Healing the Hurt

Healing the Hurt: A Guide for Developing Services for Torture Survivors was developed by The National Capacity Building Project at The Center for Victims of Torture for practitioners who may or may not have worked previously with torture survivors. It is a multidisciplinary guide that addresses some basic considerations when working with this population. This handbook is a primer, and it should not take the place of more in-depth training in torture treatment. We hope you find this resource helpful in your work with torture survivors. Various chapters are referred to under Providers Resources at HealTorture.org. Access to all handbook chapters is available by downloading the PDF files.

You can view and download the full book or scroll down the page to view and learn more about each individual chapter.

Healing the Hurt has also been translated into Korean.

Chapter 1: The Torture Rehabilitation Movement

Rehabilitation specialists commonly define torture as the calculated, systematic infliction of suffering by at least one person upon another. A key component is the complete physical control of the victim by the perpetrator (Nightingale, 1990). Once seen as a product of foreign totalitarianism and repressive regimes, torture is a weapon of terror used also in war, prison, and chaotic political situations. Examples may include: beatings and mutilations, asphyxiation and submersion, mock execution, electric shock, over/under-sensory stimulation, rape, humiliation and threats, witnessing the torture of others, and denial of food and medical treatment, to name a few. The numbers of victims of torture is difficult to pinpoint, but the estimate of torture survivors living in the United States is 400,000-500,000. Beginning in the 1970’s, numerous groups have developed to into networks that share support, knowledge, research, and political impact to meet the needs of survivors worldwide. While this movement to provide specialized treatment to survivors is new, it is growing as professionals become aware of the nature of torture, and its impact on the well-being of clients.

Chapter 2: The Effects of Torture on Families and Communities

Because of traumatic events, torture gives rise to discord and conflict within ethnic groups and community support structures. As trust is lost among family members, neighbors, and friends, entire communities can become polarized and fragmented. Under prolonged political repression, feelings on community hopelessness and resignation surface, leaving members with an overwhelming sense of despair because of the unspeakable atrocities they endured in their homelands. The practical need to focus considerable effort and attention on learning a new way of life reinforces these norms. That new life includes the American cultural norm of working longer hours and spending less time in social or family relationships, in contrast to the more communal orientation of many survivors’ original cultures.

Because most torture survivors rarely flee as intact families, survivors go through a lengthy separation and the fear of retaliation against loved ones still living abroad. Once the “honeymoon” period of reunification ends, the effects of trauma begin to surface in complex manners. Such effects interact with the stresses of cultural adjustment, loss of economic and/or social status, events back home (e.g., war, destruction of property, deaths and torture of friends or extended family), and other ongoing trauma the family may be experiencing in their new community (such as racism, neighborhood violence, etc.). Resolving conflicts between traditional and newer values is difficult without trauma. When one or more family members is coping with effects of torture, these issues become even more daunting.

The family of torture survivors may also be affected, either through torture to themselves or indirectly, by the torture of a loved one. As young people in highly traumatized and isolated families view attempts to reach out to others as a betrayal of their parents or they have internalized the fears of their parents. They fear getting their parents into trouble with authorities by bringing attention to the family. They fear a reoccurrence of what happened back home.The thoughtful provider considers the individual torture survivor not in isolation but as a part of a larger support system of family and community.

Chapter 3: Core Competencies in Working with Survivors

When providers are familiar with and respect the culture, language, and trauma experience of their clients, they create bridges of understanding. In order to provide appropriate and effective services, professionals need to develop a degree of expertise in the following four core fields of competency: KNOWLEDGE of the life experiences and resettlement issues of refugees and survivors of torture before, during, and after the violence; COMPREHENSION of torture and its long-term effects on survivors, their families, their community, and professionals who work with them; CULTURAL COMPETENCE with traumatized people; WORKING EFFECTIVELY with interpreters. This chapter provides information on the four competency areas that apply to providers in all disciplines and service domains.

Chapter 4: Social Services

Torture occurs within a cultural and social context. It breaks the connections between individuals and their social environment. It separates the bonds of communities. Social work interventions, therefore, are directed at individuals, their families and immediate environments, community, social, and functional groups, and policies and systems. These are accomplished through direct service, resource development, community interventions, education and training, research, and public policy work. The provision of social services to survivors of torture is administered by workers with a wide variety of educational foundations and life and work experiences in an assortment of settings. While this chapter is written for professional social workers, the material is appropriate for social services providers regardless of background, training, or specific tasks.

Providing appropriate and effective services to torture survivors requires a degree of expertise in four core fields:

• Knowledge of the story of refugees and asylees — before, during, and after the violence

• Understanding of the nature of torture and its long-term effects on survivors, their families and communities, and the professionals who work with them

• Cultural work with traumatized people

• Best practices for working with interpreters

This chapter augments the information concerning the core competencies presented in Chapter 3. A discussion of social work interventions during resettlement and in the political asylum process, sample scenarios illustrating the impact of the effects of torture on accessing social services, and guidelines for cultural competency and for working with interpreters and clients are included in this section. A brief note on policy work and a summary conclude the chapter.

Chapter 5: Medical Services

This chapter is a resource for physicians and nurses working with or planning services for torture survivors. Preceding chapters outline the purpose of torture and common torture methods. This chapter reviews the long-term effects of torture and describes roles and responsibilities for physicians, psychiatrists, and nurses who are helping torture survivors reduce trauma symptoms and rebuild their lives in the United States. These roles and responsibilities include education, documentation, assessment, treatment, referral, research, and advocacy. While detailed discussion of specific treatment modalities are beyond the scope of this chapter, it will introduce areas deserving further exploration by health care providers. These topics include cultural competence, working with interpreters, use of medications, and improving access to care. In addition to direct treatment approaches, physicians and psychiatrists are encouraged to integrate preventive components into their organization’s programmatic strategies. Examples of such strategies are discussed in Chapter 8. Finally, this chapter describes resources and training opportunities for physicians and nurses interested in conducting medical and psychological forensic evaluations on survivors of torture.

Chapter 6: Psychological Services

This chapter focuses on identifying basic principles and areas of learning needed to begin providing mental health care to torture survivors living in the United States. The chapter is written for mental health providers who are relatively new to working with torture survivors. Providers may be called upon to offer any of a variety of psychological services to individuals, families, groups, or communities affected by torture, including crisis intervention, counseling, assessment, consultation, facilitation, supervision, and short- and long-term therapy.

This chapter is not intended as a “how to” rewards of working with survivors manual. Rather, it serves as a point of departure to help providers determine which types of knowledge or training they need to give qualified care. In addition, the authors offer a number of references of resources for learning.

Chapter 7: Legal Services

This chapter provides an overview of challenges that arise when representing torture survivors and strategies to ensure these challenges do not act as a barrier to effective legal representation. Attorneys encounter torture survivors with a variety of legal needs. Frequently, however, the survivor’s initial and most pressing legal problem involves immigration matters, such as asylum, family reunification, or defense from removal (deportation). Because safety is crucial to the survivor’s ability to engage fully in torture treatment services, the asylum process is integral to rehabilitation.

Other related immigration legal services, including family reunification and obtaining lawful permanent resident status, may also be vital to the survivor’s steps toward rehabilitation. Survivors with a variety of immigration statuses may find themselves in need of representation in these matters. Without a lawyer’s careful attention, these issues may interfere substantially with clients’ ability to participate in their representation. In these situations, attorneys must diligently practice the basics of good lawyering: building a solid attorney-client relationship, communicating effectively with the client throughout representation, and, at all times, treating the client with dignity and respect.

Chapter 8: Planning Programs for Torture Survivors

Although the field of torture treatment is in its infancy, a body of knowledge has been developing over the last twenty years through accumulated clinical experience and research. Chapter 1 outlines the history of the torture treatment movement. Chapters 3 through 7 describe in some detail the major service components of programs for torture survivors: social services, psychological services, legal services and medical services.

This chapter gives additional information for program planners on needs and resource assessment, financing, choices in structuring services, and training and supporting staff in this demanding work. This information can be used to plan specialized programs for torture survivors. It can also be used by mainstream health, social service, or legal service providers who want to adapt their existing services to serve torture survivors.