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Expert Voices

Reducing Stigma: a First Ray of Hope

Published December 3, 2018

Kidane* was tortured while serving in the Eritrean military. The beatings were so damaging, he could no longer work. He escaped to the refugee camps in northern Ethiopia, where at first he isolated himself, staying away from others, alone with his shame and dark thoughts. But he found rehabilitative care at CVT Ethiopia, and today he is committed to helping others rebuild their lives after torture. Kidane said, “I watch for others in the camp who are living behind closed doors or who think that CVT is for the ‘insane.’” He tells them to go to CVT.

Because Kidane’s word is a testimonial to the life-changing effects of psychological care, his efforts reduce stigma and support the outreach work done by CVT clinicians, as well as the trauma-informed care, processes and logistics built into all our programs.

Helping reduce stigma is a constant activity for CVT in all our locations. Many communities hold negative opinions about mental illness, and many survivors of war believe they should simply be strong enough to bear their trauma. And the realities of torture – not only its effects but also its intention – make stigma reduction particularly important. “What we need to understand,” said Dr. Paul Orieny, senior clinical advisor for mental health, “is that torture, by design, is meant to be shaming. Torture is intended to create guilt. To create stigma.”

Torture is a technique used by people in power who wish to keep that power. Paul noted, “To do this, they create a culture of fear, of shame. They need to ensure they get control of people who could potentially oppose them.”

And, horrifyingly, torture is used to control wide communities of people, not only individuals. To do this, torturers use tactics that spread shame and stigma. Paul noted that torturers take steps to “make it bad enough, deep enough, so people have to deal with shame on an on-going basis.” This causes silence. This creates control.

For example, when sexual torture is used as a weapon of war, the goal oftentimes is to create lasting shame. “It’s personal and interpersonal when a family is forced to watch sexual torture,” Paul said. “Torturers make sure it happens in the presence of the family, in the most shameful way, so that shame is ongoing.”

Another example is when torturers force victims to commit atrocities to their own families and communities, as happened in Uganda with the abduction of children who were forced to become “soldiers” for the Lord’s Resistance Army. Today, those children are adults who are ostracized and face deep shame and stigma. But healing is possible. At CVT Uganda, Paul says, “it’s a healing group. Here we focus on vulnerability, things that were done against your will.”

And the community comes together at the closing of each ten-week counseling cycle at CVT Uganda, to celebrate the healing and share a meal together. “No judgment, just talking and sharing food,” Paul said. “It’s become a destigmatizing and unifying event for the community.”

At CVT, the set-up of each of our centers is based on everything we know about torture and about reducing stigma. This takes many forms, including placing our centers in the kinds of structures used as homes in a particular location. For example, in Uganda and the refugee camps in Dadaab, Kenya, and northern Ethiopia, CVT centers are in tukuls. In Nairobi, Atlanta, and Zarqa, Jordan, centers are located in residential neighborhoods, in houses when possible. In St. Paul, a Victorian-style home was converted to become a warm, welcoming and non-institutional setting for clients. This can normalize the situation for survivors and help them feel safe.

Also, in many cases, we locate centers in close proximity to medical clinics. In this way, it’s not obvious that a person is coming to CVT. “In Kakuma camp, for example, we are located next to Red Cross clinic – this gives people an excuse to say they’re going to the hospital,” Paul said. “It makes it easier to slide in, and this helps mitigate the stigma.”

We also take steps to chip away at negative attitudes about mental health. “In the refugee camps here in northern Ethiopia, there can be a problem in the community if a person has a mental health problem – the community may feel that the person cannot be helped or healed,” wrote Habteab Tsegay, psychosocial counselor, CVT Ethiopia. “They won’t let that person socialize and keep them away. This is a very important situation for CVT.”

CVT clinicians use multiple approaches to help survivors move past stigma and barriers so they can access the care they deserve. Two common forms of outreach in refugee camps are psychoeducation and sensitization sessions. Yacob Abreha, psychosocial counselor, CVT Ethiopia, describes these, writing, “For psychoeducation, we conduct sessions with the community to help educate them about symptoms of trauma, such as depression and suicidal thoughts. We let them know that help is available at CVT, and tell them what that care is like. For sensitizations, we go out into the community and work to contact many people. We meet with them in groups and individually, and tell them about rehabilitative care.”

Some sensitization events incorporate dramatization to help clarify and normalize the feelings survivors are experiencing. “Some have a lot of fear,” Paul said. “They may not have good language to describe what’s going on with them.” To dramatize these situations, psychosocial counselors will do role-play in front of the group, perhaps taking the role of a man who’s struggling with post-traumatic stress disorder (PTSD). He might speak as if talking to a close friend, saying “I don’t sleep, I think about the torture all the time, my thoughts won’t allow me to sleep.” In another scenario, a woman psychosocial counselor may dramatize a situation when a mother is not able to listen to her child; she may act as if she’s pushing a little one away, unable to deal with the child. This helps make the problems clear and accessible.

Urban environments also present challenges when communities share biases against mental health care. Amal Hassan, community educator in St. Cloud, Minnesota, wrote, “In the Somali community it is rare to trust others with your emotional problems because of the stigma: people will think you are crazy and talk about you. People in my community associate mental health issues with not being able to work or forgetting your social security number. Basically being identified as having a mental health problem is equal to having no purpose in America.”

Through parenting classes in St. Cloud, Minneapolis and Nairobi, adults have been able to attend sessions where they were able to speak about what they were experiencing after escaping war and atrocities in other countries. Paul said, “Once people are in, we give them space to talk about their issues.” The classes are about parenting, but trauma-informed curriculum allows clients to apply the learnings to their own experiences. And the sessions are popular. “In Nairobi, the clients don’t want the sessions to end – one group just wanted more,” Paul said.

Every day, stigma is reduced: the stigma of mental health care and the stigma of having been tortured. Veronica Laveta, clinical advisor for mental health, wrote about the final group counseling sessions at CVT Jordan: “Nothing can properly convey the enormity of what it meant to survivors to be accepted for who they are, even after exposing their most vulnerable, pained selves. In one group, two men wept openly at the prospect of saying goodbye as they talked about how the acceptance from the group touched them deeply.”

When stigma is reduced, the torturers lose. As Kidane said, “I got hope at my first session at CVT Ethiopia.”

*Name and some details have been changed for confidentiality and security.

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