The Context of Survival and Destruction: Conducting Psychotherapy with Survivors of Torture
By Barbara Chester, Ph.D., and James Jaranson, M.D., M.A., M.P.H.
NCP Clinical Quarterly 4(1): Winter 1994
Systematic torture of human beings occurs in more than 110 countries throughout the world (1). Torture is an extreme form of trauma that deliberately and strategically attacks the body, psyche, and spirit of the individual. In a more fundamental sense, torture is a violent process that seeks to destroy all levels of meaning and replace this meaning with a state-imposed definition of reality.
During the past 20 years, there has been a growing response to torture on the part of human rights groups, clergy, professional asssociations, and especially former prisoners and families of detained and disappeared persons. This response has generated international awareness, and has resulted in a large and growing body of documentation, practical experience, and research that is beneficial to clinicians working with survivors of torture. As definitions and methods of torture have been widely reviewed elsewhere (2-3), this article will focus on the complexity of current treatment issues as illustrated in the literature.
Assessment
The issue of assessment underscores the complexity inherent in treatment of survivors. While some practitioners are concerned by over-medicalizing an essentially socio-political phenomenon (4), others are concerned that politicizing treatment would cause us to ignore very real and intense suffering of a physical and emotional nature (5). In addition, cultural appropriateness of Western concepts of trauma, recovery, and measurement (6-7) are also important assessment issues.
The literature is consistent in terms of the symptom consequences of torture. After reviewing 46 studies, Somnier et al. (8) describe the most characteristic psychological reactions to torture as "sleep disturbances, nightmares, anxiety, depression, memory defects, loss of concentration, and changes in identity." In their recent review, Ramsay et al. (9) reject the notion of a unique torture syndrome, and instead view responses to torture and trauma dimensionally, or holistically, and not categorically. These authors also begin to look at the question of how specific aspects of torture contribute to different sequalae. For example, prolonged isolation, blindfolding and physical torture (including sexual abuse) result more often in symptoms of PTSD, while major depression is closely associated with losses following torture.
The accuracy of reporting problems and events may suffer due to survivors' cognitive deficits, repression, cultural differences, arousal and shame (10-11). Nonetheless, several standardized measures have been used, including the Impact of Life Events Scale (12), the Allodi Trauma Scale (13), and the Harvard Trauma Questionnaire (14). While evidence of an emic syndrome for torture or trauma has not yet been identified (15), some American Indian groups have readily identified with the concept of PTSD, at least in war veterans (16).
However. essential questions remain unanswered, including the role of premorbid personality in both surviving and recovering from the effects of torture, the use of successful and dysfunctional coping styles during torture and imprisonment, and the ability to separate the impact of torture from surrounding events (17).
Recovering Memories: The Trauma Story
Re-telling, re-framing, re-working, and bearing witness to the client's story has been a cornerstone of torture treatment (18-20). Little is known or understood, however, about the process of remembering trauma, or about the nature of the interrelationship of remembering, telling, and recovery. It has been theorized that telling is a form of exposure within a therapeutic setting that may lead to anxiety reduction and cognitive change (21). It is important to understand that "testimonies are human documents, rather than merely historical ones" (22). Like other aspects of the torture experience, traumatic memory is complex, and the trauma story is multidimensional. There is an entire lexicon of memory, involving a continuous interaction between the past and present.
Recovering memories is a risky task, particularly if it involves the components of catharsis and abreaction (18). To be effective, re-telling needs to occur within a contextual framework. Problem-solving this issue with a group of Southeast Asian elders, for example, permitted us jointly to discover that bearing witness provided sufficient benefit to the community.
Few controlled treatment outcome studies have been reported, and none of these has been specific to torture treatment. However, some success, at least in terms of symptom reduction, has been noted using behavioral and cognitive behavioral techniques such as flooding and imagery (21, 23). The testimony method provides the mediating influence of a tape recorder between the individual and his/her therapist (24). In addition, normalizing the clients physical, emotional, and cognitive reactions both during and after the experience appears to be both important and beneficial (19). Nonetheless, the timing of telling, the necessity of catharsis with telling, and cultural permissions and prohibitions regarding disclosure must be carefully addressed.
Cumulative Trauma
The nature and extent of prolonged and repeated trauma in groups under repression and in exile is an integral treatment issue. The impact of a single, extreme and acute trauma, such as torture, in the context of cumulative and, in some cases multigenerational trauma, is relatively unknown. The additive and interactive effect of severe stress led clinicians in South Africa to coin the phrase "continuous traumatic stress syndrome" in recognition of the profound lack of trust, deep feelings of rage, and severe depression seen in their clients (25).
Torture erodes the community through the destruction of important relationships and the transformation of the entire social context (4). Mass rape of women during war situations and the added element of "ethnic cleansing" noted by medical professionals in Zagreb (26) makes clear that torture involves the strategic destruction of communities and families, as well as of individuals (27). For this reason, some groups have targeted the community as the most appropriate unit of service (28).
Exile
For obvious reasons, most published studies of the impact of torture have involved work with individuals in exile. The few studies that seek to separate the effects of torture from exile are inconclusive. Wallach and Rasmussen (29), for example, determined that the frequency of sequelae in tortured, non-exiled Chileans was essentially of the same magnitude as those reported by tortured Chileans in exile. Other studies demonstrate that the experience of torture adds to the negative effect of exile (30), but also report that some symptoms, such as depression, nightmares, and cognitive problems, appear to be more common in tortured exiles than in tortured non-exiles (31).
Clearly, the importance of exile, with its attendant change of social status, loss of family, friends, community, language, and possibly legal status, is profound and needs to be part of any treatment effort. An Argentinian psychologist, herself an exile stated that: "Exile [itself] is a form of torture. Each of us comes apart; our internal world is in pieces. We live psychologically mutilated" (32).
Despair and Meaning
Stripped of the distance provided by medical nomenclature, torture results in what has been described as a "disorder of despair" (19), a "disorder of hope" (20), and "losing the world" (33). The client and therapist together need to lift the veil separating the "un-made world" of the tortured (34) and a "re-made world" of new meaning.
This task is essentially one of reconnecting through whatever means possible, including rituals and symbols (35), groups (36), and the oral and written testimony of others. This is both a creative and re-creative process, which endeavors to build a future from the " ruins of memory" (8).
Conclusion
The psychotherapist or counselor is only part of the mutidisciplinary context involved in helping the survivor make sense of the world after torture. There are other important parts of this context however, that will to a large extent determine the ability to succeed in or even to attempt this process. Without stable political and geographical boundaries, for example, groups such as the Tibetans, Kurds, and Bosnians will be unable to re-build their communities except in exile. Policy makers must take into account the dynamics and timing of testimony in the legal process. Finally, those of us who inhabit communities that are currently stable and democratic must support our collegues who have chosen to practice their therapeutic task, at great risk to themselves, in countries under repression.
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Barbara Chester is Clinical Director, the Hopi Foundation, and former Clinical Director of the Center For Victims of Torture in Minneapolis
James Jaranson is Director, International Mental Health Section, University of Minnesota at St. Paul Ramsey Medical Center, Medical Director of the Center for Victims of Torture
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