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Subjects seeking refuge and in subsidiary protection who have been tortured: paths for care and processes for human development

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Laura Arduini Monica Lammoglia Silvia Landra


In Italy the Ministry of Health, with a comment dated March 23, 2017, transmitted the final version of the "Guidelines for planning assistance and rehabilitation interventions as well as for the treatment of psychological disorders of refugee status holders and subsidiary protection status holders that have beeen subjected to torture, rape or other serious forms of psychological, physical or sexual violence" in implementation of the Legislative Decree 18 of 20141. In this way the results of three years of work of a Ministerial Technical Table which saw the participation, among others, of the United Nations High Commission for Refugees (UNHCR), the Ministry of Health and Home Affairs, the State-Regions Conference with representatives of numerous Italian regions, the Caritas of Italy, are officially collected in a useful synthesis. In fact there are many and various subjects called to join forces to give centrality and operational precision to the management of a phenomenon that, seen in its complexity, represents a health emergency, serious and substantial - in the etymological sense of a reality coming out of the submerged.

There is no shortage of critical remarks, by those who for example state that "the purpose of the guidelines seems to reinforce what someone in medical anthropology calls the empire of trauma, that is, an analysis of trauma as a category that creates health policies that focus on the body, irrespective of its social, historical, cultural and political dimension2" and however it seems to us that we should welcome an articulated effort to offer systematization to the issue of the treatment of tortured people, with multidisciplinary attention and an explicit invitation to move swiftly and competently not only in private-social contexts, but in a socio-health network of public services that includes interaction with all subjects that deal with refugees.

According to data from the UNHCR3, 65.6 milion people worldwide are forced migrants, obliged to flee from their country for political, economic or social reasons. It's an unprecedented number, steadily increasing in recent years. Of these, about 22.5 million are refugees, or persecuted according to the definition of Article 1 of the Geneva Convention4, more than half of which are under the age of 18. At a global level, with a world population of 7,349 billion people, these numbers mean that 1 person out of 113 is today an asylum seeker, an internally displaced person or a refugee. In all, the number of people forced to flee is higher than the population of France, the UK or Italy. In recent years, the number of migrants has increased steadily in Italy and among them the share of international protection applicants. We are the third country in Europe, after Germany and Sweden, for the number of asylum applications. According to the most up-to-date report available5, in 2015 asylum seekers in our country were 83,970.
If by torture we mean "physical or mental suffering inflicted deliberately, systematically or arbitrarily by one or more persons acting alone or on orders from an authority to compel another person to provide information, to confess or for any other reason"6, it is not difficult to understand the extent of the phenomenon of torture and its painful consequences for the individual and the community in a global context where a large refugee population in fact run away from war, persecution, ethnic cleansing, bloody dictatorships, or all contexts that make torture an ordinary tool of repression, control and abuse of power.
Although it is not easy to provide the exact number of people who are systematically subjected to physical or psychological violence, it is intuitive to say that a significant percentage of refugees are victims of more or less severe forms of torture.
Torture is the systematic imposition of pain: Amnesty International's research has shown how beating up someone is largely the most popular method of torture in more than 150 countries. The beatings are inflicted with punches, rods, the butt of a gun, improvised whips, iron pipes, electric wires. The victims suffer from bruising, internal bleeding, fractures, even injuries to vital organs and death. Rape and sexual abuse of prisoners are widespread. Among other common methods of torture are electroshock (found in 40 countries), suspension of the body (in 40 countries), beating the soles of the feet (over 30 countries), suffocation (over 30 countries), mock executions and death threats (over 50 countries) and detention in prolonged isolation (over 50 countries). Other methods include immersion in water, extinguishing cigarettes on the body, deprivation of sleep and sensitive functions.
This disheartening list - which raises horror in the writers and we imagine in the majority of the readers and citizens - is an incitement to consider the subject of this article not just a matter that relates solely to clinicians, to the organization of new healthcare services, to the work of competent, multidisciplinary teams, to the proper handling of a phenomenon that generates psychopathology and socio-economic hardship, but rather an ethical and anthropological question among the most delicate, concerning human dignity, the indisputable rights of each one, the essential conditions for defining oneself human and civil, in every country of the world.
Di Cesare writes that "surviving torture is not like surviving an illness, an anonimous accident, an external adversary. Suffering is more acute and difficult to bear because it is inflicted by other human beings with awareness. That is why torture is a trauma that lacerates the victim intimately, it undermines the relationship with the world, leaving scars, visible or not visible, that have difficulty in healing for a long time". Paul Rocoeur (1989) reiterates "the physical aspects of torture must not mask its real nature, that is, mental destruction, devastation of the personality through the loss of self, in short, the purpose of a humiliation sometimes worse than death".
Significant evidence of torture trauma and endless series of secondary trauma episodes mean not only a huge number of sick people to care for, but are the sign of a barbarization of civilization, of an impoverishment of cities, even the richest and most "advanced". We believe that treating the traumas of torture inevitably takes care of our deficits in humanity.

Legislation references

When we speak of asylum, we refer to one of the fundamental rights, which is therefore regulated by international law, for us by European conventions and the legislation that each state gives in turn, in this regard.
The main legislation for reference in international law is the Universal Declaration of Human Rights, sanctioned by the United Nations General Assembly in 1948 and the subsequent "Convention concerning the Abolition of Slavery" signed in Geneva in 1957. In 1984, the United Nations Assembly issued the "Convention against torture and other punishments or cruel, inhuman, or degradating treatments."
In the European context, we refer to the "European Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR)" signed in Rome in 1950, article 3 declaring that "no one can be subjected to torture or inhuman or degrading punishment " and the "European Convention for the Prevention of Torture and Inhuman and Degrading Treatment and Punishment" signed in Strasbourg in 1987.
In order to meet the need to ensure more adequate protection for those who are fleeing from armed conflict or generalized violence, in Italy, from 2014 the Legislative Decree6 was applied which provides for the recognition of a system of reception and protection for "holders of refugee status and subsidiary protection status who have been subjected to torture, rape or other serious forms of psychological, physical or sexual violence". Particular attention is given to the issue of the certification of the torture suffered, a process requiring relational delicacy along with high medical expertise, and to the importance that recipients of care are not only those who have recognized refugee status, but also asylum seekers and those who are awaiting bureaucratic times to revisit their application after a denial. In the case of a vulnerable person (minors, disabled people, elderly people, pregnant women, single parents with children, people with important physical illnesses or certified mental disorders, etc.) the application must be assessed on a priority basis, so that any process of care and treatment can be started immediately.

Timely intervention and prolonged trauma

Numerous accredited studies on psychic trauma support the importance of early intervention to prevent the development of even serious psychopathological problems. As a preventative measure, whenever possible, crisis units with psychological competence can be set up intervening in a timely manner at the site of an accident, an attack, a natural disaster with numerous dead and injured. It is noted that an immediate psychological intervention, with the possibility to immediately externalize and share painful emotional states, may be protective against the risk of developing Post Traumatic Stress Disorder (PTSD), an insidious, painful, pervasive clinical condition, that involves the appearance of anxiety-depressive, psychotic-dissociative and neurological contexts. Characteristics of PTSD are impressive symptomatic reactions (such as a panic attack, but also distressing flashbacks or real and true dissociative states) in relation to even weak stimuli that have the power to evoke the drama experienced.
Some authors offer an analytical reading of the various stages of multidimensional, prolonged trauma regarding the condition of forced migrants7,highlighting three stages of exposure to repeated traumatic events: premigratory phase, related to the context of origin (war-related violence, environmental disasters, threats and torture, persecution, abuses, forced imprisonment, deprivation, disappearance and death of loved ones, loss of affection and economic and social position), a migration phase linked to flight and travel (forced and sudden departure, refugee camps, dramatic journeys with malnutrition, untreated diseases, death of fellow travelers, exploitation and violence, detention in transit countries, rejections) and a third post-migratory phase concerning the context of the host country (rejections, forced returns, risk of detention, abrupt change of habits and lifestyles, unemployment, makeshift shelters, social marginalization, stigma, deterrence policies with barriers to access to services, complexity of bureaucratic procedures).
The traumatic chain is even longer than you might think if we consider the effects of trauma to be transmitted to the next generation. Also on this aspect we have several extensive studies. Rachel Yehuda, Director of the Traumatic Stress Studies Division, conducted a study on the children of Shoah survivors, whose parents had developed a Post Traumatic Stress Disorder: in the group of children there was a dysregulation of the hypothalamus-pituitary-adrenal axis which resulted in a slowing down of the cortisol plasmatic metabolism, alterations in circadian rhythm and increased reactivity of glucocorticoid receptors. These modifications thus suggest an intergenerational transmission of trauma with increased prevalence in children of neuroendocrine disorders and with the possibility of onset of PTSD, anxiety and depression.
Further studies have been conducted on children born to women who were present at the World Trade Center and who were pregnant during the September 11 attack: even in this case there has been a reduced production of cortisol in the baby and, at an epigenetical level, a methylation of the FKBP5 gene resulting in dysregulation of arousal and hense a minor resilience of the individuals to stress. It follows that the second generation is most likely to develop PTSD.
The Guidelines on the treatment of tortured people speak of "exhausted migrant effect"8, referring to asylum seekers who arrive in our country after having suffered multiple traumas and who already have a high degree of physical and mental suffering. "The reactive stress towards the violence suffered can also lead to a series of psycho-neuro-endocrine-immunological reactions in the victims, causing an increase in susceptibility to infections and chronic diseases.""9.
So these are subjects with whom we can hardly ever speak of timely intervention on the trauma because they come to us in observation after months and years of anguish in the country of origin or in stalemate countries like Libya.
There is, however, the possibility to act as soon as possible to tackle the repetition of trauma associated with the journey to Europe and to prevent any further insult that may result from the impact with our country.
While not working in the context that welcomes migrants at the time of their first arrival,10 but in a second reception place for vulnerable migrants (some welcomed in the SPRAR11 programme for Mental Distress, others outside of any national reception circuit present themselves spontaneously at our Foundation), we dedicate special energy to them, so that the migrant guest finds first of all a welcoming context of familiarity and recognition.
The first phase, lasting even several months, does not foresee structured talks or insights into their stories, unless they explicitly requests it. It focuses primarily on basic needs, on paths for legal regularization, on giving care and relief to physical and psychic symptoms, to foster gradual knowledge of the context, on learning the language, and the search for personal time and space as far as the structure allows, on the "choice" of some people for reference among the operators and volunteers with whom to develop a more confidential relationship. A young Iraqi, only after a kidney transplant and a few months of convalescence in our house, one day felt the necessity, or perhaps finally saw the possibility, to give one of us a long and detailed narrative about the violence suffered.
The impossibility to use, in a first moment of welcoming, words to tell about oneself (for fear and embarassment, but also because of the language barrier) gave rise to the creation of experimental and creative paths to facilitate communication, such as an art workshop on "self-portraits" aimed at young migrants or a space for women to meet and sew on fabric the story of the migratory journey, creating a tapestry made of many strips with symbols and colours that talk of the hardships of the escape route.
Sometimes symptoms occur even after a long time: a Ghanese boy, who a few weeks after his arrival in Italy had the opportunity to undertake psychotherapy with practitioners experienced in dealing with the delicate issue of the tortures undergone, at a specialized service in Milan, he then spent more than a year with us in a situation of relative well-being, acknowledging a restored calm and desire to live, establishing significant relationships with some volunteers and reaching a stable position as a carpenter. Suddenly he had panic attacks while carrying out a job, he developed an obstinate insomnia associated with the fear of not being efficient at the workshop and began not eating regularly, losing weight. Extensive discussion caught the re-emerging of the dramatic experience of torture he endured even with metal objects, probably recalled by the use of some work tools. The timeliness of the intervention that we try to offer translates into the readiness with which the signs of suffering of the subject are collected and the proposal of personalized tools to deal with them.
Not infrequently it is the crises that determine the entry into a second stage of the course: the management of the emergency opens up the possibility of a deeper dialogue with some operators for reference, in some cases psychotherapy is offered with a defined setting, extreme availability to listen is offered to all. We often witness, in people who have suffered torture or violence, the strenuous transition from distrust to trust. It happens many times that the subjects concerned, to an explicit question, answer that they can not trust anyone, that they have to imagine betrayal in any person encountered, even in who appears more helpful and "foreign to politics".
The third stage of the journey covers the steps necessary to enable a decent living for every migrant in the social fabric. It involves housing and work but also a significant network of relationships.

Multidimensional and competent intervention

The guidelines focus on the suitability of the reception spaces, the value of the relationship between operators and those who have suffered torture and the importance of an integrated multidisciplinary approach. These are not new concepts for those working in the social and healthcare field. The real novelty is the application in practice of this approach, without exception for forced migrants and victims of torture. Four macro-areas are mentioned which necessarily have to interweave goals and competencies to provide an effective response of quality: Social Area, Health Area, Legal Area and the Area of Mediation. It is stated that "there is no standard model, nor is there a predetermined set-up. Certainly, taking into charge torture victims poses the need to integrate functions, and therefore heathcare, social and legal professionalism and to coordinate activities also in relation to the services of the territory"12.
Based on our welcome and care experience, we believe that the linearity of this affirmation may be confirmed if certain criteria, for us successful, are met:
• spatial contiguity in offering different types of answers, at least in the early stages of the intervention. Indeed, as in the model of the "health homes"13 provided by national health legislation, it is crucial that migrants can recognize a place that is well integrated in the territory, in which they can find, for all the problems that they have, networks of answers"14 respectful of the complexity, without having to go through an exhausting bureaucratic process through the streets of the city;
• the articulated and transversal competence of operators of each area: doctors who know the law, lawyers who know how to deal with vulnerable people, social assistants, experts in many areas, educators who pay attention to transcultural policies and dynamics, etc...;
• the customization of projects and paths. Each person must be considered for the singularity of their own history and their own needs. A standard time of permanence, or a sequence already decided at the answer table, is not applied to anyone;
• the timeliness of response, both in an emergency, as obvious, and in the face of a new need or of a potential hidden by the subject at first, together with an appropriate ability to reorganize and find creative solutions to new demands, overcoming the limiting "we usually do it this way";
• flexibility of forms of acceptance, especially for very fragile and vulnerable people, allowing them to move rapidly from more monitored, community-based forms of life to residential forms that favour an ever-increasing autonomy, but are ready to understand relapses and regressions. It is not rare for very fragile and seriously traumatized people to have setbacks in their path or major crises in stages where everything seemed to be progressing towards a consolidated well-being.
An important suggestion of the guidelines is aimed at the operators and the main topics of training of those who work with a delicate user like the one we deal with. Despite being of different professions - clinical, social, anthropological, legal and transcultural - each one must know topics pertaining to geopolitical instability and the violation of human rights in countries of origin and transit, to the dynamics of migration, the rights and duties of refugees, to the factors of resilience and vulnerability, the main forms of physical, psychological and sexual violence, to gender-based violence, to clinical aspects in psycho-traumatic settings, to the network of the socio-healthcare services15. This is the "core competence" which should ensure the adequate and uniform level of competence of the operators involved, for whom a significant space is devoted to discuss the risk of burn out. In our context, we strive to provide all operators with areas for individual contact with other more experienced operators in the event of difficulties and emergencies, offering a periodic group supervision with an educational, psychological and social cut. Some changes in role and task, are often favoured as something considered to be protective for the development of burn out.

Action to promote the central role of the individual and the community

In its atrocity torture is intended to silence the individual, to extinguish the person in his deepest dimension. The suitability of a rehabilitation path for those who, perhaps for years, have been isolated, harassed and reduced to silence, passes through the possibility of rediscovering a solid and defined sense of self and the ability to exercise a leading role in their own context of life. In our work in Casa della Carità we have identified four significant guidelines to enable subjects to "regain control of their own lives":
• the richness of the inner world, or the peculiarities of one's own person, the desires and aspirations, the need for care and the ability to seek help;
• vital relationships, or significant family relationships, amicable ones, dramatically interrupted relationships, newly established relationships, individuals who give help, institutional representatives with whom there is a dialogue, the desire to establish new relationships. Here the world of work is also considered as a reality that can not be avoided and an indispensable context of relationships;
• places for feeling at home, that is the most significant spaces in the current housing situation, the house that has been left, the one that is desired, the important places of the city and ones own itineraries in the city;
• the full use of citizenship, that is the recognition of ones rights, often denied and/or not fully understood, but also the identification of ones potential to be made available.
On these lines, we develop the plans for action with the guests, first in the form of proposal and discussion with the multidisciplinary team, then considering them as areas for verification of the path and, at a more advanced stage of knowledge and relationship with the guest, as arguements that the subject can propose at a time of confrontation that he himself requests. We call this form of intervention "round table", wanting to gradually enhance the prominence of the person, though still in a very fragile situation and needing support, in governing the helm of his own life.
Our guests can be very compromised both physically and psychically, and in this case they may avail themselves of the support of the operator or volunteer they feel most significant to be presented with their reflections during a "round table". Operators of reference for the person, institutional figures of the socio-healthcare network partecipate at this table, and also families and friends. The "round table" discussion starts from the desires and demands of the guest, that is from his own subjectivity. Hypotheses are evaluated for the first time, or aspects that have long been shared are verified. Everybody's opinions are heard and everyone is committed to developing the viewpoint of the person concerned. A road to go down is decided, and together timing and ways of verification are decided, postponing this to a new round table for the discussion. Overall, this experimental practice, introduced recently in this specific form of "table requested by the guest", collects the continuous efforts of not setting ourselves against the subject as holders of his life, custodians of his desires and knowing what is good for him reducing a delicate path of restitution of wellness and social life to a mere technical proceedure. It is an incentive for the person to come up with more energy and determination but it is also a serious provocation for the operators not to take the place of the subject, not to generate welfare dependency culture, to truly practice respect for the person and his desire.

Questions to think about and problems to be solved

Accompanying people who have suffered repeated trauma, torture and appalling violence is a tough and fascinating journey that opens up very demanding questions. The Ministry's guidelines provide some intervention proceedures recognizing for forced and tortured migrants the right to treatment and peaceful citizenship. However, the identification of good and dignified procedures is just the beginning of a question that must involve the whole citizenry with all its components. To reflect on the care of those who have experienced violence calls for focalizing on issues that concern the most vulnerable categories among them; women, children, mentally ill. These are the people with the least voice in question, often with the impossibility of recognizing and reporting what they have suffered. Many questions awaiting answers concern the connection between health and the violence suffered, also with a view of stopping the transgenerational chain of violence.
The central theme, from which challenging and crucual questions arise for continuing the reflection, concerns the role of the whole community, that is, the person who can understand, develop a new mentality, and generate inclusion in an environment that accepts and does not inflict further torture on people who have already been sorely tried. All efforts to inform and educate the civil community are gestures whose benefits are aimed at the most fragile and reverberate effectively on everyone.



• Améry; Jean (1993): Intellettuale a Auschwitz, Bollati Boringhieri, Turin
• Camilli, Annalisa (2017): "I medici che curano le ferite invisibili della tortura", Internazionale 25.07.2017
• Di Cesare, Donatella (2016): "Tortura", Bollati Boringhieri, Turin
• Dossier Statistico dell'Immigrazione 2016 Centro Studi e Ricerche IDOS
• Franchi, Maurizio (2014): "Europa ed immigrazione: un fenomeno complesso" Defense Information
• Geraci, Salvatore et al (2014): "Quando le ferite sono invisibili: vittime di tortura e di violenza. Strategie di cura", Pendragon, Rome
• Yehuda, Rachel (2002): "Post traumatic Stress Disorder" New England Journal of Medicine, 346: pp 108-114
• Yehuda, Rachel (2016): "Intergenerational effects of PTSD on offspring Glucorticoid receptor methylation", Epigenetics and Neuroendocrinolgy, pp 141-155
• Yehuda, Rachel et al (2015): " Holocaust exposure induced intergenerational effects on FKBP5 methylation", Biological Psychiatry pp 1-6
• Medici Senza Frontiere (2016) : "Traumi ignorati. Richiedenti asilo in Italia : un'indagine sul disagio mentale e l'accesso ai servizi sanitari territoriali"
• Mollica, Richard (2007) "Le ferite invisibili: storie di speranze e guarigioni in un mondo violento", Il Saggiatore, Milan
• Ricoeur, Paul (1989): Preface de Médecins tortionnaires, médecins résistants, La Découvert; Paris
• Ravazzini M. e Saraceno B. (2010): Governare confusioni urbane, Il Saggiatore, Milan
• "Guidelines for the planning of assistance and rehabilitation interventions and for the treatment of psychological disorders of refugee status holders and the state of subsidiary protection who have suffered torture, rape or other serious forms of psychological, physical or sexual violence." Ministry of Health, Rome 22 March 2017



Article 1, paragraph 1, lettera s) of Legislative Decree 18/2014 is implemented, amending article 27 paragraph 1-bis Legislative Decree 251/2007
2 Lilian Pizzi mentioned in
3 UNHCR 2016 Data Report for 2015
4 Article 1 of the Geneva Convention defines refugees as being "rightly afraid of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, they are outside the country of which they are a citizen and can not or do not want, because of this fear, to take advantage of the protection of this country, or else, not having citizenship and being outside the country where they were habitually resident after such happenings, are unable or unwilling to return because of the aforementioned fear"
5 Global Trends Report UNHCR 2016, june 2016.
6 Definition given by the Conference of doctors of Tokyo in 1975
7 Legislative Decree n°18, art.27. paragraph 1 bis, 21 February 2014
8 Danon M., Miltenburg A (2001) and Santone G., Gnolfo F (2008)
9 Ministry of Health, Guidelines for the planning of assistance and rehabilitation interventions and for the treatment of psychological disorders of refugee status holders and the state of subsidiary protection who have suffered torture, rape or other serious forms of psychological, physical or sexual violence, Rome 22 march 2017 , para 3
10 ibid
11 The writers work at the Fondazione Casa della carità of Milan, a place of welcome for homeless italians and foreigners resulting from the collaboration between Diocesi Ambrosiana and Comune, where numerous refugees are also welcomed. For information see
12 Asylum Seekers and Refugee Protection System
13 Linee Guida par 3.2
14 Livia Turco "Health Home, place for the recomposition of primary care and continuity of assistance" Intervention at the Ministry of Health, Rome, 22 march 2007
15 Saraceno 2007, Governing urban confusion
16 Guidelines Chapter 7


By the same authors:  Actions for the mental health of Italian and foreign seriously marginalized people within Casa della Carità's strategy  

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Center for urban suffering

The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


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