It is HPRT’s view an effective treatment approach is one that takes indo consideration the patient’s body, mind, and spirit. Torture and other forms of extreme violence have been scientifically revealed to affect survivors’ physical health, their mental health status, and their psychological well-being. Survivors are existentially concerned with the unfairness and injustice of their traumatic experience. In addition, most cultures do not draw a clear line between human suffering that affects the survivor’s body, mind, and the spiritual/existential state.
HPRT has developed a comprehensive treatment work plan that can be used to monitor and guide treatment in each of the areas demonstrated to be critical in producing good clinical outcomes. Scientific evidence highlights the importance of addressing each domain in order to reduce psychiatric morbidity and promote recovery. If any of these elements are neglected, treatment will be only partially successful.
A worksheet/checklist summarizing this treatment plan can be downloaded here.
1) Trauma Story
Every refugee patient has at least one traumatic experience that figures prominently as an essential aspect of his/her life history. The trauma story is often a secret (such as a rape trauma) being desperately concealed from others; the trauma story is usually reviewed nightly in the patient’s nightmares (one survivor described her nightmares as a living hell); the trauma story is the imprint of history on the patient’s memory—a personal narrative in the mind that is retold daily as it is searched for new meanings and clues.
The trauma story is also the centerpiece of therapy. The clinical effects of traumatic life experiences can be found in the physical, psychological and spiritual symptoms and concerns of the survivor of mass violence and torture. While it has never been proven that repetition or analysis of the trauma story in the clinical setting is therapeutic, it is essential that the healer know the patient’s traumatic life history. For example, how can a doctor care for a refugee patient who is a rape victim without knowing and acknowledging this experience? The trauma story establishes a context of trust between therapist and patient and provides insights into the impact of violence as well as its ongoing effects on the patient’s life.
Limited cultural knowledge about the patient’s life (e.g. the Buddhist world view), the therapist’s distress in reviewing the trauma story, and each patient’s own reluctance and emotional inability to share his or her subjective reality create considerable barriers to devising an adequate clinical (and human) response.
2) Psychological States
At least four basic psychological states have a powerful impact on the emotional status of the patient. These psychological states include humiliation, anger, revenge/hatred and hopelessness/despair.
Patients who have been severely violated continue to have strong, upsetting feelings related to traumatic events, sometimes more than twenty years after the event(s). It is essential that the therapist work with the patient to reveal these feelings as well as their effects on the daily life and health of the patient.
Often spiritual and existential distress related to unresolved desires for justice, retribution and punishment of the perpetrators remain a daily concern for the patient.
An essential and sometimes neglected emotion associated with trauma events is humiliation. The humiliation of the survivor, his/her family and community is often the goal of violence. Public degradation can be internalized as shame and fear. Anger, hatred, and a desire for revenge can grow within the hearts and minds of survivors. Humiliation, combined with feelings of impotence and powerlessness, heightens the depression and despair of the survivor. All of these emotions can become very intense in a real life situation where many losses, such as the murder of family and friends and the loss of one’s home, have occurred.
Each and every survivor is concerned in his/her therapy with the ongoing issue of social justice.
3) Emotional States (Affect)
HPRT therapists strive not only to help the patient achieve insight into the causes and consequences of their problems, but also to reduce the negative emotional affect caused by the psychological states associated with violence. These states take a high emotional toll on the patient. Many survivors, regardless of their psychiatric diagnoses, have an emotional “firestorm” blazing inside of them. Unless controlled, these emotions can have an enormous negative impact on the health and well being of the patient. For example, this “firestorm” can lead to serious psychiatric illness such at posttraumatic stress disorder and/or depression.
4) Physical Illnesses
Torture and other forms of mass violence can directly and indirectly result in major medical problems. Common direct results include head injury from beatings, pain and disability secondary to land-mine injuries and shrapnel wounds, and the medical consequences of sexual abuse including HIV/AIDS.
Common conditions in survivors such as depression are now being demonstrated to be associated with hypertension, cardiovascular disease and diabetes. Premature death in the elderly has recently been revealed in Bosnian refugees secondary to the negative health effects of chronic depression.
Chronic depression in trauma survivors is deadly and must be successfully treated and monitored over time. Sub-clinical emotional states and chronic psychological distress can also have disastrous health consequences.
5) Concrete Social Services
The trauma survivor’s physical and social world has often been destroyed or seriously damaged. During resettlement the refugee gives up everything—possessions, home, and all of the resources of their local communities. Rates of unemployment among survivors are often high; traditional jobs such as farming do not exist in the new environment. The therapist must imagine the social condition of a survivor who has lost or given up his/her entire social world to create a new life in a foreign land.
The therapist must not only map a survival plan for the survivor to obtain his/her basic human needs (food, shelter) but also help the survivor cope with the inevitable family distress generated by the needs of children and adolescents. In many resettlement situations, parents feel they are losing control of their more rapidly acculturating children. Legal problems, especially associated with obtaining citizenship in the new country of asylum, are disturbing to survivors and need to be overcome. Coping with the harsh material conditions existing in a refugee camp are very challenging. This difficulty in simple survival can be heightened for internally displaced person, who does not receive international protection or humanitarian. For unsettled refugees and displaced persons, the stress of acculturation to the new society, village or refugee camp is enormous.
6) Therapeutic Activities
HPRT has demonstrated the critical importance of actively involving survivors in their own recovery. The tremendous resiliency of survivors must be identified and harnessed to produce therapeutic outcomes. Three areas of maximum therapeutic potential include work, altruistic behavior, and spirituality. Activities in each of these areas must be strongly encouraged.
Care of individual survivors must be contextualized to the survivor’s family and community. Sensitivity to community norms demands considerable contact of the therapeutic staff with the refugees’/torture survivors’ community. In most situations, recovery of individual patients contributes to the recovery of the entire society and/or local community damaged by mass violence.
For resettled refugees, English as a Second Language (ESL) programs (or comparable training in the language of the host country) are an important and powerful tool for communication. These new language skills reduce social isolation and empower the patient’s ability to cope in a new environment. Obtaining citizenship also has a major impact on increasing the survivor’s sense of security and well-being.
7) Therapist-Patient Relationship
The therapist must closely attend to all aspect of the therapist-patient relationship. Clear and simple communication between therapist and patient is essential for good compliance; it also promotes improved clinical outcomes. Medical interpreters must be properly used. Trained bicultural workers are the preferred choice of therapeutic partnership.
Treatment is an ongoing process. Survivors often need follow up phone calls and reminders for their next visit. Remember, they do not trust the system, and are often testing the therapist’s commitment to their care.