading straight to a clinical room.”

Palmer most often uses Pat Ogden’s Sensorimotor Psychotherapy techniques in treating trauma and loss among torture survivors. She is also a proponent of cognitive therapy, but, like Anderson, believes each treatment plan must be individualized. Palmer says one of the major steps in treating torture survivors is to help them stabilize by assisting them in identifying their strengths and coping skills and understanding why trauma affects them in the way that it does.

Once again, this often involves normalizing the client’s experience. Palmer references one client who had been a mathematician for a foreign government before being tortured and exiled. When he came for treatment, he expressed deep-seated worry that he no longer seemed capable of doing even simple math. Palmer tried to help him understand that his body and mind were reacting very naturally to the traumatic events he had endured. “I told him, ‘You can’t stop and do math when a tiger is chasing you.’ For torture survivors, it is extremely tough for them to wind down and stop running from that tiger. We have to let them know that, given their circumstances, their symptoms are normal; they are not going crazy.”

The Rocky Mountain Survivors Center also employs a variety of groups in treating torture survivors, including trauma and grief groups, meditation groups and groups designed to strengthen coping mechanisms through the creative arts. The groups also serve the purpose of helping survivors rebuild their sense of community and trust. Among the treatment goals these clients most often voice, Palmer says, are to feel safe, be confident in their ability to manage their symptoms, sleep better, worry less, identify the good things in their lives and dare to reach out to other people.

Family therapy is another important component of working with torture survivors, Anderson says. In some instances, children of survivors haven’t been told or don’t really grasp what happened to their parent. Those who don’t understand sometimes feel abandoned or resentful that the parent wasn’t providing for the family. Anderson says counselors also need to help family members understand that the symptoms the survivor is exhibiting or feeling are normal based on what happened to them.

The good news, Anderson says, is that the proper treatment allows torture survivors to heal from their trauma and resurrect their hopes and dreams. “These people are true survivors,” she says. “They have survived torture. They have survived getting to this country. They have survived adapting to a new culture. They walk through our door a shell of who they once were. Through treatment and interventions, they can become who they were before they were tortured and contribute again. It’s amazing just how resilient and successful these survivors are. These are the type of people who make any country strong.”

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.

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