Testimony to House Committee on Foreign Affairs
Subcommittee on Africa and Global Health
Neal Porter
Director of International Services, Center for Victims of Torture
June 20, 2007
Thank you for the opportunity to testify before you today on World Refugee Day.
My testimony today will focus on the Center for Victims of Torture's community mental health services to refugees and returnees in Africa. This work is a humanitarian response to the devastating affects of torture and political violence on individuals, their families and their communities. It is also a strategic investment to break cycles of decades-long violence so we can support what are often fragile peace agreements.
Torture and War Today
The universal experience among refugees today is exposure to traumatic events and human rights abuses, in particular torture. This is due to political instability, war, and repression in the home countries.
Wars today are conducted very differently than a century ago. During World War I, only 5 percent of the casualties were civilians. In World War II, that figure rose to 50 percent. In current world conflicts and war, over 90 percent of the casualties are civilians rather than combatants. (Summerfield, D. (1995). Addressing Human Response to War and Atrocity: Major Challenges in Research and Practices and Limitations of Western Psychiatric Models. Beyond Trauma: Cultural and Societal Dimensions. New York: Plenum.) It is estimated that between 5 and 35 percent of today's refugees are survivors of torture (Baker R. Psychological consequences for tortured refugees seeking asylum and refugee status in Europe. In: Basoglu, M (ed) Torture and Its Consequences Current Treatment Approaches Cambridge, UK: Cambridge University Press, 1992, pp 83-106.) Our own research has found rates much higher. For example, a survey conducted in 2004 found that 69 percent of Oromo male refugees living in Minnesota were tortured (Jaranson, J. M., Butcher, J., Halcon, L., Johnson, D. R., Robertson, C., Savik, K., et al. (2004). Somali and Oromo refugees: Correlates of torture and trauma history. American Journal of Public Health, 94, 591-598.)
I am not going to provide a history of the conflicts in the countries where CVT is currently providing mental health services: Sierra Leone, Liberia and the Democratic Republic of Congo (DRC). You are well aware of the protracted civil wars in those countries. But I would like to put a human face on the experiences of the people.
Stories of Refugees
In 1993, ULIMO rebels raided the house of a 48-year old man living in Lofa County, Liberia. The rebels killed his father and mother, several of his sisters and brothers and other extended family members. Then he and his wife and children were taken captive by the rebels. He was beaten, tied and forced to carry loads for the soldiers. His wife was raped in front of him. He and his wife eventually escaped and fled to Sierra Leone where they lived as refugees until 1997.
When CVT first met this man, he appeared physically to be in good health. But he had problems sleeping, had nightmares, expressed difficulty managing his anger, experienced intense sadness, avoided people and places that reminded him of what happened and seem quite isolated and disengaged. After he began group therapy, he revealed that he was having a lot of conflict with his 28-year-old son, who was also a member of his therapy group.
Another 16-year old boy sought out CVT's mental health services after hearing our weekly radio program on mental health issues and attending an awareness raising session our counselors conducted at his school.
The youth shared that he had witnessed a rebel assault including brutal killings and the burning of his entire village when he was four years old. Captured with his parents, he saw the rebels shoot his father dead two years later. The boy and his mother tried to escape, but were caught and beaten. He was forced to watch his mother's rape. A second escape plan was successful and they fled to a refugee camp in Guinea. Four years later, the camp was attacked and he and his mother were taken captive by rebel forces again. After receiving 12 lashes in front of her son, the mother was released and the boy was conscripted as a noncombatant. A 10-year-old child by then, he was forced to fetch water and firewood, do laundry and to dig graves and bury corpses; some of the bodies he buried were his friends. He managed another escape into the bush where he was fortunate to join a United Nations convoy to a refugee camp in Guinea and was later reunited with his mother. A month after their reunion, his mother died.
When this youth came to CVT, he shared that he had trouble sleeping and concentrating, poor appetite, nightmares and flashbacks along with a strong tendency to isolate himself while always feeling sad and discouraged.
Unfortunately, too many of the refugees we work with in Africa have told similar experiences. Certainly the physical symptoms will vary depending on the type of torture endured. But as you can tell by the brief case examples shared here, there is a remarkably common pattern of profound emotional reactions and psychological symptoms that transcends cultural and national differences.
Psychological problems that result from torture and war trauma include severe depression and anxiety; intense and incessant nightmares; panic attacks; guilt and self-hatred; and suicidal thoughts or tendencies. Torture can result in posttraumatic stress disorder, major depression disorder, and a combination of both disorders.
Those most affected by traumatic experiences find it difficult if not impossible to resume daily activities and rebuild their lives. The inability of individuals to function can incapacitate a whole community. We also know that the affects of torture and war impact future generations. Research has shown that the children and grandchildren of Holocaust survivors have higher levels of depression and thoughts of suicide.
In a 2004 report, the World Bank recognized poor mental health as a significant development issue especially in conflict-associated countries ( "Integrating Mental Health and Psychosocial Interventions into World Bank Lending for Conflict-Affected Populations: A Tool Kit," September 2004.) The report noted the well-documented link between poverty and conflicts and said, "In addition, traumatic experiences directly related to conflict, often involving loss of family members, participation in or witnessing of violent acts, and conflict-induced physical disabilities, cause further distress and hamper post-conflict reconstruction and development efforts."
Despite widespread need and the lasting affect of political violence, very few resources are devoted to addressing the mental health problems caused by torture. Yet healing the wounds of torture is integral to the process of rebuilding a post conflict society. When political violence intentionally destroys a community, the society itself must heal before peace and democracy can flourish.
Let me take this moment to correct a common myth about torture. Torture is not an effective interrogation tool. It is a notoriously unreliable tool for gathering actionable information. Torture is fundamentally a political weapon used by repressive regimes to shape cultures through fear. Repressive regimes target leaders and use torture to send fear through that leader's family and community of followers and admirers. They destroy leaders and send them back to their communities, broken and depressed, as an example to others. Most of our clients tell us that they said anything their torturer wanted them to say to make the pain stop.
For this reason, torture is the most effective weapon against democracy. The impact of torture is felt for years, even after a dictatorial regime has fallen: leadership broken and lost, families and communities too frightened to engage in public life; and a profound lack of trust in public institutions, the police and courts.
Providing healing services after political violence is a strategic investment for the United States and its allies. Not addressing the consequences of torture and war means those cycles of violence, rage and revenge will continue.
About the Center for Victims of Torture
The Center for Victims of Torture has been providing direct care to survivors of politically-motivated torture since 1985. Nearly all refugees who are settling in Minnesota over the past few years are coming from countries ravaged by torture and war. For more than a decade the majority of new clients at CVT have come from Africa, 83 percent in 2006.
At clinics in Minneapolis and St. Paul, CVT's staff include highly trained health care personnel-physicians, psychologists, nurses, and social workers, supported by volunteer health professionals, such as a dedicated team of physiotherapists and massage therapists, specialists in many fields, and over three hundred community volunteers. Our intensive treatment programs in Minneapolis and St. Paul are designed to aid survivors to become healthy, productive citizens again while also teaching us about the human response to intense trauma and effective ways of healing. We have an annual capacity in this intensive program for about 250 survivors each year. There are roughly 30,000 torture survivors living in Minnesota, 500,000 in the United States.
Clearly, the contrast between our capacity for direct service and the need is staggering. So we have extended our work through research and training of other health care professionals, both in specialized torture rehabilitation centers and in the mainstream. We are currently providing technical assistance and small grants to 33 torture rehabilitation programs in the US and 16 in countries across the world where torture has been widely practiced.
Our treatment programs in Africa are examples of how we incorporate our clinical knowledge of healing with research and training to care for thousands of survivors of torture and terror in West and Central Africa. These programs are also designed to help us understand how communities can recover from fear - the motivating source behind those who torture.
CVT's Projects in Africa
In the summer of 1999, the U.S. State Department, Bureau of Population, Refugees and Migration (BPRM), asked CVT to conduct an assessment of the mental health needs of Sierra Leonean refugees living in camps in Guinea. BPRM was concerned over reports of refugees being too traumatized to take advantage of services or programs being offered by international nongovernmental organizations. Examples were given of people being too depressed to bring their children to be fitted for prosthetics, to follow-through with medical treatments or to benefit from skills training.
I want to acknowledge and thank BPRM for their foresight. They recognized the massive scope of the traumas experienced by Sierra Leonean refugees and the need for mental health interventions beyond traditional psychosocial programming offered by humanitarian relief agencies.
Even for CVT, an organization that works with torture survivors on a daily basis, the level of violence we found among Sierra Leonean refugees who fled to camps in Guinea was nearly incomprehensible.
One person told us, "For every person directly victimized, there were 30 others who witnessed the atrocity or were made to actually perpetrate it."
We knew we did not have the staff or resources to provide for the needs of all the people in the camps who would benefit from mental health services. So we developed a model to provide appropriate mental health care for those most severely affected to those less affected in a way that would maximize resources.
We also knew funding for our work in Guinea would not be unlimited. So building capacity among the refugees was important. We wanted to leave behind skilled mental health counselors who could provide for the long term mental health needs long after our tenure.
Both objectives, providing direct mental health services to those who suffered torture and developing local capacity for the community to meet it own mental health needs, remains the overarching goal of our projects today in Sierra Leone, Liberia and the DRC.
We began working with Liberian refugees when the violence in their country flared and refugees fled to the camps in Guinea. In 2002, as Sierra Leonean refugees returned home, we moved with them to the Kono District, one of the hardest hit regions affected by conflicts in Sierra Leone and Liberia. When Liberian refugees returned in 2005, we moved to Bong and Lofa Counties, near the borders of Guinea and Sierra Leone and home to the highest number of returnees. We closed our work in the Guinea camps in 2005.
In the Fall 2006, we began operations in the southeastern district of Katanga in the DRC.
Delivery of Mental Health Services
We have three levels of mental health interventions. The first level is to address those people with psychotic mental disorders. We provide individual and family therapy to address their trauma and help them regain the ability to function within their family and community.
Once a client is identified, they will receive an intake assessment so CVT clinical staff can develop an individual treatment plan. Individual counseling is provided to clients who are either unable to attend group counseling sessions or have a greater need to address their problems in private. Clients are usually seen for one hour, for 1 - 5 sessions, and then join a small group if they are able.
The 16-year old boy I described earlier received 5 individual counseling sessions to reduce the severity of symptoms he experienced. For those most affected by trauma like this teen, individual sessions can assist them with developing a trusting therapeutic relationship.
The second level of service is designed for those with severe depression, anxiety, traumatic stress symptoms and decreased social functioning. We use small group therapy (10 to 12 individuals) and in some cases combine that with individual and/or family therapy. Most of our mental health services are provided through small group therapy.
The groups take place on a weekly basis for approximately 10 weeks, and are divided into different populations including adults, children, men and women, girls and boys. Clients benefit from the increased socialization with others who share similar stories. Each year thousands of clients benefit directly from CVT group counseling.
Let me note that most refugees are remarkably resilient. While we believe anyone in need of mental health services deserves them, we do not want to imply that all refugees are in need of "treatment." Most refugees, given a reasonably good environment, are able to rebuild their lives and contribute to their family and community's well-being. CVT is focused on individual refugees with significant post-trauma mental health problems who are in need of assistance to rebuild a productive life.
The third group we target our services to represents those experiencing the least psychological and functional impairment, which comprises the majority of the refugee population. The interventions we use at this level include large group activities such as sports and play for children and community-level events, such as psychoeducational dramas or traditional ceremonies. These activities are primarily psychoeducational and often incorporate traditional healing customs.
Training and community awareness raising activities are held in communities to bring attention to the prevalence and effects of torture, to help community members such as teachers, religious and local leaders know what they can do to help others, and to help identify potential clients. Over 26,400 people participated in CVT community sensitization activities in 2006.
One such activity occurred in Sierra Leone last year on June 26, International Day in Support of Victims of Torture. In Buedu, community members and CVT organized a commemoration at the site of a mass grave, where dozens of corpses had been unceremoniously dumped during the war. Religious leaders led traditional ritual, Muslim and Christian prayers in a deeply moving memorial service for the victims of torture buried at the site and for those who disappeared. The ceremony was a public recognition and honor of those who were lost.
Training Peer Counselors
The heart of CVT's mental health projects in Africa is its training. This training program is experiential, with para-professional Psychosocial Peer Counselors (PSCs) learning alongside professional CVT clinicians while working with clients in both individual and group settings. Once selected and hired from a target population, peer counselors undergo an intensive two-week orientation and basic training period. Then they observe and assist as the professional clinician runs a 10-week group counseling session. When the peer counselor is ready, he or she co-facilitates a 10-week session with the professional clinician, and then leads a third 10-week session as the clinician observes and assists. At that point, their performance is reassessed, and, if appropriate, peer counselors begin to lead sessions on their own.
Every month CVT clinicians also conduct formal trainings to the peer counselors on a variety of mental health and counseling subjects. In addition to formal training sessions, informal training and supervision takes place on a daily basis, with clinicians modeling, observing and giving feedback to them after every counseling session and activity.
The training for peer counselors is extensive and long in duration because CVT's goal is to develop highly capable local resources for healing and advocacy, based on in-depth knowledge and skills. To date, CVT has trained over 160 peer counselors, originally hired as refugees, many of whom have been training with CVT since 1999.
In fact, CVT's training is such a high standard that the first group of Sierra Leonean refugees trained as peer counselors in the Guinea camps obtained accreditation from the Milton Margai College in Freetown, Sierra Leone. In addition to their CVT training, they attended supplemental courses and received the equivalent of an Associates Degree in Counseling or a Certificate of Counseling. Similar accreditation is underway for the peer counselors working in Liberia and will be planned for the DRC as well.
External Relations
CVT works closely with local government ministries and others to provide training and referral services. In addition, CVT has expanded its links with specific NGOs working on related issues, including collaborating with the Truth and Reconciliation Commission in Liberia to provide training and psychosocial support for TRC participants, International Rescue Committee (IRC) and Search for Common Ground/Talking Drums Studio
(SCG/TDS) as part of a Sexual and Gender-Based Violence program in Kailahun; WITNESS program in Sierra Leone to raise the awareness of the Sierra Leone Truth and Reconciliation Commission; and in Liberia, with American Refugee Committee (ARC), to provide trauma counseling training to their Gender Based Violence program staff. CVT also provides training to other NGOs in refugee camps and communities to help them identify torture survivors, avoid retraumatization and refer them when possible.
Results
Since 1999, CVT has provided mental health services to over 10,000 refugees and returnees in West Africa. To measure the effects of the program, peer counselors regularly check in on clients who have received services from CVT. They conduct one month, 3-month, 6-month, and 12-month follow-up assessments to record and measure indicators of clients' improvement. Results are compared to intake assessments and then analyzed statistically. Analysis shows improvement that is both statistically significant and meaningful in indicators ranging from reductions in depression, anxiety, and somatic symptoms, to an increase in the number of supportive relationships. Case studies also reflect the success of the CVT program. Clients consistently report having increased hope, better coping skills, and improved relations with others after receiving help from CVT.
Benefits
CVT International Services programs reflect both the humanitarian and strategic benefits of healing survivors of the horrific human rights abuses that occur from civil conflict. On the humanitarian side, CVT provided direct trauma counseling services to over 2000 individuals in Sierra Leon and Liberia last year, and helped thousands more through training and community activities that promote mental health through social connections and physical well-being.
On the strategic side, CVT is helping to rebuild community and reclaim civic leadership in post conflict areas. As citizens and decision-makers grapple with difficult issues of justice, forgiveness, reparations, and impunity; the peer counselors trained by CVT will be positioned to act as voices that can speak to the truth of the damage, and take leadership in the healing that must occur for the country to rebuild.
Our vision is to leave behind the beginnings of indigenous torture rehabilitation programs in these countries that can then be connected with 200 colleague treatment programs around the world. In the Kono District of Sierra Leone, the peer counselors trained by CVT are taking the first steps. They have formed a national nongovernmental organization, called the "Community Association for Psychosocial Services," or "CAPS," to continue providing mental health resources for local Sierra Leonean communities after CVT has left the country. With guidance from CVT international staff, CAPS has developed a mission statement, created an executive team and board of directors, recruited a lead coordinator, designed a logo and brochure, applied for and received local NGO status with the Sierra Leonean government, become accredited with the International Rehabilitation Council of Treatment Centers and wrote their first grant proposals, obtaining $6000 from the Oak Foundation as well as a $15,000 grant from the United Nations Voluntary Fund for Victims of Torture. CVT has provided training for CAPS members on human resource management, leadership principles, developing and managing a non-governmental organization, proposal writing and strategic planning. Funding for our involvement will end in June 2008. Our focus in this last year of international staff involvement is to continue to help them develop their management and organizational skills to they can staff, raise funds and manage an effective and successful national NGO in Sierra Leone.
Conclusion
The leadership demonstrated by BPRM means that the rebuilding efforts in West Africa and DRC will include attention to healing the severe psychological wounds suffered as a result of the political violence there; CVT is proud to be a key part of this effort. In conclusion, we also wish to acknowledge other ways in which the U.S. government has been a leader in this work. The U.S. is the leading contributor to the United Nations Voluntary Fund for Victims of Torture, which supports more than 150 organizations worldwide providing psychological and other forms of assistance to torture victims, including two dozen African organizations. The US government's leadership helped inspire more than 30 other governments to pledge contributions to the Fund in 2005.
The U.S. government also plays a direct role through USAID funding for torture treatment programs around the world. This funding strengthens the capacity of local organizations to deliver services to survivors in their countries, thus healing the wounds of political violence and building indigenous civil society groups.
CVT urges members of this Committee and all members of Congress to recognize and applaud the leadership shown by these U.S. government agencies. We also recommend that providing mental health services be a vital component to any post-conflict rehabilitation effort, along with all the material assistance and repatriation services provided. By reclaiming civic leadership, rebuilding community ties, and restoring those who have been intentionally disabled, we improve hopes for reconciliation and for development.
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