The Pain of the Tortured and Treating PTSD: What are we to Think and What are we to Feel?

by J. David Kinzie, M.D.

The patients' histories are similar and by now, quite familiar and still disturbing.

Phat

When first seen, Phat was a 42-year-old Cambodian woman. She had very poor sleep, nightmares (two or three times a night); she was sad and tired. She startled very easily from any unusual sound, and she was quite irritable. She had been raised by an older sister; she had no formal education. At age 20, when Pol Pot came to power, she was put in a “reeducation camp.” She never saw any family members again; they were presumed killed. She couldn't do the required work and chants, and was frequently beaten and once burnt on the head. She saw many people die, and her life was also threatened. After Pol Pot (1975-79) was deposed by the Vietnamese army, she entered into an arranged marriage; this resulted in a physically abusive relationship. She was in a refugee camp in Thailand for 4 years. When she and her husband came to the United States , he gambled, drank, and abused her and left her for another woman. A new boyfriend questionably abused her daughter who was 16-years-old at the time and abruptly ran away. In the subsequent 4 years, there has been no word about her whereabouts. Phat has had continuous stress over this as well as financial problems. After seeing the burning and falling of the Twin Towers on 9/11, she had a significant increase in her symptoms, which have since subsided somewhat.

Maria

Maria is a middle-aged Salvadorian woman who had poor sleep, violent sexual dreams, depression, and suicidal thoughts. She had a history of past alcohol abuse which caused her business losses. She had idealized her father until he left her mothers when Maria was a teenager, and she subsequently had a very strained relationship with him. In 2977, the paramilitary began killing young men in her village, accusing them of supporting the guerillas. A young man was hidden by Maria in their home, was found, pulled outside, and killed in front of her. She ran away, returned, was kidnapped by a paramilitary gang, violently raped and tortured. Subsequently she had multiple marital problems and began heavy drinking.

Nina

Nina is a Somali woman with anger attacks, nightmares, and startle reactions. Her parents died when she was young, and she lived with relatives where she was abused and beaten. Her husband also was physically abusive and took a second and third wife; Nina lived in constant fear of his violence. In the civil war in Somalia , tribal fighting broke out. One gang broke into their home and Nina ran away. Two brothers were shot to death. She was barely able to escape massive rape of all women in her own village. She has had severe problems raising her children in the United States .

These patients are representative of the over 1000 patients in our Intercultural Psychiatric Program at Oregon Health and Science University (OHSU). They are the victims, survivors and now refugees of multiple wars, ethnic and tribal conflicts, and even random violence of gangs operating in lawless, disintegrated societies. Almost all are civilian, most are women and children, and most were not particularly politically active or part of any organized resistance to any government. They certainly were not terrorists.

Most of our patients and probably most of the world's 20,000,000 refugees are “ordinary” people caught up in violence and indeed in events for which they were not responsible, could not control and usually could not even understand.

From three different countries we see massive violence and torture of innocent victims and their struggle for survival. These specific cases have been treated in the Intercultural Psychiatric Program at OHSU, which began as a refugee clinic in 1977 and has grown since that time. The model has been one of using counselors who also serve as interpreters from their own ethnic groups. Of the 26 counselors present, 25 represent the ethnic group0s that they work with. The clinic now can handle 17 different foreign languages. It has 11 part-time psychiatrists and a patient population of over 1200 including 50 children. In 2000, the clinic received a federal health and human services grant from the Office of Refugee Resettlement specifically for treating torture survivors. This grant was recently renewed following a competitive bid process. Treatment of refugees clearly has become the treatment of those who have been traumatized severely and tortured.

Torture is usually thought of as a government sanctioned individual act against civilians to force confession or to intimidate members of a political party or tribe. However, modern warfare is much more complex, especially in the chaotic situations of loss of any kind of social order. Tribal violence and ethnic cleansings have resulted in random acts of violence against civilian populations. It is estimated that 90% of the victims of current wars are civilians. These are the people we treat in our torture treatment center. These are the ones whose life histories are so painful to hear.

Most patients who come to us do not speak English, have limited education, have been severely traumatized and suffer from the posttraumatic stress disorder and depression. Increasingly people also have psychotic symptoms which are difficult to diagnose and also difficult to treat. The treatment consists of some basic principles: establishing safety i.e., the patients feel safe in the therapeutic settings; establishing continuity i.e., the program, the doctors, and the counselors will always be there and will be the same; and reduction of symptoms with modern medications, which can be very effective. Acceptance of patients by culturally appropriate and sensitive techniques has been very useful. Nevertheless, the effects of severe trauma for many patients are severe and prolonged. Severe PTSD is also an episodic disorder with exacerbations and emissions. Exacerbations are frequent when there are reminders of the past trauma, such as vivid displays of war attacks on television, violent shows, and recently we have documented severe reoccurrence of symptoms from television broadcasts of the attacks of the Twin Towers on 9/11.

What Are We to Think?

What are we to think about these despicable acts and their effects? One can only describe the events and the suffering as evil. They are massive, traumatic events which injure and kill many people throughout the world. The list is extremely long and growing: Vietnam , Cambodia , Bosnia , Rwanda , Somalia , Ethiopia , Congo , Guatemala , El Salvador , Chili , Sudan , Darfur , etc. An intellectual analysis of these cruelties allows us to get distance from them but also keeps us from an emotional involvement. At its best, it can provide a rational approach and at its worst, it prevents us from putting human faces on the disasters.

The psychological idea that evil acts are done by deranged persons i.e., narcissistic, and antisocial personalities such as Hitler, seems inadequate to explain the massive outbreaks of violence and ethnic disorder that are occurring in many parts of the world. Sociological ideas and political analysis of group hatred and animosity toward “out-groups,” i.e. those who are ethnically and culturally different, seems more comprehensive but still inadequate. It is thought that sometimes animosities and hatred are built up over generations by past wrongs kept alive by grandparents or other ancestors who pass on to younger generations the express or implied requirement to avenge these events. Still, it seems that the killing of civilians, raping and killing of women, destroying villages, using starvation as a war tactic go beyond any means for political advantage. There seems to be something more to this mass violence than traditional analyses allow.

When thinking of evil philosophically, we in the West have been preoccupied with theological concerns. For example, Augustine (354-430) felt that moral and natural evil was punishment for disobedience of God's will. Modern Christians have the following information: evil exists, God is benevolent, God is omnipotent. These propositions don't fit. Rousseau (1712-1778) thought there was a natural connection between sin and suffering. Our misery is due to our action; it is a natural consequence much as the karma idea in Buddhism. Voltaire (1694-1778), being more realistic perhaps, felt there was no way philosophers could explain the nature of moral and physical evil. Kant (1724-1804) stated that happiness and virtue are not and should not be systematically connected. We often imply that there should be a connection between a good life and happiness i.e., how could such a good person get cancer? How could such a young person die from the accident, etc? There are widespread assumptions that goodness and health are related, but of course, they are not.

We have been unable to make sense of evil especially the most graphic example in the modern world—the Holocaust. The Holocaust is a combination of modern technology (gas chambers) and evil intent (destroying a whole class of humans). Yet despite some psychological reports of making sense out of our suffering or growing through the suffering in the death camps, in fact, most people didn't.

Amery, a survivor, “we didn't become better, more humane and morally mature. The world died for us a long time ago, and we don't have a feeling that we should regret its loss.”

We review these events. What are we to conclude? First of all, evil does exist. Our moral innocence is gone. The effect on the victims psychologically, physically and spiritually is profound and long-lasting. We cannot understand it and we must not stop trying.

What Are We to Feel?

Feelings are personal, subjective, unpredictable, and changeable as we review the severe images of the tortured and hear their stories. Feelings perhaps are deeper or more attuned to our real motives than our analytical thoughts. But they are all very personal. Seeing pictures of tortured children and civilians can cause some to call for peace, stop these utter destructions of humans by humans. For others thought the same images are a call for revenge, getting even. For patients, the feelings are often complicated, subtle, and ambivalent.

Case Histories

She was an attractive, but complaining Vietnamese woman. Her husband had been killed as a soldier during the Vietnam War. Since she'd come to the United States , she had complained of his loss and of the effect of the war on her. She somanticized, i.e. much pain, headaches, back pains, poor sleep. To the Vietnamese counselor her complaints seemed monotonous and never ceasing. On one occasion when the Vietnamese counselor was called out, she broke into a fair English and showed me the terribly deformed leg from a burn. Her husband had thrown boiling water on her. There had been additional acts of violence. She was relieved when he was killed—a feeling she could not admit to her counselor.

A Somali man was known by the Somalian community as being angry, isolated, challenging and extremely difficult. Several appointments were made to the clinic before he came. He did appear mildly aggressive, hostile, and ungiving of much information. After a long, subtle and sometimes complicated interview, we understood he had a bullet wound to the chest which partly explained his symptoms. However, there seemed to be more that he needed to say. As the rebels had rushed into his village, they rounded up many of the men including him and started shooting them. His oldest son stepped in front of him as the gun went off, took the bullet and died. The bullet also went through the patient in a nonfatal way. His guild and sorrow had never ended. We never talked about it again, but he greatly improved as we had accepted his story and him. He became a much more serene and relaxed individual who began to socialize wit others in his community.

I never really know what to feel about these events, perhaps profound sadness comes to mind. These are serious events; this is “the real thing.” Real people with real problems. There is not a solution. It cannot be fixed. It leaves one with a sense of helplessness. Even trained therapists have revenge and rescue fantasies. We also are left sometimes with our own sense of hyperarousal, anger, and irritability. At its very best though, the patient and the doctor have a unique shared experience with profound empathy and connection, and a dedication of professional responsibility.

What should we feel from this? We include both the larger American community as well as the healers who are dedicated to reducing the suffering of these survivors. We should feel sorrow for the patient and for the human condition and also amazement at human resiliency. We feel vulnerable knowing how precarious life is. We should feel hope—a realistic hope for ourselves and our patients that life even with all of its losses can still be valuable and can still be lived in a meaningful way. For professional health care providers, we also should feel a personal devotion to our work and a sense of personal responsibility and privilege to provide hope, relief, and comfort for those survivors.

Thoughts on America and Torture

So far I have written about the tortured and the perpetrators, the evil events that are out there, over there, belonging to other people, other places. There can be in this approach a sense of a moral superiority or at least isolation from these events. Some of the pictures from Vietnam , i.e. My Lai , shocked us into a sense that we are a part of it. The bombing of the Twin Towers gave us a moral ability to act since we had been attacked and wounded. It also reinforced those who see the world in demonic terms—good versus evil or the devil has done this—and reinforced the idea which is common in some political circles that we have the right, even the duty, to combat that which we identify as evil. However, whatever we may have felt, the multiple pictures of Abu Ghraib have destroyed any sense of moral superiority. The forcing of sexual acts, the intimidation, the brutality, and the utter humiliation of Muslim men leaves us both confused and disillusioned that such a thing could happen perhaps even authorized by direct or nebulous orders—a further source of moral disorientation. The possibility that Americans torture prisoners in other detention centers throughout the world is a further loss of basic moral values. We have in fact found that the evil is not out there, but is capable of happening within us. The words of Nietzsche need to be remembered. “When fighting a monster, be sure not to become a monster.”

What should we do? As doctors and health professionals, we need to keep our professional responsibility to those who are injured and ill, traumatized and humiliated. As citizens, we need to keep our dedication and our idealism to prevent such acts from occurring within our own sphere of influence i.e., our community and country. We need to remove ideas of moral innocence and moral superiority. We are one people among others in the world, humbly seeking the way for peace.

The story is told about William Stafford, the Lewis and Clark College poet. When he was a small boy in the third grade, some boys were throwing rocks at two other boys because they were black. His mother asked, “What did you do?” and he said, “I went and stood beside them.” Our job is to be sure who we stand beside and what we stand for.