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Assessment and Treatment of Torture Survivors :

Resilience-Centered Healing

Adeyinka M. Akinsulure-Smith, Ph.D. Katherine Porterfield, Ph.D. &

Hawthorne E. Smith, Ph.D.

Bellevue/NYU Program for Survivors of Torturehttp://www.survivorsoftorture.org/

Bellevue/NYU Program for Survivors of Torture

• Founded in 1995

• Over 5,000 men, women and children served

• Over 100 countries represented in our client population

• Help to rebuild the bodies, minds, and spirits of people who have been tortured or persecuted.

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

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Overarching Programmatic Philosophy

Strength/Resilience based approachNot just victims – but survivorsHelping to marshal internal and community resources

Holistic sense of the survivorInterdisciplinary approachMultiple stressors – many ways to intervene

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

Extreme Challenges Experienced by Torture Survivors and Refugees

• Multiple losses

• Ongoing effects of recurrent/reinforcing trauma

• Social dislocation; war; trauma; torture; internally displaced in home country; flight and relocation in neighboring country; refugee camps; immigration processing; resettlement in USA

• Individuals will respond to these stressors in different ways

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

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Physical and Emotional Scars of Torture

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

IRCT IRCT

Common Reactions to Torture and Refugee Trauma

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

Cognitive

Spiritual

Behavioral

Physical

Emotional

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Spheres of Marginalization• Educational Functioning

• Social Service Provision (logistical/financial)

• Legal Advocacy

• Vocational/Professional

• Social Functioning

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

Trauma-Informed Approach to Service Provision

• Safety

• Empowerment

• “It does not have to be • therapy to be therapeutic.”

HawthorneSmith,Ph.D.Bellevue/NYUPSOT

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Interdisciplinary Approach to Healing

Hawthorne Smith, Ph.D.Bellevue/NYU PSOT

Community Connection

Spiritual Engagement

Emotional Relief

Medical Treatment

Social/Legal Support

Culturally Syntonic Interventions

• Flexibility of Treatment Techniques

• Holistic Approach

• Focus on Resilience – not Pathology

Hawthorne E. Smith, Ph.D.Bellevue/NYU PSOT

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How does one change the world...?

• Utilizing the experiences and insights of our clients

• Helping the voiceless find their voice

• Collaboration among and between disciplines

Hawthorne Smith, Ph.D.Bellevue/NYU PSOT

Wisdom, Courage, Hope

Our clients:

Mr. UMs. AMs. TMr. S

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Ms. X

Ms. X: ChronologyØ1996: Democratic partyØApril & Oct, 1998: Family members murdered Øon going verbal and physical harassment

and threats due to political affiliationØ2003: Verbal and physical acts of violenceØMarch, 2005: Attempted abductionØ June, 2005: Sexual violenceØ - Family flees, travel through ItalyØAugust, 2005: Family arrive in U.S.

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Ms. X

“Every day, my daughter says, ‘Why are you crying Mommy?’ I want to feel normal, have joy…”

Ms. XMr. X

J4 months

The X Family

M3

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Considerations for Treatment

� Who is this person?� Why now and what are the expectations?� Safety and trust� Psychoeducation� Practical needs/ basic necessities� Racial/Cultural factors� What types of interventions will be used

and why?

Barriers/Challenges to Seeking and Utilizing Mental Health Services

vRefugee TraumavLack of information/knowledgevShame/stigmavGuiltvFearvIsolationvRacial/Cultural factorsvLanguagevLegal – the asylum process

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Integrated Care� Intake� Primary Care◦ Medical check up

� Mental Health ◦ Orientation Group◦ Individual Psychotherapy and/or Group◦ Psychiatric services

� Social Service Support◦ Metro cards◦ Housing Assistance◦ English language classes

� Legal Support

Our treatment process

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Ms. X: Asylum Process

Ø August, 2005: Family arrive in U.S.

Ø 2006: Asylum interview

Ø Jan, 2007: Intake at PSOT

Ø Dec, 2007: Asylum hearing, Immigration Court

Ø June, 2008: Asylum hearing, Immigration Court

Ms. X and her family, a “typical” forced migrant family

� Repeated Traumatic experiences: EXPOSURE

� Separation from family members: FAMILY DISRUPTION

� Range of psychological reactions in one family: RISK and RESILIENCE

� Participating in multiple unfamiliar systems: ACCULTURATION/RESETTLEMENT STRESS

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Theroleofpsychologistsinassessingtortureforlegaland

forensicpurposesAsylumandbeyond

Whatarethevariouslegalcontextsinwhichapsychologist’sassessmentof

tortureisrelevant?• Asylum• Humanrightstrials/WarCrimesTribunal• Criminalcases(VictimofcrimeorDefendant)• Civilcases(Damagesorotherrelief)

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Ineachofthesecontextsyouareusuallyansweringreferralquestions:

ASYLUM WARCRIMESTRIBUNAL CRIMINAL CIVIL

Whathappenedtotheperson? ✔ ✔ ✔ ✔

Whodidthistotheperson? ✔ ✔ ✔ ✔

Howdidwhatwasdoneaffecttheperson?

✔ ✔ ✔ ✔

Whatwouldhelpthepersonrecover?

✔ ✔ ✔ ✔

Implicitinthesequestionsis:

• Questionaboutcredibilityofclient• Questionaboutwhattorturedoestopeople• Questionabouthowpeoplerecoverfromtorture

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Court’sremedycouldbe:

• Asylumorotherimmigrationstatuschange• Financialremedy• Convictionofperpetrator• Someotherlegalruling,suchassuppressionofstatementsmadeundertorture

• Recognitionoftortureforreconciliation,amnesty,etc

Recognizingthatyouarenotthefact-finder

• NOTyourjobtodetermineproperconsequence—financialorotherwise

• NOTyourjobtodetermineguiltorinnocenceofaperpetrator

• NOTyourjobtomakeimmigrationdetermination

• YOUAREASSESSINGANDOPININGONTHESUBJECT’SEXPERIENCEOFTORTURE

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Assessingtortureforasylumwhenyouhaveaclinicalrelationshipvs.an

evaluationonlyClinicalrelationship• Canmovemoreslowly

throughmaterial• Credibilityofclientisimplicit• Writtenreportcanhaveless

focusonfull,detailednarrativeandmoreonclinicalpresentation,therapeuticreaction

• Canprepareclientfortestimony

• Canbeasourceofsupportforclientincourt

Evaluationonly• Oftenonly1-2sessionsfor

historytaking—Rapportisharder

• Willusuallyneedtoaddresscredibilitydirectly

• Reportshouldhavethoroughreviewofhistoryanddetails

• Nocontactwithsubjectusuallyafterreport

Assessingtorturefor“nonclinical”purposes

• Recognizethattheinteractionwiththesurvivorcanbe

• Traumatizing• Healing/Therapeutic• BOTH

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Thoroughassessmentoftorture:

• IstanbulProtocol:ManualontheEffectiveInvestigationandDocumentationofTortureandotherCruel,InhumanorDegradingTreatment.UnitedNations;OfficeoftheHighCommissionerforHumanRights:Geneva,Switzerland.

• Guidelinesincludingproperinterviewing,ethicalconsiderations,documentationissues,andreportwritingcanbefoundhere.

Interviewconsiderations• Client’sreactiontoyou- gender,race,ethnicity,countryof

origin,sexualorientation;RELATIONSHIPTOPOWER• Interrogationdynamics• Client’sexperienceofrecounting—Havetheydoneitbefore?

ASK• Presenceoffragmentation,dissociation—OBSERVEand

COMMENToninreportifpresent• Useopen-endedquestionsuntilyouneedtoaskspecificones

– “Tellmeaboutwhathappenedtoyouintheprison...whathappenednext?VS“Didtheybeatyou?”

– Whenbeingspecific,explainwhy,“Iknowthesequestionsarehard,butit’simportantthatIreallyunderstandyourexperience…”

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Reportwriting

• Ifyoudidanevaluation,followIstanbulProtocolguidelineswhichmeans:– Conductpsychosocialhistoryoffxbeforetorture– Detaileddescriptionofsubject’sexperiences– Anydocumentationthatsupports– Clinicalobservationsofbiopsychosocialfunctioning

– MedicaldocumentationbyMDevaluator– Recommendations

Testifying

• Explainyourmethodology:clinicalinterview,standardizedmeasures,recordreview,etc.

• Forasylum,talkaboutwhatmadesubjectcredible(Details?Emotionaldistressduringinterview?Changeovertime?)

• Beabletotalkaboutmalingering/fabricatingandhowyouassess

• Summaryoftortureandofeffectsoftorture• Opinionifreturnedtocountry

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Assistingaclientinpreparation

• Anxietymanagement• Copingenhancement• Normalize• Psychoeducation• HelpingtheLAWYERhelptheclient

– Practicebutdon’toverpractice– Knowthe“hot”spots

Whyarepsychologistsimportanttoongoinglegaleffortstoaddress

torture?• Becausetortureissopsychologicallydamaging,psychologistsareessentialtotheworkofdocumentingandpreventingtorture,aswellastreatingsurvivors.

• Becausetheethicalfailureofourprofessionalorganizationledtopsychologistsbeinginvolvedintorture.

• Becausewecanuseourtrainingandexpertisetorepairwhatwasdone.

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THANK YOU!!Adeyinka M. Akinsulure-Smith, Ph.D.

aakinsulure-smith@ccny.cuny.eduKatherine Porterfield, Ph.D.Katherine.porterfield@nyumc.org

Hawthorne Smith, Ph.D.Hawthorne.smith@nyumc.org

Bellevue/NYU Program for Survivors of Torturehttp://www.survivorsoftorture.org/