A Tibetan monk was arrested and imprisoned by Chinese authorities after peacefully advocating for Tibetan independence. In repeated interrogations, the 32-year-old man was subjected to torture that included beatings; electric shocks from a cattle prod repeatedly applied to his mouth, abdomen and genitals; exposure to extremes of heat and cold; near suffocation by being placed in a plastic bag; and restraint in painful positions for hours. After his release, he fled across the Nepali border, made his way to India and then to New York City, where he was referred to the Bellevue/New York University (NYU) Program for Survivors of Torture.
He was diagnosed with pulmonary tuberculosis and was hospitalized for several weeks. He was also evaluated by a program psychiatrist and psychologist, who diagnosed him with depression and severe posttraumatic stress disorder (PTSD). He was placed on antidepressants and anti-anxiolytic medication and showed a marked improvement in his symptoms. He also began supportive therapy. Since his hospital discharge, he continues to be seen regularly by the program (Keller et al., 1998).Help for Survivors
To help meet the needs of the estimated 400,000 torture survivors living in the United States today, the U.S. Office of Refugee Resettlement (ORR) will distribute $7.3 million in grants to 10 to 15 of the nation's most comprehensive torture treatment centers. The funding is a result of the Torture Victims Relief Act (TVRA), legislation passed by the U.S. Congress in 1998. Furthermore, President Clinton has requested that Congress approve another $9.8 million in grants for next year, according to an ORR spokesperson.
"All of us [centers] around the nation have been working so hard to get TVRA passed and the funding available," explained Edna Impalli, Ph.D., to Psychiatric Times. Impalli, a clinical psychologist, is the clinical and education coordinator of the Bellevue/NYU Program for Survivors of Torture. "The population of survivors of torture is huge, and we need all the help we can get."
Impalli, along with a psychiatrist, co-facilitates a support group for Tibetan survivors. She explained that since March 1995, the Bellevue center has provided multidisciplinary care to about 450 torture survivors and their families from 52 different countries (about one-third are from Africa), in addition to conducting research and providing training to health care professionals and resettlement workers. Based in the primary care medical clinic, the torture center utilizes primary care doctors; psychiatrists and psychologists; gynecologists; rehabilitative physicians; occupational, physical and art therapists; and social workers.
The center was founded with hospital funds and donations from various private foundations and government agencies. All physicians and psychologists in the program have faculty appointments at NYU School of Medicine, and the program draws on other medical center resources including the Rusk Institute of Rehabilitative Medicine. For patients who do not have insurance, a sliding fee scale is arranged. For patients who cannot afford treatment at all, fees are waived.
Impalli reported that an estimated 5% to 35% of all refugees coming to the United States from countries where torture is systematically practiced have been tortured. There are an estimated 75,000 to 90,000 torture victims in New York City alone, making it one of the nation's largest such concentrations. In 1999, about 1,600 clinical visits were made to the program.
Impalli said that in July 1999, the program received a $400,000, two-year grant from ORR to provide 26 training sessions a year to health care professionals and resettlement workers about health and mental health care issues.
"All along, we'd been providing training sessions to immigration officers, presenting at Grand Rounds and other forums at medical schools, law firms and universities in the New York metropolitan area and across the country. And in 1998, we held two conferences-one for medical students and one for psychiatrists and other physicians-on how to get involved in providing documentation for asylum applications of torture survivors. This is a critical issue and one way psychiatrists can really help is to get involved in learning how to do these evaluations and providing them when needed."
With last year's ORR funding, the program expanded its training efforts. Program staff have already conducted more than 20 training sessions and workshops for health care professionals. The program also co-sponsored a training conference for these groups in March.
"We're trying to reach out to anyone who may come into contact with torture survivors and traumatized refugees and would like to receive training in evaluating and treating these individuals," Impalli explained. "We can provide consultations for those already working with these patients or conduct training for groups of psychiatrists who would like to learn about this population."
Impalli reported that the program's mental health treatment team now includes two attending psychiatrists, seven full- and part-time senior clinical psychologists/supervisors, and 20 psychology interns and externs.
"A large number of our clients come in first for non-psychiatric medical problems because it's more acceptable to them culturally to ask for that kind of help rather than mental health assistance. But we always try to provide initial assessments by a mental health professional and primary care physician within the first several appointments. Not all patients recognize the need for mental health services, but in our program, we are seeing increased utilization [for mental health services] each year," Impalli explained, adding that such services were provided to about 130 clients in 1999.
Presenting physical sequelae include broken bones, joint and muscle pain, headaches, dizziness, burns, neurological damage, hearing loss, loss of sensation, and tuberculosis. Psychological and emotional sequelae include memory disturbance and difficulty concentrating, sexual dysfunction, emotional irritability, social withdrawal and loss of trust, insomnia, flashbacks and nightmares, and difficulty feeling or expressing emotions.Treatment Approaches Differ
Impalli noted that, in addition to providing individual therapy, the program offers group therapy in both culturally homogeneous and mixed groups. Currently, there are groups for Africans, Bosnians and Tibetans. Psychological treatments include cognitive-behavioral therapies, psychodynamic therapies, family therapy, narrative/solution-focused therapy, group therapy, testimony therapy, hypnosis and EMDR (eye movement desensitization and reprocessing), activity therapies, and expressive art therapies.
The program also collects descriptive data on demographics, types of torture and trauma, sequelae of trauma, and physical and psychological symptoms and diagnoses. A database form with standardized measures of PTSD and psychological symptoms is completed on each client, and these data are analyzed to explore specific effects of torture and trauma on refugees, adaptive capabilities important to survival and recovery, and the efficacy of various treatment approaches.
Impalli added that program staff had developed a screening instrument for identifying torture survivors among immigrant patients, and a pilot study was conducted at the Bellevue clinics to determine prevalence of torture survivors among immigrant patients seen in general medical settings. A research study of health care access and health status among asylum seekers in detention facilities is in a preliminary stage.
Asher Aladjem, M.D., associate director of consultation psychiatry services at Bellevue Hospital and assistant professor of clinical psychiatry, is director of psychiatry consultation-liaison and has been with the program since its inception. Formerly, he had worked with Holocaust survivors and Israeli soldiers suffering from PTSD.
"I got involved through the consultation-liaison psychiatric service as a liaison to the Primary Care Medical Clinic working with Dr. [Allen] Keller [M.D., program director]," Aladjem told PT. "This was an important liaison, although a little unusual, because we usually are involved with people who are medically ill, and we didn't consider the survivors of torture to be particularly medically ill. But they all were referred to us by their internists, and that's how the liaison developed, and over time I started seeing more and more patients and then helped develop the program."
Aladjem does not view PTSD or symptoms of survivors of torture as one thing. "It's a very diverse group of symptoms and there are very diverse diagnoses dealing with a lot of comorbidity-psychiatric and medical-and a lot of premorbid psychopathology," he explained. "For example, a bipolar, manic-depressive, flamboyant dancer from the old Soviet Union who was tortured clearly developed PTSD, but it did not eliminate the bipolar [disorder] he had much prior to that, so we're dealing with PTSD imposed on premorbid psychiatric diagnoses, and that's something we've seen quite a lot of. I think this is a little controversial because, in many ways, we have tried to shelter our patients and advocate for them that everything they suffer in life is a result of one trauma, and that may be so in some cases, but clearly not in all of them. So people would say, 'Is somebody more vulnerable to develop PTSD as a result of some premorbid [condition]' and the answer to that clearly is 'yes.'"