THE MEDIA > TO HELL AND BACK
By Tina Rosenberg
The New York Times
December 28, 1997
'I am now very far from home," Aziz wrote in French on a piece
of notebook paper on a plane from Dakar, Senegal, to New York. "The
people around me are probably going to a luxury room in a four-
or five-star hotel. The question in my head is where am I going?
Why am I here? How do I talk to people?" This letter was the
first of more than 60 that Aziz has written since leaving his country
-- to his family, to dead or vanished friends, to himself. He knew
that, like all the others, it would never be sent.
At the time of his flight, Aziz was 27 and almost finished with
a master's in sociology. Aziz is one of his nicknames. His real
name, like the name of his West African country, the way he got
a visa to America and some other details, cannot be revealed without
identifying him to authorities back home and endangering his family.
He is a short man with close-cropped hair and a serious demeanor.
In 1995 he had been an activist in his university's student movement,
which opposed the country's dictatorial government. Every week Aziz
would speak about freedom and democracy, usually at a secret meeting
on campus or in someone's house.
By the time the movement was a year old, most of the leaders had
been arrested. One of his closest friends disappeared one day, never
to be seen again. A second friend was killed. A third left the country,
urging Aziz to go with him.
Aziz stayed, wanting to finish his degree and take his exams. One
day, he says, soldiers came to his dorm room and took him away.
They drove him to a building where they beat him with clubs, then
released him. Two weeks later soldiers came back, dragged him into
a car and blindfolded him with a black cloth. When they reached
their destination, they wrapped a chain around three fingers of
his left hand and hung him for hours. "You have been behaving
like you are the most intelligent person, but tonight the military
is more intelligent," they told him. They warned that if he
didn't stop his activities, they would bring him back whenever they
wanted until he died. They gave him something to drink, and he woke
up 24 hours later on campus with his left arm on fire and his hand
When his sister went to his dorm to get his things, she found a
letter from the security ministry summoning him to appear. By that
time two friends with Government connections had warned him to leave.
Aziz sold his stereo, his black-and-white TV and his motorcycle
and got money from friends to buy a ticket to New York. Afraid they
would see his hand, he never said goodbye to his mother or his fiancee.
He left the country over land, making his way to Dakar for the flight
to New York.
He arrived at Kennedy on a warm evening and spent the night sleeping
on the floor. He was not afraid of being robbed. "I didn't
think about it, because I didn't have any life," he recalls.
He had $14 in his pocket, spoke no English, knew no one. In the
morning he saw a sign for the subway and, with gestures, asked someone
how to buy a ticket. The man sold him a $1.25 token for $2.50.
He got off the A train at Times Square. He was clutching his bag
and a Bible when a woman approached him and began to explain that
Jesus was coming back. Through body language, he told her he had
no place to go. She took him to a church a few blocks away. Aziz
spent two nights there, and the staff then found him a place to
sleep in Brooklyn with an African family.
With his good hand, he worked at the church as a handyman and janitor
-- among his first English words were "vacuum cleaner."
The church staff gave him clothes and meals. A church member suggested
that he call the Lawyers Committee for Human Rights, which has attorneys
who help people fleeing persecution apply for political asylum.
When he went to the Lawyers Committee, a woman took one look at
his hand and told him he needed to see a doctor.
No one knows exactly how many survivors of torture there are in
the United States. Some experts believe there are at least 200,000,
with about 35 percent of those in the New York area. "New York
is a major center because there are so many immigrant communities
here," says Eleanor Acer, who coordinates the asylum program
at the Lawyers Committee. "There are communities of Chinese,
Tibetans, certain African countries like the former Zaire. New York
is also a center for human rights work. Dissidents fleeing torture
who want to stay involved and make a difference in their home country
come to New York or Washington."
New York also has Newark and Kennedy airports, entry points for
many of the fleeing. This year's new immigration laws have made
it harder for torture victims to apply for asylum, since they must
talk about their persecution upon entry -- something genuine victims
often can't face doing. Many who do apply then spend weeks in immigration
detention centers, which can be horrifying for someone who was tortured
in jail. Despite its status as a giant refugee camp, however, New
York, unlike several other American cities, had no clinic dedicated
to the comprehensive treatment of torture survivors until 1995.
When Aziz initially walked into Bellevue Hospital, it was at the
birth of New York's first such clinic.
The doctor called by the Lawyers Committee was Allen Keller, then
a 36-year-old attending physician at Bellevue and an assistant professor
of clinical medicine at New York University School of Medicine.
Keller had lived in Cambodia, where he taught courses on treating
trauma survivors to health workers. Back in New York, he worked
with Physicians for Human Rights and often did medical evaluations
for asylum applicants.
Keller had long been frustrated that although his examinations helped
torture survivors get asylum, his work did little for their tremendous
psychological and medical problems. When he met Aziz, he and Jack
Saul, a psychologist, family therapist and clinical assistant professor
in N.Y.U.'s psychiatry department who has worked with Holocaust
victims, had decided to set up a clinic at Bellevue to treat torture
The first such center was founded in Copenhagen. In the U.S., the
premier clinic is in Minneapolis. There are clinics in San Francisco,
Los Angeles, Boston, Chicago and a few other cities. New York has
a clinic staffed by doctors from Montefiore Medical Center who treat
some patients, but the clinic's emphasis is on medical evaluations
for asylum seekers.
Saul and Keller had been introduced by a mutual friend and began
to meet regularly in the coffee shops at Bellevue and at N.Y.U.
Medical Center, where Saul taught. Bellevue, a teaching hospital
affiliated with N.Y.U., is the nation's oldest public hospital,
a place that never turns away people because they can't pay. In
the summer of 1994 Keller had gone to Sandra Kammerman, the director
of ambulatory services, to ask if he and Saul could start to see
some torture survivors. Although some of the patients would be entitled
to Medicaid, thus reimbursing some of Bellevue's costs, Kammerman
knew that many would not be. But she embraced the project. "This
wouldn't be a clinic you'd find at other hospitals," she says.
"It is in keeping with Bellevue's mission to take care of underserved
When Aziz arrived at Bellevue in 1995, Keller and Saul had done
some brief therapy with one or two patients. "We had been talking
and talking about how to build an effective service and felt we
could talk from now till doomsday," Keller says. "Aziz
needed so many things that we decided if we could figure out how
to help him, we knew we could help others."
Today the Bellevue/N.Y.U. Program for Survivors of Torture, which
is directed by Keller, has treated about 150 victims of torture
or severe political violence along with their families, including
young children. Patients come from 40 countries, roughly a third
of them from Africa and many others from Bosnia, Tibet, Bangladesh
and China. About five new referrals come in every week.
The program received about $40,000 in financing last year from the
United Nations. Most of its staff are psychologists, physicians
and a psychiatrist, from Bellevue and N.Y.U., who take a few hours
a week to treat clients. Clients have access to all of Bellevue's
services, including two social workers who help them find housing
and negotiate the city bureaucracy. Only this month has the program
been promised its own office.
The first time Aziz walked through Bellevue's doors, he almost turned
around and left; the hospital was full of police officers. When
Keller examined him, he noted that Aziz's left fingers bore fresh
scars. He had pain from his shoulder down. His nerves were so damaged
he could barely lift his arm. In response to Keller's questions,
Aziz said he had frequent headaches, was fearful and sad and had
trouble sleeping. "I wanted to tell him as little as possible,"
Aziz told me. "I thought, 'I don't know who you are, I'm escaping
my country and don't want anyone to see me.' "
Keller and Saul went to see Aziz shortly after that. They had to
begin preparing a medical and psychological evaluation to accompany
his application for asylum, which he could get by persuading an
immigration official or a judge that he could not return home because
of a well-founded fear of persecution. Saul knew that recounting
his torture to two strangers without psychological preparation would
be extremely painful for Aziz. But Aziz told them that he understood
the importance of asylum. He felt more confident talking to Keller
this time than in their first meeting. As Saul translated, Aziz
told them how soldiers made him climb, blindfolded, onto a stool.
They wound a chain around the last three fingers of his left hand.
They kicked the stool away and hung him by his fingers. The soldiers
then bounced his head against the wall. They put the stool back
under him for a minute, then kicked it away. They repeated the process
about 25 times.
Aziz told Keller and Saul that he had nightmares and flashbacks
that got worse whenever he remembered why he had fled. Unfortunately,
he said, much about being in New York triggered thoughts about how
he got here. He felt hopeless, as though he could never start a
new life and had no reason to go on. A year later, when I met him
in Saul's office, Aziz told me that he often dreamed about being
in the room with the stool. In his dream, Aziz watched from a perch
on the ceiling while soldiers hung a blindfolded man by his fingers
and smashed him against the wall, over and over and over again.
The primary purpose of torture is not to elicit information -- it
produces lies more often than truths -- but to break the victim's
personality. In this torture is wildly successful. Like Aziz, many
torture survivors suffer from the uncontrollable intrusion of the
torture into their lives through nightmares and flashbacks. For
them torture is not a past event but a constant presence. Because
they are so focused on their traumatic memories, they cannot concentrate
on normal life. They withdraw from family, school and work. They
try to numb the pain with alcohol and drugs. They startle easily
and have trouble sleeping. They also feel anxiety, depression, powerlessness
and guilt. They may try to overcome a feeling of victimization by
becoming violent themselves.
Most of these symptoms fit the classic diagnosis of post-traumatic
stress disorder, or P.T.S.D., the same condition suffered by many
veterans and abused children. But they are compounded by the circumstances
of torture, a process deliberately designed to render the victim
powerless. People who break feel shame for their weakness and betrayal.
Even those who say nothing -- even those who are asked nothing --
often feel guilty for having survived.
Usually, survivors have also suffered other traumas: the death of
loved ones and friends, the loss of home and community, the stress
of war or living in hiding. And those who flee find their troubles
further complicated by the struggles of being refugees. Starting
a new life in New York is difficult even for people with money,
friends, family, jobs and a command of English. Most of the tortured,
like Aziz, arrive with none of these and cannot even legally get
a job. One patient walked 80 blocks from his home to Bellevue to
save bus fare. Aziz is wary of others from his native land because
they might be Government spies. His mind was -- and still is --
divided. He must concentrate on the battle for food and shelter
here. At the same time, he thinks constantly of the country, friends
and family that he has left behind and possibly endangered.
Although society has passed through many periods when the symptoms
of trauma were dismissed as malingering, today scientists are finding
proof that trauma's impact on the psyche is as real as a bullet
tearing through flesh. With the advancement in the last decade of
neuroimaging devices like PET scans, which reveal brain activity
by showing where the brain uses oxygen, scientists are beginning
to see how post-traumatic stress disorder works. Early studies suggest
that the brain processes a traumatic event very differently from
an everyday one and might keep the trauma from being integrated
with other memories. That may explain why trauma sufferers have
amnesia or can retrieve only fragments, like a smell or sound, or
cannot put the events behind them. "The memory doesn't hook
up with the little voice that says: 'This is in the past. This isn't
happening now,' " says Bessel van der Kolk, a Boston University
psychiatrist who has performed some of the studies.
Every Tuesday at noon, the staff of Bellevue's Program for Survivors
of Torture meets in a conference room crammed with old computers
and audiovisual equipment to talk about their work. At one meeting
in November, the staff talked about how to make New York less intimidating,
and suggested pairing new clients with more experienced ones to
show them how to take the subway.
They discussed the program's group-therapy sessions, one in French
for West Africans and one planned for Tibetans. Hawthorne Smith,
a staff counselor, was enthusiastic about the French group. A new
patient had mentioned that he was afraid to leave the house, and
an older one chimed in that when he first arrived, he, too, stayed
indoors for six months unless he was with someone. "It's not
just good for the new ones," Smith said. "The older ones
can see where they were. Often they don't give themselves credit
for how far they've come." Saul told of the shock of a client
whose first time out in public was on Halloween night, when he found
himself in Greenwich Village during the annual costume parade.
Aziz had never paid much attention to psychotherapy before he landed
in Bellevue. "Psychology at home is not something official,
like here," he told me in Saul's office at our first meeting
last year. "There is no office to go to. The family heals someone
who has psychological problems. They make the person feel comfort
in the family and show you belong to the family." Saul laughed.
"That's still the best way," he said.
The culture gap is one of the challenges of working with torture
survivors. Political activists in Latin America, where psychotherapy
is common, tend to be willing to seek it; people from other cultures
are often less so. Doctors also need to tap into the methods that
every culture invents to deal with trauma. Many Muslim women will
not seek treatment for torture, because it is tantamount to admitting
they were raped. Cambodians, Keller says, tend to blame bad karma
for problems and say they need to go to a pagoda and be with the
monks. Doctors at the Center for Victims of Torture in Minneapolis
found that many clients were relieved to hear that their symptoms
were a normal result of torture and did not mean they were crazy,
weak or possessed by spirits.
While Aziz showed an intuitive grasp of therapy -- the importance
of letter-writing, for example -- he had other problems. One was
the hospital itself, a symbol of authority. "I did not feel
safe at home or here to tell a doctor anything," he said. Another
patient, a former monk from Tibet who was in Bellevue's tuberculosis
ward, panicked after seeing a Chinese-American policeman outside
his room and shoved his bed against the wall as a barricade.
Hospitals inspire a more direct fear in some, since doctors are
frequent participants in torture. "We realized that you can't
just do gynecological exams, attach electrodes, take blood,"
says Inge Genefke, medical director of the Copenhagen center. "You
need to explain it, and if the patient is afraid, don't do it. Leave
it for another day."
Although psychotherapy for trauma patients is popularly portrayed
as climaxing when the patient is able to recount the trauma, Saul
believes that the crucial event is getting the patient to feel safe,
connected and in control. "Once a trusting relationship is
established, the story is going to come up naturally," he says.
Saul's next step is to help the patient re-establish connections
to society, essential after a trauma deliberately inflicted by another
human being. Finally, he tries to integrate the experience of trauma
into the full sweep of the patient's life. Telling the trauma story
is important here -- part of the past of a patient who also has
a present and a future.
Saul, the program's director of mental health services, is also
a painter and encourages therapists to use a wide range of methods,
including art -- drawing and painting stimulate patients' imaginations
and allow them to communicate ideas that they can't talk about.
He urges patients to solve problems using the strengths that enabled
them to survive. Saul saw early that Aziz had many such strengths.
"As a political activist, he knew the consequences could come
to this, and he knew why he was taken. This is very important --
it helps people deal better," Saul says. Aziz's torture took
days, not months. Although he lost close friends, no one in his
family was killed. And he was able to begin treatment within weeks.
At their first meeting, Saul explained that Aziz's symptoms were
a normal reaction to torture. He told Aziz he could get better.
He asked Aziz what he wanted to talk about, and Aziz told Saul about
the political situation in his country, his involvement in the student
movement and his friends who were dead, missing and exiled.
Then Saul began to focus on Aziz's new problems. The most immediate
was that a woman in the house where he was staying had tried to
attack him with a knife. Sarena Lewit, one of the program's social
workers, scrambled to find Aziz another place to live. She arranged
for him to get about $20 a week from an auxiliary fund at Bellevue
for subway fare and some food, and she gave him a few tubs of peanut
butter and bags of rice from the hospital's emergency pantry. She
got him emergency Medicaid coverage. "She showed me Central
Park," he says. "She told me that I didn't have to close
myself in my room. She told me about going to the library to ask
about educational opportunities. But I didn't feel I could try something
and succeed. I told Dr. Saul and Keller there was no reason for
me to stay in this world."
After several meetings with Saul, however, Aziz found that his sense
of paralysis was lifting. "The first sign it was helping was
that I was finding I could use the information Sarena gave me,"
he says. Aziz started going to her office as Lewit was leaving work
and they would practice English -- he was learning it by reading
a sociology textbook from the 1950's. They walked around New York
and did touristy things like taking the tram to Roosevelt Island.
She took him to an IMAX movie on his birthday.
Lewit knew that Aziz was adjusting when he stopped wearing the secondhand
clothes she got him at Bellevue; he had figured out where to get
Calvin Klein jeans for $10. Aziz's English soon surpassed Saul's
French, and therapy sessions switched to English. Once Aziz was
feeling more secure, Saul moved on to rebuilding Aziz's social connections
and integrating his torture with the rest of his experiences. Saul
turned to writing, which he often uses in family therapy.
Aziz had said that he wanted to document his experiences, perhaps
to give to the U.N.'s Special Rapporteur on torture. Saul brought
in a laptop one day and asked Aziz if he was ready. Aziz was not
-- for one thing, he had never used a computer -- but when he got
home he began to write letters on paper, which he would bring in
and read out loud to Saul. "Writing is like art in that it
externalizes the experience," Saul says. "The trauma doesn't
have to be in their heads. It's also important for them to reconnect
with the positive aspects of their past before the trauma. I encouraged
him to write letters to his family even though he didn't want to
send them. He found it very helpful in putting experiences behind
him. You need to remember in order to forget."
Aziz already knew this. "I know I am writing now about something
that happened to me in the past," he says. "Even though
things are not good for me now, that I can write a letter is proof
of my present situation, where I can write, I can talk, I can do
anything." He could not send them, however, without endangering
his family by alerting the authorities that his relatives knew where
he was. "It has happened that when the Government found out
a family member was in touch with a person in exile, they kidnapped
the man's son and waited for him to come back," he says.
Aziz does not see Saul as often anymore, although they speak on
the phone. Saul counts Aziz as one of the program's patients who
have come furthest in dealing with their traumas, in part because
they have been in therapy longest. His hand is completely healed
now, and on the surface, so is Aziz. In November 1995, he won political
asylum. He has been eager to give something back to the program,
speaking about health and human rights to a class that Keller teaches
at Princeton and conducting a workshop for the program staff on
the perspective of Africans on getting psychological help. In the
fall of 1996 he began a graduate program at N.Y.U.; his student
loan was cosigned by Lewit and Saul. He taught himself to use the
computer, and he is now fluent in English.
But he still has nightmares occasionally, and he remains unwilling
to make close friends. "In my country I used to spend two or
three nights a week with my friends, a group of 12 or 13,"
he says. "We studied together and stayed up all night talking.
I don't know where they are now. I do know some of them have died,
and the project we had is gone. I don't want to get close to people.
I don't know what's going to happen tomorrow." Things are bad
in his country, and he can't think of a solution, he says. All he
knows is that he will wait until it is safe and then go home.
torture victim from Latin America gave this self-portrait
to the survivors' clinic in Copenhagen.