The Pain Stops Here

On a given Wednesday morning, if you saw 55-year-old Karen Hanscom, PhD, leave the Baltimore Museum of Art in her silver Audi TT sports car after attending an art history class, you might imagine that she's simply out for a morning's entertainment. But this is one of the few restorative measures Hanscom can squeeze in while doing her job as a psychologist at the cutting edge of the relatively new field of counseling torture survivors. So after class, she drives north (fast), pulls over, and parks in front of a tidy row house. The small sign on the door reads ASTT: ADVOCATES FOR SURVIVORS OF TORTURE AND TRAUMA, the organization she runs that counsels survivors of state-sponsored abuse who come to the United States seeking asylum.

"The problem of torture is horrifyingly global," says Stevan Weine, MD, a psychiatrist at the University of Illinois at Chicago who works with survivors of political violence. "But not a lot of us do this work. There are not many books and papers describing what we do." In fact, treatment programs in this country began only in the 1980s.

"The hardest thing," Hanscom says, as we sit in her small office waiting for a young woman from Cameroon to arrive for a session, "is that there are an estimated 400,000 torture survivors in the country, 40,000 survivors in this area alone, and we can afford to see only 200 of them a year."

Hanscom's office door opens and in comes Meh Vivien*, a 30-year-old woman with deep dimples and curly hair. Wearing blue jeans and a matching jacket, she sits down in the wicker chair opposite Hanscom. She looks extremely thin.

"Have you been eating?" Hanscom asks her gently.

The young woman smiles and looks at her hands. "No, not really, but I'm okay," she says. For torture victims, not eating can indicate many things: that they can't afford to buy food given that they're not allowed to work, for example, or that they're exhibiting a form of control over their bodies, because the first thing a torturer does is to take that control away.

Meh Vivien has been in the United States only a few months. As a member of the political opposition fighting for the rights of English-speaking citizens in predominately French-speaking Cameroon, she'd been arrested three times and tortured in prison. Convinced that she was going to be killed if she stayed in the country, Meh Vivien fled, carrying only the phone number of a family in Washington, D.C., whom she'd never met. Fortunately, they took her in, but now the family is struggling to afford to keep sheltering her.

"I don't have a bed; I sleep on the floor," Meh Vivien says. "But who cares? It's a house!"

*Name has been changed for client's protection.

Like many of ASTT's clients, Meh Vivien found the center through her immigration lawyer. Other clients discovered ASTT on the Internet or through referrals from former clients, who have been known (even on public buses) to discreetly approach people they suspect are fellow survivors.

Hanscom asks Meh Vivien whether she's been dreaming. In the midst of other challenges survivors face, most new arrivals suffer from post-traumatic stress disorder (PTSD), a complex series of symptoms caused by experiencing violence or the threat of violence or witnessing it against another. The symptoms of PTSD are varied, but the most prevalent include difficulty sleeping, exaggerated startle reaction, and flashbacks triggered by everyday experiences. (One client who was tortured in the laundry of a prison has flashbacks triggered by the smell of damp clothes.)

Another symptom of PTSD is nightmares—which is why Hanscom asks Meh Vivien about her dreams. "Last night I dreamed that I had to clean toilets," Meh Vivien says, looking shocked. "I told them I was going to throw up. They just made me clean them faster." The logic of the dream defied her and left her frightened. "Why should this happen to me?" she asks Hanscom.

Hanscom assures Meh Vivien that this response to the trauma she's been through is completely normal. Later Hanscom tells me that one part of her job is to help clients learn that their strength comes from unexpected places—sometimes in the very symptoms of PTSD. The exaggerated startle, for example, means a person is on high alert so she doesn't get hurt again. Clients who recognize that PTSD is characterized by a series of physiological defenses can begin to understand that painful reactions are not just unnecessary residue from past experience but the way in which their bodies prepare to fight back. What first appears to be a weakness can be seen as a small sign of strength.

"Our clients have lost safety, trust, and the ability to impact the world," Hanscom says. But she points out that each client is also a survivor who has made it to the United States against tremendous odds. This belief is at the heart of Hanscom's program. "It's a fundamental shift in the power dynamic of therapy," she says. In the "strength based" approach, a therapist helps a client define the tools she already has to move forward, or, as Hanscom puts it, "the positive things about them before they were hurt."

The positive qualities most often cited by the survivors themselves are "spirituality and the strength of their relationship with their family," Hanscom says. "In one case, the only reason my client didn't kill himself was that he had a strong relationship with his mother." Hanscom, four other clinicians, two case managers, and two doctoral interns also work to uncover a client's talents and gifts. For example, their first step with an Olympic swimmer who'd been tortured was to help him find a pool. We all have something that helps us define who we are, says Hanscom—we're a swimmer, a mother—and because torture destroys a sense of self, the first step is to rebuild that.

Hanscom pulls and old checklist of PTSD symptoms from Meh Vivien's file and a fresh one for them to fill out together. When Meh Vivien first arrived at ASTT, her PTSD symptoms had been severe. But now, after just a few months, she no longer has flashbacks or the exaggerated startle. When Meh Vivien sees the improvement between the old checklist and the new one, she smiles.

New experiences, though, are triggering old trauma, she says. Preparation for the court proceedings in her asylum case was dredging up painful memories of powerlessness. Meh Vivien's experience with torture began the second time she was arrested, when she was held for seven days and flogged on the bottom of her feet (a form of torture known as falaka, which the United States has been accused of using against detainees in its "war on terror"). She was given no food or water for 48 hours and forced to sleep on a cold concrete floor, which, she says, has given her an ongoing infection, the details of which she didn't want to discuss. Hanscom nods and explains that respecting her choice of what to talk about is part of the strength-based paradigm. For Meh Vivien, being able to decide what to say and what not to say is empowering—the exact opposite of what happens during interrogation and torture. "In Cameroon they can kill you—who can you complain to?" she says.

Hanscom and Meh Vivien talk about the upcoming court case and what Meh Vivien should expect. The young woman thanks Karen and goes upstairs to pick out a new coat from the clothes closet.

Donated clothes fill the closet; the center itself is designed to feel like a home, a place where clients can make their own tea and the walls are hung with bright fabrics and other gifts they've brought to decorate the place. From the start, survivors are given a full tour of the building, from the communal kitchen to the offices—even the basement—so that they see there are no dark places, no secret rooms. The center is designed to break down old fears of being raped in a shadowy corner or disappearing from the world into "ghost houses" devoted to torture, and to build instead a climate of trust among people who, for the most part, have never before spoken about what happened to them. (Sixty percent of ASTT's clients are women, 90 percent of whom have been raped; among the male clients, more than half have been sexually violated.)

After Meh Vivien's session, there are a lot of knocks on Hanscom's door. She meets with her counselors to discuss how to respond to unexpected moments with patients—when, for example, a small cut on a client's hand caused him to flash back to his torture, run away from work, and show up at ASTT. Or how to prepare a client to testify in court when he has promised his mother he would never tell anyone they both had been raped. Two law students call to ask how to talk to their client, a torture survivor seeking asylum. "Humanize yourselves, because the torturer didn't," she tells them. "Stay with silence for a moment longer than we are accustomed to. Trust your hearts on this—it's clear you have a great sense of professionalism and are human, so just mix the two together." (Hanscom is also an adjunct professor of law at Georgetown University. Five years ago, she went there to discuss how to work with asylum seekers who'd been tortured, and the school asked her to teach regularly.) She did all this in between planning a tentative trip to Iraq and beginning an analysis of data to evaluate the quantitative success of the strength-based method.

I visited Hanscom one morning at her home in rural Maryland, as she toasted spelt bread in her makeshift toaster (a George Foreman grill). She explained how she'd ended up with such a harrowing job: In the 1970s, when she was in her 20s, she taught children in rural Pennsylvania who worked picking mushrooms before and after school. "Back then, if a woman wanted a professional career, she had to choose between being a teacher and a nurse," she says. At the time, rural communities were reluctant to embrace traditional therapy. The state began a pilot program for members of the community whom people naturally turn to for help—hairdressers, bartenders, and teachers like Hanscom—to instruct them in fundamental therapeutic skills, including how to listen effectively. "That's listening with the body," Hanscom says. "It's about looking someone in the eyes, not fidgeting, sitting as they do, attuning your whole body to theirs."

As one of these local leaders, Hanscom was called by the police every time a case of domestic violence turned up at the hospital. When she realized that treating these victims required more training than she had, Hanscom decided to go back to school. After completing a second master's in clinical psychology (in addition to one she had in education), she began to work with parents of children with severe birth defects. To keep their children alive, the parents had to agree to terrible procedures they knew would cause their kids terrible pain, she says. That's where she sees the roots of her work now: helping people who'd been through unimaginable circumstances, in this case, parents who had to allow what amounted to torture because they had no other choice.

At 43 Hanscom moved to Baltimore, where her marriage fell apart. "So here I'm divorced, I've got two kids," she says, "I've got no money coming in." On top of everything else, she found she needed a doctorate degree to work as a licensed psychologist in Maryland. Despite raising two children and working full-time, she finished the program a year early and soon built a reputation for working in Baltimore with victims of trauma—amputees, people who'd gotten burned in factory fires, fishermen who'd had near-drowning experiences—survivors who were attempting to rebuild their lives.

In 1998 the Guatemala Human Rights Commission asked her if she'd be willing to take to Central America the model she'd developed through her work. She began spending two weeks every six weeks in Guatemala, which had seen 36 years of civil war, training elders in various communities to recognize and treat the symptoms of PTSD. It was difficult work, and the terrain was dangerous. Hanscom's Quaker friends made her carry a letter in her pocket that listed the good things she was doing for victims in Guatemala and warned that if she went missing, there would be hell to pay.

Hanscom could see that her efforts were easing the symptoms of PTSD, but quantitative analysis wasn't possible because many of her subjects couldn't fill out surveys. Initially, Hanscom says, "other counselors with medical backgrounds ridiculed me. They said, 'How can illiterate village people learn to counsel torture survivors? You need to have a degree to do that.'" (Three years later, in 2001, Hanscom received the International Humanitarian Award from the American Psychological Association for her work in Guatemala.)

In 1994, for the first time, Harvard University held an international conference on health and human rights. Two of the attendees, Corinne Bowmaker, who had worked for nine years in Cambodian refugee camps along the Thai border, and Jim Sanders, MD, who had provided medical assistance in Minnesota to survivors of torture, decided to found a center for survivors in the Baltimore and Washington, D.C., area: The large numbers of people seeking political asylum in the region led them to believe that there were many survivors going untreated. (At the time, there were only four or so centers nationwide treating torture survivors.) When they began looking for someone to head ASTT, Bowmaker mentioned their search to her acupuncturist, who introduced her to Hanscom.

"What was revolutionary was that Karen was one of the first to combine community-based therapy, which was developed to help primarily poor people with no access to counseling address everyday problems, with techniques to treat torture survivors," says Jose Quiroga, MD, a leading torture counselor in this country, who is medical director of the Program for Torture Victims in Los Angeles. Angeles.

Over the past decade, ASTT has grown from being a totally volunteer operation to having an annual budget of $500,000, thanks to the Torture Victims Relief Act, the UN, and private donors. (ASTT doesn't charge clients a penny.)

ASTT is now one of more than 25 centers in the National Consortium of Torture Treatment Programs, and Hanscom has begun writing a guide for others. "Here's what I really, really, really believe," she says. "You do not have to have training out the wazoo to be able to help somebody who's been tortured. It's really about one human being opening her heart to another human being, and being in her presence." Referring to our time with Meh Vivien, she added, "What an honor to be with someone who has shown that kind of strength in her life—choosing to live on and survive despite what has been done to her."

Beyond the little townhouse of ASTT, Hanscom is training other counselors around the country to work with torture survivors and advocates on behalf of survivors. With the tightening of immigration laws in the war on terror—including provisions in the Patriot Act that affect asylum seekers—Hanscom makes it a priority to put on a suit and head down to the capital to tell legislators that these new laws are making it harder for torture survivors to obtain asylum. On the last day I spent with Hanscom, we traveled together from Baltimore to Washington, D.C., to meet with whoever would speak to her in the offices of Maryland's two senators.

She explained in detail just how the new legislation affects those who have survived torture while fighting for freedom in their home countries. One woman, she said, who had been forced by rebels to keep guns in the bolts of fabric she sold, was accused of giving material support to terrorists. Even though the government had arrested and tortured her and the rebels had threatened her with death, under the new legislation, she had to go back to her country, where she could be killed.

Hanscom also explained to the Senate staffers that new legislation is increasing pressure to keep asylum seekers in prison until their cases come before an immigration judge. The effects of isolation and indefinite detention are devastating to those already suffering from PTSD, she told them, and described watching clients have severe flashbacks behind bars. She told the story of a 19-year-old Sikh from India whose family had been killed, one by one, in an act of ethnic cleansing. They had pooled together money to send one person to America so that the family name would survive. As soon as he landed, the 19-year-old was sent to immigration prison. When Hanscom met him, he was in shackles and couldn't stop sobbing, saying, "I've done nothing wrong."

At the end of her meetings, Hanscom could only cross her fingers and hope her advocacy would make a difference. "We all have to chip at our little piece of the wall," she says. "Sometimes it's hard to see everyone else chipping at theirs, but you've still got to trust that's what they're doing."

Sometimes the wall even falls a little bit. About a month after our interview, Hanscom called—ecstatic—to say Meh Vivien had been granted asylum. I called Meh Vivien, who answered the phone, saying, "I got it!"

From the February 2007 issue of O, The Oprah Magazine.