How can a person heal, physically and mentally, after experiencing torture or extreme violence?
In July 2017, Doctors Without Borders/Médecins Sans Frontières (MSF) opened the Comprehensive Care Center, known by its Spanish acronym, El CAI, in Mexico City, to provide specialized medical and mental health care to people who have experienced torture or extreme violence. Many of the patients here are migrants or asylum seekers who have been through horrific journeys and were referred to the center from other MSF projects in Mexico, the United Nations Refugee Agency (UNHCR), and Mexican nongovernmental organizations.
In this interview, Néstor Rubiano, a psychologist specializing in family affairs and the coordinator of the Comprehensive Care Center (CAI) in Mexico City, talks about the history of the program and discusses how MSF can help a person heal, physically and mentally, from torture or extreme violence.
Why is it important that there is a service like El CAI in Mexico City?
In 2011, MSF began to work with the migrant population and we started to witness people who had experienced a type of violence our teams had not seen before. It is violence with severity, with cruelty. And it's not just that they target migrants and refugees, [who are usually already in a vulnerable state], but they use sinister methods to inflict harm. This creates a lot of damage.
So, why is it important that El CAI exists? Because if it did not, these people would not have access to comprehensive medical care. The people receiving assistance in El CAI have suffered a lot in life, many have suffered since childhood in their country of origin, and then again on the road where they end up encountering extremely acts of violence and cruelty.
You have worked in many different places around the world. If you are to compare your experiences from El CAI with other projects, what are the differences?
In a “classic” war context, the most visible, direct thing you can see is the people who have been shot, the bombings, the destruction, or those who must flee and are displaced. That is one type of violence. But then, what we see here is a type of violence that is structural and organized. It could be, for example, a person who is taken by criminals and gets his fingers cut off and his hands are left tied up for days in a place where they do not have anything to eat. They may even bring a family member of the tortured person who in turn also gets tortured, to further intimidate and to prolong the suffering. These are acts which we see in wars too, but here they take on another dimension, because we are not in a country at war.
What are the health consequences – physical and psychological – of being exposed to extreme violence and torture? Do you have some examples?
The worst cases are those who have lost their connection with reality. They enter a parallel fantasy world to protect themselves from harm and the memories. We have had people who even ended up living on the street because they had lost contact with reality. Others lived on the street also due to lack of support from other organizations, and this is also related to addictions. We currently have a patient, Manuel*, who was homeless. He had contact with reality from time to time, but most of the time he was disconnected. He underwent treatment, was hospitalized, then continued treatment, and today this person has a job in Mexico City.
The physical consequences of this type of violence are also very serious, sometimes requiring surgery. In fact, Manuel needs surgery. And the repeated violence to which they have been subjected also affects the level of pain they can handle. One of our patients had been tortured with repeated cuts on the arm and on the hand. He had a very serious hand mobility problem. When he goes into surgery he is completely anesthetized. But when the surgeon touches a certain nerve, the patient wakes up and almost attacks the doctor. They had to sedate him again. Because of so many experiences of pain and damage, the anesthesia was not working because the body has memories.
We also see a lot of women who have been sexually assaulted. Sometimes they become pregnant. It is a very complex situation for a single woman, migrant, on the streets. With a baby, the situation becomes even tougher. And then, little by little, not only because of the treatment that we offer, but because of the support of other institutions that are also providing accommodation, training, and work, we can manage help a survivor live independently.
At CAI, you work with what we call a comprehensive or holistic approach. Can you explain what that means?
When talking about a comprehensive, holistic approach, there are different services that can help a person move forward. One part is medical services, but there are also other important parts such as protection, nutritional issues, accommodation, and social inclusion issues. MSF focuses its attention on the medical component and therefore on pharmacological and non-pharmacological care, with psychiatrists and psychologists, and we also provide support with physiotherapy because patients have injuries of varying severity that sometimes require treatment and long recoveries.
Then, when it comes to surgeries, we organize this through our collaboration with different health networks here in Mexico. We also collaborate with other actors regarding protection issues, accommodation, and different trainings and courses.
What is the objective of the treatment that you have in the CAI?
Our goal is for the person to achieve maximum independence and reduce their trauma and pain as much as possible, so that they can be independent in life. We help them face what happened to them, everything they lived through, that simply cannot be forgotten. You have to learn to live with what has happened. But you may find that there is a way to do that and there is hope.
That's what we are looking for. Restore dignity and hope.
In your job you meet people who find themselves in extremely challenging situations, but you also get to see many of them improve. What are the best moments you remember from working at CAI?
What strikes me the most is that after having experienced so much violence, people still carry so much kindness, because they are not thinking of harming another human being. They arrive here and start to see acts of kindness and care towards and between people they had not previously known, and they are very respectful with us.
Would you say that the types of extreme violence that you see have increased in recent years?
Violence against migrants has increased as a result of migration being increasingly met by criminalization and militarization, with different obstacles put in place. This means that people have to take unsafe routes characterized by organized crime and a high degree of violence.
Many of our patients have also experienced a lot of violence in their country of origin, like Honduras, in Guatemala, and El Salvador. So, they have already experienced and are subjected to it again in Mexico. And in Mexico, they are paralyzed, because they are not allowed to move on to seek safety in another country, or they are returned or detained at the border. This is a vicious circle with a high probability of violence being repeated.
