A “breath”[1] in the ultimate human cruelty aiming at human  

An interview with MSF Psychologist and Field Coordinator Öznur Acicbe Kara by Erdal Aktaş, originally published in Turkish on Sivil Sayfalar - Sept 28, 2017

‘As it happens with inattentive approaches, when you don’t care the way you should, sometimes the treatment itself results in re-traumatisation.

For example, a doctor might ask for an electromyography (EMG) for a person who had been tortured with electrocution…’

According to official figures, there are about four million ‘refugees’ in Turkey. Many of these people are trying to escape war and conflicts in their countries to survive, while still carrying with them marks of the ill-treatment and torture that they have endured in their ‘homelands’ or on the way to the places they seek shelter in.

The rehabilitation centre for migrant survivors of ill-treatment, carried out as part of the Nefes (‘Breath’) project by the Citizens’ Assembly (CA) and Doctors Without Borders (Medecins sans Frontieres – MSF), provides medical case management and psychosocial support to these people. We spoke with Öznur Acicbe, the project’s coordinator, on the services that the rehabilitation center offers and the condition of the migrants who have survived –despite- torture, as well as the roles of civil society.

[1] Breath (Nefes) refers to the center’s name

Can you introduce yourself please?

I work as the coordinator of the Nefes Project. I’m a psychologist and I have been working in civil society, in various roles for many years, especially in projects aiming to support migrants. Nefes Rehabilitation Centre team is a multidisciplinary one with psychologists, social workers, doctors, physiotherapists, community mental health workers and cultural mediators/interpreters involved. And of course we have a colleague to organize and follow the program of the whole team. Most of the team members have previous work experience in civil society, mostly with migrants.

How did this project start? Who are your partners here, and how do you work?

Nefes is actually a project of CA , carried out with the technical and financial support of MSF. Both organizations have certain experience and testimonies in the field of migration and, as well as on ill-treatment. Among these experiences, two of them were conducted with CA-MSF partnership, so there are common experiences as well.  For example, MSF often witnesses consequences of ill-treatment with the patients who come to their clinics in war and conflict zones, such as Syria, Yemen, Iraq, Afghanistan or Central African Republic. They have similar experiences in their projects over migration routes. MSF has centers in Athens, Cairo and Rome to support tortured and ill-treated migrants and refugees. We also know that in the psychosocial support center in Kilis, operated by CA and supported by MSF alike, they receive patients with stories of sexual violence.

In addition to our own experiences, there are also many reports along the same lines. An important report regarding the beginning of this project was Amnesty International’s report on Sydnaya Prison in Syria, for example. It is a report that shows how widespread torture is, also pointing out that such an exercise of violence is both physically and mentally destructive for the individuals.

Describing the problem is one thing; on the other hand, there is the fact that the support the torture survivors need is a highly specificone. We are familiar to this aspect of the services both through our own experiences and through what is available in the literature. What I mean here is that ill-treatment leaves a person with complex and heavy scars. People may face difficulties that require specialization in physical and mental healing. In the field of physical healing one might require quite specific and varied types of support, which are not always easy to reach.

Moreover, to talk about ill-treatment and torture, and to explain it over and over again to a number of medical specialists may result in re-traumatisation.

This being the case, we first tried to understand to which places these migrant survivors of torture and ill-treatment can resort to, from where they can get services, or whether they can get any services or not after ending up in Turkey. As we all know, Human Rights Foundation of Turkey (Türkiye İnsan Hakları Vakfı - TİHV) has been making great efforts in this field since many years. However, as the need increases, it becomes more difficult to meet it. Thus we wanted to support this aspect of the issue based on our experience with migrants and refugees.

What kind of services do you provide in the rehabilitation centre, and in which language? Who works here?

We can summarize our services as psychosocial support and medical case management. The person who comes to us, or is referred here,first meets our social worker, who assesses the needs by trying to understand the complaint, the story and the expectation of the person. Then this information is discussed within our multidisciplinary team that consists of of  psychologists,  doctors, social workers and physiotherapists in order to evaluate the situation with the holistic approach we aim for. Then, each professional makes her/his own assessment and presents this to the multidisciplinary team.

In light of all these evaluations our team collectively decides the way we can support the person and initiates the process.

Of course, our center does not work like a clinic. For example, as soon as our doctor makes his/her assessment based on  Istanbul Protocol, s/he contacts the relevant persons and institutions in order to carry out the treatment plan identified for this person’s medical needs. These services are provided through other institutions and followed by our team.

This actually is quite an important aspect of the work. Because a torture survivor may have rather complex and very individual, very particular problems that may require a number of different specializations to deal with.

Our doctor not only follows all these processes but also acts as a health consultant for the migrant, providing her/him with a complete feedback. Our social workers also work in a similar manner of case management. The psychologists, on the other hand, provide their support within our center. But we do plan to carry out some of the group activities in other places, as part of our community-based services, where our community mental health workers will also take an active part in.

All these works are conducted in various languages such as Arabic, Persian, French and Kurdish, with the help of our cultural mediators/interpreters.

And why is the Center here in Fatih?

This is a question we also ask ourselves from time to time. First of all, we do not aim to serve all of the migrants in the city; it would be rather unrealistic to have such a goal in a metropolis like Istanbul. Instead we opt for being in a place that is easily reachable by migrants who would need our service. Fatih is a district with a huge population. The Akşemsettin neighborhood in which our center is situated in is one with a high number of Syrian refugees. But it is not a difficult place for African migrants to come from where they live, which is mostly around Aksaray, Kumkapı and Tarlabaşı. The Afghans who live in Zeytinburnu can also reach here easily.

We know that our place is rather far to districts such as Bağcılar, Küçükçekmece, Esenyurt, Ümraniye and Sultanbeyli, which also have high populations of migrants. However there are other actors present in those areas, providing valuable support. We attach a high importance to cooperation and communication with other actors.

On the [multilingual] information leaflets of Nefeswe see that ‘the centre offers psychological and social support as well as medical case management regardless of legal status.’ What kind of obstacles do those ‘legal statuses’ bring about when it comes to access to health care in Turkey?

The legal statuses of the migrants who have taken shelter in Turkey may be roughly divided as ‘international protection’, ‘temporary protection’, ‘residence permit’, ‘irregular/undocumented migrants and stateless persons’. For a foreign person in Turkey to have an ID starting with 99, which means acquiring a temporary or international protection, is vital to use public services, both for the health sector and for access to social service mechanisms. Despite certain limits, we can say that these people may get access to health services for free.

However, it would be naïve to assume that the Syrians who are legally supported under ‘temporary protection’, and the Persian, Afghan, Iraqi or African migrants who have applied for international protection are in practice perfectly enjoying all the rights they are entitled by these identities.

After all, we are only talking about what is in theory right now. Again in theory, and in practice, the rights of a migrant who has fallen into the stateless, undocumented or irregular categories are so thin on the ground. Although the numeric majority of the migrants who have taken shelter here in Turkey are Syrians, there are irregular migrants from many countries here and many cannot enroll to any state institutions for reasons such as the ID number they hold is not valid in the province they live, or that they are undocumented. And of course there are no such distinctions in Nefes Rehabilitation Centre, exactly because we want to cover those whose status is somehow not adequate for the state.

Even if the survivors go to a hospital that has the latest technology and the most specialized doctors, their problems are often not solved, because they need to feel trust in order to be able to share their stories of torture.’

Why do they come to this rehabilitation centre in Fatih, instead of going to a hospital? There must be a gap in the public system that this center corresponds to…

In our centre we are offering services for a very specific field. It requires quite a difficult procedure to diagnose the results of torture on health, and to provide the most adequate treatment. Before coming to us, the migrants have certainly had been to other health institutions.

As I have said already, we don’t provide health care the way a clinic does, we rather manage the clinical treatment process. In that sense I can say that the difference here is the authenticity of our approach, rather than the health care services provided.

Let me put it this way: There are some very complicated physical injuries that are not typical at all, and that are the results of the methods used as part of torture and ill-treatment. Because the relevant medical treatment is either not at hand or these persons could only ask for treatment long time after the event, the injuries often happen to be in a chronic condition when they are diagnosed. Some examples for the clinical manifestation we see are various damages to the musculoskeletal system, chronic pain syndrome or problems in the urogenital system, and all these manifestations require a considerable amount of knowledge, experience and a special approach to diagnose and treat.

Rehabilitation for torture and ill-treatment is not a well-known field in Turkey. The number of medical staff who are knowledgeable on this issue is very low. Even if the survivors go to a hospital that has the latest technology and the most specialized doctors, their problems are often not solved, because they need to feel trust in order to be able to share their stories of torture. Sometimes it takes more than a few sessions just to hear about the whole story and to solve the meaning of the symptoms.

There are cases where you cannot resort to some methods of diagnosis or treatment because you don’t want to repeat a trauma in a migrant with a story of torture, who might be in a difficult psychological condition. This is why we do need a case management process based on knowledge, patience and care. Without that, persons may return home with simple drugs that only address the symptoms.

So, as it happens with inattentive approaches, when you don’t care the way you should, sometimes the treatment itself results in re-traumatisation. For example, a doctor might ask for an electromyography (EMG) for a person who had been tortured with electrocution. Then, another difference of our attitude comes into play here, which is the holistic approach.

You also said you sometimes refer people to other institutions. Which are these institutions and what are the conditions for a referral? Do you find the services in these institutions adequate enough?

We refer people to other NGOs or public institutions for them to receive social aid or support, and to hospitals and clinics to receive health services. We have strong collaborations with other organisations who provide social support, as we also try to meet the social needs of people we follow in the center, in addition to the focus on their mental and physical health.

Since we encounter in our center mostly with Syrian refugees, currently we mainly provide services for people who are under temporary protection. From time to time we meet migrants who don’t know their rights that are granted by this status, or people who are not registered to the system for various reasons. We explain how they can be registered and refer them to relevant institutions. If they have identities, we can directly refer them to health facilities, social welfare centers and state institutions like the district governorates according to their needs. We can also direct people to other local and international NGOs working in the field like us, and meeting various socio-economic needs.

The problems we have identified so far while following up referrals, regarding access to other organizations, are related to language barrier and high number of people asking for services. Other than that, the success of the referral depends highly on the level of awareness of the person they meet in places they are referred to.

On the migration routes and in Turkey, what are the forms of ill-treatment that refugees face?

Our project covers the migrants and refugees who had been ill-treated in their own countries or on the migration route. Most of the applications we have received till today have an imprisonment story; they had been tortured in prisons.

‘Especially in conflict zones, ill-treatment manifests itself in various forms of masculine violence. Targeting the genital region is one such example and it leads to problems in the urogenital system.’

Who are the perpetrators of ill-treatment?

If we talk about the relatively low number of applicants to our center, what we learn is that ill-treatment has taken place mostly in the country they had left. In the case of Syria, we know that the migrants we serve had been ill-treated by state authorities.

What are the ‘complaints’ that have brought these people to you, so far?

As I have said, the experience of ill-treatment may leave mental and physical scars on the individuals. The “scars” our psychologists encounter are difficulties that generally fall into the definitions of post-traumatic stress disorder, depression and anxiety in the relevant literature. Such difficulties acquire a different meaning and degree for each human being, and their lives are thus affected to varying extents.

Therefore, the most important dimension of the psychological support we provide is to be able to hear the complaints not as a category but as a whole, to evaluate and try to understand each person’s situation in its own uniqueness.

The physical consequences show as musculoskeletal problems and complaints of chronic pain and aches. I should add that the psychological issues I just mentioned also contribute to those chronic pains. Ill-treatment, especially in conflict zones, manifests itself in various forms of masculine violence. Targeting the genital region is an example to this sort of violence and it leads to problems in the urogenital system. I should also emphasize that we encounter systemic diseases that result from being subject to malnutrition or a poor diet and unsanitary conditions for extended periods of time, and being deprived of medical treatment.

The psychological support sessions we offer continue on a weekly basis. Social and medical case management periods depend on the person’s needs.

Do you think that it is possible to ‘undo’ the effects of maltreatment? What else can be done to bring people back to ‘normal’?

Perhaps we might start with a few words on what ‘normal’ is. But this is a rather long debate, especially when it comes to the field of mental health. To put it roughly, the concept of ‘abnormality’ –more specifically in mainstream psychology and psychiatry- is closely related to how much a person can conform to the social norms. At this point we cannot speak of what is normal and what is abnormal independently from the political context.

So, instead of correcting the migrant survivors of torture in a way they would comply with the norms, we can only talk about providing them with a ground to share the marks they are left with, and to help reduce the effects of such an experience on their daily lives.

This certainly is a process that differs from one person to another. Because the conditions in the country of asylum, such as access to shelter, education and health services, the social relations, language barrier or occupational availabilities, are concrete and permanent facts in a migrant’s life.

‘However great a tree may be, she shall die if uprooted from her soil,’ says Yaşar Kemal in Memed, My Hawk (İnce Memed). Then it is of great importance whether the new soil in this very new land lets us spread our roots again after being uprooted from our own.

In the context of Turkey, I guess we can make out the extent people are welcomed here, or how deep and wide this land lets their roots in, from the recent news on hostile attitudes to refugees.

Let’s see whether it is possible or not to talk about more tangible recoveries in physical conditions. Success in physical rehabilitation can be defined as ‘the level of satisfaction of the realistic expectations of a person who has been adequately informed of her/his situation’. Here the realistic expectations on physical recovery is affected by various factors such as the context, the level of injury and diseases, the person’s socioeconomic status and priorities, and the sources available for treatment.

These factors also directly affect the level of success they can reach. For the context of Istanbul we see the socioeconomic statuses and priorities of the migrants as the main barrier. I mean, there are all those other problems that migration brings along, as I mentioned before. Even if all conditions are feasible, many people cannot come to the centre to receive services because they have to work for long hours. In order for the treatment to be a priority, first of all, the basic needs should be met. So in the present condition we firstly opt for relieving the symptoms and a functional rehabilitation, which means increasing the level of functionality. Further to that, of course, it is a must to offer services based on knowledge, patience and care.

‘In fact, we do know that what we do is not the solution to anything. This, after all, is just a momentary ‘breath’ taken at the level of ultimate human cruelty aiming at human.’

In Turkey there are about four million people who have fled from war. Can civil society organisations single-handedly keep up with all the needs, especially in the field of rehabilitation?

Should they? Perhaps this should be asked first. Is that only the role or duty of the civil society? Basically, our approach is to determine the need and to point to it, and then to provide support and services within our own capacities, but never to take the place of the existing system. And to share the experience and information we have obtained during this process, if possible. After that,to try to form this experience within the existing system. In order to share or communize the information, one of our goals is to write up what we have learned here, and maybe to produce a scientific outcome, if we can.

At this point, what are the main responsibilities of NGOs?

I think advocacy is important here: To talk about the needs of the migrant survivors of torture, the services that should be provided, the measures to be taken, and the effects of ill-treatment. There are so many things to speak about. Lest we don’t keep silent.

What would be your finishing words?

In fact we do know that what we do is not the solution to anything. This, after all, is just a momentary ‘breath’ taken at the level of ultimate human cruelty aiming at human. But we believe in and dream of a world in which such centres and such projects would not be necessary at all.

Tags: NEFES, ‘Breath’ project, ill-treatment, Citizens’ Assembly, migrant, Amnesty International, Human Rights Foundation of Turkey, Doctors Without Borders, torture, refugee, civil society highlights, Nefes Rehabilitation Centre

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