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The PSOT at Bellevue Hospital: Helping Survivors of Torture to Rebuild their Lives

A sign reading "Program for Survivors of Torture" leads us into a narrow corridor, alongside which are a half dozen blue doors. Several bulletin boards hang on the white walls of the hallway displaying ads for housing, ESL classes, and city tours, newspaper clippings about professionals working on treatment for torture victims, and children’s drawings dotted with words reading “Free Tibet” or “Peace” in foreign languages. Overall, the place has a somewhat disheveled air, with old and cheap furniture lining the hallway (that also serves as a waiting area), but this air is coupled with a clean and even dignified feeling as well. We have arrived just in time for our interview with Dr. Allen Keller, the head of the Program for Survivors of Torture at the hospital. We can hear him inside his office on the phone and decide to wait in the narrow hallway. Fifteen, twenty, then thirty minutes later, Dr. Keller is still on the phone: the call is an important one. He eventually emerges from his office, apologizing profusely for taking so long. We assure him we can wait, being just student amateur journalists.  Dr. Keller makes the promise to see us after another set of calls and closes the door, and so we wait.

In the meantime, a man walks in into the corridor and passes on by us. He is missing an arm, and we necessarily wonder, in a place like this, what his story might be. Smiling at us, he takes a seat next to us on the couch and we squeeze in together to make space. Being at first somewhat reluctant to talk to him, as we understand how delicate this kind of subject matter is, within minutes, however, a casual conversation starts up. We find that the man speaks French, the native language of one of our group members. Before we know it we are all having a conversation in broken French about Paris and New York City, which miraculously leads into a discussion about the tribulations of being an immigrant, what it’s like to have culture shock and be faced with difficult language barriers. At some point the man begins revealing a little about his personal story, that he has been to New York before, back in the day when he was a representative for his government at the United Nations. It turns out he is originally from West Africa, where he stepped up in the ranks of his government to hold a position at the UN headquarters there. Upon returning to his home country, the man decided to start writing a book describing some of the recent events of the political situation in his home country. It was this book that led him to know "quelques problèmes" (tr. "some troubles"), he told us in French. As a victim of torture and persecution in his home country at the hands of his own government officials as a result of what he tried to reveal in his book, the man was forced to leave for the U.S. as a political asylee. Though initially hesitant to talk with us, this man proved to be surprisingly friendly and talkative with us. After our conversation, when he had left to enter his meeting with one of the program’s staff members, we were left wondering whether his high-spiritedness was in any way partially the result of his experience with the PSOT, the program for survivors of torture that we came to learn about. 

One of the oldest and most successful torture treatment programs in the U.S., the Bellevue/NYU Program for Survivors of Torture (PSOT) is located in the public hospital in New York known as Bellevue Hospital.  More than twenty programs like it that offer services to victims of torture and human rights abuses exist in the U.S. Such programs are part of a national coalition of centers known as the National Consortium of Torture Treatment Programs (NCTTP). The NCTTP is part of a global network known as the International Rehabilitation Council for Torture Victims (IRCT), which encompasses more than 138 rehabilitations centers across the world. The IRCT network represents a growing international movement of programs geared towards treating torture victims that provide support services and hope for survivors of torture who need treatment and services to recover and move on with their lives. 

The PSOT was specifically founded in 1995, under the auspices of several doctors in residency at Bellevue Hospital, one of them being the current director, Dr. Allen Keller.  Dr. Keller is an serious yet animated man in his late forties who is very committed to the PSOT and has a strong passion for the advocacy of human rights within the medical profession. Keller took time off during medical school to serve as a medical aid worker in a refugee camp on the Thai-Cambodian border, a defining experience for him as he described it, and one that caused him to make a personal connection between health and human rights: "All these refugees were there because of human rights violations. Some had had their entire families killed...That was the first time I was hearing about trauma and the personal situations of torture victims.  It really framed the way I looked at health and medicine for the rest of my life." Dr. Keller went back to Cambodia for one year after finishing medical school and, upon returning to the U.S., got involved with the group Physicians for Human Rights. Dr. Keller then joined the staff at Bellevue Hospital as a doctor in residency. He was our primary informant regarding information about and the history of his program, the Program for Survivors of Torture.

Bellevue's Program for Survivors of Torture (The PSOT)

Since its founding under Dr. Keller and several other doctors, the PSOT has treated over 3,000 clients from 80 different countries. The average length of time for a client enrolled in the PSOT is about six to eighteen months. In the past year alone, the PSOT has unofficially served and treated somewhere between 400 and 500 torture victims, a steady increase from the past few years. In 2007, the PSOT treated 202 patients, out of a pool of 228 official applicants. Of those accepted, 154 can be said to be victims of torture according to the UN definition of torture victims, 37 according to the Tokyo definition, and 21 according to the UN definition of victims of war trauma. Despite currently facing a funding crisis, the program is increasingly in high demand; for example this past June it was forced to cap its wait list at seventy people. 

Funding problems of programs like the PSOT come at a time in the U.S. when the need for torture treatment programs among asylum-seekers and refugees is immense. Currently an estimated 5%-35% of refugees in this country are torture victims, which amounts to a figure of over 400,000 persons. The disparity in this statistics is partially because of the difficulty in defining what actually constitutes torture and what does not, as well as the secrecy under which governments’ actions are often held. Among the 400,000 asylum-seekers and refugees in need of treatment services, Dr. Keller noted that only a small portion have access to programs like PSOT, while many of them remain without the connections or resources to access such programs.  Alone, they are forced to face the difficulties of dealing with having been tortured, having undergone trauma, and being in a foreign country. Dr. Keller noted, "We only see the people who make it here, those who have the resources, we don’t see all those who don’t have all the connections."  Thus, for each patient who emerges from the program with the coping skills and resources to begin their lives anew, there are many who remain outside of the PSOT support network. Despite this, the program remains overwhelmingly successful for those patients it is able to treat, support, and advocate for. 

The PSOT proclaims itself to be "like a refugee camp on First Avenue." It offers a wide variety of services to survivors of torture who are asylum-seekers and refugees, many of whom arrive to the U.S. with very little knowledge of the language and culture. As Dr. Keller puts it, "So many of our patients come here not knowing anybody or anything".  The PSOT attempts to alleviate this. Clients are often referred to the PSOT by human rights organizations, refugee resettlement programs, and non-profit agencies, many that are involved in and offer legal representation, or simply by word of mouth. PSOT clients are offered medical treatment at Bellevue Hospital, individual counseling and group therapy sessions, and links to legal liaisons and social services, such as housing organizations or language classes. The psychological support services that are available are for the treatment of post-traumatic stress disorder and the anxiety and depression that result from being tortured and having undergone intense trauma.

The Situations of Refugees ans Asylum-Seekers who are Survivors of Torture

Refugees or asylum seekers who are survivors of political torture in their home country and newly arrived to the U.S. find themselves in a unique and difficult situation. The multi-traumatizing experience of being tortured is often exacerbated by the suffering of exile and forced migration. Additionally, the experiences of torture that refugees and asylum seekers suffer tend to not only undermine their physical and mental health, but also their ability to function in a new social environment. Such persons tend to lose the fundamental trust that is necessary to adapt to any community. As Dr. Keller explained, "For somebody who has been tortured, physical injuries may result, and then later, even if they get better physically, they may still have flashbacks or problems fitting in, and they may address these flashbacks and problems by drinking or becoming socially isolated. It's a kind of chain." The experience of torture can make it more difficult for refugees and asylum seekers to integrate themselves into and adapt to a new society, already a difficult act in itself. In Dr. Keller's view, torture is in this way a holistic phenomenon, because it not only impacts a person physically, but also psychologically and thus influences his or her behavior in a strange and new society. This reinforces a sense of insecurity and isolation for refugees and asylum-seekers living in the U.S. who are survivors of torture.

Another act of the PSOT is to ensure that the terms torture and trauma are understood properly. Dr. Hawthorne Smith, clinical co-director of the program, maintained to us that it is important to correct certain misunderstandings about torture: "In this country, the consequences of torture are more than traumatic stress or depressive symptomatology, but contribute to a real sense of continued social isolation." The behaviors of self-isolation, mistrust and fear all handicap refugees in the U.S., who must negotiate their new lives as immigrants, as well as the traumatic events of their past, including forced migration and exile in addition to torture.  As one client expressed to Dr. Keller, "I felt I was tortured twice: once when I was tortured, then when I was forced to leave" and "exile is one of the most painful form of torture." The situation of exile is thus exacerbated by being a victim of torture. Additionally, many survivors of torture enrolled in the PSOT occupied high social positions in their countries of origin. They are now in overwhelmingly unstable situations in a society that does not recognize them, nor offer many open and substantial support services, such as the PSOT. 

The situation for asylum seekers is also made more difficult by the long and complex process of applying for political asylum within our country’s legal system. In attempting to plead their cases for asylum, victims are forced to revisit their traumatic past, oftentimes leading to a period of re-traumatization. From experiences like being interviewed in front of asylum officers to attending hearings in immigration court, the path of an asylum seeker is full of elements that offer constant reminders of his or her past trauma. On their part, asylum seekers will often report being interviewed in open areas and not having the adequate privacy or resources to explain their situation. As one asylum-seeking patient at the PSOT confessed: "I was at a counter, and there was no privacy, and I was afraid that others might hear what I was saying and tell my government." In attempting to avoid such situations, the PSOT provides substantial legal support and liaisons for asylum seekers. The overall success rate for getting asylum granted for PSOT patients is 98%, compared to the national average of between 20% and 25%. To provide an example of this, when a former student activist from an African country in extreme hand and arm pain as a result of torture was seeking legal asylum, Dr. Keller testified in court on his behalf, describing and validating the physical signs of abuse he saw and the patient successfully received political asylum.

Thus, in many cases, the detention of asylum seekers who have fled to the U.S. to escape torture, gross human rights violations, and persecution can exacerbate the severe trauma that they have experienced in their home countries. In response to this, the PSOT and Physicians for Human Rights joined together to release a report known as "From persecution to prison: the health consequences of detention for asylums seekers", which describes several more stressors that asylum seekers face during their detention: verbal abuses, solitary confinement, translation and communication difficulties, and lack of privacy.  Even more alarming, according to the report 74% of asylum-seekers in detention centers have had many experiences that fall under the international definition of torture. It is programs like PSOT that take on the task to rebuild the sense of security, safety, and empowerment of such persons, whether they are applying for political asylum or simply struggling to make it on their own in a new country.

The Strategies of the PSOT

What specifically explains the significant success that the PSOT has achieved since its inception? Over the course of thirteen years, the PSOT has devised strategies and specific orientations to deal with the challenges facing their clientele.  First, the PSOT acknowledges the interconnectedness of the medical, psychological, social, and legal factors affecting the ability of refugees and asylum-seekers to integrate into their new social environment. Thus the PSOT adheres to the holistic definition of health standardized by the World Health Organization, according to which health is as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Specialists working at the program have noticed that the recurrence of certain physical symptoms may impair the patient's ability to function effectively in a social setting. This has resulted in the consolidation of an interdisciplinary approach to the treatment of torture survivors. The program tries to sustain a critical dialogue across disciplines and promote a common understanding of the "big picture" when devising treatment strategies.  As Dr. Keller maintained, “What's the point of treating someone’s back pain if they are homeless? What’s the point of treating someone for sleep deprivation with they don’t have somewhere to sleep?" The program thus tries to look at the situations of torture survivors holistically.

Issues of cross-cultural and intra-cultural understanding also play huge roles everyday in the PSOT. The psychiatrists and psychologists working in the program understand that traditional forms of psychotherapy are alien to most patients arriving from non-Western societies. As Dr. Smith points out, all human cultures develop their own "coping mechanisms," or, that is, ways of dealing with and overcoming difficulties or challenges. Some of these coping mechanisms are psychological in nature, some cultural, and some social; for instance, those that might come in the form of religion, myth, and ethical and social norms. Instead of imposing foreign cultural standards on the patient, the center has tried to create a highly interactive model of communication between doctors and patients. The goal of all therapeutic services at the center is to create a "middle space" in which doctors and patients can interact, understand each other, and learn from each other.

At the PSOT, one of the most effective forms of therapy is the group therapy session. Group therapy sessions bring together between 5 and 13 patients and meet twice a week for 90 minutes a session.  The group sessions, according to Dr. Smith, are meant to act as "structured coping mechanisms" in which patients can feel comfortable opening up to one another and exchanging stories and information. By providing the space to communicate with one another, group sessions counter the isolation that refugees and asylum seekers face, which can sometimes be as debilitating and disempowering as the experience of torture in their home countries itself. The group leader also seldom has an agenda. Participants are granted near absolute freedom to talk about whatever they want, be it the different boroughs of New York, the best and worst food markets in town, the presidential election, the challenges facing immigrants, or the political situations in their home countries. "It doesn't need to be 'therapy' for it to be therapeutic," Dr. Smith noted. Indeed, the groups often tend towards dealing more with how to respond to adaptive challenges than with engaging in emotional exploration.

The mission of the PSOT is then not limited to treating survivors of torture in the traditional clinical sense.  As Dr. Keller asserts, "in our program we care for victims of torture, but also for victims of trauma." Dr. Keller also insists that the emphasis is always on treating symptoms, without getting bogged down in diagnosis. Whether the patient suffers from consequences of torture, war trauma, human rights abuses, or refugee anxiety is not presented as the main concern of the patient to the patient. Though it is important for patients to understand their condition is the result of past or present suffering, it is also equally important that they not think of their condition as pathological or irreversible. On the contrary, by identifying and treating specific symptoms, PSOT doctors simply seek to alleviate patients from the physical and psychological conditions that affect his or her immediate well-being. Among other intended effects, this is meant to prevent the patient from embracing any stigmas that he or she would accept otherwise. Instead of victimizing or stigmatizing patients, the PSOT thus seeks to empower them and to help them think of themselves as active, capable individuals. The emphasis on the notion that patients are not victims, but survivors also furthers this aim.

The PSOT is also involved in the documentation, analysis, and formal study of human rights abuses. It has consistently advocated on behalf of the human rights of minority groups since its founding. For example, Dr. Keller recently testified before Congress and the Senate regarding the human rights abuses and torture at Guantanamo Bay. The center also provides yearly trainings to immigration judges and asylum officers, through which it seeks to raise awareness and sensitize professionals in the field to the plight of survivors of torture who seek asylum. Immigration officials usually place an extremely high premium on the consistency and comprehensiveness of the testimonies of asylum seekers. As members of the PSOT would point out, in the case of survivors of torture, war trauma, and other forms of abuse, this premium is often unjustified and insensitive. The PSOT also assumes responsibility for the education of the public opinion on these matters through various means, which is especially important in a time like ours when the “war on terrorism” is blocking the development of effective strategies for helping immigrants and refugees who are survivors of torture in this country. 

A defining principle of the PSOT’s work is the respect for the sanctity of every human being's body, mind, and spirit. This emphasis on the sanctity of every human being challenges the legalistic or utilitarian understandings of human rights, which postulate that rights are just officially sanctioned entitlements. The PSOT, on the contrary, condemns gross violations of human rights on not necessarily legal or utilitarian grounds, but rather on the basis of the moral principle that human beings have no right to make others suffer and takes on a holistic view. As the work and success of the PSOT demonstrate, it would be beneficial for the human rights’ community to initiate more actions and programs based on those of the PSOT, despite it not meeting the demand of the numbers of torture survivors in this country. Despite this, what treatment it does provide makes a difference. When asked about how he feels being faced with such devastating stories on such a regular basis, Dr. Keller confessed, “It is difficult work, but I find it very gratifying because over time individuals improve, and it is very inspirational to see them get better.”
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United-states United States 2008

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