Many Ways to be Safe:
Training Providers to Recognize
Torture and Aid Survivors
Lucia Roncalli, MD, MPH, ABIHM
Diversity Rx: Quality Health Care,
11 March 2013
Nothing to declare
• Climate change, globalization, and changing patterns of
conflict have resulted in violent displacement for
millions; ~80,000/year seek asylum in the U.S.
• Asylum seekers have higher probability of having
• One effect: changes in the composition of patient
populations presenting for primary care in the U.S.
• 6-12% of foreign-born patients presenting for care in
urban outpatient clinics are survivors of torture.
– Rates are much higher among some subgroups; up to
• Many more have survived political violence and other
severe human rights violations
Crosby, S., et al. (2006). Prevalence of torture survivors among foreign-born patients presenting to an urban ambulatory care practice. J Gen Intern Med. 2006 July; 21(7): 764–768
Eisenman DP, Keller AS, Kim G. Survivors of torture in a general medical setting: how often have patients been tortured, and how often is it missed? West J Med. 2000; 172:301–4
Eisenman, D., et al. (2003). Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA August 6 2003;
• There are as many survivors of torture in the U.S. as there are
persons with Parkinson’s disease, or with polycystic kidney
• There are more survivors of torture in the U.S. than persons
with multiple sclerosis.
• Doctors receive training in Parkinson’s, PKD and M.S., but not
in human rights law or in health effects of human rights
• 67-78% of survivors haven’t told their doctors what they have
• 74% express desire to do so, but fear it may be inappropriate
• Very few physicians ask: 0-3%.
• Care is compromised.
Miles SH, Garcia-Peltoniemi RE. Torture survivors: what to ask, how to document. J Fam Pract. 2012; 61:E1–5.
Shannon, P., et al. (undated). Refugees’ perspectives on barriers to communication about trauma histories in primary care. Center for Victims of Torture
• In addition to high rates of somatization,
– Significant physical disability (17% in one
study; p< 0.0001 in another)
– Many syndromes that are culturally
important even if not recognized by
western diagnostics and nosology
– High rates of somatization: emotional
distress expressed as physical symptoms;
refractory to usual care
Hexom, B., et al. (2012). Survivors of torture: prevalence in an urban emergency department. ACADEMIC EMERGENCY
MEDICINE 2012; 19:1158–1165
CLINICAL NEED: PSYCHOLOGICAL
– Psychological sequelae:
• PTSD: 25-48% point prevalence, up to 60% lifetime
– Most studies find significant dose-response
– Severity dose-response is also significant
• Depression: 31%; co-morbidity with PTSD is common
• Anxiety: 31%
• Increased rates of familial violence, substance abuse,
• Many complex post-migration stressors
Fazel, M., et al. (2007). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review . Lancet 2005; 365: 1309–14
Hollifield, M. (2009). The range of symptoms in refugees of war: New Mexico refugee symptom checklist NMRSCL-121. J Nerv Ment Dis 2009;197.
Tamblyn JM, Calderon AJ, Combs S, O’Brien MM. Patients from abroad becoming patients in everyday practice: torture survivors in primary care. J Immigr Minor
Health. 2011; 13:798–801
Hooberman, J., et al. (2007). Classifying the torture experiences of refugees living in the United States. J. Interpersonal Viol 22(1)January 2007 1-16.
PHYSICIAN IGNORANCE ABOUT HEALTH,
HUMAN RIGHTS: CONSEQUENCES
• When physicians don’t know to ask about human rights
violations, they may waste resources on expensive testing and
• They may miss important diagnoses
• They don’t know to refer appropriately
• They may increase their patients’ suffering and isolation
– By insensitivity to routine clinic elements that are triggers
for traumatized survivors
– By missing opportunities to teach about the relation of
extreme stress to physical and psychological illness
– By missing opportunities to normalize survivors’ reactions,
and reassure them that they are not “broken forever.”
ADDITIONAL CONSEQUENCES OF
PHYSICIAN HHR IGNORANCE
• Doctors who are not educated in health and human rights are
more likely to participate in rights violations
• U.S. medical students, including those with military training,
are ignorant about human rights law and international
– 34%: unable to state when required to disobey orders
– 24% disagreed with a blanket prohibition on torture
– 22% think it acceptable for physicians to examine people
for torture to begin or continue
• U.S. physicians and psychologists at Guantanamo: “Without
the health professionals, the system would come to a grinding
Boyd, J., et al. (2007). U.S. medical students’ knowledge about the military draft, the Geneva Conventions, and military medical ethics. International
Journal of Health Services, Volume 37, Number 4, Pages 643–650, 2007.
Bean, J., et al. (2008). Medical students’ attitudes toward torture. TORTURE vol 18, November 2, 2008.
Deborah Popowski, Harvard Center for Law and Human Rights, in DOCTORS OF THE DARK SIDE
Med school and residency curricula should
include health and human rights training
• 1996: educators widely acknowledged the need for such
– yet only 17% of U.S. medical schools included training
relevant to immigrant/international issues in their
• 2009: educators still acknowledge the need for such training
– 32% of med schools offered HHR education.
– Public medical schools less likely to offer than private
Sonis, J., et al. (1996) Teaching of human rights in US medical schools. JAMA. 1996 Nov 27;276(20):1676-8
Cotter, L.E., et al. (2009, 18 March). Health and Human Rights Education in U.S. Schools of Medicine and Public Health: Current
Status and Future Challenges.
Iacopino, V. (2002). Teaching Human Rights in Graduate Education.
Provider education is
“primary prevention” for rights violations
– Exposure and documentation lessen
violation rates; PCP’s are ideally suited to do
– HHR education makes providers more likely
to support and understand fulfillment of
human rights as a crucial social determinant
– HHR education makes providers more likely
to initiate and support rights-based
HHR: health and human rights
HHR Core competencies
– Of international and national human rights laws
– Of common sequelae of rights violations
– How to treat, when to refer
– How to respond to rights violations
– Recognizing dual loyalty situations
– Ability to do these things!
– Willingness to do these things! And to support colleagues
who speak out
London, L., et al. (2007): Developing health rights competencies for S African health professionals. S. Africa Med J December 2007, Vol. 97, No. 12
Tarantola, D., Gruskin, S. (2006). Health and human rights education in academic settings. Health and Human Rights2006, 9:2 (297-300).
Elements of successful programs
• Mixed elective and compulsory elements
– Offer certificates for those who electively
complete more than the minimum requirements
• Inspiring, committed faculty seen as role models
• Administrative and collegial support
• Adequate protected time for learning
• Longitudinal, iterative curriculum
• Local application
• Culture of wider community
Successful pedagogy is varied
• Variety of teaching modalities
– Lecture, films, journaling, interviews, etc
• Opportunities for immersion experiences
• Application to local circumstances
• Variety in evaluation:
– Faculty evaluate students
– Students evaluate faculty, courses
– “360” evaluations from patients and staff
– South Africa: need long-range evaluation of graduates’
Tarantola, D., Gruskin, S. (2006). Health and human rights education in academic settings. Health and Human Rights2006, 9:2 (297-300).
Does this training make a difference?
• Ramin Asgarry, Bronx Human Rights Clinic
• After training, residents are:
– able to identify clinic patients who have high odds of
having been tortured, or of suffering torture sequelae
– more likely correctly to recognize human rights obligations
that inhere in their roles as physicians [p < 0.01],
– more likely to know the most common sequelae of torture
[p < 0.0001],
– more likely correctly to apply PTSD criteria during
evaluation[p < 0.0001].
– Changes persist 1 year after graduation
Asgary, R., et al. (2006). Evaluating asylum seekers/ torture survivors in urban primary care: a collaborative approach at the Bronx Human
Rights Clinic. Health and Human Rights 9:2 (2006).
One model: Santa Rosa Family Medicine
Residency longitudinal HHR curriculum
• First year
– 12 dedicated teaching hours. Approaches to human suffering: HHR,
liberation medicine/ Paul Farmer, social medicine.
• What is health? Is it a right? What is a right?
– UN documents, treaty bodies. Geneva Conventions
* signatories’ responsibilities to “Respect, Protect, Fulfill”
* Progressive realization
* Derogable vs non-derogable rights
– Case Studies/films: farmworkers in Sonoma County
• Labor contractors and human trafficking; response of the local
• Pesticide exposure
• Free trade agreements, collapse of subsistence agriculture in rural
Mexico. California industrial agriculture.
SRFMR curriculum years 2-3: asylum
• Collaboration with HR organizations, immigration law
• 3 sessions
– 1. didactic desk overview, subsequent evaluation
– 2. shadowing experienced evaluator
– 3. doing own interview and affidavit, with faculty
Weinstein, H., et al. (1996). Torture and war trauma survivors in primary care practice. West J Med 1996;165:112-118.
Levine, P. (2004). Waking the Tiger: Healing trauma.
• Aka: Manual on the Effective Investigation and
Documentation of Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment.
• Collaborative effort of 75 forensic and medical
professionals (Turkey, 1996)
• Formally accepted by the Office of the UN High
Commissioner on Human Rights in 2001, now is
the international standard of care for evaluation
• PHR manual expands sections of particular
relevance to US physicians and mental health
PHR: Physicians for Human Rights
Significance of obtaining asylum
• Secure escape from peril, pain, death
– For applicants and also, often, for families
Possibility of reunion w/ family members
Legal permission to work in US
Opportunity to rebuild lives
Access to health care for torture sequelae
Vindication of moral outrage, and legitimation and
documentation of suffering
Odds of obtaining asylum with/without
• Without medical professional testimony,
chances of obtaining asylum in the U.S. are
around 23% [or worse]
• With health care professional testimony,
chances of being granted asylum jump to over
• Providers who work with torture survivors risk
symptoms that are worse than garden-variety
burn-out, closer to PTSD.
• They also report life-enriching awareness
catalyzed by the work
• Odds of vicarious resilience can be maximized by
emotional support of learners, teaching specific
skills for uncovering resiliency, and giving a
cognitive framework for understanding trauma.
Hernandez, P., et al. Vicarious resilience: a new concept in work with those who survive trauma. Family Process 2007
Pross, C., Burnout, vicarious traumatization, and its prevention. TORTURE (16)1, 2006.
Peter A. Levine’s trauma framework
• Based on animal behavior and evolutionary neuroscience
• Humans possess innate resiliency and ability to overcome
• “Trauma is in the nervous system, not in the event.”
• When threat is perceived, humans are biologically
programmed to respond defensively
– Engages the sympathetic nervous system [SNS]
– High O2 consumption
– Neurally patterned defensive motor responses to
threat vary by species
Levine, P. (1976). Accumulated stress, reserve capacity, and disease.
Levine, P. (2004)
Freeze: when fight/flight fails
• Under inescapable threat, when fight/flight fails FREEZE
– Eg “playing possum”
• “Tonic immobility” occurs at maximal SNS activation, is
involuntary maximal parasympathetic over-ride
– Simultaneous SNS “accelerator” and PNS “brake”
• Evolutionary advantages
– Predators lose interest [programmed to avoid carrion]
– Buys time; prey may have escape opportunity
– Endogenous opiate surge, near-death anesthesia
• Social shame and guilt
– “Why didn’t I fight back? Defend myself/loved ones?”
– “She must have wanted that rape.”
Bados, A., et al. (2008). Traumatic events and tonic immobility. The Spanish Journal of Psychology2008, Vol. 11, No. 2, 516-521.
Schauer, M., Elbert, T. (2010). Dissociation following traumatic stress: etiology and treatment. Zeitschrift fu¨ r Psychologie / Journal of
Psychology 2010; Vol. 218(2):109–127.
Case in point…
The cheetah and the impala
Emergence from freeze
• Can be instantaneous, back to SNS defensive
responses to predator threat
• In safe environment, seemingly disorganized
movement, respiration, vocalization, is
essential to successful negotiation of stress
– Game wardens: without this, animals die
– Seen in slow-motion, are classic fight/flight
Hoagland, H, On the Mechanism of Tonic Immobility in Vertebrates. J. General Physiology, Vol 11, 715-741, 1928
Cannon, W.B. "Voodoo" death. Psychosom. Med. 19: 182-190, 1957.
Richter, C.P. On the phenomenon of sudden death in animals and man. Psychosom.c Med. 19: 191-198, 1957.
Hofer, M.A. Cardiac respiratory function during sudden prolonged immobility in wild rodents Psychosom. Med. 32:
• Happens spontaneously in the wild
– tremor, seemingly disorganized movement,
diaphoresis, deep breathing, vocalization
Social Overlay: “Get hold of yourself!”
• Social and cultural responses often shortcircuit emergence from freeze, so people are
stuck half in, half out
– Depression, concentration difficulties,
• Incomplete SNS responses create panic
syndromes and hypervigilant PTSD
Levine’s approach to healing trauma:
• “Trauma is incomplete defensive response.”
• Trauma is resolved when defensive response is
– slowly, with cortical awareness of physical
– in a controlled supportive environment
– with trained facilitation
• …triggers innate healing responses and sense
of exhilaration, mastery, well-being.
Levine’s Somatic Experiencing®
• = Emerging best practice, successfully used in
– natural disasters [Katrina, Kobe, Haiti, Indonesian
and Japanese tsunamis]
– among the chronically vulnerable [India, Israel,
– complex humanitarian emergencies [Congo,
– U.S. war veterans/ DoD
Leitch, et al. (2009). Somatic experiencing treatment with social service workers following hurricanes Rita and Katrina. Social
Work vol. 54(1).
Miller-Karas, E. (undated). The Trauma Resiliency Model: Guidelines for Working in Disaster Zones.
Selvam, R. (2005). Treating tsunami survivors for trauma:The effectiveness of a short-term psycho-physiological trauma
treatment approach among South Asian tsunami survivors. Journal of holistic healthcare. Vol 2:(4) November 2005.
Levine’s approach and
• Applying for asylum: visibility, vulnerability,
high-stakes poker without clear rules.
Activates PTSD, depression, panic
• Evaluation interview is intrinsically antitherapeutic:
• Survivors relive worst experiences of their
lives, with strangers.
• They demonstrate and recount classic threat responses,
along with guilt and shame about these
• Heightened risk of dissociating in court, and being
What Levine’s work contributes to
• Cognitive framework to understand physical
reactions is easy to teach; many asylum
applicants were rural, lived with animals
• Unobtrusive interventions from Levine’s
approach ameliorate distress
– Survivor symptoms often diminish
– Quality of life is enhanced
– Survivors are at less risk of dissociating in court
Examples: SE® principles applied to an
• “Orienting is soothing.”
• An animal that has scanned the environment and found
it to be safe is in a parasympathetic-dominant state.
• Windows! Sky!
• We orient applicants
– To who we are
– To what we do, and who will see the documents
– To what the interview will/won’t cover
– To their right to refuse ANY request we have for
information or physical examination
– To our understanding of trauma and memory
• Lapses don’t discredit them in our eyes
• Lies are unnecessary and useless
SE® and asylum: more examples
• “A healthy nervous system can swing between
trauma and pleasure.”
• Use the “psychosocial baseline” requirement
to uncover sources of pleasure, relationship,
competence, spirituality– and draw on these
later, when horror must be recounted.
• Enact scenarios/draw first on implicit, somatic
memory, rather than verbal, declarative
• Young African gay man, targeted by family,
neighbors, school, police, thugs
• Multiple incidents of atrocity necessary to
recount for court
• “Magnetic pull of the trauma vortex”
• Freeze, recovery, initiated connection with
female evaluator, enhanced well-being lasting
through hearing; no dissociation on stand.
• 23 year old female, outspoken for minority
freedoms in former USSR republic
• Detained, abused by police
• Never told her husband of her experiences
• Frequent nightmares.
• Per husband, “could have gone psychotic” when
recounting events to lawyer
• Per husband, nightmares gone after asylum
evaluation using SE® principles and skills-- even
before asylum granted.
What Levine’s work contributes to
• Residents can learn the basics
• Having a cognitive framework + practical skills
when confronted with massive trauma
protects against “secondary traumatization”
• Skills generalize to general clinic patients.
• Uncovering the innate resiliency we all
possess is exciting! And intrinsically rewarding.
• Skills also generalize to provider self-care
SRFMR asylum evaluation numbers
• Since September 2010
• 25 residents completed the required UN framework/overview at the end of
• 2 faculty + 12 residents completed the elective didactic training,
participated in clinical asylum evaluations (including 2 done in detention
• 3rd faculty member and several other residents have completed the
preliminary didactic step and plan to do evaluations when schedules
• 51 cases from 16 countries.
– 26 closed cases, 24 granted: 92% success
1 "voluntary repatriation" after solitary confinement in
1 lost to follow-up
– 12 cases are continued,13 awaiting status.
• 25/51 (49%) cases still pending,
• Some court dates set 3 years forward.
the new life that now is possible
• S was granted asylum this afternoon. She was
of course overjoyed and immediately started
dreaming about this new life which is about to
start for her. We are looking forward to
celebrating with you soon!
Rewards: overcoming profiling
• Hi Dr. Roncalli, I just wanted to let you know that G's asylum
application was approved today. Most Sikh cases get denied
by the Asylum Officers and referred to the Immigration
Judge, so that is very exciting news. Your report strongly
supported his claim so I wanted to thank you again for your
• I hope I get to work with you again in the near future.
• Happy New Year!
• Best wishes,
Rewards: educating the court
Good news!! D was awarded asylum 11/10, and P also. I couldn't wait to get back to the office to tell you,
so I hope that my voice mail message of 10/10 got to you.
A million thanks for your help. It was essential in many ways. I will admit that it was not until I read the
first draft of your report that I truly understood the extent of D’s sufferings; and this despite the fact
that I thought I knew how to detect a “shutdown” victim. But I was somewhat fooled by D’s
remarkable composure and self-control. We learn every day, and I won’t forget that particular lesson..
After the interview on 10/27, I feared that the officer would consider all this no more than the actions of a
rogue cop, and not rising to the level of “persecution” (or possibly not motivated by anti-Russian or antidemocratic motivations but just by brutish viciousness, and therefore not covered by the statute); so these
two weeks were tense, and of course even more so for D and P.
You would have been so happy to see the relief and sheer joy on their faces when, after a 3-hour
wait, we got the results on Monday! It is a bright new chapter in their young lives that now opens up.
hii dr.Lucia how you doing.. this is g.s
just want you to let you know that my case is approved.
Thanks for your time and kindneess that you gave to me.
beacuse of your help i can move my life forward now ..can
fullfill the desire that i had
• another thanks for your cookies and apple that u gave it to
me . i ate'm on my way back they were testy ...
• thanks again
• G.S T
Rounding out the curriculum:
survivor care over time
• Occasionally, survivors opt to return to clinic
for their primary care, with the evaluator as
• Residents may also participate in an ongoing
mental health group for survivors of the
• … and in work with their second-generation
• Peter Levine’s approach is carried through
these components as well.
HHR curriculum evaluations
• Have been piecemeal, collected after post-graduate
year 1 overview, and again after didactic asylum
• In process of adapting Asgarry’s questionnaire to our
– Standard content
– Trauma biology
– Personal/attitudinal change
• S.Africa: what difference are our graduates making in
health and human rights after they graduate?
• Physician HHR education is urgently needed
• Santa Rosa HHR curriculum contains many ingredients
found to be associated with success
• Adds Peter Levine’s framework re trauma and
– Benefits survivors
– Offsets provider risk of burnout, secondary traumatization
– Generalizes to clinic and hospital encounters with
• Used as recruiting “hook,” some residents come to the
program specifically for the HHR curriculum
• Needs further work on student, program evaluation
• Designed to scale up, be portable to other residencies 43