of creating a future” (Herman, 1992, p. 195). While the primary experiences of torture were helplessness and isolation, the essential experiences of the recovery are empowerment and reconnection with others (Herman, 1992, p. 196). Accord- ing to Gorman (2001), reconnection means that survivors “draw on those aspects of themselves that they most value from the time before the torture … to forge a more resilient and enabling sense of identity.”
(McIvor & Turner, 1995). In this way, a survivor’s story of shame and powerless- ness can be transformed into a story about dignity and courage (Gurr & Quiroga, 2001). This brief, psychodynamically oriented approach generally takes between 12 and 20 weekly sessions. The role of the therapist is to clarify, encourage, and witness, while the survivor is an active participant in the process (McIvor &
Turner, 1995). Gurr and Quiroga (2001) suggest that this method of exposure to the trauma may be a key element in improving the positive symptoms of PTSD, which include intrusive memories, nightmares, reexperiencing of the trauma, sleep disturbance, irritability, and startle responses.
Cognitive Therapy
Cognitive interventions are directed at helping survivors reframe their thoughts about their behavior under torture as normal human responses and necessary for their survival (Gurr & Quiroga, 2001). The therapist encourages the survivor to consider that the purpose of the torture he or she experienced was to create in him or her a sense of helplessness and total loss of control, which explains his or her behavior under torture (Gurr & Quiroga, 2001). The thera- pist also redirects the survivor’s thoughts away from self-blame and places re- sponsibility for the torture firmly on the torturer. The survivor is encouraged to create new interpretations and assumptions about the world that allow again for the possibility of trust and meaning in life (Basoglu, 1998).
Behavioral Therapy
Behavioral therapy involves an imaginal reconstruction of the traumatic events in a supportive therapeutic setting (Gurr & Quiroga, 2001). In exposure therapy, the survivor is requested on multiple occasions to imagine the traumatic situation and retain that image until the anxiety and fear diminishes. The role of the therapist is to focus on the “conditioned stimuli relating to the individual’s cognitive and emotional responses to torture, such as fear, guilt, self-blame, humiliation, shame and loss of control” (Gurr & Quiroga, 2001). Exposure therapy usually involves 10 to 20 sessions of 1 1/2 to 2 hours per session. Although this approach is considered in the general trauma literature to be effective in diminishing the positive symptoms of PTSD, it is not always directly applicable to work with torture survivors, who may have experienced multiple and diverse forms of torture over a long period of time. McIvor and Turner (1995) comment on the difficulties involved in using exposure therapy “following complex trau- matization in torture,” asserting that survivors could find it very difficult to cope with the high levels of distress and the memories recalled during exposure therapy (p. 707).
Group Therapy
Group therapy for survivors of torture has a number of advantages. It brings together people with similar traumatic experiences and reactions, which can help to validate survivors’ experiences. Group work can promote healing by reducing
survivors’ social isolation and by providing a sense of belonging to a commu- nity (Fischman & Ross, 1990). Having a homogeneous group with similar experiences is viewed by Fischman and Ross as important, as it can also pro- vide a sense of commonality and can increase the opportunity for group cohe- sion. Group treatment can also maximize the use of therapeutic resources, since the survivor population is increasing beyond the pool of trained thera- pists to provide services. However, not all survivors will benefit from group therapy, and it may not be a culturally and politically viable approach to treat- ment (McIvor & Turner, 1995). In many cultures, for example, talking about personal problems in a group context is a foreign concept, as personal issues are not to be discussed with strangers. Also, with some severely traumatized torture survivors, hearing others in the group speak about their torture may be destabilizing. In such circumstances, group therapy may not be appropriate or should be considered in conjunction with ongoing individual therapy (Drozdek & Wilson, 2004).
Drozdek and Wilson (2004) describe using a five-phase treatment model for trauma-focused group therapy with asylum seekers and refugees from political and war violence from all over the world. This model incorporates psychody- namic, cognitive-behavioral therapy, and supportive treatment approaches and is designed to “help members place their traumas in a life-span developmental per- spective” (p. 250). The stages of this model include (1) establishing a therapeutic alliance and psychoeducation; (2) presentation of biographies, discussing dam- aged core beliefs, and discussion of symptoms; (3) telling the trauma story (which involves exposure and cognitive restructuring); (4) reconnecting with the pres- ent, past, and future (which involves focusing on pre- and posttrauma changes in the survivor’s worldview and assumptions); and (5) termination, relapse preven- tion, and future orientation (Drozdek & Wilson, 2004, p. 255).
Psychoeducation
Providing education to survivors, their families, and the community about the effects of torture, the symptoms of PTSD, and ways of treating those symptoms can make an important difference in helping survivors cope. Normalizing symp- toms that they may be experiencing can reassure survivors and also their fami- lies. Psychoeducation can be provided to individual survivors in therapy, groups of survivors, and families of survivors as well as to community leaders.
Psychodynamic Therapy
Psychodynamic therapy addresses the psychic decompensation that occurs as a result of torture and the disorganization or disintegration of the self (McIvor &
Turner, 1995). McIvor and Turner, citing Bustos (1990), report that the effective- ness of psychotherapy depends on the survivor’s ability “to integrate and organize the intrapsychic processes in relation to outer traumatic events” (p. 706). They note that the effectiveness of this process is affected by factors such as previous traumas experienced by the survivor and the survivor’s personality structure
(McIvor & Turner, 1995, p. 706). Wilson (2004) notes that effective posttraumatic therapy involves helping the patient “mobilize and transform the negative ener- gies, memories and emotions of PTSD and associated conditions into a healthy self-synthesis, which evolves into a positive integration of the trauma experience”
(p. 278).
Other Modalities
Nonverbal techniques such as art therapy, music therapy, and sand play ther- apy have been used effectively to work with both adult and child survivors of torture who do not respond well to verbal processing. These therapies can be either an adjunct to or an alternative to traditional therapy. The case of Ms. T.
illustrates the value of using nonverbal therapies. Ms. T. fled to the United States from Somalia, where she experienced torture and also witnessed the murder of her only sibling. Ms. T. had great difficulty talking about her experiences in therapy and could not discuss the murder of her brother. However, she was able to use objects in the sand tray to enact in great detail the death of her brother and her escape from Somalia. This process enabled her to begin to speak of her traumatic experiences and greatly facilitated her healing process, as she and the therapist became witnesses to the trauma story as it unfolded in the sand tray.
Elements of Commonality in Different Treatment Approaches
All of the therapeutic approaches discussed previously require that the ther- apy takes place in a setting of physical and emotional safety. Regardless of the approach, therapists must be aware of the potential for retraumatization of the survivor and must educate themselves about the potential trauma triggers that might exist in the environment or occur in the session. These trauma triggers may be obvious (such as giving the survivor the feeling that he or she is being interrogated) or subtle (such as fluorescent lights that remind the survivor of the torture cell, or clipboards similar to those used by the torturer).
The telling and retelling of the trauma story is another element common to most approaches to treating torture survivors. Most approaches have elements of behav- ioral therapy, such as repeated exposure to elements of the trauma story and a cer- tain degree of systematic desensitization (McIvor & Turner, 1995). For example, the testimony method involves a detailed telling of the trauma story over a period of time, as the survivor records, writes, and edits the story of his or her experiences.
Some form of cognitive restructuring also occurs during most therapeutic ap- proaches, as the therapist and survivor address negative beliefs and reframe them in a way that can bring new meaning to the experience (McIvor & Turner, 1995). For example, survivors may initially have the negative belief that their behavior during torture was shameful. During treatment, they may be able to reframe that belief, in- corporating a realization that they did what they needed to do in order to survive.
Finally, the use of psychoeducation to empower and inform survivors is an element in many approaches. Teaching survivors about the goals of torture, the
natural reactions of the human being to trauma, PTSD symptoms, memory dysfunction, methods of coping with flashbacks, and the potential usefulness of treatment may help lower the survivors’ level of anxiety, allay any fears they may have that they are “going crazy” (Drozdek & Wilson, 2004, p. 256), and assist them in recognizing the many ways in which they stood strong and survived.
Jaranson et al. (2001) have described important principles that underlie the treatment of severely traumatized clients and that apply well to work with tor- ture survivors. Some of these principles include:
• First, do no harm;
• Show respect to survivors by permitting them to tell their story at their own pace;
• Provide supportive therapy by having regular and expected meetings in which there is “warmth and continuity” (p. 257);
• Support the physical, social, and medical needs of clients;
• Be aware of cultural differences and the impact this has on the trauma work;
• Support the traditional religious beliefs of clients; and
• Understand that the client may need long-term support (pp. 257–258).
Cultural Considerations
It is essential that any therapist working with torture survivors be willing to ac- cept the challenge of understanding and being sensitive to cultural issues that arise during therapy, since survivors often come from cultures very different from that of the therapist (Okawa, 2007). Survivors come to treatment with different degrees of cultural preparedness for therapy. In many cultures, there is no tradition of psycho- therapy or mental health treatment except for people who are seriously mentally ill.
The concept of talking to a stranger about one’s personal problems rather than talk- ing to family, an elder in the community, or a religious leader may be unheard of (Fabri, 2001). Therapists must be willing to listen to the survivor’s needs, to con- sider what the survivor would find helpful, and consider adjusting the therapeutic model used with mainstream American clients to include interventions that are cul- turally meaningful to the survivor (Fischman, 1991; Fischman, 1998).
It is important to be aware that cultural stereotypes can be misleading and that each survivor has unique individual characteristics. Ultimately, the survivor is the expert on his or her culture, and it is the survivor who will educate the therapist in this regard. Survivors will be the therapist’s most important teachers.
There are many differences among cultures as to the meaning of torture, what is considered torture, and why the survivor may have been subjected to it. Cultural meanings have an impact on the type of therapeutic approach and intervention that may be effective with a survivor. For example, in some cultures, such as in Chile, a survivor may create meaning about his or her torture by placing it in a political context, given the history of political oppression in that culture and the use of torture as a weapon to control political differences (Gurr & Quiroga, 2001). Other cultures, such as the Cambodian and Tibetan cultures, may see torture and suffer- ing in light of the Buddhist concept of karma (Gurr & Quiroga, 2001).
In many cultures, it is expected that a health professional will give patients medication so that they can be “cured” of what is troubling them. However, in other cultures, medication is unavailable or reserved for only the most seriously ill. Few cultures place as strong an emphasis on taking pills to cure ills as the American culture. Many survivors report being afraid of becoming addicted to prescribed medications. When working with survivors who are highly symp- tomatic but resist medication for such reasons, the therapist can use alternative methods, such as relaxation techniques, meditation, or exercise, to address symp- toms of anxiety, hyperarousal, or depression.
Cultures also differ in the perception of the individual in relation to his or her surroundings. Many cultures are collectivistic: that is, they perceive the individual in the context of the group or community, in contrast to the individualistic orientation of Western societies, which focus on the individual as a distinct, in- dependent agent. Survivors from collectivistic cultures may respond more effectively to group or family work than to individual psychotherapy.
Performing Culturally Competent Therapy with Torture Survivors
The following suggestions are offered to the therapist working with torture survivors from different cultures:
• Recognize that different cultures may have different communication styles.
For example, in some cultures it is considered rude or aggressive to look directly into the eyes of the person with whom you are speaking.
• Be aware of gender issues. For example, in some cultures it is inappropriate for a woman to meet alone in a room with a male, even if he is a therapist.
• Take the age of the survivor into account. In some cultures, an older person would not expect a younger person to be in a position of “expert” or advisor, regardless of whether that person has the title of therapist.
• Interview in a culturally sensitive way. In some cultures, asking questions in an indirect way is considered much more appropriate than direct questioning.
Certain issues may be considered taboo for a stranger to ask about, such as questions about sexuality.
• Be attuned to the physical setting. If the room reminds the survivor of the interrogation room in which he or she was tortured, for example, the thera- pist may want to make changes to the room or the environment in which the therapy takes place.
• Honor traditional practices. Show respect for the survivor and his or her culture by being aware of and willing to honor the religious traditions or other traditional practices that hold meaning for the survivor.