Case presentation of a tattoo-mutilated, Bosnian torture survivor
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16
SCIENTIFIC ARTICLE
Case presentation of a tattoo-mutilated,
Bosnian torture survivor
Utilising a community-based, multidisciplinary treatment network model
Ronnie D. Bower, Jr., MA, Lisa Pahl, MSW, & Michael A. Bernstein, MSW, LCSW*
Abstract of treatment modalities to assist survivors in
Torture is used to create fear, destroy individuals the healing process. Eitinger and Weisaeth2
and communities, and to suppress unwanted po- concluded after the establishment of the first
litical or religious views. The survivor of torture Rehabilitation and Research Centre for Tor-
often endures significant physical and psycho-
ture Victims (RCT), in Copenhagen, that
logical trauma. The basis for treating this trauma
“the therapeutic approach must be all en-
varies according to individual needs, community
compassing and include somatic and psycho-
resources, programme designs and cultural ac-
ceptance. The case presented here focuses on tor- logical therapy”. Many torture treatment
ture occurring during the Bosnian conflict of 1992 centres around the world recognise the need
and demonstrates how the utilisation of a com- for multidisciplinary approaches to treatment
munity-based, multidisciplinary network model and recovery. Bojholm & Vesti 3 stated that to
can be effective in helping survivors through the treat survivors, staff should have a compre-
recovery process. The unique circumstances of hensive knowledge base concerning torture
the study identify factors of imprisonment, rape, and its effects, as well as programmes de-
deprivation, physical violence and, particularly, signed specifically to serve torture survivors.
body mutilation through tattooing.
In recent years, there has been a notable
expansion in the number of torture treatment
Key words: torture, Muslim, rape, mutilation, mul-
centres in the United States. Made possible
tidisciplinary treatment, EMDR (Eye Movement
Desensitization and Reprocessing), plastic surgery by an annual appropriation from the US
Congress of USD 10 million via the US Of-
fice of Refugee Resettlement, and funding
Introduction from the United Nations Voluntary Fund for
Many countries today continue to practise Victims of Torture, there are now 33 such
torture on their own citizens.1 Since the Sec- centres in the United States.
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
ond World War, there has been an increased The Florida Center for Survivors of Tor-
awareness of the physical and psychological ture, a programme of Gulf Coast Jewish
effects of torture, resulting in the develop- Family Services in the Tampa Bay, Florida,
ment of treatment centres utilising an array region, is the only such treatment centre in
the very populous state of Florida. Unlike
most other centres around the world, it uti-
*)
Gulf Coast Jewish Family Services lises a community-based network model that
14041 Icot Boulevard focuses on the delivery of multidisciplinary
Clearwater, FL 33760
services and network training. The Florida
USA
mbernstein@gcjfs.org Center is a programme “without walls,” of-17
SCIENTIFIC ARTICLE
fering services in the communities in which Women were raped in a number of dif-
survivors live through a network of partner ferent contexts during this war. Soldiers raped
resettlement agencies providing assessment women and girls in their homes, in front of
and case management, and a cadre of volun- their community members and families, and
teer and low-cost mental health professionals, took them to converted camps, where they
psychiatrists, psychologists, physicians, attor- were systematically and repeatedly raped by
neys, interpreters and other providers. As of multiple soldiers, sometimes resulting in
February 2004, the Florida Center was ac- pregnancy. In rare cases, body mutilations
tively providing treatment services to 200 sur- through tattooing and scarring, in conjunc-
vivors from 15 countries. With a large Bosnian tion with physical and sexual violence, have
refugee population in the Tampa Bay area, the been documented.8 According to Helsinki
Florida Center has received a number of refer- Watch, the perpetrators use rape to humili-
rals and has assisted survivors with medical, ate the victim and insert fear into the com-
psychological, legal, transportation, housing munity, such that the victim and others from
and social services support. The programme the same ethnic group would flee the area.8
demonstrates how the utilisation of a com- Because of personal feelings of shame,
munity-based holistic network model can be and the survival mode that people living in
effective in helping the survivor through the wartime must adopt, many women did not
recovery process. The unique circumstances tell their family or others about their rape
surrounding the case presented here identify victimisation. The women who were raped
factors of body mutilation through tattooing, and impregnated by perpetrators were espe-
imprisonment, rape and physical violence. cially stigmatised and blamed for their vic-
The high occurrence of rape during the timisation.10 As the soldiers or civilians com-
Bosnian conflict has been well documented. mitting the rapes were not held accountable,
Because of enormous discrepancies among victims did not report the violence.8 How-
reports, it is difficult to say how many indi- ever, the women who did admit to being raped
viduals were raped. The Bosnian government often were used by a government to enrage
originally stated in 1993 that there had been their ethnic members to retaliate against the
50,000 to 60,000 Muslim women raped,4 perpetrators as an ethnic group.6,10 Further,
however, other sources state this number has the victims of rape were left on their own to
been inflated by the European and American deal with psychological and physical scars,
media.5-6 While Muslim women and girls mostly without the assistance of treatment.
were the most common targets, most sources Women who were raped during the Bal-
agree that victims of rape during the Bosnian kan conflicts had to deal with the symptoms
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
war included all ethnic groups.7 Helsinki that often result from sexual violence, along
Watch8 asserts that, “Each of the parties to with the added trauma of living in a war-
the conflict in Bosnia-Herzegovina have used stricken area. Nikolic Ristanovic11 quotes a
rape as a weapon of war” (p. 21). Rape was victim of war, stating, “Violence against
even used as a weapon of war within an women in war involves rape, their children
ethnic group, such as Serb on Serb or Mus- being killed, their families destroyed, strug-
lim on Muslim.9 Ethnic groups became gling for survival, suffering mental damage,
blurred when households consisted of two harassment and extortion as refugees, irre-
ethnic groups because of mixed marriages spective of their religion” (p. 32). The chronic
between Serbs and Muslims. exposure to torture often carries with it deep-18
SCIENTIFIC ARTICLE
rooted physical and psychological scars.12-13 She stated that she was being punished for
It is with this emotional and physical pain the person whom she had fallen in love with.
that some of these individuals become re- It was very difficult for Fatima to discuss
fugees and flee to a place of safety. her past trauma. She became overwhelmed
with emotion as she described the most hor-
Case study rific violation that she had experienced. One
Fatima is a 44-year-old Bosnian female. She night, a group of soldiers randomly selected
had arrived in the United States with refugee her as their victim and began their sexual
status after living in Germany for eight years assault. During this violation, she became
with her husband and children. She pre- aware that something was different about
sented with multiple physical and psycho- this night. The circumstances of the assault
logical symptoms. While in Bosnia, she was quickly began to change. The soldiers who
targeted as a Muslim woman by Muslim were attacking her began to hold her down
soldiers, due to her marriage to a Serbian. and a new pain was introduced. As she
Fatima explained that her town had been sub- looked down, the soldiers had begun tattoo-
jected to several surprise visits by soldiers, ing and scarring parts of her body. She felt
and that her neighbours had been taken, that these soldiers had decided that the pain
beaten, raped and imprisoned for days at a and humiliation of rape alone would not be
time. Individuals living in mixed marriages, enough, and they wanted her to suffer as much
Muslim and Serbian, were targeted repeat- indignity as possible by placing a physical re-
edly, she explained. This caused a heightened minder of this ordeal on her body. By plac-
arousal and fear among those individuals liv- ing their Muslim names on her body, they
ing within her community. scarred and marked her, proving to her com-
One night, Fatima and her husband were munity that this could happen to anyone.
awakened by soldiers who ordered them at They continued to beat, rape and tattoo her
gun-point to get dressed and follow them. throughout that night. In the morning, when
The soldiers separated the couple. She ex- she looked at her breasts, arms and shoulders,
plained that after her abduction, she was she saw the names of the soldiers who had
plagued with concern for her family’s safety. attacked her, forever embedded in her skin.
She was taken to a school gymnasium that After almost three weeks of imprisonment,
had been converted into a temporary camp the soldiers released her. They had inflicted
that housed many other women of varying not only psychological and physical torture,
ages. She was held captive for 20 days, dur- but had left her with a daily reminder of the
ing which time her concern for her family torture she survived. The reflection of her
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
grew. She was given very little food or water own image now brought haunting memories
and reported being beaten repeatedly. While of her imprisonment. She painfully explained
imprisoned, she witnessed nearly every woman that after the day of her tattooing, she felt
being dragged into areas of the room, and her life had ended and she merely existed day
repeatedly raped and beaten by groups of to day.
soldiers. She painfully explained that she, Upon her release, Fatima reunited with
too, had been victimised by five to six groups her husband and family to find them safe.
of men repeatedly during her imprisonment. Her husband had been detained for several
The effects of violence were heightened as she days, then released. She revealed her ordeal
felt betrayed by her own religious brothers. only to her husband and took great pains to19
SCIENTIFIC ARTICLE
hide the tattoos from her children. At this terest in activities including sex, difficulty
point, the family realised that for their sur- feeling safe, sensitivity to stimuli and night-
vival, they had to leave their life, their loved mares. She was able to provide brief back-
ones and their country. Shortly afterwards ground information, but past torture was
they fled to Germany. not easily disclosed until later sessions. Fa-
Fatima discussed her time in Germany tima was able to disclose that she had been
very little, but explained that she did receive raped and tattooed by her assailants but
medical and psychiatric assistance while there. was initially unable to give more concrete
She visited her psychiatrist one time per details. Physically, she appeared withdrawn
week for six years and received tranquilliser and ashamed. She failed to make eye con-
injections two times per week during the three tact, exhibited declined posture and spoke in
years preceding her arrival in the United a quiet tone.
States. She explained that her family was safe, Fatima’s case was then assigned to a case
but the constant reminder of her torture manager who had previously been a physician
caused her significant psychological pain. in the former Yugoslavia. She quickly ap-
The depressive symptoms she endured while peared at ease with this staff member, was
in Germany became unbearable as she lost able to disclose more detailed information
hope for recovery. She had twice attempted regarding her past torture and openly di-
suicide while in Germany by overdosing on scussed her medical needs with him, although
medication but had been found in time by she continued to become upset during di-
her husband both times. scussions. She explained that she still cried
Soon after arriving in the United States, every day, that her husband and children rec-
Fatima was referred to Gulf Coast Jewish ognised when she was not feeling well and
Family Services’ Florida Center for Survivors that they allowed her time alone to cry. She
of Torture by the agency that had assisted felt very fortunate that her husband did not
with her family’s resettlement process. The apply pressure on her to disclose past mem-
primary reason for referral was for psycho- ories and allowed her personal time.
logical assistance. Fatima also presented with Fatima initially expressed concerns over
medical concerns at the point of initial re- her medical conditions and stated she had
ferral. She was willing to participate in the not seen a physician for her pre-existing
intake process and disclosed background in- medical conditions since arriving in the
formation to the intake worker and female United States, which included being treated
interpreter in the absence of her family for “heart problems” in Germany for five
members. Inquiries into Fatima’s emotional years and an ulcer for six years. She min-
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
stability were made during intake; however, imised her heart condition and stated she
detailed questioning of past trauma was not had taken medication in the past for chronic
made as she was not yet ready for this ordeal. bronchitis, high blood pressure, anxiety,
She had no current suicidal ideation, but de- depression, heart irregularities and ulcers.
pressive symptoms were observed. The re- She had also undergone surgery five years
cent move to the United States, paired with prior to arrival, in which her uterus had been
her traumatic past, increased her psychologi- removed owing to a large tumour.
cal symptoms. She reported weight loss, no With rapport well-established with staff
appetite, body pains, difficulty concentrat- from the Florida Center for Survivors of
ing, memory problems, fatigue, loss of in- Torture, a master service plan that encom-20
SCIENTIFIC ARTICLE
passed all services to be delivered was quickly placed on antidepressant/anti-anxiety medi-
developed. Mental health needs, as well as cation. Individual therapy sessions through
medical and social service needs, were clearly an interpreter were then provided weekly,
defined as target areas to focus on during which used conventional talk therapy with
the treatment period. The Florida Center a cognitive-behavioural focus. Fatima com-
immediately began making community link- pleted each scheduled session for six months.
ages to needed medical facilities to address Prior to beginning her mental health
areas of concern. The Centre was able to treatment, the Florida Center for Survivors
locate area physicians to provide appropriate of Torture began to consider ways to reduce
screening and diagnosis, and medication for her flashbacks. Staff discussion turned to re-
her heart, blood pressure and ulcer condi- moval of her tattoos by plastic surgery. Staff
tions. Consistent interpretation was provided discussed Fatima’s case with a local plastic
at each appointment. During medical treat- surgeon, and a plan was formulated to pos-
ment, Fatima’s trust level grew, and discus- sibly remove the tattoos. The plastic surgeon
sions began concerning other needs. provided free consultation to Fatima and
She continued to exhibit severe Depres- discussed the number of procedures that
sion, Post Traumatic Stress Disorder (PTSD) would be necessary to remove the tattoos.
and Generalized Anxiety symptoms. Mental Fatima discussed her past abuse with much
health treatment had been ongoing for many ease and was willing to have photographs
years prior to her arrival, but she explained taken as part of her record. The plastic sur-
that the treatment had merely allowed her to geon was very moved by the circumstances
maintain her daily functioning. Staff began surrounding the case and offered his services,
discussing treatment strategies that were staff and facility for free. Considerable time
available within her community. Fatima ex- was spent in the preparation for all aspects
pressed that her mind had psychological scars of the surgery. Discussions took place with
while her body housed physical scars. The Fatima concerning the exact details of each
bruises and soreness had long healed, but the procedure and that laser surgery was to be
tattoos remained forever. These scars were utilized as the primary method for tattoo re-
her daily reminder, her flashback triggers moval. The laser had to be tested on Fatima
that kept her grounded in the past. to assure it would be successful. (Laser treat-
Fatima was, nevertheless, open to receiv- ment for the removal of tattoos has varying
ing mental health services. Her case manager degrees of success depending on the laser
utilised another Gulf Coast Jewish Family wavelength used, the colour of the tattoo and
Services programme funded by the US Of- the composition of the ink.) 14
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
fice of Refugee Resettlement, the Refugee This was completed and the first session
Mental Health Training and Consultation was scheduled. Fatima showed few signs of
Program, which trained mental health pro- apprehension concerning the tools used to
fessionals in refugee mental health issues remove the tattoos and was comfortable in
and linked clients to needed community the hospital setting. She completed the first
mental health services. The programme ar- laser surgery, and upon awakening, became
ranged for Fatima to be seen by a trained overcome with joy as several of the images
staff member at a local community mental were either completely removed or had
health centre that would provide medication faded significantly.
and individual therapy. She was immediately Surgery proved to be a turning point21
SCIENTIFIC ARTICLE
in her mental health treatment and her de- approach was described to Fatima, and an
pressive symptoms began slowly to subside. appointment was scheduled with a trained
Laser surgery was paired with continued and certified clinician. The first session was
psychotropic medication, and individual scheduled approximately three months after
therapy further improved her level of func- the first laser surgery and mental health ap-
tioning at home and in her community. She pointments.
began to discuss employment possibilities After two EMDR sessions, Fatima de-
and going out of her home more often. Two scribed that her nightmares and anxiety had
more laser surgeries followed over the next lessened, as had her preoccupation with tor-
three months. After the third laser surgery, ture memories. After three more EMDR ses-
all tattoos were either removed or unrecog- sions, which concluded the treatment, she
nisable. A fourth laser surgery was com- reported a significant reduction in recurrent
pleted with attempts to remove the more em- thoughts and trauma symptoms, while still
bedded blurs of grey. Fatima began wearing continuing with her other cognitive-behav-
shorter sleeves and expressed more freedom ioural mental health appointments. Coun-
with her body image. She was not afraid to selling sessions now were focused more on
let her children see her arms. She continued adjustment issues surrounding life in the
to express gratitude to the surgeon and was United States. Her scheduled appointments
pleased with the physical results, yet contin- became less frequent, with individual ther-
ued to have nightmares and flashbacks con- apy being scheduled one time per month,
cerning her torture. then eventually as needed.
Fatima explained that the emotions sur- At this time in Fatima’s treatment, she
rounding the memories had improved, but now wished to focus on employment, and
recurrent episodes were still present. This asked for assistance in finding a job that
led staff and clinical consultants to advise an matched her skill level. Staff assisted with ad-
additional approach, Eye Movement Desen- vocacy and linkages to appropriate services,
sitization and Reprocessing (EMDR), which and Fatima soon began working for a large
had proven helpful in other traumatised in- hotel chain. She enjoyed her work, took
dividuals. (Numerous studies, including con- great pride in accomplishing her tasks and,
trolled studies, have shown the effectiveness as evidence of her success, desired to work
of EMDR for PTSD. Additionally, practice more hours than originally scheduled. Fur-
guidelines of the International Society for ther social service needs were met during
Traumatic Stress Studies assess EMDR as the first six months of services that included
an effective treatment for PTSD.)15-19 helping with landlord disputes, housing ad-
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
The originator of EMDR, Francine Sha- vocacy, cultural training on housing issues,
piro, describes it as “a time-efficient, com- transportation arrangement and training,
prehensive methodology – backed by posi- medication compliance and advocacy, food
tive controlled research – for the treatment bank assistance, interpretation needs, and
of the disturbing experiences that underlie family support assistance. Fatima also was
many pathologies. An eight-phase treatment enrolled in a unique programme that assisted
approach that includes using eye movements refugees in matching money saved toward
or other left-right stimulation, EMDR helps large purchases such as a home, car or com-
victims of trauma reprocess disturbing puter. Her enrollment in the programme,
thoughts and memories”.20 This treatment paired with her future planning, further ex-22
SCIENTIFIC ARTICLE
emplified a regaining of hope and a con- This was evident in her willingness to expose
tinued decrease in psychological symptoms. her arms more frequently and her feeling
After eight months of treatment and more open to her family members.
services coordinated by the Florida Center Fatima continued to report PTSD symp-
for Survivors of Torture, Fatima was able to toms even after receiving antidepressant me-
significantly decrease her need for mental dications, attending traditional talk therapy,
health and social services, but continued the completing further tattoo removal proced-
monitoring of her medical conditions. Fa- ures and cognitive-behavioural therapy. It
tima also had been discussing the possibility was not until a volunteer therapist provided
of removing the faded tattoos that were too EMDR therapy that the client reported a
deep to be removed by laser surgery. This significant decrease in PTSD symptoms. The
procedure would entail actually cutting out combination of psychotropic medication, tra-
the tattooed areas. Fatima is currently debat- ditional talk and EMDR therapies provided
ing whether or not to follow through with this a holistic approach to mental health treat-
procedure. ment that gave Fatima coping skills to re-
duce her PTSD and depressive symptoms
Discussion to functional levels.
There were a number of individual variables There often are many barriers to access-
that increased the likelihood of Fatima re- ing mental health treatment for torture sur-
ducing her depressive, anxiety and PTSD vivors, including stigma, cost, transportation
symptoms. The Florida Center was able to and available providers.21 Utilising a holistic,
provide her with a case manager who was a multidisciplinary medical, psychological and
former physician who spoke Serbo-Croatian. social approach, and with considerable pre-
Because he was a physician, Fatima felt more paratory work, Fatima was willing to become
comfortable in his presence. He also was able able to participate in an array of services.
to help prepare her for her medical proce- With patient, supportive and culturally sen-
dures. Extra effort was taken in preparing sitive assistance, Fatima became eager to en-
her for the tattoo removal surgeries, with the gage in services that others within her cul-
knowledge that the removal itself could trig- ture often see as outside societal norms.
ger her back to the traumatic event. Also, We encourage those treating torture sur-
consistent interpreting with the many diffe- vivors to look at all dimensions of a person’s
rent service provider agencies throughout her well-being in order to assist them in achiev-
treatment resulted in an improved comfort ing their maximum level of functioning. A
level treatment. The relationship between holistic approach utilising existing commu-
T O R T U R E Vo l u m e 1 4 , N u m b e r 1 , 2 0 0 4
Fatima and the case manager played an in- nity resources was essential in Fatima’s suc-
tegral role in the healing process, as rapport cessful treatment. Through community net-
had been easily established and maintained. working and advocacy, treatment profession-
After the first tattoo removal surgery, als may be able to identify and recruit low-
Fatima reported a decrease in depressive cost, pro bono and additional services that
symptoms and an increase in her self-esteem, are enormously helpful to clients served. The
stating, “I feel that my life is now beginning authors have found that area network pro-
again.” Removing the physical reminder of viders typically are eager to receive training
the horrific event was a definitive way for on dealing with survivor issues and tech-
Fatima to gain more control over her life. niques, and often are willing to accept new23
SCIENTIFIC ARTICLE
referrals, given the support from staff from a rape and the reporting of rape in Bosnia-Her-
torture treatment centre. zegovina, 1992-1993. Dialogue (Berkeley, CA),
No. 21, March 1997.
7. Amnesty International. Bosnia-Herzegovina: rape
Conclusion and sexual abuse by armed forces. New York, 1993.
Fatima’s case particularly illustrates the im- 8. Helsinki Watch. War crimes in Bosnia-Herzego-
vina, Vol. II. New York: Human Rights Watch,
pact that torture-induced disfiguring through
1993:7-29.
tattooing can have on self-esteem and social, 9. Holbrooke R. To end a war: the inside story, from
psychological and interpersonal function. Sarajevo to Dayton. New York: Random House,
Further, EMDR, as a technique to reduce 1998:334-5.
10. Albanese P. Nationalism, war, and archaization of
psychological symptoms of PTSD, proved gender relations in the Balkans. Violence Against
effective. Through the support provided by a Women 2001;7:999-1023.
community-based multidisciplinary network 11. Nikolic-Ristanovic V. Women, violence and war.
Budapest: Central European University Press,
model for treating torture survivors, treatment
2000:20-32.
was able to successfully meet the varying needs 12. Somnier F, Vesti P, Kastrup M, Genefke IK. Psy-
of the client, addressing both the physical cho-social consequences of torture: current
and psychological sequelae of torture. knowledge and evidence. In: Basoglu M, ed. Tor-
ture and its consequences: current treatment ap-
Through consistent service delivery, the proaches. Cambridge: Cambridge University
training of network providers on torture Press, 1992:57-71.
treatment issues, comprehensive and special- 13. Skylv G. The physical sequelae of torture. In: Ba-
ised mental health treatment and medical in- soglu M, ed. Torture and its consequences: cur-
rent treatment approaches. Cambridge: Cam-
terventions to remove disfiguring tattoos, the bridge University Press, 1992:38-53.
client was able to significantly reduce symp- 14. Hodersdal M, Bech-Thomsen N, Wulf HC. Skin
toms and increase her level of functioning. reflectance-guided laser selections for treatment
of decorative tattoos. Archives of Dermatology
Finally, given the paucity of literature related
1996;132:403-7.
to the sequelae of tattooing as a torture 15. Davidson PR, Parker, KCH. Eye movement de-
method and subsequent treatment, addi- sensitization and reprocessing (EMDR): a meta-
tional descriptive and other research is analysis. Journal of Consulting and Clinical Psy-
chology 2001;69:305-16.
needed in this area. 16. Ironson GI, Freund B, Strauss JL, Williams J.
A comparison of two treatments for traumatic
stress: a pilot study of EMDR and prolonged ex-
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