Abstract
The experience and sociocultural context of torture and its treatment have received little attention in the biopsychosocial model of Western mental health for survivors of torture. The main focus has been on the reduction of symptoms of posttraumatic stress disorder and related conditions. Using grounded theory methodology, we investigated survivors’ perceptions of the nature and process of healing after torture. The participants included 11 adult refugee torture survivors (9 men and 2 women) from African and Asian countries. Their stories of healing centered on the role of “moving on” with their lives, which included aspects of cognitive reframing and empowerment. Reliance on belief and value systems, safety measures, and social support, despite continuing psychological and physical symptomatology, enabled the moving-on process. Implications for theory, research, and practice are discussed.
Keywords
The traditional biopsychomedical model of Western mental health treatment for survivors of torture focuses largely on reducing the symptoms of posttraumatic stress disorder (PTSD) and related conditions (depression and anxiety) via individually oriented intervention strategies. The sociocultural and political contexts of torture and its treatment are often marginalized. This is particularly problematic for non-Western survivors. Relegated to a passive patient role, their cultural and personal strengths and resources—including local meaning systems, traditions, justice structures, and spiritual and healing practices—are often minimized or ignored (de Jong, 2004; Fuertes, 2004; Silove, 2004; Summerfield, 1999).
In the present qualitative investigation, we drew from the perspectives of non-Western survivors to develop a theory that better captures the nature, process, and agents of their recovery. We anticipated that additional theoretical development would help treatment providers and policy makers fashion culturally sensitive, holistic intervention models and policies drawing on both Western and non-Western concepts and strategies. This is particularly relevant because the evidence base for effective treatments for torture survivors is limited (Carlsson, Olsen, Kastrup, & Mortensen, 2010; Jaranson & Quiroga, 2011).
The Nature and Prevalence of Torture
Various forms of both physical and mental torture have long been used in military, political, and ethnic conflict to humiliate, punish, intimidate, and extract information (United Nations, 1984), including (a) witnessing torture, (b) family torture, (c) beating, (d) rape/sexual assault, and (e) deprivation of physical necessities (Hooberman, Rosenfeld, Lhewa, Rasmussen, & Keller, 2007). Accurately determining the prevalence rates of torture is difficult because of the secrecy involved. Baker (1992) suggested that between 5% and 35% of refugees have experienced torture. Between 400,000 and 500,000 survivors of torture were estimated to be living in the United States in 2000 (U.S. Department of Health and Human Resources, 2000).
The Effects of Torture
Many researchers (e.g., Piwowarczyk, Moreno, & Grodin, 2000) have examined the physical and psychological effects of torture. The most frequently reported physical symptoms are headaches, hearing impairments, gastrointestinal distress, and joint pain (e.g., Piwowarczyk et al.), all of which can last many years (Kuch & Cox, 1992). Psychological responses to torture and trauma vary, and many factors, including social context, spiritual and political beliefs, genetic variability, resilience, and individual psychology influence such responses (Quiroga & Jaranson, 2005; Steel et al., 2009).
The most common psychological disorders following torture are PTSD, depression, and anxiety (e.g., Basoglu, Jaranson, Mollica, & Kastrup, 2001; Carlsson, Olsen, Mortensen, & Kastrup, 2006; Steel et al., 2009). Basoglu et al. found that the prevalence of one or more of these disorders ranged from 15% to 85%. Steel et al. conducted a meta-analysis of studies examining prevalence rates of depression and PTSD in torture survivors, and estimated prevalence rates of 31% for depression and 30% for PTSD. Other notable problems are sleep disturbances, neurocognitive disorders, substance abuse, and personality change (Basoglu et al.).
The Process of Healing After Torture
Many non-Western cultures have a holistic or ecologically oriented approach to wellness and treatment. The notion of targeting only symptoms of individual pathology is a foreign concept in these cultures, which assume that the healing process must involve interrelated changes in both the survivor and his or her sociofamilial environment. Such changes involve, to varying degrees, the following:
Reconstructing cultural institutions, formal and informal social networks, and sources of support (Ginzburg & Neria, 2011; Valliappan, 2011) Community-wide rebuilding of adaptive systems of health (safety and security, attachment, justice, existential meaning, and identity/role; Silove, 1999) Treating physical injuries, ailments, and complaints (Carlsson et al., 2006; Williams, Pena, & Rice, 2010), which is often a conduit for non-Westerners to express mental health concerns (Vontress, 2001) Using indigenous healers and rituals that mobilize culturally based resiliency and coping strategies related to mourning and purification (de Jong, 2004; Vontress) Drawing on religious and spiritual beliefs and practices to make meaning of and to ameliorate the survivor’s suffering (Herman, 1992; McKinney, 2011; Valliappan) Witnessing the truth via acknowledgment by governments, caregivers, and other survivors of the atrocities and trauma experienced by individual members of the community and the community as a whole (Agger, Raghuvanshi, Khan, Polatin, & Laursen, 2009; Cienfuegos & Monelli, 1983) Seeking justice for the crimes committed by perpetrators, either through retribution or restoration, by requiring apologies and/or repayment to the survivors (Rauchfuss & Schmolze, 2008) Regaining a sense of control undermined by torture and imprisonment, along with subsequent disempowering experiences (e.g., dependence, anonymity, loss of previous roles, and status) in refugee camps or the resettlement environment (Fabri, 2001; Jaranson et al., 2001) Returning to normal routines and negotiating current stressors (Turkovic, Hovens, & Gregurek, 2004).
Several researchers have stressed the importance of understanding the healing process after trauma from the perspective of the survivor (Fuertes, 2004; Mollica, 2006), and there is a small qualitative research base on the impact of torture from the survivor’s viewpoint. Acharya (2008) examined the effects of torture on female Bhutanese torture survivors using narrative thematic analysis. Using grounded theory, participant observation, reflexive writing, and oral histories from staff and clients of a torture treatment center, Hill (2009) developed a model of the social construction of suffering in female torture survivors from Latin America. In an ethnographic study of Columbian asylum seekers at a torture treatment center, Valliappan (2011) examined service gaps and critical services that promoted long-term resettlement success. Moio (2008) used grounded theory to examine resiliency, the meaning of experience, the impact of torture, and what was helpful in healing in a sample of female torture survivors from a variety of ethnic groups. Of these studies, only Moio focused on healing, but the focus was mainly on Western therapeutic healing mechanisms.
There remains a strong need for an understanding of this process from the perspective of the survivor as it relates to both natural and therapeutic healing mechanisms (Mollica, 2006). The current research fills a gap in the growing literature by developing a theory that better captures the healing process of non-Western torture survivors of various ethnic groups and genders. In addition, the qualitative studies described above included only one male participant, indicating that more research with men is needed.
Research Questions
To address the process of healing after torture, we used the following research questions to guide the investigation: How do survivors understand the experience of healing after torture? What are the recurrent themes in the survivors’ descriptions of healing? What signs of healing do torture survivors identify that would allow service and support providers to recognize when they are healing? What aspects of the lives of torture survivors should be part of an intervention if they are to heal? The collection of data related to each of these questions was intended to fill the existing gap in the literature by providing an understanding of the process of healing from the perspective of the survivor, which includes both natural and therapeutic healing mechanisms.
Methodology
Grounded theory was chosen as the methodology to address this topic because it enabled us to construct a substantive theory regarding the process being studied. Grounded theory also allowed us to develop this theory from the perspective of the survivor, which is essential to begin to help survivors of torture, because the survivors have identified how the process works, what aspects of their lives need to be impacted, and how these aspects are prioritized. In addition, quantitative methodology has been criticized by torture survivors because it does not capture a culture’s worldview (Elsass, Carlsson, Jespersen, & Phuntsok, 2009). A comprehensive theory will help treatment providers and policy makers decide how to best support torture survivors in the healing process.
Sampling Procedures
We used a purposeful sampling strategy with the goal of gathering experiences of healing from a diverse group of individuals (e.g., country of origin, gender, length of time since torture) to identify similarities across groups (Glaser & Strauss, 1967; Lincoln & Guba, 1985). Clinical staff at a torture treatment center in the southeastern United States determined whether potential participants met the following study eligibility criteria: had experienced torture as determined at intake according the United Nations’ definition of torture (1984), were at least 18 years old, had legal status in the United States, and were stable enough to participate (e.g., not in acute crisis, at least 1 year since torture experience, receiving services at the center for at least 6 months). Researchers were not involved in the selection process to preserve the confidentiality of the participants and to allow staff to select participants without influence from the researchers.
Interview Procedures
Use of interpreters
Professionally certified interpreters were available to all participants, and we encouraged the participants to use the interpreters. Eight participants chose to use an interpreter. We trained the interpreters in the nature and procedures of the study and the potential questions that participants might be asked. The interpreters completed the Collaborative Institutional Training Initiative, a web-based training program for the protection of human subjects. This program is commonly used by university-based researchers (Collaborative Institutional Training Initiative, 2012). As vital members of the research team, case managers helped shape the interview questions to make them culturally appropriate, select participants, and ensure that the procedures and gifts were culturally appropriate (all participants received a gift for their participation, equivalent to about $10).
Consent procedures
In person or by telephone, case managers (without researchers present) recruited the potential participants by reading a brief prepared description of the study. To avoid coercion, potential participants were told that they were eligible for the study but were not informed that they were recommended to participate by the clinical team. We allowed potential participants to decline participation at this time. Before each interview, the interviewers, with case managers present, questioned prospective participants briefly at the clinic to determine whether or not they qualified for the study. We explained in more detail the nature and import of the study, allowing them to choose to participate.
At the beginning of each interview, the participant read and signed a consent form that described the interviewer, the nature of the study, and confidentiality, and the interviewer answered any questions the participant had. We had the consent forms translated into Vietnamese and Somali, and the case managers interpreted in person for other languages. We informed all participants that they could refuse to answer any question, stop the interview, or take a break at any time. We assigned each participant an identification number and did not include names with the data; we stored consent forms, hard copies of transcripts, and recordings of the interviews in a locked filing cabinet in the office of the first author.
Interviews
The focus of the interviews was on each participant’s process of healing after torture. The culturally neutral term getting better was used in the interviews to allow the participants to define the healing process within their own culturally rooted meaning systems. Initial questions were created by the research team and were revised with input from case managers to ensure that they were culturally appropriate. The first author interviewed 10 of the participants and an advanced graduate student in clinical psychology interviewed 1 participant. The initial semistructured interviews, which lasted between 1 and 1.5 hours, were conducted in a private room at the treatment center, with clinicians available to provide support.
We conducted 1-hour follow-up interviews to allow the participants to add any comments or clarifications, and for us to introduce topics that other participants broached or that we identified in the literature as being important in the healing process. This helped fill gaps and made the categories more definitive and useful (Charmaz, 2000). Following the interviewing, we performed member checks in which we orally presented to each participant a summary of the information gathered during his or her interview (Lincoln & Guba, 1985). We asked the participants if the information was accurate and what changes, if any, should be made to the summary.
Data Analysis
The research team audio-recorded and transcribed more than 21 hours of interview material and subsequently analyzed the data using NVivo computer software, version 8 (QSR International, 2008). The Somali participants refused to be audio-recorded, and therefore the researchers wrote out their interviews. We imported transcripts and notes directly into NVivo, which allowed for categorizing, defining, editing, searching, and merging codes and categories.
Using the grounded theory methodology of Strauss & Corbin (1990), we analyzed the transcripts using several operational procedures: open, axial, and selective coding. Open coding involves the identification of themes and categories. After each interview, we wrote brief notes on themes that emerged during the interview, and the first author did the same when reviewing transcripts of interviews. We then organized the themes into a coding scheme.
We trained four research assistants to code the interviews: two graduate students in clinical psychology, a graduate student in applied linguistics, and a licensed psychologist with clinical experience working with torture survivors. We trained them to verify the coding scheme and categories by teaching them to locate and code themes line by line in a transcript interview. After this initial training, we assigned them a transcript to code on their own to test out the coding scheme. After this coding, we met together to decide if the themes represented the content of the data and to decide if the names of the categories were appropriate. We adjusted the codebook following the recommendations of the coders.
For the actual coding of the transcripts, one of the research assistants and the first author coded each interview using hard copies of the transcripts. The coders achieved an acceptable level of interrater agreement (70% or greater) for all codes except two. Because of this lack of adequate agreement, the authors refined the definitions of the codes and conducted additional training with the coders to enhance their understanding. When disagreements occurred, the first author and paired coder decided which code was most appropriate. During this ongoing process, we continually refined codes.
As similar themes emerged in the interviews, with no significant information being added, we decided that we had achieved saturation—the point at which new data fit into the current coding scheme (Morse, 1995). We decided that the similarity of responses allowed us to answer the research questions fully in a cohesive fashion. In preparation for axial coding, we entered the final codebook into NVivo and organized the agreed-on codes according to our analyses (QSR International, 2008).
Next, using axial coding through NVivo (QSR International, 2008), we linked themes, categories, and subcategories and organized them systematically according to context, conditions, and strategies that enabled or hindered the healing process. Then, as a part of selective coding, we developed a model in which these enabling factors were systematically related to healing. To facilitate this process, we constructed a storyline that provided a descriptive overview of the data. “Moving on” emerged as the core variable that best captured the process of healing and recovery after torture, and we linked enabling conditions and strategies to moving on.
Results
Participants
Participants included 9 men and 2 women, 4 from Vietnam, 3 from Somalia, and 1 each from Eritrea, Ethiopia, Liberia, and the Democratic Republic of Congo. Participant ages ranged from 39 to 80 years, and time since the torture experience ranged from 10 to 32 years. The length of time living in the United States ranged from 3 to 22 years, with an average of 10 years. A 12th individual did not complete the interview because she moved out of state, and 1 person refused to participate after having read the consent form. Although we did not specifically ask about the legal manner in which a participant came to the United States, 9 out of 11 participants stated they came to the United States as refugees and the other 2 stated that they received support from the United Nations or a nongovernmental organization to emigrate, implying that they came as refugees.
Description of the Torture Experiences and Their Effects
The participants were not required to disclose the details of their torture experiences; however, all of them did so to varying degrees. Participants reported that they had been targeted by perpetrators for a variety of reasons, including ethnicity, religion, occupation, military involvement, and political activities on their part or that of family members. Their torture and imprisonment, which ranged from 24 hours to 7 years, included witnessing and experiencing beatings, rape, and threats; murder of loved ones; being bound and blindfolded; starvation; and forced labor. The various physical effects of their torture were chronic pain, blindness, loss of use of limbs, and chronic headaches. Participants reported numerous psychological consequences, including symptoms of anxiety, depression, and PTSD; loss of self-esteem; humiliation; suicidality; and anger. Social effects included emotional disconnection from loved ones, isolation, loss of social status, and unemployment.
The Process Model of Moving On After Torture
The core variable that emerged through the process of data analysis in this study was the torture survivors’ relentless determination and struggles to move on, which included aspects of cognitive reframing and empowerment. Participants described a complex process involving invocation of beliefs and values, restoration of safety and stability, and reestablishment of emotional support and sociofamilial connection. We asked participants how they knew they were moving on. They indicated that moving on was related to emotional well-being; a happy, bright demeanor; more adaptive functioning (improvement in sleep, mood concentration, memory, and physical health); getting life back to normal; improved relationships (being more open with others and less isolated, regaining trust, and having positive interactions with other people); and establishing a better life (living in a safe environment, being financially stable, and having less stress). This theory, which is grounded in the participants’ graphic descriptions of their journey of moving on, is presented in Figure 1. Themes in the model are discussed below.
Process model of moving on after torture.
Moving on
Without exception the participants described a desire to move on from their experiences. An African man described what moving on meant to him: “Don’t dwell on the things you can’t control. You must go forward with life and move on. It’s like a tornado that’s coming. It’s going to come and you must deal with it and move on.” Participants described a cognitive reframing which entailed not dwelling on past events and pain, and being present- and future focused. An African man described being future oriented: “Yes, I can’t forget what I went through, that’s normal. It became like part of my life. But it is not good to concentrate on that, so I concentrate on my future.”
Participants were empowered to move on by using internal and external resources to take conscious action. In a sense, moving on consisted of being empowered to take control of the healing process. As described in more detail below, increased safety, stability, and social support, along with beliefs and spiritual practices, enabled the survivors to regain a sense of control of their lives. As a result, they felt responsible for their growth and healing, and were able to use available supports and coping strategies to move on. It was not enough to have supports available, such as advice from family and friends, education and economic opportunities, support groups, medication, and traditional healers and rituals. The survivors had to believe that if they used these supports, their lives would improve. Participants reported that the stigma of mental illness and cultural differences in the understanding of physical and mental illness sometimes prevented them from seeking help and utilizing resources.
Disclosing specific details of their torture experiences to another person was a powerful healing experience that promoted moving on. Participants explained that it lifted a burden, helping them to feel normal, less isolated, relaxed, and motivated to find a resolution to problems. A male participant in his 40s reported that discussing his experiences for the first time kept him from hurting himself:
For me to talk to that lady that day, it was like a day of salvation for me. If not, I could do something to myself wrong. . . . I didn’t feel peace but it [helped] me not to do the wrong thing.
An important factor that promoted disclosure was that participants needed to be in control of how, when, and at what pace they shared their torture experiences. When pressured to talk about their past, they worried that they might get hurt again, and thus became defensive.
Besides disclosing to receive support and relieve their own burden, participants shared with others their torture and difficult life experiences to support, strengthen, and educate others, which in turn helped participants to move on. A male participant in his 70s stated, “I’m already healed but I need to teach others to heal.” An African woman described why she took part in the study:
I trusted you [the interviewer] because you said you would help others with the [study]. I thought it was my duty to talk to you. That it will help others, and that is what I need—If you’re helping others like me, it means you are helping me.
Not focusing on oneself was an important aspect of helping others and therefore moving on. Participants mentioned referring friends to treatment, giving advice and information in support and senior groups, helping the poor, and driving senior citizens to doctor appointments as ways of helping others. A male participant expressed why he was excited about life:
That excitement I believe also come in this way: You don’t concentrate too much on yourself; you start to concentrate also on others. When you are hit with these things you normally concentrate on yourself: “They did this to me. I went through this. It is me, me, me.” But I believe that when the process of healing comes you start to think about others. That’s why I was talking about my family, my children, my wife.
Participants described experiences of activism to help others and promote a cause that did not necessarily involve disclosing their torture history. However, it was important for some participants to share with others the atrocities that happened in their home countries, to help prevent them from happening in the future.
Participants also discussed the importance of setting and reaching goals in the moving-on process. One man described how having a plan helped him conquer his depression:
For a time it was like someone was living day by day—no plans, no work, because life is meaningless. But . . . I believe that as a human you can’t live like that. You need to plan; you need to have hope that I can improve my life in the future. To start again having that kind of thought to plan, to do this, this is, I believe, is a part of healing in someone.
Belief and value systems
In the remainder of the results section, we describe conditions that enabled moving on. Participants drew on their belief and value systems before, during, and after their torture and war experiences for comfort and direction, including the practice of spiritual rituals and activities (e.g., prayer, meditating, and fasting). Most of the participants expressed that their faith in a higher power was the most important part of the process of moving on. One participant said, “The assistance of that belief can help me to forget the hardship and the bad experience in the past.” Participants described the importance of the belief that a higher power was in control of their lives. One participant stated, I thank God and I believe that God will guide me. I have surrendered to God. I have no other plans. The person who shot me meant to shoot me in the head. It helped me to heal to recognize that by God’s grace I survived. Whenever I feel sorry for myself I realize I could be dead. My faith in God has been the most important part of the healing process.
Several participants reported that they questioned the judgment of the higher power during and after their torture experiences, which challenged their faith and thus was a barrier to moving on.
In addition, many participants were helped by the belief that a higher power would judge them and their perpetrators in a fair manner, which mitigated their anger and vengeful thoughts and feelings. A participant who survived the occupation of his house by rebels commented, I have big faith that those who did this will get no benefit in this world. The only benefit is that they will feel guilty. They are living in guilt. They had no right to do this. I don’t want revenge. God will punish them.
Some participants reported that anger toward their perpetrators was a barrier to moving on. However, several participants also described the importance of forgiving the people who had hurt them, to be able to move on. Forgiveness, they explained, taught them patience, maintained their sanity, and prevented them from seeking revenge. When asked who he forgave, a man who was tortured because of his religious beliefs said, I forgive everybody. If you don’t forgive, you broke the process of feeling the spirit in your heart, which means you become bound by these people every time you see them; these are changes in your heart. You need to be released of this and move on. So, I forgive everybody.
Illustrative of the participants’ efforts to understand their torturers, which was central to the moving-on process for many of them, a male participant explained, They don’t know what they were doing because you can’t do that to a human being like that. Most of them, they were very young children, sixteen years, seventeen years, fourteen years. So after they give them drugs they are not themselves. Even now there is a program of rehabilitation for these kinds of children as child soldiers. So how can I blame them?
Available environmental supports for safety and stability
Participants reported that the use of available environmental supports for safety and stability enabled moving on. One of these was the support that the participants received from other people who helped them escape dangerous situations or who provided physical and economic aid until they were able to sustain themselves. Another key support was the safety and stability of the countries to which the participants migrated following their torture, affording them freedom of religion and speech, and educational and economic opportunities. Talking about the United States, a participant reported, “I like it here because there are rights you share with others and you have privacy too—religion and culture. In this country you must respect the rights of others.” Many participants reported that economic instability was a major barrier to establishing safety and stability. They stated that the lack of English skills limited their ability to establish economic stability.
Institutional supports such as refugee resettlement programs, Medicaid, housing aid, social security, and torture treatment centers enabled moving on. Regarding the latter, a participant stated, “But luckily enough, when I came through this program and I met these people, and they created the right environment for me, so the process of healing can get started.” Services available to clients at the torture treatment center included physical health supports such as dental work, physical therapy, massage therapy, vision checkups, and medications for various physical challenges; and mental health services such as psychotropic medications and individual and group therapy. Group therapy was especially important for several of the participants because they came to realize that they were not isolated and had a place to discuss their feelings.
In addition, it was extremely helpful that staff at the torture treatment center were from similar if not the same cultures as the participants. The experience of an African man reveals the importance of culturally competent services:
After one week I come and they called for my case manager. They introduce me. I get happy when they get . . . person that speak the language of my nation. It make me happy when I see his face.
Participants reported that a lack of understanding of these services and limited English skills made it difficult to fully access available resources.
Individual coping strategies for safety and stability
Participants identified coping strategies they used to promote safety and stability to move on, including restoration and maintenance of physical health (e.g., repairing wounds, taking medications) and the use of relaxation techniques (massage, participating in spiritual rituals). In addition, participants mentioned the role of patience in the moving-on process. When asked how he dealt with flashbacks, a Vietnamese man reported, “I tried to bear it. It means I tried to handle it. We can’t do anything else; we can’t overturn the situation. That’s why we tried to handle with my patience.”
Avoiding activities, people, and memories that reminded participants of past experiences helped them establish and maintain stability. Participants described being with others, listening to music, watching television (except violent programming), avoiding news of current wars and news from their home countries, and staying busy as strategies to avoid these memories. Describing why he avoided contact with others, one man explained, You don’t want to share because they are ashamed things, they are strange things. And when someone comes to talk to you, you become angry and upset about that. And they push you to stay alone. You don’t want someone to know what you’ve been through.
Psychological distress proved to be a primary barrier to establishing safety and stability for many of the participants. Difficulties with memory and concentration prevented them from reaching their goals, such as obtaining an education, learning English, and gaining citizenship. Several participants also mentioned that depression interfered with their relationships and their ability to work and study effectively. Most of the participants reported that intrusive memories, flashbacks, and nightmares of their torture and prison experiences still bothered them, engendering fear and interfering with their happiness, stability, and moving on. One man talked about his sadness when he thought about never being able to go back to his old life:
I can’t go back home. This is just sometimes sad. It’s not a bother to other people. But ones that think too much and think what had happened. And sometimes it do bother you. That is how some people become big target for this war, diseases like depression and other things. . . . They will be there forever or for a long time because they think too much. And I’m like that. I think too much. I don’t let things go easy.
Establishing emotional support
Participants described qualities of people and institutions that helped them establish the emotional and social support that promoted moving on. A Vietnamese man remarked,
There are three aspects of the life: the social, family, and community. Those elements can support me to survive, to improve the quality of life. Thanks to the elements, the community, the social, and the family can help me to improve a lot.
Inspiration and encouragement from family and others to make a better life gave participants strength to endure difficult challenges and move forward to reach their goals. A man who was imprisoned 30 years earlier described why he then enjoyed meeting friends at a café:
Yeah. I love talk, I love to talk. If I go out, for example, in our area is a waffle house. A lot of people they will come there. I don’t go sit alone. I will go in my own interest. I will play. Nobody knows that it is for myself. I took this like medication to go and talk and relax. It’s just like medication for myself. I will feel good.
Participants explained how important it was to be understood by someone, particularly when they had difficulty acculturating to life in the United States, which was a barrier to moving on. Several participants expressed how important it was that doctors listen to their wishes about medication. For others, being able to relate to people who had been through similar experiences helped them move on. For example, a female participant described the value of being in a support group at the torture treatment center:
When time of group comes it gives us courage to talk about the past, and forget the past, and see not only your suffering but many people suffering. And you see easily that the world has ups and downs, and you will learn through all that how to go and get further steps to build your life. I like it because it gives me hope because trust each other and because it makes life easy.
Several participants mentioned that moving on was impossible without trust. Participants described qualities of trustworthy people: committed to work, humble, kind, not pushy, and sacrificing for others. One man described the importance of trust when he said, “Right when I see people, if they don’t confuse me, I may be able to trust them. If they offer to help me without knowing me and they help from the bottom of their hearts, I may trust them.” They reported that barriers to building trust were unhelpful experiences with individuals such as doctors who did not seem to listen and friends or family members who were not understanding of the challenges related to torture.
Discussion
In their study of torture survivors, Western mental health researchers have relied largely on quantitative methods with a focus on professionally driven questions about diagnosing and treating PTSD and related conditions (de Jong, 2004; Fuertes, 2004; Silove, 2004; Summerfield, 1999). By contrast, in the present qualitative analysis we examined the process of recovery using the language, perspectives, and personal experiences of the survivors themselves. Although echoing many of the themes of quantitative studies, the findings suggest that the concerns and treatment needs of survivors extend well beyond problems with various psychopathological conditions. The participants in our study identified a wide range of psychosocial and spiritual variables and intervention strategies that either facilitated or impeded their overriding ability to move on after torture.
Our initial question to participants about the process of healing after torture quickly led to an emphasis on moving on, the key finding of our study. As such, the theory we developed is that these torture survivors were striving to move on after torture. Various factors such as the use of belief and values systems, the use of available environmental supports and individual coping strategies for safety and stability, and establishing emotional support enabled an environment in which the individual could move on after torture. Moving on entailed various cognitive reframing and empowerment techniques that promoted healing.
Comparison of the Model of Moving On to Other Models and Research Findings
Similar to Herman’s (1992) model of recovery, the present results suggest that the process of healing entailed a series of experiences that for most of the survivors followed a predictable sequence. However, unlike Herman’s stages (establishment of safety, remembrance and mourning, and reconnection), the stages that emerged in our data were multifaceted, encompassing a variety of systems of health (e.g., emotional support, belief systems) identified, in part, by Silove (1999). Moreover, rather than only describing the process and ecology of recovery a la Herman and Silove, we attempted to model the interplay of the different variables in the participants’ stories of moving on.
Moving on is a rich and multifaceted construct that has not been fully explored in the academic trauma literature, although it has been used by university counseling centers in online resources (Australian National University Counselling Centre, 2011) and the self-help literature on a limited basis after grief and loss (James & Friedman, 2009). Although this was an exploratory study and more research is needed, moving on appears to reflect at once a goal and a source of motivation (a desire to put the past behind oneself and enjoy a better state of being), as well as a process (thinking, feeling, and behaving in non-trauma-driven ways; McKinney, 2007; Summerfield, 1999; Valliappan, 2011).
The participants’ use of the term moving on involved more than merely surviving torture, and included becoming normal again and even thriving (Kira et al., 2006; Tedeschi & Calhoun, 2004; Turkovic et al., 2004). Moreover, their stories of moving on and healing were not centered on symptom reduction but on social, interpersonal, spiritual, ethical, and sociopolitical healing. Participants described being able to move on and function more adaptively despite continuing psychological distress, particularly PTSD, anxiety, and depression (Kira et al.; Moio, 2008; Silove, 1999; Tedeschi & Calhoun). Our current exploratory research expands our understanding of healing from trauma through the development of a theory that indicates mechanisms of moving on and factors that enable this process. Specifically, this theory delineates the cognitive restructuring and empowerment factors that make up the concept of moving on.
Critical were societal, institutional, and individual sources of instrumental and emotional support, along with the participants’ own personal coping strategies—all of which helped them establish a base of safety, support, and interpersonal connection (Valliappan, 2011). They then used cognitive reframing techniques such as not dwelling on past events and being present- and future focused. They were empowered to use environmental resources and personal coping skills, such as controlling memories and working through trauma, to move on even in the face of ongoing stressors—both past and present (e.g., PTSD, unemployment). Several investigators (e.g., Herman, 1992; Jaranson et al., 2001; Moio, 2008) have pointed to personal empowerment as a critical element in the survivor’s healing process. This also proved to be a major component of moving on in the present findings. Along with trust, one’s sense of agency and power are undermined by torture, war, and imprisonment. An essential aspect of empowerment that emerged in this study was self-efficacy (Benight & Bandura, 2004). Not only did participants need access to coping mechanisms, but also needed to have confidence that they could effectively use them.
The findings also expand our understanding of the role of empowerment in how torture and trauma survivors manage traumatic memories to move on after torture. Many participants reported that disclosing their torture experiences, a common prescriptive practice in Western treatment approaches to trauma (Herman, 1992), was ameliorative (Gangsei & Deutsch, 2007). However, they clearly asserted that they wanted to control when and how much they disclosed, and to avoid and forget the past as needed (Fabri, 2001; Gangsei & Deutsch). A few participants additionally stated that avoiding such disclosure altogether was essential to their stability and adaptive functioning.
Foundational were the survivors’ spiritual beliefs, values, and practices, which they depended on to endure hardships and to make meaning of their experiences (McKinney, 2011; Welch & Welch, 2005). Some people who experience traumatic events report questioning or losing their faith in a higher power (Piwowarczyk, 2005). However, the participants in this study said that although some might have questioned their faith in a higher power, they did not ultimately lose it (Shrestha et al., 1998). The participants made clear that this was more than just a simple coping mechanism, and was indeed the most important component of the moving-on process.
Similar to what other researchers (e.g., Behnia, 1997; Hill, 2009; Luci, 2010) have found, participants identified rebuilding trust as one of the first steps in seeking and receiving help from others. The torture experience shatters the survivor’s trust in humanity. Many of the participants stated that they initially connected with someone informally. This person became a friend, a secure base as it were, who helped them seek additional support and services. Service professionals also facilitated the participants’ ability to trust by believing their stories (Behnia), allowing them to guide their own treatment (e.g., sharing their stories at a pace that was comfortable for them), following through on their commitments, giving good advice, and simply caring (Fabri, 2001).
Positive Experience From Participation in the Study
Being in the study seemed to be a very relevant and positive experience for the participants, interpreters, and interviewers (Fabri, 2011). Participants expressed gratitude for being able to tell their stories and to be listened to. It appears that for some participants, being part of the study was therapeutic; participants did not display or report any distress. In a sense, participating in this study was similar to testimonial or narrative therapy. Participants were able to examine their experiences in a new context and perhaps develop new understandings of their histories (Neuner et al., 2010; Weine, Kulenovic, Pavkovic, & Gibbons, 1998). They were able to bear witness to the historical and social effects of political violence (Cienfuegos & Monelli, 1983; Weine et al., 1998). Perhaps reflecting on the moving-on process is a form of exposure, because participants had to think about what they had experienced and then were able to make meaning of their experience.
Strengths and Limitations of the Study
The qualitative methodology we adopted at this point, allowing participants to tell their stories of recovery in their own manner, provided a more in-depth and nuanced understanding of this complex process that we likely would not have obtained using a quantitative approach. Despite the heterogeneity of the sample in terms of age, culture, nature of torture experiences, and being at various stages in the moving-on process, the participants’ accounts included many common themes lending credence to the model we developed. Thus, the diversity of participants was a strength of the study, because there was a similarity in responses (Glaser & Strauss, 1967; Lincoln & Guba, 1985). However, the differences in length of time since the torture and time in the United States might have impacted the participants’ capacity to reflect on their experiences. For example, torture survivors might view their healing process differently at various points in time based on current stressors. In addition, the participants had refugee legal status when they arrived in the United States, and therefore, torture survivors who sought asylum on arrival to the United States might differ in their healing experiences.
In addition, our training in Western psychological theory and research might have biased what domains we coded. To reduce bias, our research team consisted of people from various backgrounds, disciplines, and levels of expertise. Language and cultural barriers also posed a problem. We conducted member checks to help ensure that information was understood, and participants were able to verify or clarify information. Nonetheless, misunderstandings most likely occurred. Finally, there might have been bias in participant selection because clinical staff recommended which individuals should be invited to participate. This was done to ensure that the potential participants were stable emotionally. The clinical staff followed predetermined criteria to identify emotional and environmental stability.
Future Research
Although the findings of this study pointed to a plausible model of recovery from torture, they must be cross-validated via additional qualitative and quantitative research that does not focus only on pathology (de Jong, 2004; Silove, 2004). Quantitative research could include various direct, indirect, and moderating effects of the themes that emerged in this model. In addition to the psychological sequelae of torture, the social, political, spiritual, and biological effects merit study, along with the roles of growth and resiliency. Concerning the latter, it should be assumed that resiliency is often, if not always, at play—as we found in this study—instead of viewing it as an exceptional response to trauma (Moio, 2008).
The findings from this study raise questions about how torture survivors cope with traumatic memories and the best way of incorporating them into treatment (Hill, 2009). Is avoidance harmful, or can survivors move on without directly processing experiences in ways prescribed in traditional Western approaches? Should survivors take the lead in disclosing their experiences, if they decide to disclose in detail at all? Are there conditions under which failure to disclose and confront painful memories is not a symptom of PTSD, but rather an adaptive process? In addition, future research could examine the therapeutic benefits of sharing one’s healing story (Mollica, 2006).
Practical Implications
The present findings have a number of implications for treatment, program design, and policy. Interventions at multiple levels of analysis (sociocultural, political, spiritual, psychological, and biological) that promote holistic well-being appear most helpful to torture survivors in their efforts to move on and recover. Participants reported benefiting, in particular, from initially building trust in the therapeutic relationship by having input into their treatment plan (e.g., which health concerns to address first) and deciding when and if to disclose their traumatic experiences (de Jong, 2004). Participants had a holistic view of their health and did not always distinguish between physical and mental health (Vontress, 2001). Many of the participants sought treatment first for physical health concerns and not mental health issues. This indicates that addressing physical health might be essential in recruiting treatment participants and in promoting the value of a program to a torture survivor (Wenk-Ansohn, 2001).
Torture survivors should be empowered to determine what it means to move on and get their lives back to normal. Mollica (2006) recommended that therapeutic interventions for trauma recovery should focus less on the life that used to be and focus more on a life that is becoming. Interventions should also focus on strengths-based strategies, relationships of trust outside of the treatment setting, and support of spiritual beliefs and cultural practices (Acharya, 2008; Fong, 2004), particularly with disruptions in traditional healing methods and community support. Interventions should emphasize resiliency, useful coping strategies that maintain health, and health-promoting factors to promote wellness (de Jong, 2004), not simply the reduction of symptoms. The participants also found it helpful to process experiences surrounding their torture, but did not want to be forced to tell their story. For example, the participants often did not distinguish between the distressing effects of torture and resettlement.
Policy makers and program directors should focus on establishing safety and stability, particularly at the time of resettlement. For many of the participants, the transition from government aid to self-sustainability was extremely challenging. Survivors would benefit from easier access to language and job training, housing, and placement programs (Quiroga & Jaranson, 2005; Winter, 2011), as well as extension of financial and health care support. Programs with community volunteers who help survivors acculturate seem to be beneficial in the resettlement process. In addition, helping refugee communities develop organizations for support and advocacy can help them feel united and empower them to take on their challenges as a community.
Conclusion
Participants in this study displayed remarkable strength and resilience. In response to the question of what helped them recover from their experiences of torture, they painted a picture of a complex, holistic process that included cognitive reframing and empowerment. In addition to drawing heavily on spiritual beliefs and values, they used available environmental supports, personal and cultural strengths, and coping mechanisms to move on with their lives.
Footnotes
Acknowledgements
We thank Kitty Kelly and Ibrahim Kira for their support in facilitating data collection at the torture treatment center.
Authors’ Note
Portions of this article were presented at the Biennial Conference of the Society for Community Research and Action, June 17, 2011, in Chicago, Illinois. Both authors were affiliated with the Georgia State University Department of Psychology at the time the study was conducted.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.