The International Journal of Psychosocial Rehabilitation
Psychotherapy Treatment of Torture Survivors

Peter Berliner
Associate Professor at the University of Copenhagen
Consultant Psychologist at the Rehabilitations and Research
 Centre for Torture Survivors (RCT), Copenhagen, Denmark

 Elisabeth Naima Mikkelsen
MA Student in Psychology and International Developments Studies at
 Roskilde University, and works at RCT, Copenhagen, Denmark
 
Anne Bovbjerg
Psychologist specialised in psychotherapy, counselling and supervision,
 and the leader of the Trauma Centre at The Danish Red Cross Asylum Department

Malin Wiking
Psychologist, and works at the Trauma Centre at The Danish Red Cross Asylum Department

Abstract

This article presents a project about applying a model of brief therapy to the rehabilitation of survivors of torture and organised political violence. The model includes both narrative and body oriented therapeutic approaches to the treatment of trauma. The narrative approach focuses on the construction of meaning in the traumatic events and in so doing makes it possible for the client to view his life story from different angles. The body oriented therapeutic approach includes a range of techniques that can help the client to control his bodily reactions to the trauma. In addition, the article contains an evaluation of the brief therapy project, exposing the tendencies of the treatment effectiveness. The tendencies are that despite the fact that the treatment did not notably reduce the symptom experienced by the clients, many had, due to the treatment found new and better ways of dealing with their pain. Also, since the treatment aimed at strengthening the client’s abilities to cope with the complexities of his/her problems on a daily basis, many experienced an increased sense of manageability and meaningfulness in regards to daily life.
 

Introduction
Recent studies of refugees seeking asylum in Western countries have showed consistently higher rates of mental distress in the refugee population compared to those found in the general population. The symptoms include depression, anxiety, demoralisation, stress, fear pain, and PTSD (Silove & Steel, 1998; Edvall-Dahlgren et al., 1989). The potential for trauma is present at various stages of the refugees’ experiences such as during the flight from the country of origin, and during the reception procedure in the host country (Packness, 1998, Monaldi & Strummielo, 2001). In addition, several studies show that many refugees suffer from experiences of torture, political violence and various other forms of physical abuse in addition to their migration experiences. These horrifying memories of the past interfere with their concentration, causing them to be anxious and withdrawn (Silove, 1999; Silove, Ekblad & Mollica, 2000). Inevitably, the increasing numbers of survivors of torture and political violence presenting to asylum services in Western countries pose significant challenges for the mental health services in these countries, calling for the development of new methods and intervention strategies to the rehabilitation of torture survivors.
 
Literature Review
Torture survivors are assisted either by stopping torture, i.e., primary prevention, or by the provision of torture rehabilitation services, i.e., secondary and tertiary prevention. Amnesty International has adopted the simplest, most broad definition of torture: “Torture is the systematic and deliberate infliction of acute pain by one person on another, or on a third person, in order to accomplish the purpose of the former against the will of the latter” (A.I., 1973).

In 1984, the United Nations, in the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted the following definition:
 
This definition was restricted to apply only to nations and to government sponsored torture. It did not include cases of countries where torture such as mutilation or whipping is practices as lawful punishment, nor did it include cases of torture practised by gangs or hate groups.
In 1986, the WHO working group introduced the concept of Organized Violence, which was defined as:
 
 
 
Torture is a perverted form of human interaction, which involves at least two persons, the victim and the torturer. It is characterised by extreme degradation, humiliation and dehumanisation as the torturer inflicts severe physical or psychological suffering on the victim. The torturer/victim relationship is characterised by its anonymity and is highly asymmetric in that the situation creates a relationship of extreme dependency, permitting the psychological manipulation of the victim (Doerr, 1992). Thus the victim is trapped in a double bind situation because he either has to co-operate with the torturer, by giving confidential information or he has to suffer more pain and possible death (Lira, 1990).

Torture is a technique with the purpose of carrying pain almost to the infinite. Michel Foucault writes: “Torture is the art of maintaining life in pain, by subdividing it into a thousand deaths, by achieving before life ceases the most exquisite agonies” (Foucault, 1979).
 
At an individual level, torture has been used as punishment with the purpose of destroying the victim as a human being through the systematic infliction of severe pain and psychological suffering. Also, torture has been used to destroy the victim’s identity by forcing him to become a traitor to his comrades and to his ideology. At a social level, authoritarian governments of all colours have used torture as a political tool to create fear and intimidate dissident groups with the purpose of preventing the population from expressing opposition towards government policies. Thus, countries subjected to a climate of terror may contain whole communities affected by violence. In order for such societies to engage in processes of reconciliation and national healing, the social reparation needs to go through the sequential steps of truth, compensation, justice and pardon (Padilla and Comas-Diaz, 1987; Becker, 1990; Bronkhorst, 1995; Quiroga & Gurr, 1998).
 
In 1997, Amnesty International reported torture and maltreatment in 115 out of 215 countries (53,5%). The prevalence of torture in selected samples of refugees varies from 5 - 70% depending on the composition of the sample in relation to nationality, sex, age, and point in time (Lavik, 1996). The prevalence in samples of unselected refugees showed intermediate values. For instance, a random sample of 3000 asylum seekers who arrived to Denmark in 1986 showed a torture prevalence of 20% (Jepsen, 1988), while a prevalence of 23% was found by a Swedish group of Red Cross in a sample of refugees requesting asylum in Sweden (Horvath-Lindberg, 1988). In the last 10 years, the medical and psychological service programs for survivors of political or other forms of organised violence have expanded enormously. While Amnesty International identified 100 programs in 25 countries (A.I., 1997), the IRCT listed 94 programs in 49 countries, belonging to its network of torture rehabilitation services (IRCT, 1997) and further estimated that as many as 166 programs were existing in 81 countries in 1997 (IRCT, 1998).
 
Torture methods have been divided into physical and psychological methods. The Chilean Human Rights Commission listed 85 different types of physical torture (Orellana, 1989). Physical torture can be brutal with severe physical damage and a high lethal rate (Vazquez, 1977), but often the torturers want to avoid visible body marks. The most frequent methods of physical torture are beatings, suspension, stretching, electric torture, submersion, suffocation, burns, cuts and sexual assaults. The time between the exposure to torture and the medical examination is crucial; the closer the victim is examined to the time of torture, the easier it is to observe any physical signs (Quiroga & Gurr, 1998).
 
In contrary to the physical effects of torture, the psychological symptoms are much more persistent, as torture is intended to damage the person’s self esteem and destroy the person’s trust in fellow humans. The psychological methods of torture are mostly tailor-made and will often include induced exhaustion and debility through food, water and sleep deprivation, isolation of the victims, monopolisation of perception for example through movement restriction and high pitch sounds. In some cases, the victims and their families are threatened with death or they experience sham executions. In other cases the victims witness the torture of another prisoner or of family members (Quiroga & Gurr, 1998).
 
There are similarities between emerging psychological symptoms in torture survivors and the main constellation of symptoms corresponding to those collected in the syndrome labelled as Post Traumatic Stress Disorder (Cunningham & Cunningham, 1997). However, labelling torture survivors as having PTSD is much too inadequate a description of the complexity and magnitude of the effects of torture (Reeler, 1994; Becker, 1995; Lira, 1998). A widespread theme in the testimonies given by survivors of genocide and organised violence is that many experience the feeling of having survived their own death; a symptom similarly described in relation to holocaust survivors.

The diagnosis DESNOS (Disorder of Extreme Stress not otherwise specified) includes several of the symptoms found in torture survivors and varies from PTSD by emphasising the torture survivor’s changed perception of the self, advantageously leaving the DESNOS diagnosis to describe survivors of long-term suppression and totalitarian control (Herman, 1995).
 
Many torture survivors develop symptoms of major depressions, obsessive compulsive disorders and psychoses, and there is a significant level of sexual dysfunctioning whether or not the person was subjected to sexual torture. Numerous studies have showed that many torture survivors experience changes in their identity (Somnier & Genefke, 1986; Barudy, 1989) and have a high level of comorbidity (e.g. Cunningham & Cunningham, 1997, Somnier et al., 1992). The torture survivor may have lost body parts, which means the loss of normal bodily function. Also, they may have lost family members, work, or credibility and status, because even though they resisted a breakdown during the torture, their colleagues are nevertheless likely to be suspicious of them. If the torture survivor leave the region to seek asylum, the losses can be compounded and exceed to include the break down of marriages and courses of education as well as deteriorations in wealth and status. Thus, torture is not only a very important life event, but also the cause of many other important life events, often leading to the loss of normal life development (Turner & Gorst-Unsworth, 1993; Skinner, 1997).
Additional research reviewed by Charney (1993) and Southwick (1994) has established a psychobiological mechanism for PTSD. This could explain the endured duration of the PTSD symptoms, and why current treatments are only partially effective, thereby having significant implications for the treatment of PTSD patients and survivors of torture.
 
While all the effects listed above have implication for the assessment and treatment of torture survivors, the relationship between the therapist and the survivor should also be considered. A trusting relationship must be developed in order for progress to happen. Similarly, cultural understanding is essential when choosing the methodology of the social assessment of the torture survivors, as a standard western psychiatric interview can be highly counter productive (Mollica, 1989). There are good arguments for a bio-psycho-social approach to treat and rehabilitate torture survivors, as this approach provides long-term flexible involvement to cope with relapses, thereby endorsing increased functionality for the torture survivors in order for him to achieve personal goals. As a result, increased functionality for the survivor becomes the main outcome objective for the therapy, rather than symptom reduction (Shalev et al., 1996) though that may also be a goal for treatment.
 
Often, the needs of the victims of organised violence are multiple and many have a combination of psychological, social, medical and legal problems, explaining why numerous programs of psychological treatment have adopted multidisciplinary approaches. Some of the treatment approaches used with torture survivors are cognitive therapy, insight therapy, psychodynamic therapy, behaviour therapy and the testimony method. It looks as if the therapists bring to the task whatever school of psychotherapy they have learnt. However, since there is little evidence in the literature saying that one approach is better than another, the effectiveness of available treatment programs remains unproven (Quiroga & Gurr, 1998). Some programs involve group treatment, and focuses on symptoms of torture-related PTSD, while other programs organise group therapy for children and adolescents within or across cultures. Overall, group therapy provides opportunities to develop trust and build social network. Also, it is very important that the treatment programs acknowledge that there are major differences between cultures in how they conceptualise the process of torture and its meaning. Consequently, indirect supportive methods may be more useful than those of pushing the survivors to talk about their experiences of torture (Mollica, 1988). Thus, cultural issues in psychotherapy indicate the need for different approaches for each culture when designing interventions (Quiroga & Gurr, 1998).
 
The approach of community development aims to empower a particular community, by addressing the internal and external needs of the individuals, the groups and the agencies that coexist within it (Aristotle, 1990). Various efforts have been made to train members of a community to help victims of torture and repression through small group discussions within the community. This is done in order to recognise the signs of torture and trauma, and share the traumatic experiences, thereby supporting the survivors in helpful activities (Loughry, 1990 in Hong Kong and the Philippines; Beristain, 1992 in Guatemala and El Salvador).
 
Whilst relaxation therapy and sensitive physical techniques can relieve some of the legacies of severe pain, dysfunction and stress, medication also has a definite place in the therapies found to effectively help torture survivors. However, the use of medications should be modified by the ethnic differences in metabolism, nutritional status, concomitant medications and age (Quiroga & Gurr, 1998). 
 
Despite the fact that no accessible papers or private reports give any information about the cost effectiveness of the treatment services and approaches listed above, the costs to a society of not providing therapy to torture survivors are not insignificant. Also, services of torture treatment in countries where torture has occurred or still is occurring denote that torture is wrong and that all people are valued and worthy of treatment. Thus, the services of torture treatment in countries practising torture systematically can support the people in their struggle for equal participation and democracy, thereby contributing to the overall country development. The growing interest in this new field of psychology and medicine is increasingly leading to the establishments of torture rehabilitation programs around the world (Quiroga & Gurr, 1998).
 
In conclusion, it is clear that in order for services to meet the needs of the consumers and thereby become sustainable in the longer term, they need to follow a range of principles. The principles are:
·        Interventions should be based on the best current knowledge while also consider any cultural differences.
·        Interventions must be diverse to meet the range of needs, differing in type and severity.
·        Participation[2] is essential in determining the best use of resources and in developing sustainability.
·        Good governance of services, and education and training at all levels are essential for good performance.
 
However, efforts of providing more profound information about the interventions offered by the torture rehabilitation services in different environments are seriously impeded by the fact that most studies published about torture survival are mainly descriptive in character. The studies describe various disorders in traumatised torture survivors, such as PTSD, anxiety, pain, dissociation, somatoform and cognitive disorders, and social withdrawal but the symptoms are only assessed before therapy has taken place. Combined post traumatic stress - post traumatic growth studies of therapy are almost non existent, and the few clinical follow-up studies that exist have limitations due to the lack of definitions of diagnostic criteria and the lack of control groups (Mollica et al., 1990). In other words, in order to come up with clear and valid recommendations on the functioning of rehabilitation services, and thereby be able to answer any of the many possible questions about approaches to torture rehabilitation, studies on several areas are needed (Quiroga & Gurr, 1998).
 
The remainder of the article contains a presentation of a brief therapy project conducted at the Danish Red Cross. The project, which was running for a two-year period, was established because the traditional psychosocial treatment methods offered by the Red Cross Trauma Centre comprised psychiatric or psychological consultations and occasional sessions of relaxation therapy, even though this strategy proved incapable of reaching torture survivors suffering from severe symptoms of PTSD. Thus, in order to provide the torture survivors with optimal treatment the project aimed at developing new methods for rehabilitating survivors of torture. The project introduced a combination of narrative and body therapeutic approaches to the treatment of psychological trauma. The team behind the project was inspired by Levine’s methods of treating chock-traumatised individuals (van der Kolk, 1996; Levine, 1997).
 
Brief Therapeutic Treatment of Traumatised Asylum Seekers
The Danish Red Cross Asylum Department is responsible for refugees seeking asylum in Denmark. For the most part, the refugees stay at the Red Cross asylum centres for longer periods of time until their asylum status has been decided by the Danish Government. Asylum seekers severely affected by symptoms of PTSD are referred to the Red Cross Trauma Centre where different forms of psychosocial treatment are offered. Traditionally, treatment of trauma in Denmark has been based on psychodynamic analytic theoretical frameworks, involving long-term therapies with 50-100 sessions and great exposure to the trauma as a significant part of the treatment. As an alternative, the project conducted at the Danish Red Cross asylum centre included a short-term therapeutic model, meaning that the torture survivors suffering from PTSD were offered eight sessions of treatment, each session consisting of two hours. The model comprised a combination of psychotherapy and relaxation therapy. It was believed that the short-term therapy model could reduce the torture survivors’ symptoms of PTSD and thereby enhance their quality of life, because, instead of exposing the torture survivors to their respective traumas, the short-term therapy model emphasised techniques that:
1.      could give the client the possibility to regain control and distance to the traumatic experience;
2.      tried to uncover as many resources as possible in the client’s past;
3.      reinforced the regaining of action potentials through talents/interests/abilities that are part of the client’s potentials (Berliner & Wiking).
 
As mentioned above, the short-term therapy model included a narrative and body therapeutic approach inspired by Levine (1997), in which focus is on the psychosomatic consequences of trauma. Many torture survivors suffering from trauma either have muscular tensions or over-relaxed muscles, which indicates that the body is reacting to the trauma and is dealing with it at an unconscious level. The body’s way of dealing with the trauma results in somatic grievances, which metaphorically is termed as the language of the body, or in other words, the body’s way of communicating the trauma.
 
The following provides a brief description of the different methods and techniques used during the eight session of the brief therapy treatment. The psychologist and the relaxation therapist introduce the course of treatment by informing the client about the potential perspectives of the treatment. The psychologist explains how the treatment can be an opportunity for the client to transform some of the problems in his life. The relaxation therapist gives information about how, during the sessions, the client will learn a range of methods and techniques to alleviate his physical sufferings. Subsequently the client is asked to account for the symptoms he is experiencing. It could be that he is not able to sleep at night, that he suffers from nightmares, or that he avoids social contact. Being quick-tempered or suffering from flashbacks are also symptoms of PTSD. 
 
The session continues as the psychologist tries to normalise of the client’s symptoms by using Levine’s tale about the animal from the prairie/pampas/Serengeti. The tale is about how animals, when hunted, often plays dead as part of a survival instinct. However, in contrast to human beings, the animal is able to recover from the shock immediately after it has occurred. Through these facts, the client is introduced to a narrative of a temporary state of shock, which can be a way to help the client to deal with his anxiety in relation to whether he is going mad or suffering from psychiatric disorders.  The client is thereby offered other ways of perceiving his reactions to what has happened as well as his present state of mental health.
 
The second session is devoted to the establishment of the safe place in the client. The safe place is a place the client knows well and therefore is able to describe in detail. It is often closely associated with good memories and positive experiences from the client’s life, such as school years, childhood, family gatherings etc. The idea behind the technique of the safe place is that the client can use it as a mental refuge whenever flashbacks and other repressive thoughts are troubling him. Also, the safe place can be used in meditation and relaxation exercises, and when the client tries to go to sleep. However, it is important to note that in some cases the safe place can provoke many different feelings in the client, as it can be also related to the loss of mental and physical places from the past.
 
In the third session, focus is on the actual symptoms that the client is experiencing, but in some cases it can be too difficult for the client to speak of his thoughts and feelings regarding the trauma. As an alternative, treatment can focus on the physical pain the client is experiencing, because the body and the physical pain are perceived to contain a narrative about the trauma. By getting the client to either talk about his current physical condition or by getting him to draw his pain, a narrative about the traumatic experiences slowly begins to emerge. Similarly, through relaxation therapeutic exercises aimed at strengthening particular areas of the body, the client’s narrative about how he experienced himself in certain situations can develop into emphasising the strengths and resources existing in his (re)actions. This way of combining the relaxation techniques with more verbal or creative treatment methods allows the client to express his problems in a different way, giving his the opportunity to bring his thoughts and feelings to surface.
 
Relaxation therapy is used also to raise the client’s awareness of his body and to increase the muscular relaxation. By stretching and relaxing of the muscles concerned, the client can experience that the physical pain is alleviated. Also, the relaxation techniques can help the client to calm down and relax, and they can help him detect his body’s resources in order to rebuild his defence-system.
 
The third session also includes the symbolic escape with help from the fight and flight instinct. This technique is conducted with the client lying on a mattress on the floor, and is about gently exposing the client to parts of the trauma. However, as the client relives the trauma from the past he is now helped to escape and to get away from the oppressors, as opposed to when the trauma actually happened.
 
In the fourth session, the work is focused on the traumatic experiences in the client’s past, and the technique of the safe place is used frequently as a way for the client to control his memory. At this point, a more narrative approach is adopted, which focuses on verbally constructing the meaning of the traumatic incidence from the client’s past in order for him to view his personal life-story/narrative in relation to a larger discursive framework such as religion, politics, ethics, etc. Thus the discursive framework represents a larger more meaningful narrative in the client’s life. In so far, the client is religious or is affiliated with a particular ideology; chances are that it can be less problematic for the client to reconstruct the meaning of his traumatic experiences. For instance, a person who is very religious has the option of praying to his/her God in order to ask for meaning of what has happened. Similarly, myths and legends from either the client’s culture or the psychologist’s culture can be used to make sense of the trauma.
 
Whereas the fifth and the sixth session continue the work with the themes and techniques introduced in the previous sessions, the seventh and eighth session are set on the future. These sessions concern the question of how the client wishes to feel in two years. Focus is on the client’s ability to use the safe place in order to control his bodily reactions as well as his thoughts and feelings associated with the trauma. Likewise, as the renegotiations of the trauma become manifested and the client begins to perceive his traumatic experiences and personal narrative as corresponding to a particular superior, meaningful narrative existing in his life, his capability of controlling his physical and psychological conditions is enhanced. Subsequently the treatment is directed into emphasising the socioeducative aspect of the client’s life, meaning that at this point, focus becomes on improving the client’s overall control of his life. This means that the client is presented with different options of how to deal with issues influencing his daily life, thereby offering him a chance to move away from the role of the victim. The socioeducative aspect of the treatment could for instance be a discussion with the client about what the advantages are of going to the library and read the newspapers in his native language, instead of staying at home, alone.

An additional way of getting the client to relate differently to his problems is to invite his significant other(s) to the session. Thereby the seventh and eighth session becomes about how the client, in co-operation with his nearest relations, can sustain the improvements achieved during the therapy, and how these improvements can be used in his daily life.
 
During the course of treatment, the psychologist and the relaxation therapist are aware of not creating transference or causing the client to regress to a former emotional state. Instead they aim at establishing an equal collaboration with the client. As a result of the treatment, the client gains the experience of having physical control over his body, and he experiences a sense of wholeness in relation to himself as an individual with a variety of strengths and resources.

The following case illustrates clearly some of the dilemmas and paradoxes pertaining to the (re)negotiation and (re)construction of the meaning of traumatic events. 

Case: The Story of the wolf (Told by the Psychologist)
He is a young man of his best years, handsome and much civilised as he appears at the clinic. He seems a little confused as we sit down to begin the session. His attention is on a poster hanging on the wall; a picture of a mysterious house by a canal made by the artist Magritte. The picture is beautiful and harmonious, but only until you realise that it is really quite wrong: whereas the house and its reflections in the canal is dark, the sky is rather bright, transparent and blue just as in the midst of a nice summer-day. People who see the picture become fascinated and also lightly disturbed by this illusion represented in the picture, as it reveals a much darker side than visible by first impression. I think of it as a very Jungian picture, and the young man is deeply fascinated as well as disturbed as we reveal its depths together.
 
He tells me that he was a student at an art-school back home in Chechen, before the upcoming conflict and civil war with Russia. We work together in various settings and I follow my schedule of ‘digging up’ his resources and happy memories, creating and establishing his ‘safe place’ and so forth. Also, I tell him the legend about how animals survive shocks in nature, and I try to come up with the worst imaginably beast in his country. I ask him about an animal that hunts sheep, and he proposes the wolf as the animal most likely to hunt for sheep. However, as we continue and go through the narrative, this technique does not seem to work as it usually does. Unlike my other clients, this young man is not engaged in the exercise with the wolf as the perpetrator and the sheep as the victims. After some time he tells me that his nation has adopted the wolf as a sacred symbol of the fight for freedom and liberation. This means that he has been taught to identify himself with a wolf, which has become a symbol of partisan activity in a very rough war between poorly armed freedom fighters opposite the Russian war-machine. Regrettably, the setting is over before I am able to interpret and correct my mishap in the mythic symbols of this case.
 
Later, in another session, he reveals another story about himself that increasingly is disturbing and hurting him in his thought as well as in his nightmares. On two occasions, he has been captured by the Russian authorities and been subjected too hard and lengthy torture. In addition, he was forced to see a friend being eaten by wild dogs, but presently this is not really what troubles him. Rather, he is plagued by, as he puts it ‘the laws of war’, which forced him to torture and kill some Russian criminals, who were turned into soldiers by the Russian army, with the purpose of killing people in the Caucasus region in unscrupulously high numbers, as he describes it. At the time, he was sure that torturing and killing these criminal soldiers was the only thing to do. Alternatively, they would have gone into local villages and terrorised the population, by killing and raping children and women, young ones as well as old ones. However, he now feels that torturing and killing these men was not fully justified, and is anguished by the thought that he was rougher to these guys than was needed. He is afraid that he will have to answer to his God for his actions in this respect, because according to his God no man may take justice into his own hand, meaning that it is forbidden to take the life of another human. Thus, along the lines of his religious belief he was very wrong to kill and torture these men, and he regrets having done so and is tortured by the memories of what happened during this episode.
 
Here is a true dilemma to be negotiated: is there such a set of parallel laws of human life that cannot be mixed and jointly understood, but rather seem to exist in their own order and legitimacy? We approach and negotiate the dilemma in different ways. We consider the fact that we are sitting in the locations of the Red Cross in Denmark in a civil state and a civilised country, as we prefer to think of it. The laws of war as they are described in the Geneva Conventions are ratified by most countries in the world, and these rules must first and foremost be the foundation from which to consider issues of acts of war. However, we must appreciate also that the rules set by the Geneva Conventions first of all are ideals to believe in and from which to set the standards. The question is why Russian soldiers are not made to follow the rules which their government has ratified in several protocols, and why is this young man considered a war-crime perpetrator according to these protocols? He does not know how to interpret this or make an understandable synthesis of this presumably rather contradictory stuff. On the one hand, it was his indisputably duty and responsibility to discreetly exterminate the enemies of his country, but on the other hand, he can be proclaimed as a warcrime perpetrator according to the Geneva protocols. Also, his God will judge his actions as violating essential religious ethics and morale laws. So, is he in fact a hero or a perpetrator?
 
Through the therapy, we negotiate the dilemma and we try to make some sense of what has happened and discover its meaning. In this respect, meaning is perceived as understanding and acceptance of some basic rules and laws of human life. This is quite difficult because in humanity as we know it, we do not really have the innermost and final answers to such dilemmas, do we? – And, we could, by good reason, doubt if we ever will reach such answers. Sometimes, it looks as if there is a genuine contradiction between the standards and the philosophy of human rights and the Geneva Conventions on one side, and the practise of war even in the so-called civilised world on the other. If not in practice then in theory we are able to recognise and consider these different, contradictory or even antagonistic laws of life, meaning that despite the fact that the young man is not fully satisfied or reassured by the outcome of our discussion, he is nevertheless very relieved at least to discuss these issues. Thus, we establish that his actions should be considered and judged by different human standards:
 
1.      By the standard of combatants fighting against one another, he might be in his rights to follow orders, in so far that there was no situation of imprisonment of the soldiers as it is described in the Geneva protocols.
2.      If there was a situation of imprisonment, he would be a possible a war-crime perpetrator.
3.      According to his religion, he would have to answer to his God for his deeds and maybe suffer for it.
 
The discussion reminded me of how Tibetan monks and nuns were able to put up with torture in Chinese imprisonment, and I told him about how they thought of the liberation of Tibet as their foremost goal. Also, they felt that the Dalai Lama was there with them, which transformed their suffering into a religious time of trial. The Tibetan monks and nuns were even filled by sorrow for the perpetrator because, according to Buddhist belief, he would be the victim of torture in another life as a consequence of the basic laws of cause and effect.
 
By Buddhist human standards and philosophy my young man has been exposed to both sides of the coin in one single life, meaning he has been the victim of torture as well as the torturer. It could be argued that this represents a very instant process of cause and effect, but the question is whether this can justify his actions. Most likely not, but he is relieved by the opportunity to negotiate it this way. Even if we can not forget what has happened, we might possibly forgive others and ourselves.
Also, we talk about responsibility. As he is the father of a new-born son, he recognises that there has to be some kind of morale laws and ethical choices from which to create the standards of life.
He is still worried about his past and about how he can find meaning, moral and ethic confirmation in these patterns of the past. Nevertheless, he is now free to seek meaning by challenging the narratives and values, which he grew up with.
 
The Wolf it is a gruesome and violent beast, however, the wolf is also a very clever fighter and a social member of its tribe and it belongs to the same ancient source of dogs, which we hold as pets in our homes. Any course of life must be viewed from different perspectives and from different systems of values, even though it cannot always be ignored as a moral or more profoundly as a legal problem in theory and practise.
 

From the case, it is possible to learn that intervention and support are not only about symptom reductions, but rather that these phenomena encompass the client’s psychological, physical, moral and social abilities to cope with real life problems on a daily basis. The question is therefore whether the short-term therapy model, with its narrative and body therapeutic approach, is capable of embracing such complexities of human trauma.
 
Evaluation of the Brief Therapy Project
The National Red Cross Psychosocial department invited MET[3] to perform an outcome assessment of the short-term treatment program conducted with traumatised asylum seekers at the Red Cross Trauma Centre. The purpose of the evaluation of the project was to assess the methods and techniques used for treatment in the project, thereby measuring the treatment effectiveness. The evaluation had a combined trauma - resilience focus and made use of a follow-up design. In order to scrutinise the theoretical framework and thereby develop a more sufficient understanding of the treatment process, the evaluation comprised both quantitative and qualitative analyses of the data in its assessment of the effectiveness of the treatment methods.
 
It is important to note that the results of the evaluation are irresolute due to practical complications. Consequently, only tendencies and descriptions of the treatment effectiveness are presented here.
 
Even so, the evaluation revealed the importance of early systematic interventions in torture survivors suffering from severe trauma. In order to prevent the asylum seekers from deteriorating, the intervention should happen already in the pre-asylum phase. Also, the evaluation emphasised the need of a larger, controlled evaluation of the method used for treatment of torture survivors in a context of the pre-asylum phase.
 
As mentioned above, the objectives of the short-term therapy treatment project were to help the client to gain control and distance to the trauma, to uncover possible resources in the client’s past, and to help him regain his action potentials.
 
The evaluation pointed to the fact that the brief therapy treatment seemed to have an effect on the general psychological modes of functioning. This did not mean that the symptoms had diminished, but rather that the clients had found new and better ways of dealing with their pain. There was a clear tendency of perceiving ones health more positively after treatment, despite the little change in how the clients perceived their quality of life. Thus, even though no change was shown in symptom reduction, it was clear that the clients during treatment had strengthened their sense of comprehensibility, manageability and meaningfulness. This included partial relief of mental and physical numbness, which were substituted by new action potentials. In addition, as the treatment progressed the clients were able to provide descriptions of the traumatic experiences, and subsequently it became possible to obtain a clear picture of what the clients had been through.

From a theoretical perspective the treatment is aimed to impact the symptoms and the resiliency factors, in which resiliency is perceived as being able to employ the resources available in the client in order to deal with present problems and symptoms. This aim is underlined by the fact that a person can be emotionally strong while simultaneously lacking the actual tools to deal with a particular situation. Evidently, this form of treatment focuses on the traumatic experiences in order to capture the nuances of strengths and weaknesses so that the client can learn to live with what has happened. Techniques such as creating the safe place and learning to relax make use of the different potentials inherent in the clients.
 
The evaluation of the brief therapy model concluded that it is possible to reach asylum seekers suffering from severe trauma through the use of these particular treatment methods. The model’s combined focus on psychological, physical and social parameters made post-traumatic growth possible in the context of the traumatised asylum seeker. Further development of methods for treating asylum seekers suffering from severe trauma, should use a combination of qualitative and quantitative methods in order to focus on the combination of psychological, physical, and social problems as well as the resources present in the real context of the traumatised asylum seeking population.
 
Conclusion
As a response to the increasing numbers of torture survivors presenting to asylum services in Western countries, this article has presented a model of intervention strategies for the treatment and rehabilitation of survivors of torture and political violence. The brief therapy model included a combination of narrative and body therapeutic approaches to the treatment of trauma. Whereas the narrative approach about constructing meaning of the traumatic event makes it possible for the client to view his life story from different perspectives, the body therapeutic approach includes a range of techniques helping the client to control his bodily reactions to the trauma.

The case showed the significance of not only focussing on symptom reductions, as it illustrated how the intervention strategies should strengthen the client’s abilities to cope with the complexities of his problems on a daily basis. The evaluation of the brief therapy model showed that even though the clients did not experience notably symptom reductions, many had found new and better ways of dealing with the pain. As the treatment related to the specific complexities present in the client’s life, and subsequently focused on presenting the client with new action potentials, the brief therapy model, with its narrative and body therapeutic approach, proved particularly effective on the clients’ sense of manageability and meaningfulness in daily life.
 

Footnotes
[2] Participation is defined as the involvement of the target community in the creation and management of services.

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References

Amnesty International. (1973) Torture in the Eighties. USA Edition. A.I. Publication.
 
Amnesty International. (1997) Report 1997. Amnesty International Publications. USA.
 
Barudy, J. (1989) A program of Mental Health for Political Refugees: Dealing with the invisible pain of political exile. Social Science and Medicine. 28:715-727.
 
Becker, R., Haidary, Z., Kang, V., Marin, L., Nguyen, T., Phraxayavong, V., Ramathan, N. (1990). The two-practitioner Model: Bicultural Workers in a Service for Torture and Trauma Survivors. In: Hosking, P. (ed.). Hope after Horror: Helping Survivors of Torture and Trauma. Sydney. Uniya. 1990.
 
Beristan, C. M., Riera, F. (1992) Salud Mental: La communidad como apoyo. Talleres Gráficos UCA. San Salvdor, El Salvador.
 
Berliner, P. & Wiking, M. (2002). Evaluation of the Brief Therapy: Outcome assessment of psychosocial treatment of traumatised asylum seekers. MET, Institute for Psychology, University of Copenhagen. 
 
Björkqist (1998) Traumatised Refugees and Refugees Reception Procedures in Nordic countries. Summery report published by the Nordic Minister Council
 
Bronkhorst, D. (1995) Truth and Reconciliation. Obstacles and Opportunities for Human Rights. Amnesty International Dutch Section. Amsterdam 1995.
 
Comas-Diaz, L., Padilla, A. M., (1990). Counter transference in Working with Victims of Political Repression. American Journal of Orthopsychiatry 60:125-134.
 
Gray, G., Iacopino, V., & Lira, E. (1998). Treatment of survivors of political torture: Administrative and clinical issues/commentary. Journal of Ambulatory Care Management, 21 (2), 39-42.
Cunningham, M., and Cunningham, J. D., (1997). Patterns of Symptomatology and Patterns of Torture and Trauma Experiences in Resettled Refugees. Australian and New Zealand Journal of psychiatry. 31:555-565.
 
Doerr-Zegers, O., Hartman. L., Lira, E., Weinstein, E. (1992). Turture: Psychiatric sequelae and phenomenology. Psychiatry. 55:177-184.
 
Ekblad. S, Wennström C. (1997) Relationships between traumatic life events, symptoms and Sense of Coherence subscale meaningfulness in a group of refugee and immigrant patients referred to a psychiatric outpatient clinic in Stockholm. Scan J Soc Welfare 6, 279-285.
 
Ekblad S, Belkic K, Eriksson N-G (1996), Health and  disease among refugees and immigrants. A quantitative review approaching meta-analysis, implications for clinical practice and perspectives for further research. I. Mental health outcomes. Stockholm, National Institute for Psychosocial
Factors and Health, Division of Psychosocial Factors and Health/Department of Public Health Sciences, Karolinska Institute, WHO Psychosocial Centre, Report No. 267.
 
Foucault, M. (1979). Discipline and Punishment. The Birth of the Prison. Vintage Book (pp. 33-34).
 
Freedman, J. & Combs, G. (1996): Narrative Therapy. New York: W. W. Norton & Company.
 
Frankl, V.E. (1984). Man’s search for meaning: An introduction to logotherapy (3^rd ed.). New York: Touchstone / Simon and Schuster.
 
Herman, J.L. (1992): Trauma and Recovery. Basic Books. Harper Collins Publishers USA.
 
Horvath-Lindberg, J. (1988). Victims of Torture. The Swedish Experience. Chapter 4. Torture and the Infliction of Other Forms of Organized Violence. In: Miserez, D. (ed.). Refugees - the Trauma of Exile. The Humanitarian Role of the Red Cross and Red Crescent. Martinus Nihoff Publishers. 1988.
 
IRCT. (1997) Need for International Funding of rehabilitation Services for Torture Victims. Torture. 7:41-42.
 
IRCT. (1998) Prevention Dimensions in Programmes for Torture Victims.
 
IRCT. (1998) RCT Strategy for Rehabilitation Programmes for Torture Victims.
 
Jepsen, S. (1988). The General Health of Asylum Seekers. The Danish Experience. In: Miserez, D. (ed.). Refugees - the Trauma of Exile. The Humanitarian Role of the Red Cross and Red Crescent. Martinus Nihoff Publishers. 1988.
 
Lavik, N.J., Haiff, E., Skrondal, A., Solberg, O. (1996). Mental Disorder Among Refugees and the Impact of Persecution and Exile: Some findings from an outpatient population. British
Journal of Psychiatry. 169:726-732.
 
Levine, P.A. (1997). Walking the Tiger: Healing Trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books.
 
Lira, E., Baker, D., Castillo, M. I. (1990). Psychotherapy with Victims of Political Repression in Chile: A Therapeutic and Political Challenge. In Gruschow, J., Hannibal, K., (eds.). Health Services for the Treatment of Torture and Trauma Survivors. American Association for the Advancement of Sciencie (AAAS) Publication.
 
Loughry, M. (1990). Helping Each Other. Paraprofessional Work with Torture and trauma Survivors. In: Hosking P. (ed.). Hope after Horror: Helping Survivors of Torture and Trauma. Sydney. Uniya, 1990.
 
Mollica, RF. (1988) The Trauma History: The Psychiatric Care of Refugee Survivors of Violence and Torture. In Ochberg, F.M. (ed.). Post Traumatic Therapy in Victims of Violence. Brunner/Mazel, New York.
 
Mollica, RF., Wyshak, G., Lavelle, J. et al. (1989). The Psychosocial Impact of War Trauma and Torture on Southeast Asian Refugees. American Journal of Psychiatry, 144: 1567-1572.
 
Mollica, RF., Wyshak, G., Lavelle, J., Truong, T., Tor, S., Yang, T. (1990) Assessing Symptom Change in Southeast Asian Refugee Survivors of Mass Violence and Torture. American Journal of Psychiatry, 147: 83-88.
 
Mollica, RF., Mc Innes, K., Poole, C., Svang, T. (1998). Dose-effect relationship of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry 173, 482-488.
 
Monaldi & Strummielo (2001) Good Practice Guide on the Integration of Refugees in the European Union, Published for Consiglio Italiano Per I Refugiati
 
Orellana, P. (1989). Violaciones a los Derechos Humanos e Información. Colección Documentos. Fundación de Ayuda Social de las Iglesias Cristianas. (FASIC). P. 163-166.
 
Packness, A., (1998) Indikatorer af betydning for voksne asylsøgeres mentale helbred, Institut for Folkesundehdsvidenskab, Panum, Københavns Universitet. [Significant Indicators of Adult Asylum Seekers Mental Health. The Institute of Public Health, Panum, University of Copenhagen]
 
Pargament, K.I. (1996). Religious methods of coping: Resources for the conservation and transformation of significance. In E.P. Shafranske (Ed.), Religion and the clinical practice of psychology, (pp. 215-240). Washington, DC: American Psychological Association.
 
Quiroga, J. & Gurr, R. (1998). Approaches to Torture Rehabilitation: A desk-study, covering effects, cost effectiveness, participation and sustainability. Human Rights Consultancy.
 
Reeler, A. P. (1994) Is Torture a Post Traumatic Stress Disorder. Torture ¤:59-63.
 
Silove, D. & Steel, Z. (1998) The Mental Health & Wellbeing of On-shore Asylum Seekers in Australia. Psychiatry Research and Teaching Unit
 
Silove, D. (1999) The Psychological Effects of Torture, Mass Human Rights Violations, and Refugee and Trauma. The Journal of Nervous  and Mental Disease, 187; 231-236
 
Silove, D., Ekblad S. & Mollica R.F. (2000) Health and human rights. The rights of the severely mental ill in post-conflict societies. Invited Lancet commentary April, 29, 1548-1549.
 
Skinner, D. (1997). Torture Survivors in the long term after liberation. Torture, 7(1), 4-8.
 
Somnier, E., and Genefke, I. K. (1986). Psychotherapy for Victims of Torture. British Journal of Psychiatry, 149:323-329.
 
Somnier, E., Vesti, P., Kastrup, M., and Genefke, I. K. (1992). Psychosocial Consequences of Torture: Current knowledge and evidence. In Basuglu, M., (ed.). Torture and its Consequences . Current Treatments Approaches. Cambridge University Press, Cambridge, UK.
  
Southwick, S. M., Bremner, D., Krystal, J. H., and Charney, D., S. (1994). Psychobiologic Research in Post-Traumatic Stress Disorder. Psychiatric Clinic of North America. 17:251-264.
 
Turner, S. & Gorst-Unsworth, C. (1993). Psychosocial Sequelae of Torture. In Wilson, J. & Raphael, B. (eds.), International Handbook of Traumatic Stress Syndrome, New York, 703-713.
 
United Nations. 1984. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. U.N. Doc. A/39/51.
 
van der Kolk, McFarlane, Weisaeth (1996) Traumatic stress: The effects of overwhelming Experience on Mind, Body and Society, The Guilford Press, New York
 
Van Geuns, H.A. (1987). The Concept of Organised Violence, a WHO perspective. In Health Hazards of Oragnised Violence. Proceeding of a Working Group. Netherlands April 22-25.  Ministry of Welfare, Health, and Cultural Affairs, Rijswijk.
 
Wilson, S.A., Becker, L.A., & Tinker, R. H. (1995). Eye movement desensitization and reprocessing (EMDR) treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63 (6), 928–937.
 
World Health Organization (WHO). 1986. The Health Hazards of Organized Violence. Report on a WHO Meeting. Veldhoven 22-25 April 1986.

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