Distressing trauma cues can be internal (e.g. intrusive thoughts or memories of trauma events), or external, involving situations or activities that act as reminders of the trauma by way of their resemblance to various aspects of the trauma events. For example, medical investigations involving electrodes attached to the body (as in electrocardiography) may act as a trauma cue in torture survivors with an experience of electrical torture. Undressing for a medical examination may evoke dis- tress or fear in survivors with an experience of being stripped naked during torture. Swimming in pools or sea may be avoided in cases with suffocation experience resulting from submersion under water (or ‘waterbo- arding’). A woman with a history of rape may avoid sexual activity or physical contact with their partners or men in general. A job interview by an authorityfigure may evoke memories of brutal interrogations.
Trauma cues may also reflect secondary fear con- ditioning effects of the trauma. Various aspects of the original trauma setting, objects, sights, smells, sounds, tastes, or tactile sensations present at the time of the trauma may become associated with the trauma and act as reminders in other contexts or settings. We have seen a torture survivor, for example, who could not wear white socks, because their color acted as a reminder of the blank sheet of paper that she was forced to sign as confession to a crime she had not committed; her ‘confession’ was later typed on the paper. Trauma cues may also evoke fear by signaling further threat to safety. For example, a torture survivor may avoid crowded places for fear of coming across police officers, even when there is no realistic risk of re-arrest and further torture. The following questions are often helpful in identifying trauma cues and asso- ciated avoidance behaviors:
1. Do thoughts or memories of these events enter your mind against your will and make you feel so distressed that you have to make an effort to push them out of your mind?
2. Are there any situations or activities in your daily life that remind you of past events and make you feel distressed, anxious, or fearful?
3. Do you go out of your way to avoid any of these situations or activities either because they remind you of past events or because you think there is a danger of reliving the same events?
The first question is aimed at identifying intrusive trauma memories associated with distress and avoid- ance. The second question elicits information about anxiety cues associated with past trauma and the third one clarifies which of these cues are associated with avoidance behaviors. It is helpful to elicit information on as many trauma cues as possible and make a list of them. Various situations or events that triggerflash- backs could also reveal useful information about dis- tressing trauma cues. It is useful to bear in mind that stimulus generalization in the process of fear condi- tioning may lead to highly idiosyncratic examples of trauma cues in some cases (e.g. the torture survivor with avoidance of white socks). Hearing people speak English acted as a distressing trauma cue in an ex-Guantanamo detainee (who eventually decided to overcome such distress by taking English courses). Some survivors develop overt avoidances of various trauma cues, which are fairly easy to identify. However, more subtle and elaborate forms of avoid- ance may be more difficult to detect. Some survivors may have changed their life routines in subtle ways to avoid trauma cues. Others may divert their attention from distressing thoughts by occupying themselves with other activities. When trying to sleep, they may keep the TV on or listen to music just to interrupt the flow of thoughts into their mind. Some survivors rely on safety signals in executing certain activities. In cases with high levels of distress or fear, some form of avoidance is highly likely and further probing (e.g.“Is there anything you have difficulty doing now because of your fears or distress that you could easily do before the trauma events?”) might help identify them.
We should note here an assessment of trauma cues and associated avoidance behaviors may indirectly elicit information about the nature of trauma experi- ences. For example, avoidance of men in female sur- vivors may point to an experience of sexual abuse or
rape. Avoidance of electrical appliances may suggest an experience of electrical torture. If the survivor does not relate such experiences in detail, there is no need to probe into them. Some survivorsfind it easier to talk about their trauma as they recover from its effects later in treatment. As the trauma story unravels in treatment, it may reveal additional trauma cues that were not elicited in thefirst session. Thus, assessment of trauma cues is not limited to thefirst session. It is a process that continues throughout treatment. Two case vignettes are provided below from case studies (Başoğlu & Aker,1996; Başoğlu et al.,2004a) to illus- trate the nature of trauma cues and associated avoid- ance behaviors in survivors of torture.
Case vignette #1
A 23-year-old, single, female survivor was detained by the police and tortured for 20 days in the early 1990s. The purpose of the torture was to obtain information about political activist relatives and a confession incriminating various people. Torture involved verbal abuse, blindfolding, beating, stripping naked, hang- ing, electrical shocks to fingers and nipples, cold showers, sexual advances, several incidents of rape, insertion of a baton into the anus, submersion into water, forced ingestion of salty water, being led to believe she was going up a flight of stairs when blind- folded, threats of torture and death to family, expo- sure to bright light, and threats of further torture. On psychiatric examination she had full-blown PTSD. She was anxious, dysphoric, but not depressed. She avoided a wide range of situations or activities that either reminded her of her torture experience or evoked intense fear because of perceived threat of re-arrest and torture. These included the following: 1. Avoidance behaviors associated with generalized
conditioned fears:
* staying home alone
* sleeping in the dark
* going out alone
* going to public places, such as a post office or a
coffee house
* meeting friends, going to social meetings
* getting in a car on her own
* going up a flight of stairs alone (a reminder of
the occasion when she was led to believe she was going up a flight of stairs when she was blindfolded)
* walking near the street (she was picked up by a
police car when walking on the street side of the pavement)
* walking by a police station
* going near police officers on the street or tall
men with a moustache (thus resembling the police officers who conducted her torture)
* going near white Ford cars (resembling the
police car that picked her up on the street)
* talking and making appointments on the
phone (for fear of police surveillance of telephone conversations)
* carrying someone else’s telephone number on
her (for fear of getting that person into trouble with the police in case of re-arrest)
2. Avoidance behaviors associated with distressing
trauma reminders:
* watching certain movies
* drinking tea (she was offered a cup of tea
during interrogation)
* reading newspapers, talking about sex
(reminder of her rape)
* talking about her torture experience, signing a
paper (reminder of the confession she signed)
* sound of a police wireless radio
This case is fairly characteristic of torture survivors who continue to live in their home country in an environment of continued threat of arrest and torture. Generalized fear and avoidance relate to a wide range of situations and activities and in some cases may reflect in part a certain degree of realistic risk of re-arrest and torture. Nevertheless, the nature and extent of generalized fears and avoidance often go well beyond reasonable self-protective behaviors. Although there was some risk of re-arrest and torture in this case, a realistic evaluation of her circumstances (e.g. she was not a militant political activist sought by the authorities) did not justify fear and avoidance to an extent that crippled her daily functioning and made her almost housebound. As detailed in Part 1, fear conditioning leads to a wide range of avoidance behav- iors, many of which have little self-protective value. Such fear and avoidance may even persist in a safe environment, as illustrated by the second case vignette.
Case vignette #2
A 22-year-old, male, single asylum-seeker, who had arrived in Sweden in 1997, had been detained and tortured on eight separate occasions between 1994 and 1997 in his home country and spent 18 months in prison on one occasion. He reported an experience of
more than 20 different forms of torture, including forced stress positions, severe beatings, electric tor- ture, being hanged by the arms, near-suffocation, and sham executions. He left his country after this last detention. In psychiatric examination he had full- blown PTSD with additional complaints of fatigue, headaches, and pains in the chest. He also com- plained of feeling that he was still at risk of re-arrest and torture, despite the fact that he knew he was perfectly safe in Sweden. He avoided social interac- tions and had difficulty in forming close relationships. His social avoidance and concentration difficulties made it difficult to attend language courses and learn Swedish. He avoided sleeping because of fear of nightmares. He had difficulty socializing because he felt anxious with people and also feared that he might lose control and assault someone. He avoided travelling on buses because this triggered flashbacks of a past incident when the police had boarded a bus he was on and arrested some people. He did not watch TV and movies because certain news or scenes of violence reminded him of his torture experience. He avoided dealings with the Swedish immigration office and his lawyer because this meant having to talk about his torture experience.
This case also shows that avoidance behaviors can develop in relation to various traumatic stress symp- toms. The intensity of fear associated with perceived threat to safety can have a profound impact on the person’s daily functioning. We have seen an Iraqi ref- ugee, for example, whofled his country in the 1990s to settle in London. His fear of recapture by Iraqi agents was so intense and pervasive that he avoided going home every night, spending all night travelling on London busses and going home at daybreak when he was completely exhausted. His fear of recapture and further persecution by the Iraqi authorities did not appear realistic, because he was not a high-profile political activist or someone holding a high position in any political organization in his country. An exhaus- tive list of all possible avoidance behaviors is not possible, given that such behaviors may take highly idiosyncratic forms.
Trauma cues in war survivors also vary consider- ably according to the nature of the war events experi- enced. As in torture survivors, assessment needs to focus on situations or activities that act as distressing reminders of past trauma or that are perceived as posing further threat to safety. Traumatized survivors often tend to avoid situations where they think similar
events are likely to occur. For example, visits to a terri- tory previously held by the enemy may be avoided, even when the war is over and such a visit involves no realistic threat. Depending on the nature of the partic- ular trauma event, other war trauma cues include air- plane or helicopter sounds, military personnel or other people in uniform, sights of devastation, sudden loud sounds (e.g. explosions), crowded places, movies involv- ing violence, people with physical injury, ambulances, sirens, hospital settings, and media news or TV pictures of any form of violence or disaster. Two additional case vignettes presented inChapter 9 illustrate further the nature of trauma cues in asylum-seekers exposed to various forms of war trauma, including torture.
Step 2: explaining treatment
and its rationale
Once the trauma cues and associated traumatic stress responses are identified, the next step is to help the survivor understand why they need treatment for trau- matic stress problems and what treatment involves and how it works. Some survivors may not be fully aware of how their traumatic stress problems affect their life functioning or they may simply not perceive traumatic stress reactions as a treatable problem. It is therefore useful practice to ensure that the survivor fully understands the impact of traumatic stress on their life and their need for treatment.