Psychological Therapies for Survivors of Torture

Edited by Jude Boyles

Introduction – Everyone should know what happens to us

My first ever client who was a survivor of torture was an Iranian man called Reza. Two pictures from Tehran that his mother sent me still hang on the wall of my therapy room, and I have thought of him often while editing this book. I read through some of his quotes before writing this introduction – they provide its title and the last words of the book – and was reminded just how overwhelmed and deskilled I felt when we first met. I remember wishing then that there was more guidance for therapists embarking on this work.
Reza once said the following to me, and, in many ways, he is describing the overarching theme of this book – the importance of adopting a holistic and flexible approach:

One time you helped me with my housing. One time you listened to me about my prison. One time you helped me find peace inside as I was so fear[ful] and panicky, and one time we talked about the politics of my country. But every time you cared for me and were like a sister.

Survivors often tell us that what helps is not just the caring, human presence of a therapist who listens and wants to hear their story, but a therapist who can directly offer help when they need it to manage overwhelming responses to trauma. Our clients also tell us that it is important that we are willing to engage with them in conversations about their home country’s politics and the UK government policies that deliberately keep people seeking asylum in poverty: ‘… torture survivors living in exile in the UK are pushed into poverty by government systems’ (Mendez, 2013: 2). They tell us that sometimes we need to act – by writing a letter, chasing the housing provider or ringing their legal representative.

Reza said to me in one of our early sessions: ‘Do you know what they do to us in my country? You would not believe it if I tell you.’ Sadly, in the UK, survivors are frequently not believed. The UK Parliament’s Home Affairs Select Committee (2013: 11) reports that there is a ‘tendency of those evaluating asylum applications to start from the assumption that the applicant is not telling the truth’. Following the refusal of his asylum claim, Reza said: ‘They say I have lied, but I have not told them most of what they did to me.’ He was devastated, and found it almost impossible to find the words to describe the agony of not being believed, and the humiliation of being portrayed ‘as a liar’. Without exception, all the survivors I have worked with have found the process of seeking asylum distressing and humiliating, and many have fared badly within it. I have witnessed how the stress of a badly administered system, long delays and poor decision-making creates high levels of anxiety. I have seen even the most resourceful and resilient survivors worn down by the process, as each year passes. Most survivors live with an inherent dread of their claim being refused and/or being returned to the country from which they fled. The fear of detention is exacerbated when survivors have to report to the UK authorities. An ex-client described to me how the threat of reporting hung over her for most of the month between reporting dates, and she felt safe only for a few days immediately afterwards. Boyles and Shaez (2015: 13) write: ‘… he has only one or two days after reporting when he feels a sense of relief or safety. Then his anxiety begins to build again towards his next reporting date.’ The process of seeking asylum can take from three months to seven or more years, and many people will be separated from their immediate family during that time.

As human rights therapists, we bear witness to these abuses, whether they occur in the country of origin, a third country in transit, or in the UK. We name them as human rights violations. We know that, alongside responding to psychological distress, we need to act to ensure a survivor’s basic needs are met and they are made aware of their rights in their country of exile.
Too often, survivors living in poverty or who are homeless and under threat of return are denied access to psychological therapies because of their circumstances. They are told that they cannot ‘use treatment effectively’ until their life is stable or they have been granted refugee status. This can be a very long wait for most people. Survivors have a right to treatment wherever they are positioned in the asylum process, and they can benefit from therapy at all stages. Therapists must be willing to be flexible and to adapt their models and their sometimes fixed approaches to working with trauma in order to provide help to survivors for whom the trauma is not yet over.

The appalling treatment of people seeking asylum in the UK comes as a shock to many therapists. As a supervisor, I have seen the impact on therapists when they come up against the cruelty of the asylum process for the first time. It is painful for therapists to sit with a client’s distress when a full and painfully given disclosure is dismissed in a few lines in a Home Office refusal. We in the west work in a context of racism, xenophobia and anti-migrant feeling, and I have consistently witnessed first-hand the impact this has on clients, therapists and interpreters from refugee and ethnic minority backgrounds.
I have worked in the refugee field for nearly two decades and always knew that any one of my clients could be detained. But one of my worst moments was when it happened for the first time. I felt powerless and outraged, and deeply saddened to witness the mental stability for which he had worked so hard in therapy dissolve in a ‘cell’ in an immigration removal centre. Sometimes, when we spoke on the phone during his detention, it was evident that the experience was retraumatising him and he was finding it hard to distinguish between his cell in the Democratic Republic of the Congo (DRC) and the one in the UK.

I am still shocked… I will never forget it.You ask yourself,‘Why am I in prison, I have not done anything?’ It is the same. (Boyles & Shaez, 2015: 14)

Reza asked me in our early work together if I knew what torture was. I can’t remember my response to him, but I remember we talked of his fear that I could not possibly understand what it is to be tortured, not knowing if you will live or die, day after day. It is daunting to try to summarise the range of experiences and forms of torture I have come across in my working life, but it also feels important that I try, as the details of torture are easy to avoid. Survivors are imprisoned by the state or organised groups, and may be tortured for weeks, months or years. Some are held in camps, brutally beaten and raped, and escape after a few weeks. Many live in such camps for years. Survivors are beaten, whipped, burned, electrocuted, suspended, have nails removed or limbs chopped off, and are sexually violated in numerous, cruel ways. They are held in packed, stinking cells, naked with no facilities to wash. They are subjected to sexual violence by other prisoners and repeated rape by their guards. Some are held in solitary confinement. They may have to urinate and defecate in their cell. The smells are unbearable and can haunt a survivor for years after. Prisoners hear the screams of others being tortured, or are made to witness or take part in torture or other atrocities, or they see family members or colleagues killed. It is not just adults who are tortured, but children and young people too.

Many survivors describe mock executions and other forms of humiliation that are hard to bear and leave them feeling ashamed and defeated. Food and/ or water are often given just once a day, and can be foul or contaminated. Survivors are made to lie in the sun or drink urine. Women are forced to become sexual slaves to soldiers, and both women and men are forced to undertake hard labour. They are threatened, mocked and stripped of all dignity. They are forced into painful positions and kept awake by water being repeatedly thrown into the cell or by continuous loud noises. For some, imprisonment with others may provide some comfort and a sense of solidarity. For many, the cell is also a place of violence.
I have worked with activists who were detained and tortured several times and who had some expectation of being imprisoned and/or harmed. Others were not political activists, but were attending their first demonstration, or were lesbian or gay or from a persecuted minority tribe. Some had a family member who was active or involved in politics. Many women describe sexual violence that began in childhood and continued into marriage, as well as repeated rape in conflict: ‘Many states exhibit a societal acceptance of widespread and systematic violence perpetrated against women, where abuse forms part of women’s daily lives’ (Smith & Boyles, 2009: 8).

Some survivors leave quickly following their release or escape from prison; others plan their journey into exile with their political party and/or family over many months. Many do not remember how they got to the UK, or describe long and traumatic journeys. Some leave with family; others leave their family behind, hoping to be reunited soon. Some planned to come to Europe; many did not know their destination until after they arrived.
All leave behind their culture and homeland, and a known way of life. They leave behind their family, community, work, political life, home and friends. Some survivors have left developing countries and/or countries in conflict, where access to food, education and healthcare is limited. Others have left countries and lives where they had established careers as engineers, lawyers, farmers, and have lost their professional identity, their business and their land.
The UNHCR, the United Nations refugee agency, estimates that there are 59.5 million forcibly displaced people in the world. Women and girls will make up 50% of these. Around 86% of all refugees are displaced within the developing world, not to industrialised countries (UNHCR, 2017).

I approached the contributors to this book because they all have significant experience of working with survivors and share a commitment to human rights. Some are based in NHS primary or secondary care psychological therapy services; others work in third-sector specialist or refugee therapy services. A number work or have worked in rehabilitation centres for survivors of torture. What we all have in common is a commitment to work holistically, from a rights-based approach.

Our aim is to share what we have learnt with therapists who are working in a range of settings. We are aware that most therapists do not have access to in-house services, such as advocacy or physical therapies, to support their work with survivors, who may have multiple, complex social and medical/ health needs. It is our hope that this book will inform and give confidence to practitioners that there is much they can offer in their day-to-day work with survivors of torture.
As human rights practitioners, we believe in the right of survivors of torture to rehabilitation and justice. Article 14 of the UN Convention Against Torture (UNCAT) (OHCHR, 1984) entails a duty on member states to provide effective rehabilitation to survivors. Rehabilitation is an ‘important component of reparation’, and the UN Basic Principles on remedies for victims require that ‘rehabilitation should include medical and psychological care as well as legal and social services’ (Mendez, 2013: 2).
Rehabilitation may hold a different meaning for therapists working in the torture field than for those in social care. For the purposes of this book, we define rehabilitation as the right to physical and psychological care that supports a survivor to recover from their experiences, as well as access to a range of services that meet their multiple needs, including legal, medical, social and educational.

It is important to remember that not all survivors are traumatised, and not all need or want therapy. Many survivors I have met have been saddened and distressed by their experiences of torture, but their difficulties have been to do with living in exile and being separated from their family and homeland, as well as the stress of the asylum process. Therapy is not for everyone, and many survivors would not choose a talking therapy. Many will recover or choose to seek support from within their families, communities, in women’s groups or with fellow activists and survivors, friends and allies. When asked, many would probably put other concerns or issues first, before therapy: the right to work, to be treated with dignity and respect, to fairness and not to be kept waiting endlessly in the asylum process, and to an asylum process that is itself independent of the government agenda. Survivors often say that they just want to be allowed to rebuild their lives in safety, with community support, and access to education and training.
I once asked a survivor, Amy, who came from Burundi and had been waiting for four years for a decision on her claim for asylum, what she wanted from therapy. I suspect the question held little meaning for her. She said:

I want to go home and be safe, if you don’t want me here, and if I can’t do that, I want them [the Home Office] to let me stay, leave me in peace so I can rebuild my life. I don’t need your help; I just need my visa [grant of refugee status] so I can live.

Therapists in this book reflect on how hard it can be at times to remain confident that the very practice of therapy and the ways in which we understand trauma will not further oppress and undermine those we are seeking to help. Many of us struggle daily with the fear that we are applying individualistic approaches to working with trauma and distress that do not respect ‘the complexity of how different human beings living in different cultures respond to terrifying events’ (Bracken, 2002: 80). As a white therapist practising in the refugee field in the racialised context of the UK, I am very conscious of the considerable power I hold as a professional. I am reminded daily of my ability to oppress, influence or harm people through my belief system and frameworks for understanding and ‘treating’ distress. Working self-reflexively is at the core of the work, and of this book, as is ensuring we are properly supported and trained to undertake this work. Many of the writers refer to Judith Herman’s wonderful book, Trauma and Recovery (1992).

The first three chapters of this book reflect Herman’s three-stage approach to working with survivors of atrocity. In the first chapter, I explore my experience of assessing survivors holistically, and emphasise the importance of providing direct help where possible in early sessions, to instil hope and support engagement. I advocate for an assessment process that gives both client and therapist time to fully explore the full range of difficulties, and thereby ensure that we establish a sense of safety before trauma work is undertaken.

In Chapter 2, Norma McKinnon reflects with her client, Kevin, a survivor of torture from Darfur, what made the difference for him in his therapy and his experience of processing his painful history in Sudan.

In chapter 3, Kirsten Lamb draws on her work in both an NHS secondary care service and a torture rehabilitation centre to explore the final phase of work with survivors, that of reconnection.
Next Rajita Rajeshwar considers how therapists might facilitate conversations about racial and ethnic differences in therapy and shares her own experiences of working with survivors, as a second-generation British Tamil.

In the next chapter, we are given a first-hand account of torture by Prossy Kakooza, a lesbian survivor of torture from Uganda. Prossy was imprisoned and tortured because of her sexuality, and describes vividly the benefits and challenges of having counselling in the UK. Prossy reminds therapists to learn about the asylum process, in order to better understand the context in which survivors are living.

Linking with this, in Chapter 6, Katie Whitehouse shares her work with women survivors in a women-only setting in Leeds, and reminds us of the limitations of the international legal framework to protect women from gender-based abuses. Katie emphasises that psychotherapy cannot be undertaken without attention to the social, cultural and political context of women’s lives, and an understanding of the discrimination women have lived with in their home country and continue to live with in the UK. Her chapter explores how women’s experience of torture is very different to that of men, and how they are also exposed to other forms of gender-based abuse, such as female genital mutilation, domestic violence and forced marriage.

Ann Salter shares her work with separated young people, and encourages therapists to be mindful of the impact on young people of being separated from their family and the risks they are exposed to in exile, as well as the challenges they face in the asylum process.

Colsom Bashir worked for many years as a specialist clinical psychologist for refugees within the NHS in a deprived area of Greater Manchester. In the first of two chapters, Colsom addresses the very central issue of shame, which features in many survivors’ narratives, and encourages us to ensure we place these narratives in the context of the wider narratives and social purposes of shame. The NHS in England offers few choices to people seeking psychological help, and CBT is currently the model offered by most providers. In chapter 9, Colsom provides guidance for CBT therapists on working from a human rights framework in a setting where therapists may be working within significant time constraints and other limits imposed by their organisation.

Next, Ashley Fletcher, a gay activist and psychotherapist from Manchester, describes his work with gay men who have been tortured because of their sexual orientation. He emphasises the importance of the commitment to supporting survivors’ applications for asylum, by writing professional reports and letters. He points out that the therapist is in a powerful position to document and testify to the impact of torture on a survivor, but also to provide the decision-maker with an understanding of the experience of being gay in the survivor’s country of origin.

In chapter 11, Emma Roberts turns the focus on a very important aspect of the work – the needs of survivors who have come as a family, or have been reunited in the UK. Emma came to train in systemic family work through having had to manage situations where women survivors with no access to childcare arrived at therapy sessions with their child. Her chapter describes vividly the difficulties and dilemmas facing the therapist when seeking to hold the distress of families where the roles of the parents have been reversed and their children have abandoned cultural and religious beliefs and practices deeply held by their parents.

Next, Carl Dutton describes his work with survivors at the Haven project, in Liverpool, which is now closed – a casualty, along with so many other wonderful projects, of the last decade of austerity. Carl argues for a creative and community-based approach to supporting survivors and shares some of the groupwork that was at the core of the Haven’s approach.

In her second chapter, Chapter 13, Ann Salter examines the issue of trauma and attachment in her work with young people, and the impact of torture on development. Ann’s chapter is relevant for those working with children and young people, as well as therapists working with adults who may have been tortured as children or young people.

Working with interpreters is a skill with which most therapists will not be familiar. It can provoke anxiety, and the therapist can experience the interpreter as an intruder. There can be an assumption that having a third person in the room negatively impacts on the client, and inhibits the therapist in developing a therapeutic alliance. In Chapter 14, the first of two chapters on working with interpreters, I, with my former colleagues Desiré Kinané and Nathalie Talbot, argue the need for therapists to regard the interpreter as a partner in the therapy triangle, and we share our experience of developing those working relationships to benefit survivors. We argue that the skilled interpreter also bears witness to the survivor’s narrative, alongside the therapist, and can be a warm and affirming presence that supports a survivor’s recovery. The chapter offers practical advice on how to engage suitable interpreters and on good practice in joint working.

In the following Chapter 15, Beverley Costa, from the groundbreaking Mothertongue project, explores the training and supervision needs of interpreters, and unpacks some of the common dynamics in the triadic relationship.

In Chapter 16, Jess Michaelson examines the impact on the therapist  of working with survivors. She shares her own experience of finding a place of internal safety in which to practise safely and offers guidance on how we can mitigate against vicarious trauma. Importantly, she also writes about how the work with survivors can help therapists to grow professionally and build personal resilience.

Our final chapter is by social worker Anna Turner, who provides an insight into social work with survivors. She emphasises the key role of social work in the refugee sector and outlines the core principles underpinning social work today and its potential to bring about social change and the empowerment and liberation of people. Anna argues that social justice, human rights, collective responsibility and respect for diversity are central to social work practice, and highly applicable to working with survivors of torture and their families in exile.

This book doesn’t claim to be a comprehensive or definitive picture of work with survivors of torture in exile. It is a snapshot of these individual practitioners’ experience, and the stories of some of their clients. Kevin speaks for so many people like him when he asks (Chapter 2): ‘Do I not have a right to live? Do I not have the rights of a human being?’ The chapters that follow describe how these authors have sought to answer those questions.

References

Boyles J, Shaez M (2015). In the shadow of detention. Therapy Today 26(4): 10–16. Bracken P (2002). Trauma: culture, meaning and philosophy. London: Whurr Publishers.
Herman JL (1992). Trauma and Recovery: the aftermath of violence – from domestic abuse to political terror. New York: Basic Books.
Home Affairs Select Committee (2013). Asylum: seventh report of session 2013–14. London: Stationery Office. https://publications.parliament.uk/pa/cm201314/cmselect/emhaff/71/71.pdf (accessed July 2017).
Smith E, Boyles J (2009). Justice Denied: the experience of 100 torture surviving women of seeking justice and rehabilitation. London: Medical Foundation for the Care of Victims of Torture
Mendez JE (2013). Foreword. In: Pettitt J (ed). The Poverty Barrier: the right to rehabilitation for survivors of torture in the UK. London: Freedom from Torture.
OHCHR (1984). Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT). Geneva: OHCHR.
UNHCR (2017). Global Trends: forced displacement in 2016. Geneva: UNHCR. www.unhcr.org/uk/ statistics/unhcrstats/5943e8a34/global-trends-forced-displacement-2016.html?query=global%20 trends%202016 (accessed July 2017).