The Last Refuge

Survivors of torture from across the globe rebuild their lives in the heart of Manhattan, with the help of unusually close doctor-patient relations.

The Last Refuge

I walk in at seven o’clock on the dot, expecting to be one of the first to arrive at the benefit concert for the NYU/Bellevue Program for Survivors of Torture (or PSOT). To my surprise, as I step into the third-floor event space of an otherwise nondescript Times Square sports bar, I find there’s already quite a crowd.

The director of the organization, Dr. Allen Keller, is working the room, jovially schmoozing with a pair of older women in one corner. A few twenty-somethings are chatting and sipping beers at the bar. And in the middle of the room, a regal West African woman is holding court in a shocking pink evening gown, surrounded by a small group of supporters, all PSOT clients and survivors of torture.

People are speaking English, French, Mandarin, and languages I can’t identify. They hug in greeting, exchanging easy, enthusiastic handshakes and kisses on the cheek. Torture survivors and refugees are mingling easily with their social workers, interpreters and psychiatrists, perhaps chatting lightheartedly with someone who once helped them apply for asylum or is familiar with all the details of their beatings or political persecution. Knowing what these people are to each other, the friendly hugs and laughter that pass between the clinical staff and their patients is almost jarring.

About halfway through the evening, the woman in pink heads to the front of the room. For the first time all night, the crowd goes quiet as the woman introduces her song in French. She speaks in moving words about the life she had fled, and what led her to leave her own country and come to New York. The song she is going to sing, she says, always gave her hope for something better.

Then, to my surprise, she launches into ABBA’s “I Have a Dream.” The shock of hearing such a lighthearted song invoked as a freedom anthem makes me smile, and I think about how Dr. Keller introduced the program earlier in the night.

“It’s all about concentric circles!” he said, waving a hand in the air and hopping from one foot to the other, as if his energy was barely being contained by the stage. “So…tell a friend!”

Since its founding in 1995, PSOT has served approximately three thousand clients who have been tortured, persecuted or otherwise traumatized to the extent that they had to leave their home countries and seek refuge in ours. Most of their clients enter the program undocumented, having arrived in the U.S. with little but the shirts on their backs. Most are still awaiting the results of asylum claims that can take years to come to a decision. Until their asylum cases are filed, they are ineligible for work authorization and Medicaid, and many sleep in homeless shelters, scrounging for  food in a city they don’t know, often without much English. And around every corner they face the scars of their traumas.

“A lot of what we hear this time of year is, ‘I’m cold,’” Jo Snapp, PSOT’s acting director of social services, said in an interview this winter. Snapp says that many of her clients come from countries where they have never dealt with cold weather. She related one story of a client, a rape survivor, who was trying to find a winter coat. Snapp directed her to a coat drive, but when she arrived, there were too many men standing outside. “She couldn’t go in,” Snapp says, brow furrowed. “She left.”

Jo Snapp, PSOT’s acting director of social services, in the hallway at Bellevue
Jo Snapp, PSOT’s acting director of social services, in the hallway at Bellevue.

“This is such a brutal time for our clients,” she continued. “How do you find your way to the soup kitchen if you have traumatic brain injury and have a tough time concentrating while reading the map? Will you go, if food deprivation is part of your torture history and brings up too many triggers?”

PSOT, one of about thirty-five torture survivor treatment organizations around the country, offers comprehensive services for people who find their way to its offices at Bellevue Hospital Center in the East Village of Manhattan. They provide medical and psychiatric care, refer clients to lawyers, help them keep track of the status of their legal cases and offer social work services.

The demographics of their clients are extraordinarily diverse, ranging from college-educated intellectual dissidents to illiterate human trafficking victims. Although they hail from all over the world, most PSOT clients arrive in this country alone, and through PSOT they find help, support, and perhaps most importantly, a community.

“This community can be one of the most restorative aspects of a program like this,” says Snapp.

To help torture victims regain a sense of trust in those around them, PSOT depends partly on support groups, organizing them by language and geography, and also according to shared experiences. There are groups for Africans who speak French, Africans who speak English, people who have been persecuted for their gender identity, groups specifically for women, and others.

“A lot of the work we do is rebuilding trust,” says Dr. Keller.

The clients I spoke with seemed to keenly feel this impact.

Dr. Allen Keller, Director of PSOT
Dr. Allen Keller, Director of PSOT

“You feel homeless, you don’t have [a] place to stay,” said one older African man who was detained and beaten for writing about corruption in his home country (and for that reason cannot be further identified here). This client, whom I will call Mr. A, continued: “Thank god for [the] program–we have meetings every week. It’s a really big help. It’s a blessing.”

“You can’t talk to people outside [the program],” he elaborated, saying that he has to be careful whom he relates his experiences to, because he fears putting himself or his loved ones in danger. “But,” he said, “here I feel safe.”

Mr. A went on to discuss the difficulty of waiting for a decision on his asylum claim, a stressful experience that many of the program’s participants share. “I’m waiting five years—my kids ask me, ‘When do we get asylum?’ And I say, ‘I don’t know.’” Mr. A paused, and put up his hands in front of him, in a gesture that said slow down. “Let people do their jobs.”

“We are depressed from the torture, mistreatment,” he continued. “When we come here, we don’t know when is the end. In our [support] group, we feel good. I tell people, be patient. At least we are safe here.”

Last October, PSOT temporarily lost its home when Hurricane Sandy wrought havoc at Bellevue. The buildings were evacuated when the hospital’s backup generators failed and the flooding began. PSOT’s client files, contact phone numbers, interpreter phones and other vital program resources remained locked inside, inaccessible.

“It’s kind of ironic, a refugee program displaced,” says Keller reflectively. “You just feel betwixt and between. Multiply that by a million for people forced to leave their homes. Any time there’s a traumatic event, it rekindles concerns.”

Snapp relates a story from a client who said that where he was from, extreme weather, blackouts and lack of clean water were not unusual. The hurricane itself was not such a big deal.

Dr. Keller with two PSOT clients (Photo courtesy Jon Tan)
Dr. Keller with two PSOT clients (Photo courtesy Jon Tan)

“But,” she says, “when he found out Bellevue was closed, that’s when he started to panic.”

Motivated by concern for their clients’ well-being, PSOT staff members were able to resume many of the program’s services in just a few days. Program staff and leadership proudly talk about colleagues who visited homeless shelters and soup kitchens, seeking out clients for whom they didn’t have telephone numbers. Smiling, Snapp tells me about their director of development, who, as a Mandarin speaker, was trained as an interpreter on the fly. (She also acknowledges Human Rights First, a legal aid organization that has lent them office space, as well as Bellevue, which has donated space in their outpatient center for clinical visits.)

Despite the valiant effort to get the program up and running again, Snapp says, “You feel the difference. The level of distress has increased in an already vulnerable population. The hurricane was a tremendous disruption to their healing process.”

The importance of PSOT’s services is underlined for me when, three months post-Sandy, I attend the medical clinic at Bellevue, shadowing Dr. Keller. He sees a patient who, having lived in the United States for more than a decade, is well settled in this country. Due to political sensitivities, I have been asked to withhold this man’s name and country of origin, but the appointment proceeds much like many that I’ve conducted myself, as a medical student, with men in their sixties. He and Dr. Keller talk about his diabetes and hypertension, and they review his medications, which he understands better than many American patients I’ve seen.

Words from the Dalai Lama adorn the wall at PSOT
Words from the Dalai Lama adorn the wall at PSOT

He’s waited awhile to come in for his regular follow-up appointment, though, so as doctors do with everyone who misses appointments, Dr. Keller asks him why he hasn’t been seen in so long. He has Medicaid, so he doesn’t need to be seen at PSOT, or even at Bellevue, where services are provided regardless of insurance status.

It turns out that after the hurricane, he kept checking to see whether Bellevue had reopened, and until then, “They told me to go to [another clinic in] Harlem. But I always come here.”

It’s not hard to see how much the PSOT staff cares about its clients, and how much the clients depend on the community they find in the program. As a medical professional, I found this particular aspect of the program intriguing–how do you provide the support and community that these people need and still keep the professional distance that all counselors and physicians are trained to maintain?

Dr. Asher Aladjem, another co-founder of PSOT as well as its chief psychiatrist, is particularly well-versed in the art of maintaining professionalism while treating torture victims.

He says that, by virtue of the specific circumstances of PSOT patients, they necessarily have different relationships with their care providers than the average patient. “Not more personal,” he is careful to say. “Just different. Less traditional. These people need a lot of psychoeducation.”

Dr. Asher Aladjem, co-founder of PSOT
Dr. Asher Aladjem, co-founder of PSOT

By that, he means that these patients, depending on where they are from and what they have been through, might need to be treated differently than people raised in a culture where psychiatry and psychiatric illness are accepted parts of the cultural milieu. This might even extend to trust of the psychiatrist. For instance, in Russia, psychiatry and psychiatric medications have been used as tools to discredit or “reeducate” people considered to be politically dangerous. For a patient from that part of the world, simply being treated by a psychiatrist might create roadblocks for treatment.

Leah Weinzimer, program director of the Libertas Center for Human Rights, a similar organization based in Elmhurst Hospital in Queens, confirms and expands on Dr. Aladjem’s perspective. Unlike other hospital-based services, programs like Libertas and PSOT cater to clients’ need for flexibility. “Bureaucracy requires you to follow a very strict process,” Weinzimer says, and gives the example of registering for a medical appointment, which Libertas aids people in doing. Even filling out the registration form can be difficult for this population. “Contact information for a family member, when people don’t have family members here, we’ve observed that that can be stressful. We try to make the experience less intimidating.”

“Our clients feel connected to us,” she continues, echoing the sentiment I have heard from several PSOT service providers and clients. “We’re the place that has a comprehensive understanding of what’s going on. We pay attention to as much of the picture as possible, and value that.”

Dr. Aladjem does acknowledge that this effort to provide comprehensive services sometimes means accommodating his PSOT patients in unique ways. This can get tricky, as when he is serving as an expert witness in an asylum case, testifying that a certain set of medical findings adds up to evidence of torture. But at the same time, because he is a psychiatrist with PSOT, he might be the doctor who knows the patient best. So, in court, who is he? Expert witness, or patient’s doctor? Sometimes the line can blur; sometimes, to give these patients the treatment they deserve, it must blur.

Beyond the treatment relationship, I was particularly interested in what I saw at the benefit: clients laughing with their therapists over food in a relaxed, friendly, social atmosphere. For a medical professional trained to maintain distance from my patients, the scene was striking.

I asked Dr. Aladjem about that event specifically, and he explained that because of their unique social and psychiatric needs, the boundaries we typically maintain between provider and patient can be, in a controlled way, loosened.

He gave the example of a female Muslim client who, right after the September 11th terrorist attacks, sought him out specifically. She had seen terrorism before; he had not. She wanted to make sure he was ok.

“They perceive that the program is their family, their support system,” he said. In the wake of Hurricane Sandy, they were “re-traumatized when their family was taken away from them.” And so, with the program up and running again after the storm (albeit in temporary quarters), they all “just needed a party,” Dr. Keller said.

The January night that I attended the program’s Monday evening clinic with Dr. Keller was rainy and cold. I arrived early and took refuge in the waiting room of Bellevue’s outpatient center, the program’s temporary clinical home.

Dr. Keller arrived, Blackberry pressed to his ear, and whisked through the door into the clinic’s inner sanctum without noticing me by the front desk. I explained the situation to a social worker manning the desk and was buzzed in to follow him.

After wandering around for a few minutes in the maze of offices and exam rooms, I heard Dr. Keller’s voice coming from my left and peeked through the door. Waving me in, he continued his conversation, in which he appeared to be setting up a meeting with a legislator–in addition to being the executive director of PSOT, he is also a strong advocate for anti-torture legislation in New York State and the country. (He has been a leading voice in support of the Gottfried-Duane Bill in the New York State legislature, which would revoke a doctor’s license if he or she participated in torture anywhere in the world. Proponents argue that such laws are needed to prevent torture by Americans outside of U.S. borders, or in U.S. military detention facilities such as Guantanamo Bay.)

After a moment he hung up the phone and welcomed me warmly, though almost immediately spirited out of the room again to go “check on something.”

Dr. Keller updates Aladjem on a patient in his office.
Dr. Keller updates Aladjem on a patient in his office.

Coming back in, he informed me that there was another visitor today, and would I mind if we had a pre-med student join us?

Thus began our whirlwind of clinic appointments, referrals to social workers, consultations with PSOT’s legal consultant (a kindly and unimposing man referred to as “Mr. John”) and passionate explanations of the plight, medical and psychological, of torture victims. Clients were uniformly glad to see him, and he displayed the impressive memory for personal details that is common among longtime primary care physicians. In this case, though, the personal details were of a unique sort: what country the patients were from and why they had fled, where their asylum cases were hung up, where their family members were, and who he thought might need to see a social worker soon.

The clinic officially closed at eight p.m., but the hours rolled on as Dr. Keller was pulled into rooms and consultations. He has an incorrigible tendency, I discovered, to grab whoever is standing around, tell them what they have in common and encourage them to get to know each other.

At ten p.m., he was finally ready for our interview to begin. Having forgotten to eat dinner, he announced that we could either get a bite to eat or he could drive me home and we could talk on the way. Then, reconsidering, he said that, no, we were going to have to eat something. He didn’t think he’d had lunch either.

Like some of the other clinical staff I had spoken to, Dr. Keller tensed a little when I asked him about the benefit concert, and the potential loosening of clinical boundaries. Describing the event as “quite unusual,” he went on to repeat the mantra that is ingrained in of us from day one of medical school.

“I’m not their friend,” he said.

Pondering his eggroll for a moment, though, he continued. “I think the issues are more complex for the mental health workers. But we are very clear that they are not to form outside relationships [with clients].”

Like Dr. Aladjem, though, he had more to say on this subject, comparing the care that PSOT provides to high-cost “concierge” medicine. In the concierge model, a patient pays a fee to have 24-hour access to a personal doctor. Proponents say that it promotes better, more attentive medical care; those not in favor say it exacerbates disparities between the haves and the have-nots.

“Concierge medicine is all the rage,” Dr. Keller said. “I would argue that all patients are entitled to that. I pride myself on knowing my patients like the back of my hand.”

He explained that should a PSOT client end up in a different medical facility, or even in the inpatient wards at Bellevue under the care of a different team, the PSOT staff likes to know. For this unique population, he believes strongly that the PSOT service providers should be involved in their care, wherever that care is taking place, and that this necessitates being easily accessible for his patients.

“What we’re doing is good care that’s applicable for all,” he says. With his signature, matter-of-fact shrug, he added, “If I bled for all of my patients, I’d have no blood left.”

After a long day of networking, advocating, treating, advising, and repeatedly forgetting to eat, he finally headed home. As he drove away, I was struck by his unpretentious need to care for everyone within reach. I found myself reflecting on the artful way in which the PSOT and Libertas staffs navigate the fine line between professionalism and personal involvement.

Dr. Aladjem explained it succinctly: “It’s passion. You cannot do this work if you are not passionate.”

Speaking with the understanding that he would be represented anonymously, Mr. A told me of the harrowing flight from his home country, and about how he and his friends and family have suffered as a result. He told me how he had been “shocked” to be targeted by his own government. He pointed out, seriously and slightly wistful, that the decision to apply for asylum left no possibility of returning home. He expressed the difficulties of living in the U.S., such as not being eligible for jobs in his field of expertise because they require permanent residency.

But then, revealing a wide, charming smile, he told me that he keeps applying for jobs anyway. He related how a friend had convinced him to go to the English-speaking PSOT therapy group so he could improve his English. He talked about his friends in the program, and how much he appreciated the medical care and psychological support he receives from PSOT and Bellevue. And as we were wrapping up, he made me promise to read his website, where he continues to speak out about corruption in his home country.

“I don’t criticize because I’m against the country,” he said. “I criticize because it’s honestly wrong.” Then, with that disarming smile and a shrug reminiscent of Dr. Keller’s: “It’s underground work.”