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Photo taken from the UNAMID Flickr page.

Clinicians and staff at the Bellevue/NYU Program for Survivors of Torture are confronted, daily, with accounts of the worst things humans beings can do to each other. Clients include amputees, people who have been purposely blinded, beaten, disfigured or debilitated. The clinic also serves people of any gender who have experienced rape and other forms of sexual violence as a tool of warfare.

“But what many of our clients let us know, is that even with these physical ramifications, sometimes it’s the emotional scars that are the longest lasting, and the most difficult to see,” said Dr. Hawthorne Smith, clinical director for the program. His patients include some who’ve witnessed loved ones being killed and others who are placed in double-bind situations, where they’re captured and told to give away their comrades or a young member of their family will be abused. There is a lot of survival guilt.

Smith specializes in addressing these scars. A tall and soft-spoken man of 50, he has been with the program since its inception in 1995, when he started as an intern while earning his PhD in Counseling Psychology at Columbia University’s Teachers College. By then, he already had a background in counseling, having cut his teeth with court involved youths in Washington DC, and helped to facilitate shelters for homeless families in San Francisco, particularly following the 1989 earthquake. But he also had a strong background in international relations, having earned his Bachelor’s Degree from Georgetown’s School of Foreign Service, participated in a study abroad program at Cheikh Anta Diop University in Dakar, Senegal, and earned his Master’s in International Affairs from Columbia University’s School of International and Public Affairs in 1992.

The program estimates that the country hosts more than 400,000 torture survivors, with up to 90,000 of these residing in the New York metropolitan area and having to navigate what Smith calls the city’s “infamous warmth and fuzziness.”

“I knew I had these two passions, international affairs and psychology, and to me it was very apparent that they overlapped in very significant ways,” Smith said of the days before he started working at Bellevue. But then, “at the very first meeting, I was there, and it just seemed like such a beautiful overlap between international affairs and psychology, the healing arts, everything I was looking for. That was 1995, and they haven’t been able to get rid of me since!” he said with a hearty laugh. But it is not a laughing matter that 1995 and the opening of the program came at a time when central Africa, from which 67 percent of Smith’s clients hail, was experiencing some of the world’s most violent conflicts, including civil war in Sierra Leone and genocide in Rwanda.

Now, there are over 20 torture treatment centers throughout the United States, though Smith believes it’s especially important to have a comprehensive program in New York City. The program estimates that the country hosts more than 400,000 torture survivors, with up to 90,000 of these residing in the New York metropolitan area and having to navigate what Smith calls the city’s “infamous warmth and fuzziness.” Most importantly because approximately 80 percent of the program’s clients are asylum seekers, as distinct from refugees, large cities such as New York are often the first US port of a call for his clients.

According the Homeland Security’s Office of Immigration Statistics, the United States in 2013 (the most recent data available) granted asylum to 25,199 people. However, the Office of Refugee Resettlement (ORR) website explains that unlike refugees, who are processed in a different country before being resettled in predetermined communities and who receive immediate ORR benefits such as housing and healthcare, asylum seekers are only eligible for such support once they’ve made their way to the country on their own and have gone through a lengthy asylum application process. Although the US Citizenship and Immigration Services’ policy is to interview asylum seekers within 45 days of their submitting an application, it has acknowledged that this timeframe is not always achievable due to an increase in applications. Anecdotal reports suggest the process can last up to ten months, leaving many asylum seekers stuck without the right to work, and therefore without the means to support themselves.

That asylum seekers must seek out basic necessities on their own, in an unfamiliar place, without access to employment, and on top of psychological difficulties incurred by torture, suggests they are often under higher amounts of stress than are refugees. “The best medication you can give an asylum seeker is a green card,” said James Lavelle, LICSW, the director of International Programs and Community Organizing for the Harvard Program in Refugee Trauma (HPRT), in a recent phone conversation. Lavelle, who has been providing mental health services to refugees and asylum seekers for almost 40 years, explained that rates of depression and Post Traumatic Stress Disorder (PTSD) are common among both groups. However, while little formal research has been conducted on the subject, there is a sense among some mental health professionals that daily survival stressors such as finding a place to live, or uncertainties such as fear of deportation, can add to the effect of previous trauma among asylum seekers.

Clients need to know “that they exist on our cognitive radar screens,” says Smith.

Bellevue and other torture survivor centers across the US are therefore also equipped, as part of their treatment process, to help asylum seekers meet these basic necessities refugees are already entitled to. They are also offered other services such as legal assistance, as “maybe they’ve come on a visa that’s temporary, maybe they’ve come on a false document, maybe they stowed away on a boat, whatever, but all this to save their lives. And then they come here and they’re not out of status, they’re not illegal,” says Smith, “because now they’ve applied for asylum and are in that process. And part of what we deal with is helping people to walk through that.”

The Bellevue/NYU program has treated more than 4,000 men, women and children from over 100 countries around the world, and for a clinician to have knowledge of the different types of trauma on a psychological level can be just as important as having an understanding of the socio-political environments from which they stem. Clients need to know “that they exist on our cognitive radar screens,” says Smith.

Amidst the current refugee crisis, it is hard to ignore that they exist. “Gallows humor here is that if you’re reading about it in the New York Times, within two to three months we’re going to be seeing people from there in this clinic,” he explains. However, it is not always true that clients come from well-known conflicts. Most, in fact, have escaped countries that receive very little media attention, such as the Central African Republic or Republic of Congo.

Having knowledge of these political and cultural contexts becomes key in the healing process. Culture comes into play as early as the intake interview stage, where clinicians work with their clients to determine the type of services or therapy they need. In many cultures it’s unheard of for someone to talk to a psychologist or social worker, which makes the Bellevue program’s group support sessions so innovative: they act as the extended family, or group of elders to which a person may have turned in their home country. Groups are in this way designed to harmonize with the culture of the client.

And yet, Smith finds that the group he has been running for the past 19 years, of Francophone African survivors of torture, is a group of traumatized people, but not a trauma-focused group. People do not talk about their trauma, but about adaptation, resilience and hope. In fact, as Lavelle explained, it is common in group therapy for people to hold back from discussing the fundamental causes of their trauma, reserving that information for individual therapy sessions. Instead, clients focus on the here and now, discussing present day emotions tied to worries about their children’s education or financial constraints, rather than the original trauma events.

Group sessions can also give clients the sense that they are supporting others who have been through similar experiences. In this way Smith aims to emphasize that his clients are not simply victims. Anyone can be a victim. They are survivors who have internal coping mechanisms that have enabled them to live through their traumatic experiences and find safety in another country. Now they are isolated, uprooted from their usual support networks, and many have lost contact with family members.

“It goes deeper than that. You gotta understand you can’t save anybody. All you can do is put somebody in a context where they can save themselves.”

Smith was quick to admit that this takes a toll on him. People bring him movies they think he should watch, like Hotel Rwanda. These politely line a bookshelf in his intricately decorated office, next to the maps of the world, postcards, family photos, and African votive art that scarcely leave an inch for more. He declines, and opts instead for the “stupid comedy, or something like that,” which he enjoys watching with his children. He also enjoys writing and music, and plays the saxophone to international accomplishment.

He believes that when dealing with second-hand trauma, a phenomenon that often happens to clinicians helping survivors of torture, it’s important to find ways to transform this energy into something positive or creative. “We need to be conduits, as opposed to containers,” he explained.

And yet he also knows that not everyone can be helped. On his first day as counselor after graduating college, a more experienced counselor came up to him and said “Look, first thing, is you gotta get the Robin Hood complex outta you. You can’t save everybody.” Smith replied that he agreed. “No,” continued the counselor, “It goes deeper than that. You gotta understand you can’t save anybody. All you can do is put somebody in a context where they can save themselves.”

“Sometimes,” said Smith, “we have to give ourselves permission not to know.” Clinicians at Bellevue will not always know how to help someone. But in trying to be humanistic and work together as a team, they can put people in a better position to help themselves. This may not always be sufficient, but it’s absolutely necessary.

Elettra Pauletto

Elettra Pauletto is a freelance political risk analyst, writer and translator. She lives in New York City, and is currently pursuing an MFA in creative nonfiction at Columbia University.

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