International Trauma Studies Program

By Tina Rosenberg
The New York Times
December 28, 1997

'I am now very far from home," Aziz wrote in French on a piece of notebook paper on a plane from Dakar, Senegal, to New York. "The people around me are probably going to a luxury room in a four- or five-star hotel. The question in my head is where am I going? Why am I here? How do I talk to people?" This letter was the first of more than 60 that Aziz has written since leaving his country -- to his family, to dead or vanished friends, to himself. He knew that, like all the others, it would never be sent.

At the time of his flight, Aziz was 27 and almost finished with a master's in sociology. Aziz is one of his nicknames. His real name, like the name of his West African country, the way he got a visa to America and some other details, cannot be revealed without identifying him to authorities back home and endangering his family. He is a short man with close-cropped hair and a serious demeanor. In 1995 he had been an activist in his university's student movement, which opposed the country's dictatorial government. Every week Aziz would speak about freedom and democracy, usually at a secret meeting on campus or in someone's house.

By the time the movement was a year old, most of the leaders had been arrested. One of his closest friends disappeared one day, never to be seen again. A second friend was killed. A third left the country, urging Aziz to go with him.

Aziz stayed, wanting to finish his degree and take his exams. One day, he says, soldiers came to his dorm room and took him away. They drove him to a building where they beat him with clubs, then released him. Two weeks later soldiers came back, dragged him into a car and blindfolded him with a black cloth. When they reached their destination, they wrapped a chain around three fingers of his left hand and hung him for hours. "You have been behaving like you are the most intelligent person, but tonight the military is more intelligent," they told him. They warned that if he didn't stop his activities, they would bring him back whenever they wanted until he died. They gave him something to drink, and he woke up 24 hours later on campus with his left arm on fire and his hand mangled.

When his sister went to his dorm to get his things, she found a letter from the security ministry summoning him to appear. By that time two friends with Government connections had warned him to leave. Aziz sold his stereo, his black-and-white TV and his motorcycle and got money from friends to buy a ticket to New York. Afraid they would see his hand, he never said goodbye to his mother or his fiancee. He left the country over land, making his way to Dakar for the flight to New York.

He arrived at Kennedy on a warm evening and spent the night sleeping on the floor. He was not afraid of being robbed. "I didn't think about it, because I didn't have any life," he recalls. He had $14 in his pocket, spoke no English, knew no one. In the morning he saw a sign for the subway and, with gestures, asked someone how to buy a ticket. The man sold him a $1.25 token for $2.50.

He got off the A train at Times Square. He was clutching his bag and a Bible when a woman approached him and began to explain that Jesus was coming back. Through body language, he told her he had no place to go. She took him to a church a few blocks away. Aziz spent two nights there, and the staff then found him a place to sleep in Brooklyn with an African family.

With his good hand, he worked at the church as a handyman and janitor -- among his first English words were "vacuum cleaner." The church staff gave him clothes and meals. A church member suggested that he call the Lawyers Committee for Human Rights, which has attorneys who help people fleeing persecution apply for political asylum. When he went to the Lawyers Committee, a woman took one look at his hand and told him he needed to see a doctor.

No one knows exactly how many survivors of torture there are in the United States. Some experts believe there are at least 200,000, with about 35 percent of those in the New York area. "New York is a major center because there are so many immigrant communities here," says Eleanor Acer, who coordinates the asylum program at the Lawyers Committee. "There are communities of Chinese, Tibetans, certain African countries like the former Zaire. New York is also a center for human rights work. Dissidents fleeing torture who want to stay involved and make a difference in their home country come to New York or Washington."

New York also has Newark and Kennedy airports, entry points for many of the fleeing. This year's new immigration laws have made it harder for torture victims to apply for asylum, since they must talk about their persecution upon entry -- something genuine victims often can't face doing. Many who do apply then spend weeks in immigration detention centers, which can be horrifying for someone who was tortured in jail. Despite its status as a giant refugee camp, however, New York, unlike several other American cities, had no clinic dedicated to the comprehensive treatment of torture survivors until 1995. When Aziz initially walked into Bellevue Hospital, it was at the birth of New York's first such clinic.

The doctor called by the Lawyers Committee was Allen Keller, then a 36-year-old attending physician at Bellevue and an assistant professor of clinical medicine at New York University School of Medicine. Keller had lived in Cambodia, where he taught courses on treating trauma survivors to health workers. Back in New York, he worked with Physicians for Human Rights and often did medical evaluations for asylum applicants.

Keller had long been frustrated that although his examinations helped torture survivors get asylum, his work did little for their tremendous psychological and medical problems. When he met Aziz, he and Jack Saul, a psychologist, family therapist and clinical assistant professor in N.Y.U.'s psychiatry department who has worked with Holocaust victims, had decided to set up a clinic at Bellevue to treat torture survivors.

The first such center was founded in Copenhagen. In the U.S., the premier clinic is in Minneapolis. There are clinics in San Francisco, Los Angeles, Boston, Chicago and a few other cities. New York has a clinic staffed by doctors from Montefiore Medical Center who treat some patients, but the clinic's emphasis is on medical evaluations for asylum seekers.

Saul and Keller had been introduced by a mutual friend and began to meet regularly in the coffee shops at Bellevue and at N.Y.U. Medical Center, where Saul taught. Bellevue, a teaching hospital affiliated with N.Y.U., is the nation's oldest public hospital, a place that never turns away people because they can't pay. In the summer of 1994 Keller had gone to Sandra Kammerman, the director of ambulatory services, to ask if he and Saul could start to see some torture survivors. Although some of the patients would be entitled to Medicaid, thus reimbursing some of Bellevue's costs, Kammerman knew that many would not be. But she embraced the project. "This wouldn't be a clinic you'd find at other hospitals," she says. "It is in keeping with Bellevue's mission to take care of underserved patients."

When Aziz arrived at Bellevue in 1995, Keller and Saul had done some brief therapy with one or two patients. "We had been talking and talking about how to build an effective service and felt we could talk from now till doomsday," Keller says. "Aziz needed so many things that we decided if we could figure out how to help him, we knew we could help others."

Today the Bellevue/N.Y.U. Program for Survivors of Torture, which is directed by Keller, has treated about 150 victims of torture or severe political violence along with their families, including young children. Patients come from 40 countries, roughly a third of them from Africa and many others from Bosnia, Tibet, Bangladesh and China. About five new referrals come in every week.

The program received about $40,000 in financing last year from the United Nations. Most of its staff are psychologists, physicians and a psychiatrist, from Bellevue and N.Y.U., who take a few hours a week to treat clients. Clients have access to all of Bellevue's services, including two social workers who help them find housing and negotiate the city bureaucracy. Only this month has the program been promised its own office.

The first time Aziz walked through Bellevue's doors, he almost turned around and left; the hospital was full of police officers. When Keller examined him, he noted that Aziz's left fingers bore fresh scars. He had pain from his shoulder down. His nerves were so damaged he could barely lift his arm. In response to Keller's questions, Aziz said he had frequent headaches, was fearful and sad and had trouble sleeping. "I wanted to tell him as little as possible," Aziz told me. "I thought, 'I don't know who you are, I'm escaping my country and don't want anyone to see me.' "

Keller and Saul went to see Aziz shortly after that. They had to begin preparing a medical and psychological evaluation to accompany his application for asylum, which he could get by persuading an immigration official or a judge that he could not return home because of a well-founded fear of persecution. Saul knew that recounting his torture to two strangers without psychological preparation would be extremely painful for Aziz. But Aziz told them that he understood the importance of asylum. He felt more confident talking to Keller this time than in their first meeting. As Saul translated, Aziz told them how soldiers made him climb, blindfolded, onto a stool. They wound a chain around the last three fingers of his left hand. They kicked the stool away and hung him by his fingers. The soldiers then bounced his head against the wall. They put the stool back under him for a minute, then kicked it away. They repeated the process about 25 times.

Aziz told Keller and Saul that he had nightmares and flashbacks that got worse whenever he remembered why he had fled. Unfortunately, he said, much about being in New York triggered thoughts about how he got here. He felt hopeless, as though he could never start a new life and had no reason to go on. A year later, when I met him in Saul's office, Aziz told me that he often dreamed about being in the room with the stool. In his dream, Aziz watched from a perch on the ceiling while soldiers hung a blindfolded man by his fingers and smashed him against the wall, over and over and over again.

The primary purpose of torture is not to elicit information -- it produces lies more often than truths -- but to break the victim's personality. In this torture is wildly successful. Like Aziz, many torture survivors suffer from the uncontrollable intrusion of the torture into their lives through nightmares and flashbacks. For them torture is not a past event but a constant presence. Because they are so focused on their traumatic memories, they cannot concentrate on normal life. They withdraw from family, school and work. They try to numb the pain with alcohol and drugs. They startle easily and have trouble sleeping. They also feel anxiety, depression, powerlessness and guilt. They may try to overcome a feeling of victimization by becoming violent themselves.

Most of these symptoms fit the classic diagnosis of post-traumatic stress disorder, or P.T.S.D., the same condition suffered by many veterans and abused children. But they are compounded by the circumstances of torture, a process deliberately designed to render the victim powerless. People who break feel shame for their weakness and betrayal. Even those who say nothing -- even those who are asked nothing -- often feel guilty for having survived.

Usually, survivors have also suffered other traumas: the death of loved ones and friends, the loss of home and community, the stress of war or living in hiding. And those who flee find their troubles further complicated by the struggles of being refugees. Starting a new life in New York is difficult even for people with money, friends, family, jobs and a command of English. Most of the tortured, like Aziz, arrive with none of these and cannot even legally get a job. One patient walked 80 blocks from his home to Bellevue to save bus fare. Aziz is wary of others from his native land because they might be Government spies. His mind was -- and still is -- divided. He must concentrate on the battle for food and shelter here. At the same time, he thinks constantly of the country, friends and family that he has left behind and possibly endangered.

Although society has passed through many periods when the symptoms of trauma were dismissed as malingering, today scientists are finding proof that trauma's impact on the psyche is as real as a bullet tearing through flesh. With the advancement in the last decade of neuroimaging devices like PET scans, which reveal brain activity by showing where the brain uses oxygen, scientists are beginning to see how post-traumatic stress disorder works. Early studies suggest that the brain processes a traumatic event very differently from an everyday one and might keep the trauma from being integrated with other memories. That may explain why trauma sufferers have amnesia or can retrieve only fragments, like a smell or sound, or cannot put the events behind them. "The memory doesn't hook up with the little voice that says: 'This is in the past. This isn't happening now,' " says Bessel van der Kolk, a Boston University psychiatrist who has performed some of the studies.

Every Tuesday at noon, the staff of Bellevue's Program for Survivors of Torture meets in a conference room crammed with old computers and audiovisual equipment to talk about their work. At one meeting in November, the staff talked about how to make New York less intimidating, and suggested pairing new clients with more experienced ones to show them how to take the subway.

They discussed the program's group-therapy sessions, one in French for West Africans and one planned for Tibetans. Hawthorne Smith,
a staff counselor, was enthusiastic about the French group. A new patient had mentioned that he was afraid to leave the house, and an older one chimed in that when he first arrived, he, too, stayed indoors for six months unless he was with someone. "It's not just good for the new ones," Smith said. "The older ones can see where they were. Often they don't give themselves credit for how far they've come." Saul told of the shock of a client whose first time out in public was on Halloween night, when he found himself in Greenwich Village during the annual costume parade.

Aziz had never paid much attention to psychotherapy before he landed in Bellevue. "Psychology at home is not something official, like here," he told me in Saul's office at our first meeting last year. "There is no office to go to. The family heals someone who has psychological problems. They make the person feel comfort in the family and show you belong to the family." Saul laughed. "That's still the best way," he said.

The culture gap is one of the challenges of working with torture survivors. Political activists in Latin America, where psychotherapy is common, tend to be willing to seek it; people from other cultures are often less so. Doctors also need to tap into the methods that every culture invents to deal with trauma. Many Muslim women will not seek treatment for torture, because it is tantamount to admitting they were raped. Cambodians, Keller says, tend to blame bad karma for problems and say they need to go to a pagoda and be with the monks. Doctors at the Center for Victims of Torture in Minneapolis found that many clients were relieved to hear that their symptoms were a normal result of torture and did not mean they were crazy, weak or possessed by spirits.

While Aziz showed an intuitive grasp of therapy -- the importance of letter-writing, for example -- he had other problems. One was the hospital itself, a symbol of authority. "I did not feel safe at home or here to tell a doctor anything," he said. Another patient, a former monk from Tibet who was in Bellevue's tuberculosis ward, panicked after seeing a Chinese-American policeman outside his room and shoved his bed against the wall as a barricade.

Hospitals inspire a more direct fear in some, since doctors are frequent participants in torture. "We realized that you can't just do gynecological exams, attach electrodes, take blood," says Inge Genefke, medical director of the Copenhagen center. "You need to explain it, and if the patient is afraid, don't do it. Leave it for another day."

Although psychotherapy for trauma patients is popularly portrayed as climaxing when the patient is able to recount the trauma, Saul believes that the crucial event is getting the patient to feel safe, connected and in control. "Once a trusting relationship is established, the story is going to come up naturally," he says. Saul's next step is to help the patient re-establish connections to society, essential after a trauma deliberately inflicted by another human being. Finally, he tries to integrate the experience of trauma into the full sweep of the patient's life. Telling the trauma story is important here -- part of the past of a patient who also has a present and a future.

Saul, the program's director of mental health services, is also a painter and encourages therapists to use a wide range of methods, including art -- drawing and painting stimulate patients' imaginations and allow them to communicate ideas that they can't talk about. He urges patients to solve problems using the strengths that enabled them to survive. Saul saw early that Aziz had many such strengths. "As a political activist, he knew the consequences could come to this, and he knew why he was taken. This is very important -- it helps people deal better," Saul says. Aziz's torture took days, not months. Although he lost close friends, no one in his family was killed. And he was able to begin treatment within weeks.

At their first meeting, Saul explained that Aziz's symptoms were a normal reaction to torture. He told Aziz he could get better. He asked Aziz what he wanted to talk about, and Aziz told Saul about the political situation in his country, his involvement in the student movement and his friends who were dead, missing and exiled.

Then Saul began to focus on Aziz's new problems. The most immediate was that a woman in the house where he was staying had tried to attack him with a knife. Sarena Lewit, one of the program's social workers, scrambled to find Aziz another place to live. She arranged for him to get about $20 a week from an auxiliary fund at Bellevue for subway fare and some food, and she gave him a few tubs of peanut butter and bags of rice from the hospital's emergency pantry. She got him emergency Medicaid coverage. "She showed me Central Park," he says. "She told me that I didn't have to close myself in my room. She told me about going to the library to ask about educational opportunities. But I didn't feel I could try something and succeed. I told Dr. Saul and Keller there was no reason for me to stay in this world."

After several meetings with Saul, however, Aziz found that his sense of paralysis was lifting. "The first sign it was helping was that I was finding I could use the information Sarena gave me," he says. Aziz started going to her office as Lewit was leaving work and they would practice English -- he was learning it by reading a sociology textbook from the 1950's. They walked around New York and did touristy things like taking the tram to Roosevelt Island. She took him to an IMAX movie on his birthday.

Lewit knew that Aziz was adjusting when he stopped wearing the secondhand clothes she got him at Bellevue; he had figured out where to get Calvin Klein jeans for $10. Aziz's English soon surpassed Saul's French, and therapy sessions switched to English. Once Aziz was feeling more secure, Saul moved on to rebuilding Aziz's social connections and integrating his torture with the rest of his experiences. Saul turned to writing, which he often uses in family therapy.

Aziz had said that he wanted to document his experiences, perhaps to give to the U.N.'s Special Rapporteur on torture. Saul brought in a laptop one day and asked Aziz if he was ready. Aziz was not -- for one thing, he had never used a computer -- but when he got home he began to write letters on paper, which he would bring in and read out loud to Saul. "Writing is like art in that it externalizes the experience," Saul says. "The trauma doesn't have to be in their heads. It's also important for them to reconnect with the positive aspects of their past before the trauma. I encouraged him to write letters to his family even though he didn't want to send them. He found it very helpful in putting experiences behind him. You need to remember in order to forget."

Aziz already knew this. "I know I am writing now about something that happened to me in the past," he says. "Even though things are not good for me now, that I can write a letter is proof of my present situation, where I can write, I can talk, I can do anything." He could not send them, however, without endangering his family by alerting the authorities that his relatives knew where he was. "It has happened that when the Government found out a family member was in touch with a person in exile, they kidnapped the man's son and waited for him to come back," he says.

Aziz does not see Saul as often anymore, although they speak on the phone. Saul counts Aziz as one of the program's patients who have come furthest in dealing with their traumas, in part because they have been in therapy longest. His hand is completely healed now, and on the surface, so is Aziz. In November 1995, he won political asylum. He has been eager to give something back to the program, speaking about health and human rights to a class that Keller teaches at Princeton and conducting a workshop for the program staff on the perspective of Africans on getting psychological help. In the fall of 1996 he began a graduate program at N.Y.U.; his student loan was cosigned by Lewit and Saul. He taught himself to use the computer, and he is now fluent in English.

But he still has nightmares occasionally, and he remains unwilling to make close friends. "In my country I used to spend two or three nights a week with my friends, a group of 12 or 13," he says. "We studied together and stayed up all night talking. I don't know where they are now. I do know some of them have died, and the project we had is gone. I don't want to get close to people. I don't know what's going to happen tomorrow." Things are bad in his country, and he can't think of a solution, he says. All he knows is that he will wait until it is safe and then go home.

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