A Child's Right to Rehabilitation

Paul Orieny, Ph.D, is CVT senior clinical advisor for mental health. 

Every year, CVT is invited by The United Nations Voluntary Fund for Victims of Torture (UNV) to its two-day convening in Geneva of high-level rehabilitation experts and practitioners to discuss best practices, examine the latest research and share knowledge about their work in the field. This year’s April event was themed “Redress and rehabilitation of child and adolescent victims of torture and the intergenerational transmission of trauma,” and included workshops, discussions and expert speeches.

Paul Orieny, CVT senior clinical advisor for mental health, made a speech to an audience of attorneys, counselors and UN human rights representatives from over 100 countries. Below are excerpts from his speech, which was widely recognized by colleagues at the conference and included in the outcome report published by UNHR.

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Across the world today, in emergency resettlement settings, children are likely to make up half or more of the population affected by conflicts and disasters. The many risks that they face can have a devastating impact on their mental health, not to mention their physical well-being and their future. Some of the children we see are direct torture survivors, many are secondary torture survivors, and all of them are affected by war, displacement and atrocities.

While the effects of torture seen in children are similar to adults, there are extra layers of unique and powerful characteristics that set children torture survivors apart from other experiences of humanitarian crises. These include characteristics such as:

• Night terrors
• Bed wetting
• Fear of separation from parents
• Withdrawal
• Isolation
• Inhibition at school
• Disruptive behavior (such as ‘acting out’)
• Reduced impulse control
• Excessive stubbornness and authoritarian attitudes

In addition, these children may experience:

• Re-traumatization from school environments where there are alarms during fire drills and presence of uniform school police officers
• Decreased functioning of their traumatized parents and guardians further exacerbating the children crises
• Specific effects unique to children who were sexually tortured
• Serious interruption of normal developmental processes including areas of the brain that regulate stress and emotion
• Attachment disturbance and separation anxiety
• Being orphaned due to death or disappearance of parents and guardians

For us at CVT, with a mission to heal the wounds of torture on individuals, their families and their communities and to stop torture worldwide, we assert that children have a right to rehabilitation. The Convention Against Torture (CAT) outlines providing victims with a right to “as full rehabilitation as possible.”  How might we best do this for children torture survivors? What does a right to as full rehabilitation as possible for children mean? Clinically this is a critically important question with no quick or easy answer. 

From CVT’s perspective, I would say that we lean towards a human rights-based approach much more than a humanitarian approach to rehabilitation of children, meaning that our ideal approach would be to do whatever it takes to bring rehabilitation. It’s true that in many of the humanitarian contexts where torture and trauma services are needed, we have overwhelming needs beyond the resources that are available, and the most practical thing is to do is short-term psychosocial support in emergency humanitarian situations. We play a key role helping survivors cope with ongoing stressors and building resiliency, but is this enough for children torture survivors? And does it meet the right to full rehabilitation?

Beyond current coping, we know that torture’s far-reaching and complex wounds are internal and external, practical and spiritual, physical and emotional, individual and communal, short-term and long-term and can run deep into the victim’s psyche, body and spirit. We need to provide more in-depth rehabilitative therapeutic interventions that make it possible for children to claim back their lives. 

For example, CVT’s typical intervention framework follows a tri-phasic model of trauma recovery, with initial focus on stabilization, then exploration of trauma memories, and finally broader integration of self and community. The treatment period lasts at least 10 weeks, with a full assessment at the beginning and regular follow-ups. When appropriate, part of the treatment includes trauma processing, which is necessary to heal and break the cycle of avoidance, hyper-arousal and re-experiencing the torture situation again.

The UNV is unique in supporting this in-depth work that not many other funders do. More investments should be put in programs that supplement and go beyond the emergency psychosocial support framework, to a deeper full rehabilitation that is multidisciplinary as much as possible, as part of the right to rehabilitation.

Children and adult torture survivors often enter treatment with many multi-layered and interdependent needs; with complex and severe torture history; and often are trying to recover from torture within the context of other stressors. In fact, when one understands torture as the use of intolerable pain to destroy the physical and psychological integrity of the individual, family and community, one also must conclude that an integrative approach to recovery is necessary. Treatment needs to be re-integrative and multidisciplinary to heal the complex wounds of torture, and to address a broad array of physical, psychological, relational, and psychosocial injuries. Treatment should as well take into account the fact that the damaging effects on children from their traumatic experiences are further exacerbated by their parents and guardians who are also suffering their own significant traumatic experiences.

There is still a lot of work to be done.

CVT extends rehabilitative care to children in Ethiopia, Jordan, Kenya and Uganda. At the end of January 2016 in Jordan, 1,720 of the 5,264 clients we saw were under 18 years old. These included Syrian and Iraqi refugee children, and we see young people from many countries in our other programs. In our Ethiopia program, we see Eritrean refugee clients, with large numbers of children, including unaccompanied minors in the camps.

From our firsthand experience, there is a severe shortage of mental health resources to help refugee children who have endured torture. Mental health services are inadequate and often non-existent in some places, and there is a complete lack of social support. Schools are ill-equipped to address these children’s problems. While there is a wealth of research regarding other trauma affecting children, there is almost no literature with any depth regarding children who have survived torture.

I hope this workshop will serve as an impetus to motivate action on relevant research, writing and interventions that may be utilized by providers working with torture survivors who are children, and that findings are shared with schools, primary care providers, social services, NGOs and others who work in the interests of children. Such action will greatly benefit all relevant players in understanding and addressing the issues surrounding children torture survivors, contributing to the stabilization of children’s mental and physical health, their success in school, and their productive participation in families and in society in general.

Thank you.